Perspective on robotic surgery and its role in head and neck cancers

摘要

Robotic surgery has already made its mark in other surgical specialities such as cardiology, gynecology, and urology.[12] In head and neck surgery also a promising role awaits. Already immense potential is displayed by the ongoing current clinical experiments across the world. It offers all the benefits of minimally invasive surgery such as small incisions, minimal tissue damage, less blood loss and eventually short hospital stay with minimal procedure-related morbidity. Lasers which are currently the preferred and affordable tools are not without shortcomings. The problem of line of sight, long rigid manipulators, limited view of soft tissue, haptic information deficiency, no distal dexterity and four degree of freedom motion are constraints in their routine use.[3] The robotic assistance overcomes several of these limitations with a promise of wider application. Robotic surgery can be considered akin to renaissance in history of head and neck oncologic surgery. The concept of tele-surgery, as put forward by National Aeronautics and Space Administration (NASA) in 1970 for the treatment of orbiting scientists, was later advanced by Defence Advanced Research Projects Administration (DARPA) to perform live surgeries on wounded soldiers.[4] Since then, three main operating robotic systems, da Vinci system by Intuitive Surgicals, Computer Motion system by Aescop and the Zeus Robotic System, are available for clinical use [Figure 1]. The da vinci surgical system is utilized for almost all surgical procedures in the head and neck region. The surgeon sits at the console where he receives three-dimensional view of the surgery through two angled endoscopes inserted usually transorally for laryngeal, tongue of base, skull of surgery.[567] The two other arms of the robot are used for holding the instruments and performing the surgery. It is the master slave kind of adaptation that allows the surgeon to carry out his modus operandi with precision and better hemostasis.Figure 1: Complete da vinci surgical system with (A) surgeon's console; (B) a patient-side robotic cart with robotic arms; (C) high-definition 3D vision systemFrom the patient's perspective, improved surgical efficacy and reduced surgical tissue trauma are assured. The functional outcomes in terms of airway maintenance by tracheostomy are less required and more than 80% of the patient can take oral feeds by two weeks of the surgery.[8] Blood loss is less as compared to the classical head and neck surgery, thus eliminating the need of blood transfusions. The hospital stay is reduced despite extensive procedure, thereby minimizing the disruption of the patient's life and lives of their family members. The enticement to the surgeon is tremor free surgery, easy access to difficult areas and confined spaces, the operating chair where the surgeon can comfortably sit and operate in dexterous and intuitive manner. Not only this, current experiments to design a curriculum for integration of training program in robotic surgery by J.J Moles et al. already indicate that only less time is required to learn the basics of robotic surgical manoeuvres.[9] Endolaryngeal suturing can also be performed with ease using robotic technques. Besides transoral resection of various oral, oropharyngeal, laryngeal lesions, other novel approaches to excise skull base tumors, to perform thryoidectomy, and neck dissections are also being developed.[1011121314] These current experiments and clinical applications indicate that in the near future, a valuable and effective tool will be at the disposal of head and neck surgeon. But given its current form in terms of the size and the dimensions of current robotic systems along with the initial installation cost and high maintenance cost, its future adoption will take some time. The safety issues also pose an impediment since its FDA clearance is still awaited. Further improvements such as modulating the size, addition of sensors, image guided navigational system