Advancing Technology of Medicine: The Da Vinci Robot Richard Ly 10/18/13 Professor Wolcott In this paper, it will discuss the

advantages of robot-assisted Laparoscopies with the Da Vinci robot when compared to conventional laparoscopic surgeries or laparotomies. It will go over the information of the actual surgical procedure; however, it will not go into great detail as that is not the reason for this paper. Sources used in this will date from 2005 to the present. The reason for this is to briefly show the first model of the Da Vinci robot. In that article, it states problems and complications the first model went through and most of the articles most recently published will explain the advancements of the Da Vinci robot and techniques involving it. Within the sources used for this annotated bibliography, most of the authors are employees of hospitals, more specifically in the Department of Surgery or subgroups of Minimally invasive surgeries. Other authors were electrical engineers. Credibility depended on the authors' degree as well as the institution of their employment. This paper would best help a person who will be or could be undergoing robot assisted laparoscopic surgery as it may help inform the patient to be more knowledgeable of this new technique used in surgery. It would also be beneficial to students in high school or college that may interested in general medicine. This paper could also be interesting to an engineer major that could be specializing in medical technology. This paper, due to the terms used, decreases the possible audience.

Although difficult, it is not impossible so a high school student would be able to understand the what each part of the annotation is implying. A few terms that may aid the reader to have a better understanding of the topic would be laparoscopies-viewing of the abdomen via fiber optic instrument to aid the surgeon in doing a procedure -, morbiditypercentage of a patient's chance of receiving a disease- , and carcinoma-cancerous tumor-. After reading this paper, it gives a broad understanding of the advantages of robot -assisted surgeries over conventional surgeries. Anderson, Casandra. Joshua Ellenhorn, Minia Hellan, Alessio Pigazzi. "Pilot Series of Robot-Assisted Laparoscopic Subtotal Gastrectomy With Extended Lymphadenectomy For Gastric Cancer." Springer Link. 8 March 2007. 18 October 2013. In this article, a team of four doctors from the Department of Surgical Oncology of the City of Hope discuss the technique of robot-assisted laparoscopic surgery to remove carcinogenic tumors of the lymph nodes. For this study, 7 cases (3 females and 4 males) underwent laparoscopic subtotal gastrectomy with omentectomy and robot-assisted extended lymphadenectomy. For this, surgery took approximately 420 minutes and were completed successfully without conversionreverting back to the conventional method. There was, however, one complication due to one of the patients requiring a colon resection for a devascularized segment. After performing this case study, the team concludes that the technique of robotassisted surgery to remove tumors of the lymph nodes is feasible. In result, the patients have a higher chance of shorter hospital stay post-op and lower morbidity rate. What becomes a problem with this case study, however, is that the results are short term and when dealing with carcinomas, long-term results are extremely

important and, at this time, are not available. When comparing the robot -assisted laparoscopies and the conventional laparotomies, the robot-assisted laparoscopies provide an improved amount of dexterity for the surgeon as well as increased freedom within the surgical site, no surgeon tremor, and more precision in the procedure. Antoniou, Starvros A. George A. Antuniou, Oliver O. Koch, Rudolf Pointner, Frank A. Granderath. "Robot-assisted Laparoscopic Surgery of the Colon and Rectum." Springer Link. 20 August 2011. 18 October 2013. In this article, the authors, Stavros A. Antoniou, George A. Antoniou, Oliver O. Koch, Rudolf Pointner, and Frank A. Granderath, review the robot-assisted laparoscopic surgery within the colon and rectum. These authors are all employed within different hospitals, one of which works in the Center for Minimally Invasive Surgery. The article focuses on the improvements in surgery as well as postoperative oncologic outcomes although since studying the oncologic outcomes are more long-term, the material available is minimal. The authors explain that the use of the robot had a low percentage of complications during the procedure of the colectomies. Even with the time to set up the robotic system, the amount of time to perform the procedures with the assistance of the robot is reasonable. Robot-assisted surgeries allow the surgeon to take advantage of numerous benefits: advanced degrees of freedom, the magnifying camera effect, a stable camera platform, and the 3-dimmensional imaging. With the potential of increased precision, the surgeon is able to decrease the amount of nerve loss within certain surgeries. Even with this growing technology becoming a norm in the surgical field, it still is in its infancy. Certain procedures, such as a splenic

flexure mobilization, are not yet feasible since the robot system is unable to reach the left upper abdomen. The patients movement during a surgery also becomes extremely limited, thus limiting the use of the robot in other surgeries where this is required. Although the Da Vinci Robot is still in its infancy, it still provides many benefits to the surgeon when performing procedures where increased dexterity will greatly improve the patient's outcome. Advincula, A. P. "Surgical Techniques: Robot-assisted Laparoscopic Hysterectomy With The Da Vinci Surgical System." The International Journal of Medical Robotics and Computers. Volume 2, Issue 4, 15 December 2006: pages 306-311. In this article, the author, A.P. Advincula- a member of the Department of Obstetrics and Gynecology of the University of Michigan- discusses the technique of robot-assisted surgery with use in laparoscopy hysterectomies. Although using the Da Vinci robot in performing a laparoscopic hysterectomy provides numerous advantages such as increased dexterity and precision, laparotomy hysterectomies is still the most common technique used. Robot-assisted surgeries offers the ability to perform an almost suture-less hysterectomy due to the improvements in the robot's energized instrumentation. Bodner, Johannes. Paolo Lucciarini, John Fish, Reinhold Kafka-Ritsch, Thomas Schmid. "Laparoscopic Splenectomy With The Da Vinci Robot." Journal Of Laparoendoscopic & Advanced Surgical Techniques. Volume 15, Number 1, 1 February 2005: pages 1-5. The contributing authors of this journal article are all Doctors of Medicine. This article explains the early stage of the Da Vinci robot. In the earlier model of the Da Vinci robot, it required two people to use the robot in

surgery: one at the console and one at the tableside controlling the robot. This study was based on splenectomies using only the Da Vinci robot by the same surge on. In the article, the authors note that a previous paper by Talamini stated that splenectomies wouldn't be an ideal procedure to be done with the robot since 2 of 7 splenectomies were forced to convert back to the conventional method. However, the authors of this article report that none of the splenectomies ran into any complications in surgery. Past research stated that the size of the spleen would greatly impact the results of the surgery, however, the first splenectomy performed in their study was an abnormally oversized. Even with this, the surgery was still done without any complications. In the discussion section, the authors note that, when studying these 7 consecutive cases, the results were ideal: no surgical complications and excellent short-term remission rates. The authors also state that within a few years advancements will occur to the point where only one person will be needed to operate the robot. Eisenberg, Dan. Tamas J. Vidoszky, James Lau, Bernadette Guiroy, Homero Rivas."Comparison of Robotic and Laparoendoscopic Single-site Surgery Systems in a Suturing and Knot Tying Task." Springer Link. 27 February 2013. 18 October 2013. The authors of this article, Dan Eisenberg, Tamas J. Vidovszky, James Lau, and Homero Rivas, are all members of the Department of Surgery within their hospital. In this article, the authors conducted a study based on the comparison between the two different techniques of laparoscopies: Laparoendoscopic Single Site (LESS) surgery and the use of the Da Vinci Robot. To compare the two, the authors gave five minimally invasive surgeons the task to suture and tie a square

knot with both techniques. These surgeons all have previous experience in LESS surgery as well as similar single-site surgeries more specialized to their practice. The surgeons received some formal training with the Da Vinci robot when arriving at the site; however, before this, none of the surgeons had personal experience purely with the robot in their practices. To measure the quality of the work, the sutures were tested with a "leak" test where saline would be injected into the suture with a syringe and have pressure be put onto it. When performing the test, the results showed that 100% of the surgeons were able to complete the task within the 20minutes mark when using the robot whereas only 20% of the surgeons were able to complete it within the 20minutes mark on their first try. Not only that, however, but the sutures done with the robot actually had no leaks when tested and 90% of the sutures done without the robots did leak. During this study, the authors noted that this comparison of the two different techniques was based on the performance of the task. With that, it is easily shown that the use of the robot did increase time efficiency as well as quality of the sutures; however, the Da Vinci robot takes a large amount of time to set up for the procedure and the time that was recorded only involved the time of the task. Friedman, Diana W. Thomas S. Lenvay, Blake Hannaford. "Instrument Failures For the Da Vinci Surgical System: a Food and Drug Administration MAUDE Database Study." Springer Link. 14 December 2012. 18 October 2013. In this article, the authors, Thomas S. Lendvay-a member of the Department of Urology at the University of Washington-, Diana C. W. Friedman and Blake Hannaford- both members of the Department of Electrical Engineering at the University of Washington - discusses the

instrument failures of the Da Vinci robot. To do this, the team uses the FDA database to review the reported cases of system failures of the Da Vinci robot. From what the FDA Database shows, wrist or tool-tipped failures are most commonly reported, cauterizing instruments follow next, then it would be instrument shaft, and lastly would pertain to the cable and housing. Although this may be what is shown on the FDA database, it is not 100% accurate since it is was is "reported"; there is an unknown amount of cases of system failures that go unreported at the hospital's discretion. Even if the hospital would report any known malfunctions of the Da Vinci system, there is still a good percentage of system failures that the surgical team may not notice. Perhaps the reason the instrument's wrist or tool -tip has the most failures is because it's what would most be noticeable since the surgeon's vision is always focused on the instruments. Hagen, Monika E. Oliver J. Wagner, Ihsan Inan, Philippe Morel, Jean Fasel, Garth Jacobsen, Adam Spivack, Kari Thompson, Brian Wong, Lauren Fischer, Mark Talamini, Santiago Horgan. "Robotic-Single Incision Transabdominal And Transvaginal Surgery: Initial Experience With Intersecting Robotic Arms." The International Journal of Medical Robotics and Computer Assisted Surgery. Volume 6, Issue 3, 19 April 2010: pages 251-255. In this article, the team of doctors from the Center for the Future of Surgery of the University of California and the Division of both the Anatomy and Digestive Surgery of the University Hospital Geneva, Switzerland review the technique of robot-assisted single-incision in both transabdominal and transvaginal surgeries. In this case study, the doctors perform the surgeries on male and female human cadavers. Performing robot -assisted

transabdominal laparoscopy was successful. During this, the surgeon uses the "chopstick" method, crossing the left and right instruments of the Da Vinci robot to prevent collision and increase movement within the surgical site. When doing this, the surgeon notices a slight loss of range with the left instrument due to the thi rd instrument (the camera). The surgery was successful without any problems in the cadaver. When performing the robot-assisted transvaginal laparoscopy, it was shown that it was not feasible due to the constriction of the vagina and the limited space between the thighs. Although this may not be completely accurate when comparing to a living human since the cadaver has limited space both inside(inflated bowel) and outside (between thighs) as well as suboptimal bedding, resulting in difficulty in the set up of the surgery. Joseph, R.A. Salas N.A., C. Johnson, A. Goh, S.P. Cuevas, M.A. Donovan, M.G. Kaufman, B. Miles, P.R. Reardon, B.L. Bass, B.J. Dunkin. "Chopstick Surgery: A Novel Technique Enables Use of the Da Vinci Robot To Perform Single-Incision Laparoscopic Surgery." Surgical Endoscopy. Volume 24, Issue 12. December 2010: Page 3224. The contributing authors to this article explain the improvements of the Da Vinci robot. Before the "chopstick" technique was incorporated into the Da Vinci robot, the surgeon would run into minor complications of the instruments of the robot colliding with one another inside the patient as well as outside. With the use of this technique, not only did it eliminate the collision of instruments, it also greatly increased the range of motion within the surgical site of the patient. Kang, Chang Moo. Dong Hyun Kim, Woo Jung Lee, Hoon Sang Chi. "Conventional Laparoscopic and Robot-assisted Spleen-Preserving Pancreatectomy: Does Da Vinci

Have Clinical Advantages?" Springer Link. 7 December 2010. 19 October 2013. In this article, the team of doctors -of the Division of Biliopancreas of Yonsei University College of Medicine, the Clinic of Pancreatic and Biliary Cancer of Yonsei University Health System, and the Department of Surgery of Yonsei University Wonju College of Medicine of Seoul, Korea- discuss results of their case study of the use of the Da Vinci Robot in Pancreatomy to remove any tumors while preserving the pancreas. In this case study, the team obtains two group of patients that require this surgery. When asking the patients of which type of surgery they would want, the younger patients leaned toward the robot-assisted surgery whereas the older patients were more towards the conventional route. When the surgeon performed the procedure, the patients that underwent robotassisted surgery had a significantly greater amount of their pancreas when compared to the patients that received the conventional surgery. The better results of the robot-assisted surgery is because of the advantages it gives the surgeon. With it, it provides a 3dimmensional view, wrist-like movement of the instruments, no tremor, and scale adjustment of the instruments as well. Although the results were much better with the patients that received robot-assisted surgery, the cost of this technique exceeded twice the cost of conventional surgery. Before the Da Vinci robot, performing this type of procedure effectively, the surgeon would need a great amount of experience but now with the robot, it takes a substantially shorter amount of time to learn this procedure. Kerbl, David C. Jason Y. Lee, Phillip Mucksavage. "The Da Vinci Surgical System Overcomes Innate Hand Dominance." Journal of Endourology. Volume 25, issue 8. August 2011: page 1385. The contributing authors of this article explain the disappearance of innate hand dominance when using the Da Vinci robot. In this case study, the authors obtain

multiple volunteers of all levels of experience with robot-assisted surgery. Everyone was given a basic tutorial on operating the robot, regardless of the experience. The volunteers were then given 30 minutes to practice basic tasks with the robot. Afterwards, their manual dexterity was tested first, and later was again tested with the robot. When comparing the results of the tests, the first test showed significant differences with the majority of the people of the level of dexterity of each person where as the use of the robot almost completely eliminated the gap between each hand. Pedraza, Rodrigo. Madhu Ragupathi, Tara Martinez, Eric M. Haas. "Robotic-assisted Laparoscopic Primary Repair of Acute Iatrogenic Colonic Perforation: Case Report." International Journal of Medical Robotics and Computer Assisted Surgery. Volume 8, Issue 3. 20 June 2012: pages 375-378. The contributing authors of this article are doctors that are part of either the Division of Minimally Invasive Colon and Rectal Surgery of the University of Texas Medical School or the Colorectal Surgical Associates LLP of Houston, Texas. In this article, the team of doctors describe a case study of repairing a perforation that was caused by a colonoscopy with the technique of robot-assisted laparoscopy. During a colonoscopy, the chance to have a perforation is 0.016-0.2%. When this does happen, it is very serious and would most commonly be repaired by doing a laparotomy. Now with the Da Vinci robot, surgeons are able to repair perforations and, in result to using the robot, the patient will have less time spent in the hospital post-op with a lower morbidity rate and lower chance of infection during the procedure. The use of the robot allows the surgeon to have improved dexterity, stable camera platform, 3-dimensional visualization with the capability of 10 fold magnification. The surgeon also has

increased range of motion within the site and no "surgeon tremor". The article describes one situation where the use of the Da Vinci robot is ideal since conventional techniques of laparoscopies wouldn't be possible with the special characteristics of the perforation. With the assistance of the robot, the surgeon was able to maneuver throughout the abdomen with ease. The improved camera allows the surgeon to spot the problem out quicker and fix anything else around it that the tear affected. Pineda-Solis, Karen. Heriberto Medina-Franco, Martin J Heslin. "Robotic Versus Laparoscopic Adrenalectomy: A Comparative Study In a High-Volume Center." Springer Science+Business Media (2012) Web. October 9, 2013. A team of doctors -from the Department of Surgery of both Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico and the University of Alabama, and the Section of Surgical Oncology of the University of Alabama- compare the two types of laparoscopic surgeries: robotic-assisted and conventional. The doctors used two groups of patients that underwent the same type of surgery: adrenalectomy, the removal of the one or both of the adrenal glands. One group undergoes robot-assisted adrenalectomy (RA), while the other group of patients receive laparoscopic adrenalectomy (LA). When comparing the two groups, the group that underwent the RA had a shorter amount of time in the hospital post-op and a shorter recovery time compared to LA. During LA, there is a higher chance of infection for the patient since the incision is significantly larger compared to the incision done in RA. When performing LA, there is also a higher chance of mistakes since it requires two people to perform this procedure: one to hold the camera and guide the surgeon and one to perform the actual procedure. LA also has a limitation of

movement for the surgeon. Although in the case study, the lower chance of infection and other benefits of RA are traded for time of the procedure; RA, when compared to LA, takes longer. Ragupathi, Madhu. Diego I. Ramos-Valadez, Rodrigo Pedraza, Eric M. Haas. "RoboticAssisted Single-Incision Laparoscopic Partial Cecectomy." The International Journal of Medical Robotics and Computer Assisted Surgery. Volume 6, Issue 3. 27 July 2010: pages 362-367. In this article, the team of doctors describe a case study with the use of the Da Vinci robot to perform a single-incision laparoscopic partial cecectomy. In this case study, the doctors use a 53 year old male. The patient was presented with a tubulovillous adenoma and provides consent to undergo the robotic-assisted surgery. The surgery is completed without any complications occurring within the patient. In this case study, the surgeon uses the "chopstick" technique to cross the two instruments of the Da Vinci robot to prevent collisions within or on the outside site of the patient of the surgery. This also increases the range of movement for the surgeon. Although this technique provides great cosmetic benefits of a small incision, it benefits the surgeon as well. With the use of the robot, the surgeon is able to move more freely within the site of the surgery and has improved dexterity when performing the surgery. The surgeon is also able to overcome restrictions that conventional laparoscopic surgeries would face. Spinoglio, Giuseppe. Luca Matteo Lenti, Valeria Maglione, Francesco Saverio Lucido, Fabio Priora, Paolo Pietro Bianchi, Federica Grosso, Rual Quarati. "Single-Site Robotic Choecystectomy (SSRC) versus Single-Incision Laparoscopic Cholecystectomy(SILC): Comparison of Learning Curves. First European Experiences." Springer Link. 17

December 2011. 18 October 2013. In this article, the doctors of the Department of Surgery of SS Antonio e Biagio Hospital, Unit of Minimally Invasive Surgery of European Institute of Oncology, and the Department of Oncology of the SS Antonio e Biagio Hospital compare single-site robotic cholecystectomy (SSRC) and single-incision laparoscopic cholecystectomy (SILC). When performing SSRC, no major complications occurred during the procedure and there was no need of a conversion to the conventional method either. When the surgeon uses the technique of SILC, a major disadvantage is present that the Da Vinci robot is able to overcome: intuitive control. Unlike SILC, SSRC gives the surgeon an easier mobility of the instruments, resulting in an improved control. When comparing the post-op status of the patients, the group of patients that underwent SILC were required to stay at the hospital longer and also received a higher percentage of morbidity. The use of SSRC increased satisfaction due to the smaller scar; cosmetically, this is favorable. Turchetti, Giuseppe. Ilaria Palla, Francesca Pierotti, Alfred Cuschieri. "Economic Evaluation of Da Vinci-Assisted Robotic Surgery: A Systematic Review." Surgical Endoscopy. Volume 26, issue 3. March 2012: Page 598-606. In this article, the contributing authors use sources of people from the Institute of Medicine of Washington, and numerous people within the field of health technology. This article discusses the economic side of robot-assisted surgeries. This specifically focuses on the cost of the operating time and hospital stay. From the articles the author uses to compare the cost between robot-assisted surgery and conventional surgery, it shows that the cost of robotic surgery due to a longer time in the operating room; however, the main factor in the cost would directly correlate

with the experience of the surgeon with the robot. Robot-assisted surgeries also result in less days in the hospital post-op.