To improve the quality of care and to offer less invasive treatments to patients, surgeries with the support of a robot have become more and more commonplace within the operating room. Specialists at Amsterdam UMC welcomed the latest and most advanced robotic system, the da Vinci XI, in 2018 as an opportunity to build on their extensive experience with robot-assisted surgery.

Due to the improved ease of use, flexibility for different surgeries, and better accessibility of almost all anatomical spaces in the human body, the numbers of operations and surgeons using the robotic system are steadily increasing. The purchase of a second XI system was completed this year with funding from the Cancer Center Amsterdam Foundation.

With two XI systems at Amsterdam UMC, many more robot-assisted surgeries involving mainly oncological procedures can now be accomplished. We can perform cancer operations at high numbers with great precision, guided by the latest imaging techniques ! Dr. Rutger-Jan Swijnenburg.

Robotic arms make life better
What makes robot-assisted surgery better in comparison to currently existing surgical procedures? A major advancement is that robot-assisted surgery offers a greatly improved system to perform minimally invasive or “keyhole” surgery. A camera and a number of instruments are inserted through small incisions in an abdomen which is inflated with CO2 gas. When compared to open surgery, the smaller incisions cause less trauma to the patient's abdominal wall, resulting in less pain, reduced blood loss, and a faster recovery time. In addition, the robot offers a platform for fully image-guided surgery for potentially more precise removal of tumors, with less damage to surrounding tissues.

The surgical robot also has many advantages over standard laparoscopic techniques, where a surgeon employs instruments and a camera to perform operations through small incisions in the patient’s body. The robot offers the surgeon an extremely dexterous extra hand, so to speak. Besides the robotic camera arm, there are three additional arms the surgeon can use during the operation. The robotic arms with the camera and instruments are positioned over the patient with great precision and stability. These arms are digitally connected with the surgical console, where the surgeon sits, and provides full control over all arm movements. The steady real-time camera stream is displayed in 3D, which gives a very accurate image of reality. The robotic instruments can fully articulate (rotate), greatly increasing the surgeon's freedom of movement, speed of action, and accuracy compared to standard laparoscopy.

Besides these important advantages for both the patient and surgical precision, there is also a significant benefit for the surgeon: comfort! It is known that laparoscopic surgeons often suffer from neck and muscle complaints because of the unnatural positions in which they often operate. In the robot console, the surgeon sits in a chair, and the heights of the control panel can be adjusted to suit their specific needs. This helps prevent physical fatigue and enables the surgeon to perform at a consistently high level during the (often) time-consuming oncological operation.

The Robotic Liver Surgery Cockpit. The vision of the surgeon looking into the robotic console. Different imaging techniques, such as fluorescence (upper panel), ultrasound (left lower) and 3D CT scans (right lower), can be uploaded and employed according to the surgeon’s needs. The Robotic Liver Surgery Cockpit. The vision of the surgeon looking into the robotic console. Different imaging techniques, such as fluorescence (upper panel), ultrasound (left lower) and 3D CT scans (right lower), can be uploaded and employed according to the surgeon’s needs.

Increased precision during liver surgery
The benefits of robot-assisted surgery are exploited for operations on the liver, among other surgical interventions. Every year, 175 liver operations are performed at Amsterdam UMC, with about half of these currently performed with a robot, giving excellent outcomes. Liver surgery is challenging as this organ is located entirely in the upper abdomen, behind the rib cage and against the diaphragm. The complicated anatomy of blood vessels and bile ducts, in addition to the liver’s wedge shape, impairs accessibility and demands high surgical precision. Whereas liver patients used to be hospitalized for 5 to 7 days, now the average recovery time is only 3 days following robot-assisted surgery.

During liver surgery, the articulating instruments offer some great advantages. Tumors can be removed from all areas of the liver. Blood vessels and bile ducts from and to the different liver segments can also be selectively traced and sealed with high precision. As a result, tumors can be removed very precisely with a clear safety margin, while retaining as much functional liver tissue as possible for the patient.

Imaging with tumor augmenting tracers
A recent major advancement in robot-assisted surgery is the integration of advanced imaging techniques. One of the lines of research at Amsterdam UMC is ‘Image-Guided Precision Cancer Surgery’ with Dr. Rutger-Jan Swijnenburg as one of the Principal Investigators. Imaging techniques and tracer molecules are being developed that visualize specific tumor features. For robotic liver surgery, for example, there is ‘indocyanine green’, a fluorescent contrast agent that is absorbed by the liver after intravenous injection and cleared through the bile ducts. The fluorescent signal is not visible to the naked eye, but a special camera in the robot called ‘the FireFly’ can see the tracer and visualize  the bile ducts and liver tumors. In addition to fluorescence imaging, the system also offers the possibility to project ultrasound during the surgery, as well as 3D reconstructions (overlays) of previous CT or MRI scans, a project Rutger-Jan is working on with researchers from the Leiden University Medical Center. This creates a virtual ‘robotic surgery cockpit’ in which various imaging techniques can be integrated with the real-time surgical imaging according to the needs of the surgeon. More surgical interventions supported by tumor-specific imaging tracers are being developed in collaboration with experts at Amsterdam UMC Imaging Center. The development of new and specific tracer molecules for both PET and fluorescent imaging will enable the visualization of tumor cells that currently cannot be detected.

Predictive models based on advanced computing will allow early identification of patients who will respond well to treatment.” Nina Wesdorp.

Surgical progress supported by Artificial Intelligence
To further improve the selection of patients with liver tumors who will benefit from surgery, Nina Wesdorp and Geert Kazemier of the Surgery department Amsterdam UMC are working to optimize tumor response evaluations using artificial intelligence (AI). “By applying AI to medical imaging like CT scans, we are developing models that can automatically perform a tumor response evaluation,” says Dr. Wesdorp. “In addition, with the help of AI, much more information (image features) can be extracted from CT scans, which are not visible or quantifiable with the naked eye. We use these image features to develop advanced models in order to predict the effect of a treatment.” By automating tumor response evaluations, more consistent assessments can be made which will result in improved prediction of the response to the therapy or treatment. Furthermore, advanced predictive models will allow early identification of patients who will respond well to treatment. Advanced imaging techniques can therefore contribute to better patient selection, as well as more effective robot-assisted surgeries for cancer patients, an important mission aim of Cancer Center Amsterdam.

Dr. Rutger-Jan Swijnenburg Dr. Rutger-Jan Swijnenburg