Robot-assisted endoscopic surgery

During the last three years, robot-assisted surgery systems are increasingly being applied in endoscopic surgery. They were introduced with the objective to overcome the challenges of standard endoscopic surgery. With the improvements in manipulation and visualisation that robotic-assistance offers, technologically complex procedures can be performed endoscopically and standard endoscopic procedures can be performed easier and with greater comfort to the surgeon. This serves the purpose of improvement of quality of care. The goal of this thesis was not only to assess the feasibility of various robot-assisted procedures both in experimental and clinical settings, but also to compare robot-assisted surgery to standard open and laparoscopic interventions. All studies aimed at assessing the benefits, challenges and potential pitfalls of using this new technology. In chapter 1 of this thesis, an introduction into robot-assisted surgery is provided. In chapters 2 to 5 of this thesis, the clinical experience with robot-assisted surgery at the University Medical Centre Utrecht is presented. This started with a series of 40 laparoscopic cholecystectomies as described in chapter 2. This relatively simple procedure was carried out repetitively in order to learn how to work with the, at that time, new technology of robotic assistance under accustomed circumstances. During these procedures only one conversion and no intra-operative complications occurred demonstrating it s safety. In our consecutive series of more complex procedures, as described in chapters 4 and 5, the number of conversions and complications was also low. Concerning the efficiency, operating times were comparable to times mentioned in literature and to times in our institute for procedures performed with standard endoscopic instrumentation. The critical remark that needs to be made, however, is the considerable set-up time we encountered in our series. The time needed to install and sterilely drape the equipment averaged 15 minutes. In chapter 3 we took a closer look at the time-loss and realised that robotic assistance in our institution will burden the operating schedules by approximately 20 minutes per procedure. This time-loss needs to be reduced in order to use robotic systems on a daily basis. In chapters 6 and 7 of this thesis, two challenging (robot-assisted) laparoscopic surgical procedures were compared to the standard open procedure in an experimental setting. It was noticed to be achievable to perform anastomoses with great ease and with a similar result as through the open approach, even though we had no previous experience with performing these procedures in a laparoscopic fashion. Furthermore, both robot-assisted retroperitoneal aortic replacements in pigs and ex-vivo intestinal anastomoses, as described in chapters 8 and 9, were compared to standard endoscopic surgery. For both procedures, clear advantages from robotic assistance were experienced. The vascular anastomoses were performed faster, with fewer errors and lower blood-loss with the use of the robot. A time/action analysis was performed for the intestinal anastomoses and it was demonstrated that even experienced laparoscopic surgeons performed better with use of the robot, even though they had no previous exposure to robot-assisted surgery. In conclusion, this thesis demonstrates that robot-assisted surgery is safe and efficient in both standard and complex endoscopic interventions. Robotic assistance was proven to offer distinct benefits over standard endoscopic surgery. To implement these systems in day-to-day surgery, the benefits will have to be demonstrated to outweigh the considerable investment of costs and time