FEATURED ARTICLE

Robot-assisted Neurosurgery

Indu Kapoor, MD, Associate Professor
Hemanshu Prabhakar, MD, PhD, Professor
Charu Mahajan, MD, DM, Associate Professor
Department of Neuroanesthesiology and Critical Care
All India Institute of Medical Science
New Delhi, India

Indu Kapoor, MD
Indu Kapoor, MD
Hemanshu Prabhakar, MD, PhD
Hemanshu Prabhakar, MD, PhD
Fan Wang, PhD
Charu Mahajan, MD, DM

During the last three decades, robots have been incorporated into various surgical fields due to their evolving versatility and stability in the operating room. Robots were introduced in the neurosurgical field to improve the quality of several operative procedures which require a higher degree of safety and accuracy. Another advantage of robot-assisted surgeries is more precise surgical incision, leading to less pain, which further leads to a shorter hospital stay.1 The brain is considered ideal for robotic application because it is symmetrically confined within the rigid cranial vault and is more prone to damage even with the slightest deviation of tools.2 Robots were first used in the neurosurgical operating room in 1985 for the purpose of holding and manipulating biopsy canulae. Kwoh and colleagues performed this first robot-assisted stereotactic biopsy using the Programmable Universal Machine for Assembly (PUMA) 560 industrial robot.3 In 1991, Drake and colleagues reported use of the same robot as a retraction device in the surgical management of thalamic astrocytoma.4 Neuromate was the first FDA-approved robot with integrated stereotactic systems and was commercially available in 1997. Another robot, ROSA (Robotized Surgical Assistant) is now popularly used in various neurosurgical procedures.5 It consists of a computer brain displaying images and a robotic arm which helps in placement of electrodes (Figure 1). ROSA has been used in minimally invasive neurosurgeries since 2007, which include lead placement for deep brain stimulatio7 depth electrode placement for seizure monitoring,8 ablation of epileptogenic foci9 and spinal pedicle screw fixation.10 Robots are capable of performing both craniofacial and spine surgeries. Minimally invasive spine surgeries are associated with poor visibility and increased exposure to radiation, leading to higher incidence of pedicle screw malpositioning. As per recent retrospective reviews, accuracy of pedicle screw placement between hand guided surgery and robot assisted surgery did not show a statistically significant difference.11 Also the length of procedure, postoperative length of stay and total blood loss did not differ between two groups. The results from this study cannot hold a strong conclusion from the results due to small sample size. Further large studies are required to comment on accuracy rate of robot assisted spine surgeries. The advantage of robotics in spine surgeries include elimination of neurosurgeon’s physiological tremor, decreased radiation exposure, guidance for insertion of implants, minimal paravertebral muscle dissection, minimal retraction, and minimal bleeding and infection.12

Figure 1

Figure 1Elderly patients have also benefitted with use of robots in surgical procedures. According to a retrospective study, advanced age does not appear to be associated with increased risk of morbidity or poor outcome in patients undergoing robotic assisted minimally invasive surgery.13 They included 399 patients who underwent robotic surgery for gynecologic disease. The older population seemed to have fewer complications; furthermore, when stratified by the type of procedure performed, there was no difference in surgery times among those under 70 and over 70 years of age. Literature, however, lacks in providing information about the outcome of elderly patients undergoing robot-assisted neurosurgical procedures.  In pediatric patients, use of robots have rarely been reported. Robot-assisted surgeries are of special interest in this patient population, who often have altered anatomy and challenging relationships between eloquent areas and pathological areas. De Benedictis and colleagues retrospectively evaluated 116 pediatric patients between 2011 and 2016, who underwent 128 ROSA-assisted neurosurgical procedures for treatment of various diseases.14 Their results showed that the ROSA device improves the safety and feasibility of several minimally invasive procedures, while minimizing the risk of failure and intraoperative complications. Further large prospective studies are needed to validate previous results and to optimize the impact of robotic surgeries on the quality of neurosurgical procedures in pediatric patients. As per our institutes’ experience, retrospective analysis of patients undergoing robot-assisted neurosurgery found that the most common indication for ROSA assisted neurosurgery was drug refractory epilepsy (56 patients) followed by endoscopic pituitary surgery (27 patients), tumor excision (11 patients), biopsies (four patients), arteriovenous malformation excision (three patients) and microvascular decompression (one patient). In our study (unpublished data), children and adolescents, epilepsy surgery, postoperative mechanical ventilation and lower postoperative GCS were associated with longer length of stay in the ICU and hospital. Other parameters such as ASA status of the patients, preoperative GCS, type of anesthesia, intravenous fluid, blood loss, blood transfusion and duration of anesthesia did not influence ICU and hospital stay.

Perioperative anesthetic considerations in robot-assisted surgery starts with proper preoperative counselling of patients in view of prolonged operative time and high cost of surgery. Intraoperative considerations include invasive monitoring in patients with cardiac or respiratory comorbidity, complete neuromuscular blockade when applied or fixed to patient’s cranium or spine and aborting the robotic procedure in the case of uncontrolled bleeding at surgical site. If given a choice between intravenous or inhalational anesthetic technique for robot-assisted surgery, evidence does not support superiority of one technique over another in patients undergoing various urology, gynecology or gastroenterology procedures.15 There is no literature about the choice of anesthetic technique to be used in robot-assisted neurosurgery. The main concern for anesthesiologists in such surgery is an unexperienced surgeon, who may take longer operative time resulting in overall prolonged exposure to anesthetic drugs. Postoperatively, this may have cognitive implications in high risk patients such as elderly patients and patients with previous history of cognitive dysfunction.     

Future of robots in the field of neurosurgery is promising, where robots are used in various neurosurgical procedures as well as in different patient populations. Though at present most common systems in robotic surgery are dependent systems where the surgeon retains full control of surgical instruments. In neurosurgery, a shared control system is commonly used, where passive arm hooked up to surgeon that moves only when permitted, but yet it can filter unwanted physiological tremors.

References:

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