The most cited drawback of robotic surgery is the loss of fine feeling of the instruments on tissue.
The other drawbacks are the expense of the surgical system and the need for precise positioning of the robotic arms to provide for a full range of motion without repositioning the arms.
Haptics refers to the feedback of moving the robotic controls on the surgeon.
The current version of the da Vinci robotic surgical system does not have haptics Incorporated into the system. I admit it would be nice for the next version of the system to have haptics and enable the surgeon to feel the tension on sutures, as well as the tension of instruments on tissue.
The robotic radical prostatectomy procedure is a delicate urologic procedures that is a good one to use in discussing haptics.
In my opinion, the loss of feedback is not a major or significant drawback. Although I think it will make the robot easier to use and possibly a little safer, the 10 times magnification more than makes up for this shortfall. We have different senses that are used to some extent in surgery. The sense of sight allows us to see tension in tissue and sutures. As long as the instruments are kept in the field of view, the loss of fine sense of feel is not a problem for me.
There is a limited sense of feel with the da Vinci. When instruments have tension, eventually it will be felt in the instruments. When I am retracting the prostate with my left hand, I feel the tension when it gets to a certain level, granted not as soon as I would with me hands. When I lift on the vas and seminal vesicles with my 4th arm, I can feel the tension in the instrument. If my instruments are colliding with each other, or with the bony side wall, or with a laparoscopic instrument the instruments don’t move as smooth as usual.
To date I have performed 65 robotic operations and 49 prostate operations and have not had any complications related to lack of haptics. I haven’t had any vessel or bowel injuries.
I find the argument used by other surgeons amusing. When laparoscopy first was used, open surgeons would criticize that there was poor feel from the laparoscopic instruments. I agreed with this as well back then, but with care this was not a major issue. Now the laparoscopic surgeons with the straight instruments that are controlled at a distance with a fulcrum at the port site use the same argument that was used against them against robotics.
The open surgeons sometimes say that they need to use their hands to feel things that I cant even see well at 10 times magnification. I perform a fair amount of major open surgery and personally cant feel things that well through 2 sets of gloves.
Another endpoint could be the quality of nerve sparing or the margin status. My nerve sparing looks better and less traumatic with the robotic approach and my margin rate is improved with robotics as compared to open, which I discussed on a recent blog entry.
I do have my own questions regarding robotics for more delicate operations such as pyeloplasties in young children and will ask a friend and experienced robotic pediatric urologist, Dr. Jeffrey Stock, to comment on this if he would.
I will also attempt at suturing with very small needles the next time I get a chance to practice on the robot, which may be next week when we have a demo for local high school students.