Ultrasound Opens New Doors in Robotic Surgery

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Patel-robot_1335535553.jpg - Vipul Patel, MD - Robot
Vipul Patel, MD, medical director of the Global Robotic Institute at Florida Hospital in Orlando, and his team have completed more than 5,000 robotic-assisted radical prostatectomies.
Source: Global Robotic Institute at Florida Hospital, Orlando

Since its introduction more than a decade ago, robotic-assisted surgery has stood out as a game-changer. The robotic console provides a robust platform to enable minimally invasive procedures in urologic, cardiothoracic, gynecologic and general surgical procedures. Today, robotic surgery is witnessing an evolution. The most recent surgical ultrasound systems, specifically Analogic Corporation’s BK Medical Ultrasound Systems Advanced Robotic Technology (ART), are ushering in a new level of precision and diagnostic confidence. Intraoperative robotic-assisted ultrasound helps surgeons to perform more complex procedures robotically with potentially improved outcomes, particularly in radical prostatectomy and partial nephrectomy.   

Robotic consoles have experienced tremendous growth. Intuitive Surgery, the undisputed leader in the field, launched its da Vinci Surgical System in 1999, and received FDA clearance for general laparoscopic surgery in 2000. By 2003, the company had installed 210 systems. Throughout the decade, the FDA cleared the platform for additional procedures, including thoracoscopic surgery, cardiac procedures, urologic, gynecologic, pediatric and transoral otolaryngology procedures. Today, the installed base has reached nearly 2,000 da Vinci Surgical Systems.

Indeed, the surgical robot has become a fixture in operating rooms across the country. Pioneers like New York University (NYU) Robotic Surgery Center in New York City have paved the way. And as regional and mid-sized hospitals have entered the field, early adopters have expanded their repertoire and infrastructure. Today, NYU is home to three da Vinci Surgical Systems.

“Robotic surgery is a minimally invasive surgical technique like laparoscopy in that the surgeon places instruments and cameras through four or five ¼-inch incisions in the abdomen,” says Michael Stifelman, MD, director of robotic surgery at NYU Langone Medical Center. However, there are critical differences between laparoscopic surgery and robotic-assisted surgery. “With standard laparoscopy, the surgeon does not have a lot of dexterity or fine motor control.” For example, it can be difficult for surgeons to suture in these conditions.

Consequently, laparoscopic procedures had been limited to gross procedures. Surgeons would resort to a conventional open incision for delicate procedures, or those requiring reconstruction or gentle tissue handling. However, the advent of robotic consoles changed the paradigm.

The console’s slender robotic arms return fine motor control to the surgeon and allow him or her to complete more complicated procedures in a minimally invasive environment.  

Imaging in evolution

Just as imaging is critical to conventional surgical procedures, it also plays an essential role in robotic-assisted surgery. One of the first-generation solutions is the laparoscopic ultrasound transducer. First-generation probe technology relied on a sonographer or assistant to control the probe.

“The surgeon needs ultrasound for these procedures. Intraoperative ultrasound technology is an exciting new device in the armamentarium of tools available to the urologist,” says Ashok K. Hemal, MD, director of the robotic and minimally invasive surgery program at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

James Porter, MD, medical director of robot-assisted surgery at Swedish Medical Center in Seattle, explains, “A laparoscopic surgeon has to adapt when he or she starts performing robotic procedures. [In the first-generation model], the surgeon is no longer at the bedside and has to depend on the bedside assistant to perform ultrasound.”

It was a bit of a delicate dance that hinged on close communication. The surgeon directed the assistant to maneuver the probe through the incision. With each move, the surgeon assessed positioning of the probe and re-directed the assistant as needed. “It was a bit like watching a tennis match,” says Stifelman. The surgeon would stare at the probe on one screen and then shift to review the imaging data on another screen. “It was cumbersome.”  

In March 2011, Analogic introduced a new, leading edge paradigm. The Advanced Robotic Technology solution returns control to the surgeon thanks to intraoperative robotic-assisted ultrasound. ART is comprised of several components: BK Medical’s Flex Focus 700 ultrasound imaging system, its ProART transducer, its 3DART transducer and its RST Robotic Stationary Transducer Arm. Analogic also expanded and improved