By Don Sadler
When they hear the term “robotics,” many people think of sci-fi movies or TV shows set many years in the future. But robotics are very much a part of the modern day operating room.
In fact, there has been a tremendous surge in robotic-assisted surgery in recent years. It’s estimated that more than 7.2 million robotic surgical procedures were performed worldwide in 2020.
More Frequent Usage
“Robotic surgery is definitely being used on a more frequent basis in general surgery, neurosurgery and orthopedics,” says Christopher Gazdick, RN, MSN, NE-BC, administrative director of perioperative services at Hackensack Meridian Health.
“Many of the robotic applications have stemmed from the general surgery arena but other specialty areas have also increased their footprint,” Gazdick adds.
In the U.S., tele-surgical robotic systems are most frequently used in urology, gynecology and general surgery procedures, notes Renae Wright, DNP, RN, CNOR, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN).
“Applications for robotic surgical systems are continuing to expand,” says Wright. “These currently include cardiothoracic and head and neck surgery as well as orthopedic, neurologic and spine surgery.”
Wright says we’re also starting to see some robot-assisted procedures move to the ambulatory surgery side. “This is especially evident in minimally invasive surgery and total joints where robotic systems are gaining traction for elective minimally invasive procedures and hip and knee replacement procedures,” she says.
According to Rice University robotics expert Marcia O’Malley, robotics is also making inroads in new areas. For example, robots are capable of guiding cameras in colonoscopies and endoscopies, implanting electrodes in the brain, performing microsurgeries inside the eye and providing rehabilitation therapy for stroke patients.
“Capsule robots no larger than a pill are now helping diagnose gut diseases and semi-autonomous robots already routinely perform preprogrammed tasks, including taking X-rays,” says O’Malley.
“Improved sensing and control schemes allow rehabilitation robots to detect how stroke patients intend to move their arms and wrists,” she adds. “Using that information, the robots can help direct the patient’s movement, offering the right amount of assistance in every repetition of a therapy session.”
What is Robotic Surgery?
The term robotic surgery often conjures up images of robots in the OR performing surgeries, but this isn’t the case. Surgeons still do the procedures, but they use robotic arms to control miniaturized instruments that are inserted into tiny incisions like with other minimally invasive techniques.
Erin Keeney, MSN, RN, CNOR, director of perioperative services at Anmed Health, defines robotic surgery as “minimally invasive surgery where the surgeon has 3DHD vision of the surgical field. It uses wristed instruments that mimic the natural movement of the hand without manipulating the trocar site.”
“Robotic-assisted surgery is a technological advancement in surgery that merges insights, execution and performance,” adds David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC. “This gives surgeons a less invasive option to open or other minimally invasive types of surgery.”
According to Taylor, robotic surgery combines the benefits of laparoscopic and open techniques by using a minimally invasive approach along with the supplementary benefit of a three-dimensional, magnified image. “It also offers surgeons improved ergonomics and dexterity compared to traditional laparoscopy,” he adds.
Wright points out that not all robotic systems are used for what have historically been thought of as a minimally invasive approach – or in other words, surgery through small incisions.
“Some procedures, like total joints, still require larger incisions for exposure,” Wright says. “But the use of the robot allows surgeons to be more accurate with their cuts and remove the minimal amount of bone or tissue needed for an implant or joint prosthesis to fit just right, with minimal disruption to surrounding tissue.”
RALP and the SMART Technique
David B. Samadi, MD, the director of urologic oncology at St. Francis Hospital in Long Island, N.Y., was one of the pioneers in performing robotic-assisted laparoscopic prostatectomy (or RALP) in the U.S. 20 years ago. Since then, he has performed more than 9,000 of these procedures.
Samadi has devised his own custom RALP: the Samadi Modified Advanced Robotic Technique, or SMART. Using this technique, he has achieved a 90 percent patient satisfaction rate with prostate cancer treatment decisions more than a year after surgery.
In addition, 96 percent of Samadi’s patients regain urinary control within two to three months of surgery and 85 percent regain sexual potency within 12 to 24 months of surgery.
“If the surgeon is experienced in robotics, there is no longer any reason not to perform the surgery robotically,” says Samadi. “I believe that the era of open prostate surgery has ended.”
Gazdick says the staff at Hackensack University Medical Center has trained staff to do robotic surgery 24/7. “This was a massive undertaking when it comes to the cost of training and the schedule demands,” he says. “However, it allows for more flexibility when scheduling cases.”
University Medical Center started off with just a couple of robots five years ago but has six robots today. “The volume of the service has grown exponentially and is a driver to the general surgery and urology volume of the organization,” says Gazdick.
“With the advent of particular robotic programs like the Intuitive Iris system and the Zimmer Biomet systems, we are able to overlay or conform the surgery to the actual patient,” Gazdick adds. “This allows for better outcomes and surgeries that are specific to each patient’s condition.”
The surgeons at Anmed Health have embraced robotic surgical technology with ease, says Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president, perioperative services at Anmed Health.
“The robotic arm has a high degree of dexterity, which allows surgeons to operate in very tight spaces in the body that would otherwise only be accessible with an open surgery,” says Dennis.
“Robotic technology also gives surgeons a better vision of the surgical field, which allows them to access areas within the surgical field that were inaccessible previously,” adds Keeney. “And surgeons aren’t as fatigued.”
Benefits of Robotic Surgery
Using robotic-assisted surgery can result in a host of benefits for patients and OR personnel. Patient benefits include:
- Shorter surgery times and hospital stays
- Reduced pain and discomfort
- Faster removal of catheter (as soon as one week after prostate surgery)
- Higher rates of regained urinary control and sexual potency after prostate surgery
- More comfortable and faster recovery time and return to normal activities
- Smaller incisions, resulting in reduced risk of infection and faster healing
- Reduced blood loss and need for transfusions
- Minimal incision, scarring and trauma
“Robotic surgery is better for patients because it decreases length of stay and post-op pain,” says Keeney. “Now we can do procedures as outpatient that would normally require an overnight stay.”
Meanwhile, the benefits of robotic-assisted surgery to surgeons and perioperative nurses include:
- Improved surgical visualization and interoperative imaging
- Greater precision and accuracy
- Enhanced dexterity with tremor reduction
- Improved ergonomics
- Fewer surgical complications
Using smoke evacuation technology during robotic surgery also improves visualization of anatomic structures, says Wright.
“This benefits everyone in the OR by reducing the risk of disease transmission and exposure to the harmful chemicals found in surgical smoke,” she says.
According to Wright, robotic surgical systems vary in the amount of control the surgeon has during the procedure. “At one end of the spectrum, the robot may be used for preoperative surgical planning or to provide intraoperative navigational guidance while the surgeon operates,” she says.
“And some robots are designed to hold items like retractors or cutting guides during the procedure,” Wright adds. “These items may be manipulated by the surgeon or programmed to follow a pre-specified plan.”
At the opposite end of the spectrum are autonomous robots. “With these, the surgeon supervises the execution of an operative plan that is carried out by the robot,” Wright explains.
Challenges and Keys to Success
Not surprisingly, surgeons and perioperative nurses usually face challenges when adopting robotic surgery for the first time.
“New staff and surgeons obviously take more time to do a case,” says Gazdick. “This can lead to time overages that impact the schedule or make robotics less useful in comparison to standard laparoscopic surgery.”
Patient positioning is another challenge. “Proper positioning and docking of the robot is definitely an issue because of the different types of procedures and sizes of the patients,” says Dennis.
Wright also points to communication and teamwork challenges among staff with robotic-assisted surgery.
“Reliance on verbal communication is essential in robotic surgery,” she says. “This is especially the case with tele-surgical robotic systems where the surgeon works at some distance away from the perioperative team and loses the ability to participate in the nonverbal aspect of communication.”
Distractions and failures in communication have been identified in the literature as contributing factors to medical errors and adverse events, says Wright.
“The AORN Guidelines for a Safe Environment of Care and Team Communication offer recommendations that address barriers to effective communication. These include specific strategies to reduce distractions, noise and interruptions,” says Wright.
Another potential challenge to OR staff that are new to robotics is skepticism about how robotic surgery will be beneficial to patients, clinicians and the organization.
“They may feel unsure of the impact that robotic surgery will have on their workflow and how they care for patients,” says Wright. “Leaders can support staff through this by listening to their concerns and communicating the vision for the robotic surgery program, as well as the benefits the program will bring to the patient community.”
Of course, cost is also an issue with robotic-assisted surgical systems. “The only negative for us would be the cost of the unit,” says Keeney.
“Cost seems to be the major obstacle with the system, and volume increase has not yet made a difference in the delta,” adds Dennis.
Taylor believes the success of a robotic-assisted surgical system lies with the investment in a collaborative approach that the organization commits to it.
“Not just the initial cost of purchasing a robotic system or its annual costs, but the commitment of a team centered around the system and the surgeons who will use it,” says Taylor. “This includes training and education, mentorship and support.”
Gazdick agrees.
“Collaboration and transparency are the keys to success,” he says. “It’s best for everyone to speak openly and honestly and emphasize the good of the program overall versus individual program needs.”
“From a perioperative nursing perspective, success in robotic surgery means keeping patients safe during these procedures,” says Wright. “The perioperative nurse’s role in this ranges from providing direct patient care in the OR to having a seat at the table in the boardroom where decisions regarding robotic programs are being made.”
Positioned for Growth
Taylor believes that the robotic surgical market is positioned to grow even faster in the coming years.
“Intuitive Surgical’s da Vinci system has been the dominant robotic platform for years in general surgery, but new entrants to the market like TransEnterix’s Senhance system are nibbling at their market share,” says Taylor. “The future is limitless as companies leverage advances in the technology to include those related to bionics, disease discovery and rehabilitation.”
While exciting, Samadi reminds that robotics ultimately are just a tool.
“It’s a piece of equipment,” he says. “But in the hands of a skilled and experienced surgeon, robotics can result in extremely high levels of patient satisfaction.”
