To fully understand the contributions of soft-tissue robotic surgery it is critical to first grasp the concept of minimal access surgery.
We must go back to Hippocrates, to the very basic ethical principles of Medicine. Primum non nocere. First, do no harm. It is the maxim of medical practice.
It is also relevant to recall that historically medicine was first, and it took a very long time (variable in different parts of the world) for surgery to develop (with not very honourable beginnings). Surgery is the most invasive aspect of medical practice. Surgery invariably entails inflicting harm, a means to reach a curative end that collaterally harms healthy tissues along the way. The ethical quandary this poses is evident, seemingly at odds with the foundational tenets of medicine. While harm can also arise (as is does) in non-surgical medical contexts, surgery starkly exposes this tension. Admittedly, the aim of the procedure is not causing harm, but achieving a beneficial outcome for the patient. But the greater the unavoidable harm involved, the greater must be the justification to perform the procedure and the control over the outcomes.
Surgical practice pivots on techniques designed to attain specific objectives. The evolution of these techniques hinges on accumulated knowledge, technical feasibility, and visionary contributions from pioneers. Contemporary advancements stem from scientific and medical methodologies, underpinned by global medical oversight. Modern surgical procedure development is characterized by meticulous attention to patient safety, especially when novel technologies are involved.
Throughout history, surgeons have strived to minimize incurred damage. Engaging in procedures that exacerbate a patient’s condition or opting for a more morbid approach when a less invasive alternative exists would be paradoxical. The pursuit of reduced morbidity has historically propelled surgical technique refinement.
The damage caused by a surgical procedure has two components. The necessary one is the one related to the disease to be treated. For example, if we are operating because of a malignancy and we must extirpate an organ or part of an organ, this tissue will be gone and its absence might have consequences. If we perform a total laryngectomy for a T4a laryngeal cancer (which is the best option for the patient and the one that will provide the best survival chances), there will be a permanent tracheostomy.
The other part of the damage is caused by the approach. The approach is another pivotal concept in surgery. Frequently it is the approach which defines a surgical technique. The approach is the route we follow to reach the target. The damage associated with the approach is extremely variable depending on many factors like the disease to be treated, the anatomic location, the surgical technique, but also patient´s features and even surgeon´s expertise. The approach has several requirements. It should be feasible for the desired objective and the associated damage should be acceptable. Typically, part of the surgical damage is partly reversible. For example, we might make a cut in the skin and dissect the underlying tissue to reach a target, and then close the incision layer by layer. In some cases, the scar will be the only sequelae.
But the technique should also be reproducible. This concept applied to surgery might appear surprising. Reproducibility depends on several factors, but mainly on the technical difficulty. Technical complexity is managed with training. Every surgical technique has an associated learning curve. The learning curve for a given technique might be characterized to allow for extrapolations, but ultimately it is personal for every surgeon. It depends on the previous experience, the specific training and personal dexterity. For several reasons, high complexity surgical techniques might not be attainable by every surgeon.
In surgical design, certain absolutes prevail—namely, avoiding damage to vital structures and preventing intolerable sequelae. An intricate risk-benefit equilibrium underscores decision-making, guided by functional and aesthetic considerations.
The most obvious cosmetic sequelae are the scars. Incisions are designed to leave the best possible scar from a cosmetic point of view. The typical strategy is the use of skin creases, but there are many others like transition areas between cosmetic subunits, areas covered by hair, the use of mucosal incisions… Again, they are limited by other factors, like an appropriate exposure of the target, viability (blood supply) of the skin flaps… Although the scar is the most obvious (visible) concern, there are in every situation other considerations in the deep tissues or organs.
The concept of minimal access surgery is quite straightforward: minimize the damage associated with surgical approaches. While this ethos is inherently shared by all surgeons, it has evolved into a central theme in the design of contemporary techniques. Furthermore, its realization hinges on disruptive technologies, ushering minimal access surgery into a position of prominence.
Minimal access starts outside the human body. The challenge is how to reach the target with minimal damage. There are two different ways to perform minimal access surgery. The most intuitive one is to use natural orifices. Trans-oral, trans-nasal, trans-vaginal, trans-anal surgery… developed this way. But some targets need to be approached through the skin. So, minimal incisions (or punctures) are designed. The main reason is not to leave a minimal scar, but to make a minimal disruption of deep tissues. Secondarily a more favourable scar will result. Usually, the minimal access requires the aid of technology so the surgeon can see and manipulate. So, instruments to view inside are needed. They are named endoscopes. Instruments to manipulate the tissue from the outside are in constant evolution and improvement.
Recent years have witnessed rapid technological advancement. In the dawn of the 21st century robotic surgery came into the scene, constituting the apogee of sophistication in minimal access surgery. Presently, a surgeon can sit at a console outside the scrub area, and have a real sensation of immersion in the surgical field. This is not virtual surgery but augmented reality surgery. The surgeon is inside the patient having a close look at the surgical field. A 3D high definition view that offers possibilities beyond the human vision. And with tailored instruments, including those with advanced energies, that faithfully follow the movements of the surgeon´s hands, but also do have capacities beyond the human hand. The computerized environment provides every required additional information to take the most accurate surgical decisions.
This is robotic surgery, and a world of possibilities lies ahead.
J Granell. August, 2023.