During our consultations, many of my patients describe having “searched the web” for information about their specific problem. While they find a wealth of information on the diagnosis (some say “too much”), they often comment that it is difficult to determine why some surgeries are done “open”, others laparoscopically, and still others laparoscopically with the da Vinci® robot. I’ve therefore written the explanation below which distinguishes these three surgical approaches for abdominal procedures. It’s worth noting, however, that while a laparoscopic or robotic technique certainly offers great benefit to the patient who needs abdominal surgery, there are still many general surgery procedures where the traditional “open” surgical approach remains the best (examples include skin lesions, thyroid surgery, breast surgery, hemorrhoidectomy and even a few selected abdominal procedures).

Robotic, Laparoscopic, and Open Surgery
How Do They Differ in Abdominal Operations?
Explanation written by Barry N. Gardiner, M.D.

Over the years, there have been a handful of pivotal events that have truly brought about fundamental change in the way surgery is performed: the discovery of anesthesia by Clarke in 1846; the introduction of sterile technique by Semmelweis, Pastuer, and ultimately Lister in 1867; the development of the heart lung machine by Gibbon in 1931. These are just a few high profile examples of discoveries that have made modern day surgery possible. Conventional laparoscopic surgery and robotic laparoscopic surgery are two more recent developments that have profoundly influenced the way many abdominal operations are done, but to understand their importance, they must be contrasted with traditional “open” surgery.

Traditional (“Open”) Abdominal Surgery

“Open” abdominal surgery (fig. 1) is accomplished by making an incision through the abdominal wall that is large enough to provide the surgeon
Figure 1
Figure 1
with: a direct three dimensional view of the operative site (because we normally view the world in 3-D), the ability to feel the structures being operated on, and unrestricted access to the patient’s anatomy so the surgeon can use his/her wrists (very important) to accurately position and use a wide array of surgical instruments inside the patient. As a result, the open approach to surgery offers the surgeon the ability to perform a wide variety of complex and challenging maneuvers, and prior to 1989 was essentially the only surgical approach available for performing abdominal operations.

However, patients “pay a price” for these large abdominal incisions. The majority of pain that is experienced from an abdominal operation does not actually come from what is done to the diseased structure inside the patient (whether that is the gallbladder, the colon, etc), but from the incision the surgeon makes through the layers of tissues and muscles of the abdominal wall to reach the diseased structure. In general, the longer the incision and the more muscle tissue that is disrupted, the more postoperative pain the patient experiences and the longer it takes to recover. In addition, any incision heals with a scar. The visible scar on the outside has only cosmetic implications, but that same scarring also occurs inside the abdomen, producing what are commonly called adhesions. These adhesions can allow the intestines to twist, producing a bowel obstruction. Adhesions also increase the technical difficulty involved in performing any future abdominal operation should one be required for a different disease process. Minimizing these problems whenever possible had therefore long been a goal, not attained until the advent of video laparoscopic surgery.

Conventional Laparoscopic Surgery
(also known as Minimally Invasive Surgery)

In 1901 George Kelling was the first physician to actually look inside the abdomen without making a large incision. Known as laparoscopy, he viewed the abdomen through a simple hollow tube. (fig. 2)
Figure 2
Figure 2
Bernheim introduced this procedure to the United States in 1911, but visualization was so limited that virtually nothing of significance was done with this technique. Then, in 1951 Hopkins developed an optical telescope to replace Kelling’s simple hollow tube. (fig. 3) This telescope represented a major advance over Kelling’s simple tube. It was slightly less than half inch in diameter and could also be introduced
Figure 3
Figure 3
into the abdomen through a small puncture rather than through a large incision. However, visualization through it still remained very limited because under normal circumstances the entire abdominal cavity is filled with structures that all touch each other, leaving virtually no space inside the abdomen to visualize anything. Then in 1967 Semm invented a device (the automatic insufflator) that allowed the abdominal cavity to be filled with gas, creating visual space inside the abdomen by gently pushing structures away from each other (notice how the abdomen in figure 4 is “distended with gas”). With the abdomen insufflated,
Figure 4
Figure 4
Hopkins’ telescope (laparoscope) provided an unparalleled view of structures inside the abdomen. This telescope and Semm’s insufflator remain in use essentially unchanged to this day. However, this laparoscope was initially a one hand, one person device. (fig. 4) To perform direct vision laparoscopy, the surgeon had to hold the telescope with one hand leaving just one hand with which to operate. And since only one person at a time could view the operative site through this device, no one could actually assist the surgeon. Direct vision laparoscopy was therefore limited primarily to diagnostic use. Then in 1982 the high definition color video camera was miniaturized. In 1987 it was connected to the Hopkins’ laparoscope (fig. 5) and the modern age of
Figure 5
Figure 5
video-laparoscopy was born. This allowed a video image from inside the abdomen to be projected onto a television monitor in the operating room. (fig. 6) The surgeon could now operate standing upright instead of bending over the patient and just as importantly everyone in the operating room could see exactly what the surgeon could see. This enabled an assistant surgeon to pass instruments into the abdomen through additional small tubes (called “ports”) and participate in the operation. With this development, Mouret was able to complete the first laparoscopic cholecystectomy (removal of the gallbladder) in France in
Figure 6
Figure 6
1987.


Even so, it became immediately apparent that operating from a video image through small punctures in the abdominal wall instead of through the traditional large open incision presents its own challenges. The surgeon’s hands are now located outside of the patient (fig. 6 & fig. 7) more than a foot away from the operative site (so there is no longer the natural touch and feel of the tissue associated with open surgery); the video image is 2-dimensional (rather than our normal 3-dimensional vision); and the instruments need to be inserted through small
Figure 7
Figure 7
punctures to reach the disease structure, so they are long, rigid, and most significantly, they are “un-wristed” (fig. 8) All of these limitations severely restrict the surgeon’s access to the anatomy and make complex surgical maneuvers (such as suturing) more difficult to accomplish. Despite these significant drawbacks, a few of us started
Figure 8
Figure 8
utilizing this technique initially to remove the gallbladder because this operation required relatively uncomplicated surgical maneuvers. This approach changed a painful “open” operation to a much less invasive one with less postoperative pain, less scaring, and a much faster recovery. The benefit to the patient proved to be so obvious and so significant that patient demand for the laparoscopic cholecystectomy established it as the standard of care in this country within three short years. Very soon thereafter, appendectomies and inguinal hernia repairs were also being done routinely with the laparoscope. But as time passed, it became evident that the majority of general surgeons found applying the laparoscopic approach to the more complex or advanced procedures either too limiting or simply too difficult for them to master. Clearly additional innovation would be needed if a minimally invasive surgical approach to more complex procedures was to be used by the majority of surgeons, rather than just by the minority of us who had pioneered the laparoscopic surgical approach.

Robotic Laparoscopic Surgery
(this is also Minimally Invasive Surgery)

An approach was needed to restore to the surgeon the capabilities of open surgery while maintaining the patient benefits of laparoscopic surgery. To accomplish that, three problems needed to be solved:
Figure 9
Figure 9
This was accomplished in 1998 by Intuitive Surgical, Inc. with the development of a “robot” known as the da Vinci® Surgical System. I was asked by Dr. Fred Moll, the co-founder of Intuitive Surgical, to serve as the company’s primary clinical consultant and principal investigator during the design phase and development of this system. As a result I bring a unique perspective on what was involved in developing this device and why it took the form that it did.

Figure 10
Figure 10
We designed the da Vinci® System with three parts: a work station (or surgeon’s console), a patient side cart, and a computer connecting the two together. (fig. 9) The surgeon’s console (fig. 10) contains the computer, the “handles” for two laparoscopic instruments, a foot mechanism to control movements of the camera, and a magnified 3-dimensional image of the operative site projected over the surgeon’s hands. (fig. 11) The latter provides the surgeon with the most realistic representation possible of the patient’s anatomy. (left side of fig. 11)
Figure 11
Figure 11

The patient side cart contains four motor driven mechanical arms (fig. 12) holding the camera and the instruments that are actually introduced into the patient. Rather than the rigid, straight instruments used in conventional laparoscopy (fig. 13), da Vinci® instruments are fitted with articulated “wrist” joints at the point of use inside the
Figure 12
Figure 12
patient. (fig. 14) Even though this device has been termed a “robot”, it makes no movements on its own. Rather, the computer instantly translates movements made by the surgeon at the console into
Figure 13
Figure 13
precisely the same movements of the instruments inside the patient. Without this computer interface between the surgeon at the console and the patient side cart, control of the da Vinci® instruments with articulated wrists would be impossible. (fig. 14) The computer also measures the forces encountered by the tips of the instruments inside the patient and feeds those forces back to the surgeon’s hands at the console re-establishing the “feel” of actual surgery. The da Vinci Surgical System® provides the surgeon with unparalleled dexterity, precision, and control and restores nearly unrestricted freedom of movement of these articulated instruments inside the patient.

Figure 14
Figure 14
The creation of this robotic system thus removed most if not all of the physical limitations placed on the surgeon by conventional laparoscopic surgery. This has resulted in two very significant advances in surgical practice. In the hands of surgeons skilled in its use, it not only enables laparoscopic techniques to be used in more complex abdominal procedures (ones that typically have been done and many times are still being done with open surgery), but in some operations it allows us to actually improve upon traditional open surgical techniques as well.



Which Approach For Which Surgery?

Which one of these three surgical approaches is most appropriate for any given patient will depend on his/her specific circumstances. Fortunately, the vast majority of abdominal surgeries can now be accomplished with either a laparoscopic or robotic laparoscopic approach if the surgeon is experienced with and credentialed in using those approaches by his/her hospital.
[Note: a few centers are experimenting with robotic techniques for non-abdominal cavity operations on structures such as the thyroid and the breast. Trying to apply either robotic or videoscopic techniques to these procedures makes an otherwise very straight-forward operation highly complex, and in my opinion, does not currently provide added benefit to the patient.]

These are the approaches to specific conditions that I recommend most often in my surgical practice:
  • Cholecystectomy, appendectomy, inguinal hernia repair, and most colon resections are perfectly suited to conventional laparoscopic surgery. These procedures are relatively straight forward and in my experience are usually made more complicated by use of the robot. So, absent unusual or unforeseen circumstances, I do not ordinarily need to recommend either open surgery or the da Vinci® Surgical System for these procedures.

  • Robotic laparoscopic surgery is an excellent choice for the vast majority of remaining abdominal procedures, especially those that require much suturing. This includes most operations for GERD (gastroesophageal reflux disease), repair of hiatal hernias, and operations on the stomach, small intestine, lower part of the colon, and rectum. It also includes surgery on solid organs such as the spleen, body or tail of the pancreas, or removal of the adrenal glands. Perhaps most significantly, the da Vinci® system is particularly well suited for repairing hernias of the abdominal wall (either epigastric, umbilical or incisional hernia). Using the robot for repairing these specific hernias results in the best possible placement of the mesh, the lowest incidence of recurrence, and in general less postoperative pain.

  • There are some highly complex and very extensive procedures (such as major liver resections) that have been done with the da Vinci® Surgical System in very selected circumstances, but procedures of this magnitude are usually best accomplished with open surgery.

To summarize then, in my opinion most general surgical procedures within the abdominal cavity are best done either with a conventional laparoscopic or a robotic laparoscopic approach because of the obvious benefits afforded to the patient with these minimally invasive techniques. General surgery procedures for structures that are not in the abdominal cavity (such as procedures on the thyroid, breast, and skin) are generally not enhanced by utilizing a laparoscopic approach.