Robotic vitreoretinal surgery needs refinement, but shows promise for future

WAIKOLOA, Hawaii — Robotic vitreoretinal surgery, which could be performed on patients in remote locations such as Iraq while the surgeon is in another location, is feasible despite needing significant mechanical improvements, a surgeon said here.

Steven D. Schwartz

Steven D. Schwartz, MD, discussed work done at the University of California, Los Angeles, Center for Advanced Surgical and Interventional Technologies (CASIT) to refine a robotic surgery model for use in intraocular surgery. He spoke at Retina 2008, held in conjunction with Hawaiian Eye 2008.

"Robotic surgery is actually gaining acceptance in mainstream critical care," Dr. Schwartz said. "The robot translates complex hand and wrist movements in a coordinated manner while maintaining hand-eye coordination."

He explained that advantages such as a three-dimensional view, greater magnification, superior instrument maneuverability and reduced tremor are very useful in other surgical specialties, in which trans-Atlantic surgeries have already been performed.

"Ironically, ophthalmic surgery and instrumentation formed the foundation for robotic surgical strategies and instrumentation, so the biggest advantages may be irrelevant to vitreoretinal surgery," Dr. Schwartz said.

At CASIT, Dr. Schwartz and his colleagues performed surgery with the da Vinci (Intuitive Surgical) model to assess the feasibility of performing robotic intraocular surgery, as well as the equipment's dexterity and maneuverability. They performed foreign body removal, capsulorrhexis and 25-gauge pars plana vitrectomy in 10 porcine eyes, he said.

The model has two components, "the master and a slave," Dr. Schwartz said, explaining that the surgeon manipulates the master console, which controls the multiple-arm surgical unit. The unit is equipped with detachable surgical tools that are already commercially available.

"You really have complete control over the robotic arms," he said. "There was no measureable delay between the movement of the surgeon's controls and the movement of the robot."

Dr. Schwartz said there are still aspects of the model that are less suitable for ophthalmology, such as the high location of the robotic arm pivots. He said they are working to move the pivots closer to, or even within, the eye. In addition, Dr. Schwartz said, they are also working toward designing additional instruments better suited for intraocular surgery.

"The control and manipulation of the surgical instruments was relatively easy and intuitive. Wrist movements were more intuitive than the robotic arm instruments," he said.

He noted that the intraocular visual system was poor compared to currently available systems that many ophthalmic surgeons use. Also, the location of the endoscope, which was centered on the porcine eyes, further limited the use of the robotic arms.

"We concluded that robotic intraocular surgery is feasible, but probably not with the da Vinci system in its current iteration," Dr. Schwartz said. "There are engineering challenges, but we think they are surmountable."