New Trend in Robotic Surgery Dr YUEN Pong Mo

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1 New Trend in Robotic Surgery Dr YUEN Pong Mo
机器人手术的新趋势 阮帮武 教授 MBChB (CUHK), FHKAM(O&G), FHKCOG (HK), FRCOG (UK) Director of Minimally Invasive Gynaecology, Hong Kong Sanatorium & Hospital Honorary Clinical Associate Professor, Department of Obstetrics & Gynaecology, The Chinese University of Hong Kong Honorary Consultant, Department of Obstetrics & Gynaecology, Kwong Wah Hospital

2 Laparoscopy offers advantages of less blood loss, less post-operative pain, shorter
hospitalization time, and quicker recovery. Though basic laparoscopic procedures are widely practiced, relatively few gynaecologists possess the skills in performing advanced procedures like hysterectomy and myomectomy, not to mention the more complex procedures such as radical hysterectomy and pelvic reconstructive procedure. This is because laparoscopy is hampered by its two-dimensional visualization, counter-intuitive hand movements, limited degrees of instrument motion and inferior ergonomic surgeon position. The steep learning curve and longer operating time are major obstacle to the more widespread applications of this minimally invasive technique. The introduction of robotic technology into surgical practice overcomes the limitations of conventional laparoscopy and facilitates the application of these minimally invasive techniques for more advanced and complex procedures. 腹腔镜的优势是减少出血量、术后疼痛、缩短治疗时间和加快恢复。通过基础的腹腔镜检查的广泛应用，只有少数医生具有高超子宫切除术和子宫肌瘤的手术技术。它没有涉及更多的复杂的手术，例如根治性子宫切除术和骨盆的重建。这是因为腹腔镜受二维视野、计数器的直觉手动、有限的设备移动和初级的人机工程学手术位置的限制。极高难的学习周期和长时间的手术时间是微创技术广泛应用的主要障碍。机器人在手术中的应用克服了传统腹腔镜的局限和促进微创技术的应用。

3 History of Surgical Robotics
机器人外科手术的历史 The concept of surgical robot was first developed in late 1980s at the National Aeronautics and Space Centre (NASA) to perform battlefield surgery by enabling surgeons to carry out surgical procedures remotely over a distance. With the involvement of the Stanford Research Institute (subsequently named SRI International), the concept of robotic telemanipulating system was combined with the virtual reality systems to provide a robotic, tele-surgical system. In early 1990s, 2 companies, the Computer Motion, Inc. and the Intuitive Surgical, Inc. were started to commercialize the robotic surgical systems. 机器人外科手术的概念出现是在1980年美国国家航空空间站中心的战地手术操作，它是通过外科医生操作机器人完成跨越距离的程序。斯坦福研究院的加入（随后命名国际SRI），机器人远程熟练操控系统与实际的真实系统相结合提供给远程外科系统的机器人。在1990年早期，计算机驱动公司和机器人外科手术公司一起开始了机器人外科系统的商业运作。

4 The Computer Motion system, Zeus, was
developed from the very beginning as an integrated robotic surgical system. It used the same type of robotic arm that was designed to hold a laparoscopic camera (AESOP) and integrated operating room control system (HERMES) to create a suite of systems that provided a surgical environment. The system was designed for laparoscopic surgery and received the U.S. Food and Drug Administration (FDA) regulatory clearance in October However, Zeus manufacturing was discontinued following the acquisition of Computer Motion, Inc. in March 2003 byIntuitive Surgical, Inc. which developed the da Vinci Robotic Surgical system. Thesystem, based upon the original telepresence concept, was introduced in 1999 andreceived FDA approval for use in general surgical procedures in July 2000, urology inJune 2001 and gynaecology in April 2005. Zeus 计算机驱动系统公司在初期的时候与机器人外科手术系统公司联合发展。它使用了机器人同样类型的手臂，它能支撑住腹腔镜的摄像机（AESOP）与手术室的控制系统（HERMES）相结合创造了一套外科环境。这个为腹腔镜手术的系统在2001年10月通过美国FDA认证。然而，ZEUS厂家在2003年的3月中断了与机器人外科手术公司的合作。机器人外科手术公司开发了机器人系统。这个系统在原始远程监控概念的基础上，1999年介绍推出，2000年7月通过FDA认证在综合外科手术的应用，2001年7月通过泌尿科应用和 2005年4月通过妇科应用。

5 The da Vinci Surgical System
Figure 1. da Vinci S Surgical System, ©[2009] Intuitive Surgical, Inc. The da Vinci Surgical System (Figure 1) consists of an ergonomically designed surgeon’s console, a patient-side cart with four interactive robotic arms, the high-performance InSite® Vision System and the proprietary EndoWrist® Instruments. Da Vinci 外科系统（图1）由改造的设计的外科操作台、带有4个交叉的机器人手臂的病人边车、高效能的Insite视觉系统和专利的EndoWrist设备组成。

6 The mobile surgeon console consists of a stereoscopic viewer, two handles and five
foot pedals. The console is operated by the surgeon in a sitting position and controls the three, and in the latest model four, mobile arms of the robot for intra-abdominal manipulations, camera movements, and electrosurgical coagulation. The surgeon's fingers grasp the master controls below the display, with hands and wrists naturally positioned relative to his or her eyes (Figure 2). The system seamlessly translates the surgeon's hand, wrist and finger movements into precise, real-time movements of surgical instruments inside the patient. There is no tactile sensation and the surgeon has to rely on visual feedback. The console can be positioned anywhere inside or outside the operating theatre. However, the FDA regulations require that the console be placed in the same room as the operative table except in telesurgery. 移动的外科控制台由一个实体镜的阅读器，2个手柄和5个脚踏板组成。外科医生在坐式的操作台位置进行手术，它由控制3 、最新的模板4、机器人针手臂移动针对腹内的移动摄像机、电子外科的凝结物组成。外科医生的手指抓住在显示器下的控制器，手腕自然地放到他或她的眼睛。（图2）系统把外科医生的手腕转精确实时的转化成外科设备的移动。它没有触觉感应，外科医生只能依靠视觉的反馈。操作台可以放置手术室的任何地方，无论是里面还是外面。 然而，FDA 要求操作台除了远程手术操作台在同一个房间是可以调换的。

7 Figure 2. Surgeon operating the hand controls in a natural and comfortable position
The 2 hand controls operate either the camera or the robotic instruments arms, but not both at the same time. When 3 robotic instruments arms are used, only 2 can be used at any one time, the third one is inactive and can only be used for tissue holding and retraction. The 4 foot pedals are separated by another long and narrow pedal, 2 on each side, which adjusts the focus of the camera. The outer left foot pedal uses the clutch mechanism to allow repositioning of the hand controls without moving the robotic arms, like raising the computer mouse to reposition the mouse without moving the pointer. The inner left foot pedal provides a navigation control of the camera movement by moving both hand controls in and out, right and left, up and down. The instrument arms remain still while adjusting the camera position. The 2 pedals on the right control the monopolar and bipolar diathermy. 两只手无论操作摄像机还是机器人设备手臂，不完全在同一时间。 当3个机器人设备手臂在使用时，仅有2个能在任意时间使用，第3个是不活跃的用于组织固定和收回。第四个脚踏是从另外一个长的和窄的踏板分离开，每一边两个调节摄像机的焦距。外面左边踏板使用支撑机制重置手控，机器人手臂不动。例如提升计算机的鼠标重新放置，指针没有移动。里面的左脚踏板通过移动手控里外左右上下调节摄像机的导航控制。 设备的手臂保留并调节摄像机的位置，右边2个脚踏板控制单极和双极的透热疗法。

8 The image is provided by the Insite® Vision System (Figure 3) through a 12 mm
endoscope (0 or 30 degree) comprising of two laparoscopes fused together. The surgeon operates in a sitting position and looks through a binocular three-dimensional (3-D) viewing monitor with optimal hand-eye alignment. The image is displayedabove the hands of the surgeon so that it gives the surgeon the illusion that the tips ofthe instruments are an extension of the control grips, thus giving the impression of being immersed at the surgical site. The high definition image provides improved clarity and detail of tissue planes. 图像由Insite成像系统（图3）通过12mm内窥镜（0 或30度）和2个腹腔镜融合组成。外科医生在座位上随着最佳的手动调整操作使用双目并用的3-D 监控。外科医生手的上方显示图像能够让医生看到说明器械的提示，它是控制栅极的延长，因此在手术位置有陷入的印迹。高定义图像展示了清晰的组织水平。

9 Figure 3. InSite® Vision and the endoscope, ©[2009] Intuitive Surgical, Inc.
The patient-side cart provides four robotic arms (3 in the previous model), 3 instrument arms and 1 endoscope arm, that execute the surgeon's commands. The movements of the surgeon are digitalized, scaled at 1/1, 1/3, or 1/5, and transmitted by computer to the intra-abdominal instruments without noticeable delay. Normal physiological hand tremor is also filtered, making it possible to perform very fine and precise tasks. Attached to the robotic arms are a full range of proprietary EndoWrist instruments (Figure 4). The extra-abdominal movements of the instruments controlled by the robotic arms have four degrees of freedom. The intra-abdominal articulations of the micro-instruments at 2 cm from the tip mimic those of the human hand and wrist. They possess seven degrees of freedom and therefore function more instinctively and overcome the fulcrum effects seen with conventional laparoscopy. 病人的边车提供了4个机器人手臂（3个在模板的前方），3个设备的手臂和一个内镜的手臂。它执行医生的指令。 外科医生的移动是数字化的，比例在1/1,1/3, 或1/5，这种移动被计算机传送到腹内的设备，它没有明显的延误。正常生理的手震动是可以渗透的使其操作完成精确的任务。附加的机器人手臂是全套的专利EndoWrist设备（图4）。机器人的手臂有4个自由度控制腹外设备的移动。微小设备的腹内结合处在2cm的范围模拟人类的手腕。他们有7个自由度，因此它的功能更多以及克服了传统腹腔镜的支点效应。图4

10 Figure 4. EndoWrist Instruments, ©[2009] Intuitive Surgical, Inc.
The patient-side cart provides four robotic arms (3 in the previous model), 3instrument arms and 1 endoscope arm, that execute the surgeon's commands. Themovements of the surgeon are digitalized, scaled at 1/1, 1/3, or 1/5, and transmitted by computer to the intra-abdominal instruments without noticeable delay. Normalphysiological hand tremor is also filtered, making it possible to perform very fine andprecise tasks. Attached to the robotic arms are a full range of proprietary EndoWrist instruments (Figure 4). The extra-abdominal movements of the instruments controlledby the robotic arms have four degrees of freedom. The intra-abdominal articulationsof the micro-instruments at 2 cm from the tip mimic those of the human hand and wrist. They possess seven degrees of freedom and therefore function moreinstinctively and overcome the fulcrum effects seen with conventional laparoscopy. 病人的边车提供了4个机器人手臂（3个在模板的前方），3个设备的手臂和一个内镜的手臂。它执行医生的指令。 外科医生的移动是数字化的，比例在1/1,1/3, 或1/5，这种移动被计算机传送到腹内的设备，它没有明显的延误。正常生理的手震动是可以渗透的使其操作完成精确的任务。附加的机器人手臂是全套的专利EndoWrist设备（图4）。机器人的手臂有4个自由度控制腹外设备的移动。微小设备的腹内结合处在2cm的范围模拟人类的手腕。他们有7个自由度，因此它的功能更多以及克服了传统腹腔镜的支点效应。图4

11 The patient-side cart is wheeled in between the patient’s legs, and the robotic arms are
attached to the metal robotic trocars so that they are integrated together. The robotic instrument is then put through the trocar and mounted onto the robotic arm so that the multi-articulated instrument tips can be operated by the hand controls. The manipulation of the robotic instruments is just like operating with the human hand, together with the capability of grasping, retracting, dissecting, cutting, coagulating and suturing. Figure 5. The immersive feeling of doing open surgery in an ergonomic sitting position. 病人边床在病人的腿和机器人的手臂之间转动。病人边床附着在金属机器人套针上使他们更好的联合在一起。套针和架置的机器人的手臂使多关节设备尖端能够用手控操作。机器人的操作好像人手的操作能抓、缩、剖、切、凝和缝的能力。图5

12 机器人在妇科的应用 Applications of Robotics in Gynaecology
The world’s first robot-assisted gynaecological surgical procedure reported in human was a case of tubal re-anastomosis using the Zeus Robotic System in The da Vinci system was also firstly used for tubal re-anastomosis in In 2002, the first series of robot-assisted laparoscopic hysterectomy was reported. Currently the da Vinci system is the only commercially available surgical robotic system. Following the FDA clearance in 2005, the number of reports on robot-assisted gynaecological procedures increases dramatically and it has virtually been applied to all abdominal and laparoscopic gynaecological procedures including ovarian transposition, abdominal cerclage, repair of vesico-vaginal fistula and trachelectomy after subtotal hysterectomy. Despite the well accepted benefits of laparoscopic surgery for benign gynaecological pathologies, the use of laparoscopy in gynaecological malignancy is still the exception. However, the application of robotics in gynaecology focuses mostly on oncological procedures and most of the publications so far are in these area. 全世界人类第一次机器人妇科输卵管重新缝合手术的病例由Zeus 机器人系统1999年完成。 Da Vinci 系统2000年第一次完成输卵管重新缝合的手术。2002年报道了第一套机器人协助腹腔镜子宫切除术。现在Da Vinci 系统.现在已经是商业化的外科手术机器人系统。随着2005年FDA认证的通过，机器人协助妇科手术的报道戏剧性的增加并且申请了腹部腹腔镜的手术包括卵巢移位术、腹内环扎术、修复膀胱阴道瘘管和几乎全部的子宫切术后的子宫颈切术。尽管腹腔镜手术对妇科病理的早期发现的治疗很有利，但腹腔镜的在妇科恶性肿瘤方面的治疗仍有望期待提高。然而，机器人应用在妇科肿瘤方面的手术和出版物都很局限。

13 Myomectomy 子宫肌瘤切除术 Senapati and Advincula recently described their technique in robot-assisted laparoscopic myomectomy as a means to overcome the difficulties encountered with hysterotomy, enucleation, repair, and extraction during conventional laparoscopy. They reported the first series of robot-assisted laparoscopic myomectomy in 35 patients. There were 3 conversions and 1 patient was excluded because of adenomyosis. Of the 31 completed cases, the mean number of myomas removed was 1.6 and the mean diameter was 7.9 cm. The mean estimated blood loss was 169 ml, the mean operating time was 230 min and the median length of stay was 1 day. Two patients developed post-operative complication. Senapati 和Advincula的机器人协助腹腔镜子宫肌瘤切除术的技术中克服了传统腹腔镜的困难包括子宫切开、摘除、修复和取出。他报告了一系列的机器人协助子宫肌瘤手术的腹腔镜手术，共35个病人，有3个转化，1个子宫内膜异位形成排除。31个完整病例，肌瘤移除平均数1.6个和平均直径7.9cm。平均评估血量丢失169ml，平均手术时间是230分钟。停留的中间长度是1天。2个患者发生了术后合并症。

14 In a retrospective case control study, Advincula et al
In a retrospective case control study, Advincula et al. compared 29 cases of robot-assisted laparoscopic myomectomy with 29 cases of abdominal myomectomy. The robotic group had longer operating time (231 vs 154 min), less blood loss and transfusion rate (195 vs 364 ml and 0% vs 6.9% respectively), shorter length of stay (1.5 vs 3.6 days) and lower complication rate (13.8% vs 41.4%). In a retrospective study comparing 15 robotic-assisted laparoscopic myomectomy to 35 matched control laparoscopic myomectomy, Nezhat et al. also reported a significantly longer operating time with the robotic assistance (234 vs 203 min). However, there were no differences in blood loss, hospitalization time, and postoperative complications. 在回顾个案控制研究病例里，Advincula和al 把29个机器人协助的子宫肌瘤切除术病例和29个腹部子宫肌瘤切除术进行对比。机器人操作时间长（231和154分钟），血量丢失少、输血率（195vs 364ml 和0%vs 6.9%分别的），停留的时间缩短（1.5 vs3.6天）及合并症发生率低（13.8%vs41.4%）。回顾性研究对比15个机器人协助腹腔镜子宫肌瘤手术和35个配对对照腹腔镜子宫肌瘤手术。Nezhat 和al 报道机器人协助（234vs203）的重要的长时间手术。然而，在血量丢失、住院时间和术后的并发症没有重要的差异。

15 Bedient et al. retrospectively compared 40 robotic myomectomy with 41 laparoscopic
myomectomy. The laparoscopic group had a significantly larger mean uterine size, larger mean size of the largest fibroid, and greater number of fibroids. When adjusted for uterine size and fibroid size and number, no significant differences were noted between robotic vs laparoscopic groups for mean operating time (141 vs 166 minutes), mean blood loss (100 vs 250 mL), intraoperative or postoperative complications (2% vs 20% and 11% vs 17%, respectively), hospital stay more than 2 days (12% vs 23%), readmissions, or symptom resolution. Bedient 和al 回顾性对比40个机器人子宫肌瘤手术和41个腹腔镜子宫肌瘤手术对比。腹腔镜检查的患者有显著地宫体积增大小和肌瘤增多。调节子宫尺寸大小及数目的时候，在机器人和腹腔镜的手术平均时间（141 vs166分钟）上没有明显的差异。血量丢失的平均值（100 vs 250ml ）, 手术中或术后合并症（2%vs 20% 和11% vs 17%，分别）住院多2天。12% vs23%是新接诊或症状分辨率。

16 In a recent case control study, Charles et al
In a recent case control study, Charles et al. compared 75 women who had undergone robotic-assisted laparoscopic myomectomy with 50 patients who had undergone myomectomy via laparotomy. There was a significant increase in mean duration of surgery for robotic-assisted myomectomy (192 vs 138 min). There was a significant decrease in blood loss (226 vs ml), change in hematocrit concentration on postoperative day 1 (5.1 vs 7.1 g/dL), length of stay (0.51 vs 3.28 days), number of days to regular diet (0.85 vs 2.30), and febrile morbidity (1.33% vs 38.0%) in robotic-assisted myomectomies. There were no significant differences in operative or postoperative complications. Published data on robot-assisted myomectomy are limited. Despite the advantage of ease in suturing, robot-assisted myomectomy requires significantly longer operating time compared with both the conventional open and laparoscopic approach. 在最近的病例的研究中， Charles 和al 75名妇女做过机器人协助腹腔镜子宫肌瘤手术和50 名患者做过子宫肌瘤腹腔镜手术进行对比。机器人协助手术时间明显增长（192 vs138分钟），血量丢失明显减少（226 vs 459ml ）。术后分血器集中地改变1天（5.1 vs7.1g／dL）, 停留时间(0.51 s3.28天),规律节食的天数(0.85 vs 2.30).机器人手术子宫肌瘤发热的发病率（1.33% vs38.0%）。手术中和术后合并症没有明显区别。机器人协助手术的出版数据非常有限。机器人协助的子宫肌瘤的手术优势在于缝合，但它的手术时间要长于传统的开放手术和腹腔镜手术。

17 Hysterectomy for Benign Disease
早期疾病的子宫切除术 The first report of robot-assisted laparoscopic hysterectomy was published in 2002 by Diaz-Arrastia et al. Since then numerous case series have been reported with encouraging results. Kho et al. published the largest series of robotic hysterectomy involving 91 patients. Mean docking time was 2.95 min and mean console time (surgeon’s time dedicated exclusively to the performance of the surgery) was 73 min. Total operating time was 122 min and it was 14 min shorter when compared to conventional laparoscopic hysterectomy in their institution. Payne et al. compared 100 patients undergoing total laparoscopic hysterectomy with patients with robotic hysterectomy. Overall the robotic cohort experienced longer operating time by an average of 27 min. However, the last 25 robotic cases had shorter operating time compared with the laparoscopy cohort (78 vs 92 min). The mean blood loss and themean length of hospital stay was significantly reduced in the robotic cohort. The number of exploratory laparotomies (0% vs 11%) and rate of intraoperative conversions (4% vs 9%) were both lower in the robotic cohort. Robotic assisted hysterectomy appears to be better than laparoscopic hysterectomy with similar or shorter operating time. It allows more hysterectomy to be performed using the minimally invasive approach. 第一个机器人腹腔镜子宫肌瘤手术在2002年由Diaz-Arrastia报道有大量鼓励性的结果出版了一系列大量的应用机器人操作的91名子宫切除的患者。平均扣除时间是是2.95分和平均操作台时间（外科医生熟练的外科手术的操作）是73分钟。总的操作时间是122分钟和与再研究院传统的腹腔镜手术相比缩短了14分钟 。Payne 和ad 做了100名做腹腔镜的子宫切除术和100名机器人的腹腔镜子宫切除术对比。全部的机器人操作的平均时间是27分钟。然而，最后的25个机器人病例比传统的手术时间短。（78vs92分钟）.机器人队列血量丢失的平均值和住院时间的平均值是明显减少。机器人队列的试探性腹腔镜数量（0% vs11%）和手术进行中的转化率（4% vs 9%）都低。机器人协助的子宫切除术表现出比腹腔镜子宫切除术更好或手术时间缩短。它可以使用微创方法做子宫切除术。

18 Hysterectomy for Endometrial Carcinoma Staging
子宫内膜癌的子宫切除术 Boggess et al. compared the outcomes of 322 women undergoing endometrial cancer staging by different surgical techniques: 103 by robotic assistance, 138 by laparotomy and 81 by laparoscopy. The robotic cohort had the highest lymph node yield, and lowest hospital stay and blood loss. Operating time was longest for laparoscopy (213 min) followed by robotic (191 min) and laparotomy (147 min). Postoperative complication rates were lowest for robotic (5.9%), followed by laparoscopy (13.6%) and laparotomy (29.7%). Boggess和al 对比322名患有子宫内膜癌的妇女在不同外科技术的对比：103名通过机器人协助，138人通过剖腹手术，81人通过腹腔镜。机器人有最高的淋巴结量，最少的住院时间和最少的血液丢失。机器人腹腔镜的手术时间最长（213分），剖腹手术（147分钟）。机器人的术后合并症率最低（5.9%），腹腔镜（13.6%）剖腹手术（29.7%）。

19 Conversion rates for the robotic and laparoscopic groupswere similar
Conversion rates for the robotic and laparoscopic groupswere similar. Similarly, Bell et al. compared patients who underwent hysterectomy with bilateral salpingo-oophorectomy,pelvic and para-aorticlymphadenectomy via robotic assistance (40), laparotomy (40), and laparoscopy (30) for endometrial cancer staging. The operating time was longer in the robotic cohort than the laparotomy cohort but similar to the laparoscopic cohort (184 min, 109 min and 171 min). Estimated blood loss was significantly reduced in the robotic cohort (robotic 166 ml, laparotomy 316 ml, laparoscopic 253 ml). Complication rate was lowest in the robotic cohort (robotic 7.5%, laparotomy 27.5%, laparoscopic 20%). Return to normal activity for the robotic patients was significantly shorter (robotic 24.1 days, laparotomy 52 days, laparoscopy 31.6 days). Lymph node retrieval did not differ between the 3 groups (robotic 17, laparotomy 14, laparoscopic 17). 机器人和腹腔镜的转化率相似。Bell et al 把110名子宫内膜癌的妇女做过子宫切除术（双侧输卵管卵巢切除术、骨盆的、主动脉旁的淋巴切除术）通过机器人协助（40）、剖腹手术（40）和腹腔镜（30）作对比。机器人的手术时间比剖腹手术时间长，但类似腹腔镜（184分钟，109f分钟和171分钟）机器人的手术时间血液丢失没有明显减少。（机器人166ml，剖腹手术316ml，腹腔镜253ml）。机器人队列合并症率最低（机器人7.5%，剖腹手术27.5%，腹腔镜20%）机器人治疗后的患者恢复正常活动的时间短（机器人24.1天，剖腹手术52天，腹腔镜31.6天）。淋巴回流在3个部分是不一样的。（机器人17. 剖腹手术14，腹腔镜17.）

20 When compared with open surgery, meta-analysis showed that the robotic surgery to
be significantly associated with a shorter hospital stay, a smaller risk of complications, reduced blood loss during surgery, a reduction in the need for transfusion, and a greater number of resected lymph nodes. However, it was associated with a longer duration of operation (by a mean of min), a greater risk of needing to convert to another surgical method (OR to 94.97), 与开放性手术对比，meta分析显示机器人手术住院时间明显缩短，合并症风险小，手术期间血液丢失少，减少所需输血、切割多数淋巴结。手术持续时间（平均89.25分钟）。风险需要转换方法(OR 到94.97)。

21 Radical Hysterectomy for Cervical Cancer
宫颈癌的根治子宫切除 The first robot-assisted radical hysterectomy and bilateral pelvic lymph node dissection was reported by Sert and Abeler in Since then, several different series of robot-assisted radical hysterectomy involving a total of 45 cases were published. Magrina et al compared patients undergoing robotic radical hysterectomy with 31 and 35 patients operated by laparoscopy and laparotomy respectively. The mean operating time for patients undergoing robotic, laparoscopy and laparotomy radical hysterectomy were 190, 220 and 167 min respectively; the mean blood loss was 133, 208 and 444 ml respectively; the mean number of removed lymph nodes was 25.9, 25.9 and 27.7 respectively; and the mean length of hospital stay was 1.7, 2.4 and 3.6 days respectively. There were no significant differences in intra- or postoperative complications among the three groups and no conversions were required in the robotic or laparoscopic groups. Boggess et al. compared the outcome of 51 consecutive robot-assisted radical hysterectomies with 49 historical abdominal radical hysterectomies for early-stage cervical cancer. All of the robotic procedures were completed successfully without any conversion to laparotomy. Sert 和Abeler在2006年报道了第一个根本的子宫切除术和双侧骨盆的淋巴结剥离术。从此开始，机器人协助根本的子宫切除术共计45个病例报道出版。Magrina et al 把27个患者做机器人的根本子宫切除术和31个和35个患者分别作腹腔镜和子宫切除术对比。机器人、腹腔镜和剖腹手术根本子宫切除术的手术平均时间是190、220和170分钟。平均的血液丢失分别是133、208、444ml；移除淋巴结的数目分别是25.9/25.9/27.7. 住院时间的平均时间分别是1.7/2.4/3.6 天.术前后合并症没有明显区别。机器人或腹腔镜没有转换要求。Magrina et al 对比51个机器人根本子宫切除术和49个早期宫颈癌的腹部根本子宫切除术。所有机器人手术都很成功，无需转化成剖腹手术。

22 When compared with conventional laparoscopic surgery, robotic surgery was
associated with significantly reduced blood loss during surgery (mean difference ml, to -9.53), reduced need for a blood transfusion (OR , 0.09 to 0.64), shorter hospital stay (mean difference days, to -0.06) and a smaller risk of conversion to another type of surgery (OR 0.43, 0.21 to 0.85). There was no difference in the overall risk of complications and duration of operation. 与传统的腹腔镜对比，机器人更能减少在手术中的血液丢失（平均差异 ml ， 到-9.53），减少需求的输血（OR 0.43,0.21到0.85）。风险合并症和手术持续时间没有区别。.

23 Compared with open surgery, the use of robot was associated with a significantly
shorter hospital stay (mean difference days, to 01.29), reduced blood loss during surgery (mean difference ml, to ) and a reduced need for blood transfusion (OR 0.18, 0.07 to 0.44). No significant difference were seen with respect to duration of operation, number of lymph nodes resected, rate of positive margins, the proportion of patients with complications or the need to resort to another type of surgery. 与开放性手术相比，机器人的住院时间明显缩短（平均差异-0.25天，-0.28 到01.29），手术期间血液丢失减少（平均差异 ml， ml 到-20891），减少需求输血量（OR 0.18, 0.07 到 0.44）。手术期间淋巴结剥离的数目、切缘阳性率、合并症比率 和需要做其他类型的外科手术的无明显的区别。

24 Compared with conventional laparoscopy, use of the robot was associated with
reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of stay, number of lymph nodes resected and the proportion of patients with complcations. 与传统的腹腔镜相比，机器人手术血液丢失减少（平均差异-63.52ml， 到-26.54）。手术持续时间、住院时间、淋巴结剥离数目和合并症的比例无重要区别。 Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of Compared with conventional laparoscopy, use of the robot was associated with reduced blood loss during surgery (mean difference ml, to ). There was no significant difference with respect to duration of operation, length of

25 Radical Trachelectomy
根治性宫颈切除术 A total of 4 cases of robot-assisted total laparoscopic radical trachelectomy for early cervical cancer have been reported so far. Operating time ranged from 172 min to 387 min with a mean of 316 min. Blood loss was less than 200 ml in all cases. There were no complications reported and all patients had their period return after the operation. The follow-up period was short and there was no pregnancy being reported yet. 迄今为止早期宫颈癌机器人协助根治宫颈癌的病例共4个。手术的时间范围从172分钟到387分钟，平均316分钟。所有的病例中血液丢失少于200ml。没有合并症的报告。术后月经正常。随访期短仍然没有怀孕的报告。

26 Conclusion 结论 Robot-assisted surgery is one of the latest innovations in the field of minimally invasive surgery and studies on different surgical procedures have confirmed its feasibility and potential benefits. Surgical robotic system is an enabling technology that allows surgeons the ability to perform laparoscopic procedures in an open surgery environment. Robotic surgery establishes a straight foot-hand-eye axis that does not exist in either open or laparoscopic surgeries. It restores the 3-dimensional view that is lost in laparoscopic surgery. The great advantage of robot-assisted laparoscopy is the successful transfer of open surgery to a laparoscopic environment, even for laparoscopically “naive” surgeons, with a significantly shortened learning curve. It is envisaged that surgical robots will make minimally invasive surgery easier and more efficient, especially for those complex and prolonged procedures. 机器人外科协助手术是微创外科手术的最新的发明之一，在外科的手术中已经证实他的可行性和潜在的优势。外科机器人系统可以让外科医生在开放式手术环境里做腹腔镜手术。机器人外科建立了足-手-眼睛轴，它不存在于无论是开放式还是腹腔镜手术。它的3-D视野腹腔镜手术是没有的。机器人协助腹腔镜的手术最大的优势是成功地把开放式转移至腹腔镜环境，甚至为没有“经验”的腹腔镜外科医生缩短了学习的周期。我们设想一下机器人使微创外科手术更容易和更便利，尤其是疑难拖延了的手术。