Robotics, telesurgery and telementoring--their position in modern urological laparoscopy

Laparoscopic surgery in general is handicapped by the reduction of the range of motion from six to four degrees of freedom. This has a major impact on technically difficult procedures such as laparoscopic radical prostatectomy. Solutions for this problems include the understanding of the geometry of laparoscopy with sophisticated training programs, but lie also in newly developed surgical robots, computer simulators and telementoring. This article evaluates the value of these alternatives based on own experiences and an analysis of the current literature.

Own experiences with robot-assisted surgery include 406 laparoscopic radical prostatectomies using a voice-controlled camera-arm (AESOP) as well as 6 telesurgical interventions with the Da Vinci-system. Additionally, substantial experimental studies have been performed focussing on the geometry of laparoscopy and new training concepts such as perfused pelvitrainers and computer simulation. Moreover, the current literature of the last 10 years on telesurgery and telementoring has been reviewed.

The geometry of laparoscopy includes the angles between the instruments which have to be in a range of 25 degrees to 45 degrees; the angles between the instrument and the working plane that should not exceed 55 degrees; and the angle between the shaft of the needle holder and the needle which has to be adapted according to the anatomical situation in range of 90 to 110 degrees. 3-D-systems did not yet proved to be effective due to handling problems such as shutter glasses, video-helmets or reduced brightness. At the moment, there are only two robotic surgical systems (ZEUS, Da Vinci) in clinical use for telesurgery, of which only the Da Vinci provides stereovision and all six degrees of freedom (DOF). In the meantime, more than 200 laparoscopic radical prostatectomies have been performed with this system. Until now, however, there was no evidence of any advantages over the conventional laparoscopic approach. The ZEUS in combination with the telecommunication system SOKRATES is the only device enabling to realize telemanipulation and telementoring over long distances (i.e. transatlantic).

Robotic surgery represents a turning point of surgical research. However, broad use of robotic systems is limited mainly because of the high investment and running costs. Whereas there will be a clear role of audio-visual telementoring in future training concepts, the need of telemanipulation/telesurgery has not yet been clarified. New technological concepts promote the development of hand-held mechanical manipulators (i.e. 6-DOF-needle-holder) used in combination with mono-tasking computerized robots (i.e. AESOP) resulting in a significant cost reduction.