Robotic Surgery: A Paradigm Shift In Oncology

The Beginning Of Advancement:
The introduction of robotic surgeries in minimally invasive surgeries has offered more precision, access to modern imaging, a better range of motion, and less operation time. Robotic surgery with PUMA 200 was first used in neurosurgery in 1985 (1). While it was extensively used in the 1990s, the AESOP system produced by Computer Motion became the first FDA-approved system for endoscopic surgical procedures. Probot was used for prostate gland surgery, while ZEUS was used for open-heart surgery. ZEUS had robotic arms attached to the operating table. It was with ZEUS that the first trans-Atlantic surgery was performed, wherein the surgeon was based in the USA and the patient was in France. Later in early 2000, a da Vinci robotic surgical system was developed with surgical instruments and an imaging system (2). The system consisted of a Surgeon Console, controlled by the surgeon, the Surgical Cart, of which three arms performed the procedure, and the Vision System was a visual aid. This allowed the surgeons to operate distantly with the help of a three-dimensional imaging system. These advances in robotics minimized the blood loss during surgery, reduced the pain and hospitalization, thus improving the recovery time. Enhanced recovery after surgery (ERAS) pathways developed later resulted in reduced tissue damage, side effects, and medication (3). The next few years witnessed a range of upgraded robotic models in medicine like the Cyber Knife radio-surgical robotic system, RAVEN, and SOCRATES system which were all in different aspects of medical care.

Evolution Of Robotics In Oncology:
With the advances in the field, robotics is now increasingly used in complicated cancer surgeries. While robotic surgery was being integrated into the management of diseases, neurological surgeries required advancement beyond human expertise. With the limitations of accessibility in neurosurgery, robotic surgery was first adopted in this field to work at the microscopic level (4). Transoral robotic surgery (TORS) is extensively used in head and neck cancers. TORS has reported a shorter operation time, higher rate of negative surgical margin status, faster recovery, and shorter hospital stay. A paper by Nyugen et al. compared the outcomes of TORS and non-robotic surgery in early-stage oropharyngeal squamous cell carcinomas. The findings reported better survival outcomes in cases where TORS was used (5). A summary of the clinical cases reported the use of single-surgeon thoracoscopic lung resection for primary lung cancer with a voice-controlled robot in 2000. The results of the robotic surgery were encouraging and can be instrumental in changing the landscape of cancer treatments (6). The da Vinci system had a better visualization of the field and was superior to the conventional surgery when used in hysterectomy with bilateral salpingo-oophorectomy. An article reported the use of robotic myomectomy as an alternative to the open surgery approach. Robotic surgery in the treatment of gastric cancers either using da Vinci or ZEUS robotic surgical has become prevalent. Robotic surgery for the resection of the esophageal tumor, a distal gastrectomy, an ileocecal resection for cecal cancer, a left hemicolectomy, a sigmoidectomy, a thymectomy has been performed to date (2). Furthermore, the first robotic total mesorectal excision (TME) was reported by Pigazzi et.al. in 2006. This was followed by several reports validating the safety and feasibility of the procedure (7). Robotic surgeries have been successfully integrated into cervical cancer and endometrial cancer. The difficulty of performing open surgery on morbidly obese patients can be overcome by robotics (8). Although the efficacy of the same is yet to be proven, robotic surgeries lowering the comorbidities associated with mortality might be interesting. Although radical surgery is commonly used in ovarian cancers because of its advanced-stage detection, the inability of robotics to perform simultaneous surgery on the pelvis and abdomen has restricted its use. According to the published data, robotic surgery has lowered the incidence of postoperative complications including bowel injury and wound dehiscence (9). Another application of robotics has been confirmed in invasive ductal and lobular breast cancer, adenocarcinoma, and fibroadenoma (1). Consistent with the application of robotics in other malignancies, a study evaluated the efficacy and safety of robotic-assisted breast-axilla insulation thyroidectomy (RABIT) in thyroid cancers. Robotic surgery was associated with better visuals and handling of the gland. Furthermore, it also reported excellent cosmesis (10).

Surgical Robotics Beyond Oncology:
Besides oncology, robotics has paved its way in the management of several other diseases. The da Vinci robotic system and ZEUS have shown successful outcomes in coronary artery bypass grafting. Another procedure that is assisted by robotics is mitral valve surgery. The Covid-19 pandemic postponed several treatments for patients worldwide. However, urgent surgeries in life-threatening diseases like cancer, should not be delayed. The recent pandemic highlighted the need for the safety of healthcare professionals to restrict the spread of the virus and to ensure quality care to patients (11). This opened a new avenue for robotics to be integrated into the healthcare sector. A review provided insights into several modifications in the operation theatre to ensure the safety of healthcare professionals and patients. It proposed the use of safe smoke evacuation and minimizing energy devices to lower the risk of exposure to aerosolized particles. It also provides guidelines to clinicians for using robotics (12).

Advent Of Robotics In India:
Robotics has been widely used since the 2000s. However, robotics is still naïve in India with only a few hospitals implementing it. While surgeons in India have undergone training for the robotic systems available, it is used judiciously because of the high costs (13). Robotic surgeries are being increasingly used in GI and gynecological surgery, and uro-oncological procedures in India. Robotic surgeries for low rectal cancer as an alternative to laparoscopy are picking up. Similarly, gynecologists in India have used robotics in benign as well as malignant cases(14). Despite the increased use of robotics, it is not easily accessible to the community at large (1). There is a paucity of data supporting the benefits of robotics that might overweight the costs (14).

Addressing The Pitfalls:
While we have witnessed great progress in the field of robotic surgeries, there is a need to address some persistent issues. The soaring cost of the robotic system currently limits the use of the same. Furthermore, lack of medical insurance cover and timely training for surgeons has been a constraint (4). Additionally, there is a need to report long-term outcomes without bias. This will help establish the implications of robotics in clinical management. Furthermore, the integration of robotics requires knowledge about its speed, resolution, processing language, and bandwidth (15). The requirement of high speed and bandwidth with a fast data transfer, capacity, connectivity, and without delays can be achieved with 5G wireless transmission technology (16). A novel concept of “one-to-many” focuses on the idea of a surgeon performing surgeries on multiple patients. The first successful surgery of this kind was witnessed in 2019 because of the low latency, high speed, reduced time-lag of 5G (17). Moreover, the Internet of Things (IoT) can integrate multiple technologies in a single environment. The potential of IoT to connect the real world has uncovered its application in healthcare. The use of cloud robotics to process and share data is making surgeries safer and more accurate (18).

Future Prospects:
Despite the limitations, robotics has emerged as a promising alternative to open surgeries. There are several applications of small surgical robots. A robotic cardiac catheter is one such example (4). The advancements in technologies are predicted to improve the design and ease of using robotics. This may be done by constructing a centralized platform with imaging, navigation, and enhanced sensory capabilities. The computational capability of robotics is an important part of the system. Integration of AI to minimize errors and develop robots that can learn and remember is likely in the future (19). Developing the next generation of robots by enhancing visualization and manipulation can alleviate the limitations of today’s surgery. The constant advances in this state-of-the-art of surgical intervention will help enhance patient care in the future.

Author’s website - http://drsandeepnayak.com
MACS clinic - https://macsforcancer.com

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