HumanReproductionvol.13no.10pp.2748–2750,1998Oneyearofexperienceworkingwiththeaidofaroboticassistant(thevoice-controlledopticholderAESOP*)ingynaecologicalendoscopicsurgeryL.Mettler1,M.IbrahimandW.JonatDepartmentofObstetrics&Gynaecology,UniversityofKiel,Michaelisstr.16,24105Kiel,Germany1TowhomcorrespondenceshouldbeaddressedTheaimofthestudywasacomparisonofroboticversushumanlaparoscopiccameracontrol.Utilizingrobotictech-nologyarobothasbeendesignedspecificallyforthepurposeofholdingandmanoeuvringthelaparoscopeunderthedirectcontrolofthesurgeon.WetestedAESOP(auto-matedendoscopicsystemforoptimalpositioning)in50patientsundergoingroutinegynaecologicalendoscopicsur-gicalprocedures.Theeliminationofthecameraholderallowstwodoctorstoperformcomplexlaparoscopicsur-geryfasterthanwithouttheroboticarm.Thetimingofsurgicalproceduresperformedbysurgeonsusingthevoicecontrolwascomparedtothetimingofsimilaroperationsusingthefootorhandcontrol.Thevoice-controlledAESOPworksmoreefficientlyandfasterthanthehandorfootcontrol.Keywords:gynaecologicalendoscopicsurgery/roboticassistanceIntroductionOverthelasttwodecadesminimallyinvasivesurgeryhasbecomeincreasinglypopularandhasbeendemandedbybothsurgeonsandpatients.Itsbenefitsliepredominantlyinreducingpainandprovidingamorerapidrecoveryforpatientscomparedtotraditionalsurgery.Todaymanyadvancedtechniquesarebeingperformedingynaecology,urology,cardiacsurgery,brainsurgeryandorthopaedicsurgeryaswellasingeneralsurgery.Tocontrolthesurgeon’svisualfielditiseithernecessaryforthesurgeontoholdthelaparoscopeandcameraattachmentorrelyonassistance.Atpresentandintheimminentfutureimprovementsinefficiencyandsafetyinminimallyinvasivesurgerywillincludethedisciplinesofrobotics,computerassistance,3-Dopticsandmechanics.Thebenefitsofsophisticatedtechnologieswillbemeasuredbyfactorssuchasshortenedoperatingtimes,improvedoutcomes,lessermorbidity,diminisheduseofpersonnelandeliminationofotherinstrumentation.UtilizingrobotictechnologyofferedbyacompanyinGoleta,CA,USA,calledComputerMotion,arobothasbeendesignedforendoscopicsurgeonsspecificallyforthepurposeofholdingandmanoeuvringthelaparoscope*Automatedendoscopicsystemforoptimalpositioning2748underthedirectcontrolofthesurgeon.AESOP(automatedendoscopicsystemforoptimalpositioning)hasbeentestedinavarietyoflaparoscopicproceduresandhasalreadyperformedatleastaswellas,ifnotbetterthan,ahumanassistantintermsofcameraholdingwithlesserroneouscameramotionandaccidentalcontactsoftheendoscopiclenswithinternalorgans.Roboticcontrolofthelaparoscopiccamerascopeandvisualfieldhasimprovedefficiencyandshortenedoperativeproceduresinminimallyinvasivesurgery.Aboutayearagovoicecontroloftheroboticarmbecameclinicallyavailableandhasbeenusedsuccessfully.AESOPoffersthepossibilityofhandcontrol,footcontrolandvoicecontrol.Itwastheaimofthepresentstudytocomparevoiceversusfootcontrolinso-calledsolosurgeryusingtheAESOP.MaterialsandmethodsAESOP(ComputerMotionInc.)holdsandmovesthelaparoscopeduringsurgery(Harding,1994;Kavoussietal.,1995;Garcia,1996;Geisetal.,1996).Thesurgeoncandirectthearticulatedmetalarmbymeansofafootpedalorhandcontrolorbyusingthevoicecontrol.Inaddition,laparoscopicviewscanbekeyedinforreturnvisitsbyusingthememoryfeaturewhichisavailableforthreepositions.Withsmoothmovementsoffootorhandthesurgeoncansmoothlyshiftthelaparoscopeinanydirection–left,right,up,down,forwardorbackward.Thepressureappliedbythesurgeoncontrolsthespeed.Atalltimestheverticalandhorizontalorientationismaintained.Itcertainlyeliminatesunwantedmovementsofthelaparoscopecausedbytheassistant’sheartbeat,breathingorsuddensneezes.AESOPiscontrolledbycomputerwitharead-onlymemorysoftware.Withtheroboticarmasanassistant,laparoscopicprocedurescanbeperformedbyasolosurgeonincludinghysterectomy,adnex-ectomy,ovariancystenucleation,ectopicpregnancytreatment,omenectomyandothertypesofsurgery.EventelesurgerycanbeperformedcontrollinganAESOPcomputerlinkedtoatelephoneline.Tele-roboticsurgerywithAESOPwaspioneeredintheUSAbyDrLouisKavoussi,DirectoroftheBradyInstituteofUrologyattheJohnsHopkinsUniversitySchoolofMedicineandalsoperformedinEuropebytheurologistProfessorJanetschekinInnsbruck.Figure1givesapictureoftheAESOPcontrolarmhookedtoaspecialstoragecarriagewithwhichitcanbeeasilyadaptedtotheoperatingtable.Avoice-controlcardfortheindividualsurgeonhastobeestablishedandinsertedatthebeginningoftheprocedure.Figure2showstheAESOPcontrolarmattachedtotheoperatingtableduringanendoscopicgynaecologicalprocedureattheDepartmentofObstetricsandGynaecology,UniversityofKiel,Germany.Italsodemonstratestheuseofthevoice-activatedheadsetusedbythesurgeon.Voicecontrolfollowsaccordingtothefollowingprinciples:(i)thesurgeoncarriesasmallvoicereceiveraroundthehead;(ii)AESOPrespondstoshortcommands,suchas:AESOPmovein;moveout;moveback;movedown;moveup;moveright;moveleft;left;right;©EuropeanSocietyforHumanReproductionandEmbryologyRoboticassistanceingynaecologicalendoscopicsurgeryup;down;back;in;save1;save2;save3;return1;return2;return3andquit.Duringtheprocedurethecomputeralsogivescommands,suchaspressmanualmodebutton.Nonoiseintheoperatingtheatredistractsthedirectvoicecontrolofthesurgeon.PatientsAsthecontrolarmoftheAESOPisusedasacameraholderonly,nopatientconsentforthisroboticdevicehadtobeobtained.Twentyfivepatientsweretreatedingynaecologicalproceduresusingthefootandhandcontroland25patientsusingthevoicecontrol.ResultsNomishapsoccurredinanyofthesurgicalprocedures.ThenumberofpersonnelrequiredduringlaparoscopicsurgeryFigure1.AESOP2000–anacronymforautomatedendoscopicsystemforoptimalpositioningasavoice-controlledroboticassistantforendoscopicsurgeryinitsmobilecarriage.usingtheroboticarmattachedtotheoperatingtabledroppedfromthreetotwo.Thevisualfieldwasfoundtoberocksteady.Inourexperiencethefootandhandcontrolfavouredinteractionsbythefirstassistantandthevoicecontrolofthevisualfieldwasbestdirectedbytheoperatingsurgeon.Voicecontrolincreasedthesurgeon’sconcentrationandprovedtobeclearlysuperiortofootorhandcontroloftheroboticarm.TableIcomparesthelengthoftheoperatingtimesofthoseproceduresperformedbyfoot/handcontrol,byvoicecontrolandwithanassistantcameraholder.Theeliminationofthecameraholderallowstwogynaecolo-gistsoronegynaecologistandanursetoperformcomplexlaparoscopicgynaecologicalsurgicalprocedures,suchasovariancystenucleation,myomectomiesandhysterectomiesusingtheclassicintrafascialsupracervicalhysterectomytech-nique(Semm,1991).Incaseswiththreeadditionalports,inadditiontotheoptictrocar,theassistantcanhelpwithathirdarmaddingtothesurgeon’stwoarmsinaction.InKielanursealwaysassistsinallsurgicalprocedures.Theuseoftheroboticarmtoholdthelaparoscopeandcameraalongwithitsabilitytoprovideanabsolutelysteadyvisualfieldincreasestheconcentrationandefficiencyofthesurgeon.Astheapplica-tionofthehandpiecelimitsthesurgeontousingtwoarmsforthelaparoscopicprocedure,footcontrolseemspreferable;however,inourexperiencethisproceduretakeslongeraswehadfirsttocontrolthefootpiecebyeyeastheeye/footco-ordinationwasnotalwaysoptimal.Therobotwiththevoicecontrolenablesustoasktheroboticarmtomoveup;down;left;right;in;out;tosaveone,twoandthreepicturesandreturntothesepictures.Itallowsasaferandmoresecuremovementofthescope.DataspecifiedinTableIdemonstratethedecreaseintheoperatingtimeoftheprocedure.Certainlylessfoggingandsmudgingofthescopelenswasobserved.Asaresulttherequirementtocleantheopticinheatedwater(50°C)duringtheprocedurewasseldomgiven.Inthesolosurgerymodelthesurgeonperformedbothsimpleandcomplextasksmorerapidlyandwithouterrorusingvoicecontroloftheroboticarm(andvisualfield)whencomparedFigure2.PositionofsurgeonsusingAESOP2000ascameraholderduringahysterectomyattheDepartmentofObstetricsandGynaecology,UniversityofKiel,Germany.2749L.Mettler,M.IbrahimandW.JonatTableI.Roboticarmusedin50gynaecologicalendoscopicsurgicalprocedures,acomparisonbetweenfoot/handandvoicecontrolandgynaecologicalendoscopicsurgerywithanassistantcameraholder.Timesareroundeduptothenearest5minandcomprisethewholepreoperativepreparationtimeaftertheanaesthetizedpatienthasbeenrolledintotheoperationtheatre,includingthetimetakentofixandsetuptherobotictool.SurgicalprocedureNumberofcasesLengthofoperationtime(min)withoutroboticarmLengthofoperationtime(min)withroboticarmhand/footOvariancystenucleationMyomectomyHysterectomy29174957060705050voice604040tofootcontrolorhandcontrolofthevisualfield.Thestudiesdemonstratedclearlytrendsinfavourofvoicecontrolofthevisualfieldbothinourhumanandpreviousporcineexperiencesduringlaparoscopicsurgery.DiscussionIndustrialrobotshavedisplacedworkersinmanyfields.Willsurgeonsbesidelinedasroboticdevicesadvanceinoperativecapabilities?Wethinknot.AESOP,forexample,isasophistic-atedtooltoassistthesurgeoninmovingtheoptic.Innowaydoesitreplacethesurgeon.Itsupportsthesurgeonindoinghisbestandenableshimtogiveamorepowerfulapproachthanwaspossibleinthepast.Technologyisdevelopingandweasdoctorsneedtobepartofit.Weneedtoidentifytheappropriateuseofnewtechnologiesinourfieldofmedicine.Patients’outcomesdoofcoursetakefirstplace.Usingthesolosurgerymodelthesurgeoncanperformbothsimpleandcomplexproceduresasdescribedheremorerapidlyandwithouterrorusingvoicecontroloftheroboticarm(andvisualfield)whencomparedtofootcontrolandhandcontrol.Ourstudiesdemonstratedtrendsinfavourofvoicecontrolofvisualfieldbothinhumanandinourpreviousporcineexperiencesduringlaparoscopichysterectomy,ovariancystresectionandmyomectomy.Itisdefinitelytheconclusionofourworkinggroupthatatthepresenttimethefixationoftherobotictooltotheoperatingtabletakessometimeandthewholeprocedurerequiresmoreconcentrationfromthesurgeon;however,thepossibilityofworkingmoresteadilyinaconfinedfieldisgreatlyappreciated.Atthepresenttimethelimitationsofthedeviceareseeninthecaseofadhesionswheremovementsoftheroboticarmoverlargerdistancesarerequired.Insuchcasestheroboticarmtakeslongertorespondtothevoicecontrolthanperformancebyhand.Aroboticassistantisseentobeacost-effectivedevice,takingtheplaceofthetraditionalassistantifsowishedbythesurgeon.Thistypeofsurgeryisbestappliedinsmallerclinicswherefewerpersonnelareavailable.Inlargeruniversityhospitalswhere,foreducationalreasons,morepersonnelareavailable,thesetechniquesare,however,usedtosupportthetechnologicaldevelopment.ThecostofAESOP2000,describedhere,andthenewerversionAESOP3000,whichhasmorejointsandiseasiertomove,amountstoUS$60000.Thisiswellwithinthepricerangeofothertools,suchaslasers,alsousedinendoscopic2750surgicalprocedures.InthelongrunthecostbenefitisindeedmorefavourableasAESOPreducesthenumberofpersonnelrequiredintheoperatingtheatreandcanbeusedforsolosurgery.Withregardtoteachingpossibilities,AESOPincreasestheinputofanassistantwhocanbeveryhelpfulusingthismoderntechnology.Forexample,bymovingthecamerawiththehandorfootcontroltheassistantcanhelpduringtheproceduretobringinormoveawaythecamerawhilethesurgeonisperformingasuture.Teachingpossibilitiesareincreased.AESOPcanbeeffectivelyusedinteleroboticsurgerywheresurgeonsworkingatdifferentplacescancommunicatebyvoiceoverthevideoscreen.Inconclusion,inthelongrunaroboticassistantisseentobeacosteffectivedevicereplacingthetraditionalassistantandprovidingthesurgeonwithamorestableoperatingfield.ReferencesGarcia,C.(1996)Clinicalutilityofaroboticassistantduringlaparoscopiccholecystectomy.8thAnnualInternationalConferenceoftheSocietyforMinimalInvasiveTherapy,Como,Italy,Sept.16–20.Geis,P.,McAfee,P.,Kim,C.andBrennan,E.(1996)Roboticarmenhancementtoaccommodateimprovedefficiencyanddecreasedresourceutilizationincomplexminimallyinvasivesurgicalprocedures.IVthInternationalSymposium,MedicineMeetsVirtualReality,SanDiego,USA,Jan.17–20.Harding,R.(1994)Gearingupforanewerainsurgery:roboticassistance.Same-DaySurgery,18,86.Kavoussi,L.,Moore,R.,Adams,J.andPartin,A.(1995)Comparisonofroboticversushumanlaparoscopiccameracontrol.J.Urol.,154,2134.ReceivedonJanuary5,1998;acceptedonJuly21,1998
