Three-dimensional robotic surgery useful in ocular microsurgery

Bimanual, three-dimensional robotic surgery seems to be technically feasible for performing ocular microsurgery when used in pig eyes, and may be a boon for surgeons in geographically remote areas that lack access to state-of-the-art technology.

Key Points

Los Angeles-Bimanual, three-dimensional robotic surgery using commercially available technology (da Vinci Surgical System, Intuitive Surgical) seems to be technically feasible for performing ocular microsurgery when used in pig eyes. The procedure may be a boon for surgeons in geographically remote areas that lack access to state-of-the- art technology, according to Angelo Tsirbas, MD, assistant professor, Department of Ophthalmology, Jules Stein Eye Institute (JSEI), Los Angeles.

Ophthalmic surgeons have joined the growing list of specialists who are turning to the robotic assistant to access tight places. Cardiac surgeons, general surgeons, urologists, thoracic surgeons, and nose and throat specialists already have used the technology.

"The arm ports for the 8-mm robotic instrumentation were placed on either side of the globe at about 45° angles from the axis created by the midline position of the endoscope. The surgeon was seated at the surgical console, about 15 feet from the surgical table and the robotic cart," Dr. Tsirbas explained. "The surgeon viewed the operative field via a three-dimensional image while his hands held the master controls at a comfortable distance below the display. Each slave arm was equipped with sterile black diamond microforceps. The forceps held the 10-0 microfilament nylon, and the contralateral arm was used to manipulate the robotic Debakey forceps."

Three participating surgeons

Three surgeons participated in the surgery. Dr. Dutson was the only one experienced with the robotic instrumentation and had no experience with ocular surgery. Drs. Tsirbas and Mango are ophthalmologists who had no experience with robotic surgery. Each of the surgeons placed three separate interrupted sutures in one of the porcine eyes while the time to place the sutures was measured. The two ophthalmologists then placed three sutures each in the corneal lacerations of the two other eyes under an operating microscope, and the time needed to complete these procedures was recorded.

The investigators reported that the time required for the robotic surgery was substantially lengthier than that for the procedure done under an operating microscope. The durations for robotic surgery were 465, 655, and 750 seconds, compared with 183 and 190 seconds. "The average robotic surgical time for the placement of each 10-0 suture was 207 seconds versus 62 seconds with conventional microsurgery," they said.

Drs. Tsirbas and Dutson expected that with mastery of the learning curve the time required for suture placement would decrease. Many of the issues encountered by the two surgeons not experienced in robotic surgery were related to hardware.

The ability to visualize the surgical field using the robotic system was considered excellent; all landmarks were clearly visible.

Dr. Dutson, who had experience with robotic surgery, pointed out that the "ultrafine scaling used on the robot provided a different feel to the surgery from the standard scaling used for intra-abdominal surgery." He said he also believed that the finer surgical instrumentation improved the control during placement of sutures.