외과 영역에서 로봇 수술의 적용

김진경,양승윤,김성현,김형일 대한의사협회 2021 대한의사협회지 Vol.64 No.10

Background: Application of robotic surgery in the field of general surgery has been increasing. This paper is an overview of the current uses and future perspectives of robotic surgery in four major divisions—endocrine, upper gastrointestinal, hepato-biliary-pancreatic (HBP), and colorectal surgery. Current Concepts: In endocrine surgery, cosmetic advantage is the highest priority when selecting a surgical approach for thyroidectomy. Currently, the transaxillary route is the most common approach. The introduction of the single-port system could maximize the advantages of this technique. In upper gastrointestinal surgery, the use of robots has the advantage of better retrieval of lymph nodes, less bleeding, earlier discharge, and less complications than the laparoscopic approach. However, a more prospective comparative trial is required to confirm those findings. In the HBP field, the indications of robotic surgery have expanded, starting with cholecystectomy to more challenging procedures, such as donor hepatectomy and pancreaticoduodenectomy. Meticulous dissection using robots could provide benefits to patients. In colorectal surgery, robotic surgery is an excellent technical tool for minimally invasive surgeries for rectal cancers, especially in male patients with narrow, deep pelvises. However, further studies are required to confirm the impact of robotic surgery on rectal cancers. Discussion and Conclusion: Robots are used to provide optimal surgical outcomes. Investigating new technologies and innovative surgical procedures is the highly important for a surgeon in the era of minimally invasive surgery.

Current Trend of Robotic Thoracic and Cardiovascular Surgeries in Korea: Analysis of Seven-Year National Data

강창현,복진산,이나래,김영태,이선희,임청 대한흉부외과학회 2015 Journal of Chest Surgery (J Chest Surg) Vol.48 No.5

Background: Robotic surgery is an alternative to minimally invasive surgery. The aim of this study was to report on current trends in robotic thoracic and cardiovascular surgical techniques in Korea. Methods: Data from the National Evidence-based Healthcare Collaborating Agency (NECA) between January 2006 and June 2012 were used in this study, including a total of 932 cases of robotic surgeries reported to NECA. The annual trends in the case volume, indications for robotic surgery, and distribution by hospitals and surgeons were analyzed in this study. Results: Of the 932 cases, 591 (63%) were thoracic operations and 340 (37%) were cardiac operations. The case number increased explosively in 2007 and 2008. However, the rate of increase regained a steady state after 2011. The main indications for robotic thoracic surgery were pulmonary disease (n=271, 46%), esophageal disease (n=199, 34%), and mediastinal disease (n=117, 20%). The main indications for robotic cardiac surgery were valvular heart disease (n=228, 67%), atrial septal defect (n=79, 23%), and cardiac myxoma (n=27, 8%). Robotic thoracic and cardiovascular surgeries were performed in 19 hospitals. Three large volume hospitals performed 94% of the case volume of robotic cardiac surgery and 74% of robotic thoracic surgery. Centralization of robotic operation was significantly (p<0.0001) more common in cardiac surgery than in thoracic surgery. A total of 39 surgeons performed robotic surgeries. However, only 27% of cardiac surgeons and 23% of thoracic surgeons performed more than 10 cases of robotic surgery. Conclusion: Trend analysis of robotic and cardiovascular operations demonstrated a gradual increase in the surgical volume in Korea. Meanwhile, centralization of surgical cases toward specific surgeons in specific hospitals was observed.

로봇수술로 인한 의료과오 민사책임에 있어 과실 판단의 문제

김재완 아주대학교 법학연구소 2020 아주법학 Vol.14 No.1

Modern medical technology has been remarkably developed and new surgical methods using robots are being used in clinical surgery. Although surgical robots currently in use do not have the autonomy of artificial intelligence, they are precision and automated medical robots that work together with physicians in all or part of the operation process. The ultimate actor of robot surgery is a doctor of surgery, while the robot of surgery is a medical device under the Medical Devices Act of the Republic of Korea. The core of the determination of legal liability for medical accidents caused by robot surgery is to judge negligence in relation to the actor. However, there is a realistic problem that doctor's liability is not recognized in the case of medical malpractice litigation caused by robot surgery. The new medical practice of robotic surgery belongs to a more advanced field of expertise, and requires a high degree of attention from doctors. On the other hand, the highly specialized expertise in the medical and medical fields is also a characteristic that makes it difficult for the patient to prove the negligence of the doctor. Since robot surgery is a new treatment method different from existing surgical methods, there is a problem that is more difficult to judge medical malpractice. In the conventional medical practice, the legal standard of judicial precedent on the doctor's duty of medical treatment, the duty of care and the violation of the duty of explanation is also applied to the determination of negligence in civil liability due to robot surgery. In particular, it is a matter of reviewing and judging the negligence of this in relation to the part where the new treatment method and technology called robotic surgery are implemented. In this paper, we examine the legal criteria for the negligence presented by the precedents in the past medical malpractice lawsuits, clarify the problems and limitations thereof, and suggest the normative criteria for the negligence in the civil liability for the medical malpractice due to robot surgery, a new treatment method. In addition, it is possible to predict the occurrence of medical accidents due to the implementation of more advanced medical technologies, especially robot doctors equipped with artificial intelligence systems. It emphasizes that it should lead to research and practical tasks that recognize the problems and limitations of the realistic liability law, and constantly consider and present normative criteria for negligence. 현대 의료기술은 눈부신 발전을 거듭하여 임상 수술에서 로봇을 이용한 새로운 수술방법이 사용되고 있다. 현재 사용되고 있는 수술로봇은 인공지능의 자율성을 갖추지는 않았지만, 수술의 모든 과정 또는 일부를 의사와 함께 작업하는 정밀하고 자동화된 의료로봇이다. 로봇수술에 있어 궁극적인 행위 주체는 외과의사이고, 수술로봇은 우리나라 「의료기기법」상 의료기기에 해당한다. 로봇수술로 발생한 의료사고에 대한 법적 책임 판단의 핵심도 행위자와 관련하여 과실을 판단하는 것이다. 그런데 로봇수술로 인한 의료과오소송의 판례에서는 의사 측의 과실책임이 인정되지 않고 있는 현실적인 문제가 있다. 로봇수술이라는 새로운 의료행위는 더욱더 고도의 전문분야에 속하는 것으로, 의사에게 고도의 주의의무를 요구한다. 한편, 의학 및 의료영역의 고도로 특화된 전문성은 환자 측에서 의사 측의 과실 입증을 어렵게 만드는 특성이기도 하다. 로봇수술은 기존의 수술방법과는 다른 새로운 치료방법이라는 점에서 의료과실에 관한 판단에 더욱 어려운 문제가 있게 된다. 종래의 의료행위에 있어 의사의 진료의무와 주의의무 및 설명의무위반에 대한 판례의 법리적 판단기준은 로봇수술로 인한 의료과오 민사책임에서의 과실을 판단할 때에도 적용된다. 이때, 특히 로봇수술이라는 새로운 진료방법 및 기술이 시행된다는 부분과 관련하여 이에 대한 과실의 검토와 판단이 문제 된다. 본 논문은 종래의 의료행위 및 로봇수술로 인한 의료과오소송에서 판례가 제시하고 있는 과실에 대한 법적 판단기준을 검토하여 그 문제점과 한계를 밝히고, 새로운 치료방법인 로봇수술로 인한 의료과오 민사책임에 있어 과실에 대한 규범적 판단기준을 제시해 보기로 한다. 또한, 향후 더욱 새롭게 발전된 의료기술, 특히 인공지능시스템을 갖춘 로봇의사 등의 시행에 따른 의료사고 발생도 예상할 수 있으므로 이에 대한 현실적인 책임법의 문제 및 한계를 인식하고, 과실에 대한 규범적 판단기준을 끊임없이 고민하고 제시하는 연구 및 실무적 과제로 이어져야 한다는 점을 강조한다.

대장직장암절제술에서 로봇수술과 복강경수술의 비교

신재원,김선한 대한의사협회 2012 대한의사협회지 Vol.55 No.7

Laparoscopic surgery is an acceptable option for colorectal cancer. Robotic surgery is an emerging methodology and may be a solution to some difficulties inherent to conventional laparoscopic surgery. The aims of this study are to review the outcomes of laparoscopic and robotic surgery, and to discuss robotic surgery from the perspective of treating colorectal cancer. In rectal cancer, robotic surgery takes a longer operative time and has a higher cost, but decreases conversion to open surgery and shortens the learning curve. It has a great potential for preserving bladder and sexual function after total mesorectal excision (TME). The TME quality may also be better. Robotic surgery can also modify the current standard anastomosis following rectal resection, which is a double-stapling technique. Using a robot enables transanal specimen retrieval then a single-circular stapled anastomosis, which is associated with low pain and fast recovery. More solid answers including the long-term oncologic safety will be provided by ongoing randomized trials. In colon cancer, the ease of performing intracorporeal suture anastomosis may be a benefit. Since complete mesocolic excision with wide lymphadenectomy is becoming more and more acceptable to achieve better oncologic outcomes,the role of robotic surgery in providing a stable environment for radically dissecting lymph nodes should be evaluated. Recently developed new technologies such as fluorescent imaging and a robotic stapler seem promising potentially providing further benefits such as a decrease in anastomotic leakage. Single port robotic surgery is also an interesting concept requiring clinical evaluation. Robotic surgery is a developing field and may provide further functional and oncological benefits to colorectal cancer patients. Large scale randomized trials are timely important.

Comparison of Surgical Skills in Laparoscopic and Robotic Tasks Between Experienced Surgeons and Novices in Laparoscopic Surgery: An Experimental Study

김혜진,최규석,박준석,박수연 대한대장항문학회 2014 Annals of Coloproctolgy Vol.30 No.2

Purpose: Robotic surgery is known to provide an improved technical ability as compared to laparoscopic surgery. We aimed to compare the efficiency of surgical skills by performing the same experimental tasks using both laparoscopic and robotic systems in an attempt to determine if a robotic system has an advantage over laparoscopic system. Methods: Twenty participants without any robotic experience, 10 laparoscopic novices (LN: medical students) and 10 laparoscopically-experienced surgeons (LE: surgical trainees and fellows), performed 3 laparoscopic and robotic training-box-based tasks. This entire set of tasks was performed twice. Results: Compared with LN, LEs showed significantly better performances in all laparoscopic tasks and in robotic task 3 during the 2 trials. Within the LN group, better performances were shown in all robotic tasks compared with the same laparoscopic tasks. However, in the LE group, compared with the same laparoscopic tasks, significantly better performance was seen only in robotic task 1. When we compared the 2 sets of trials, in the second trial, LN showed better performances in laparoscopic task 2 and robotic task 3; LE showed significantly better performance only in robotic task 3. Conclusion: Robotic surgery had better performance than laparoscopic surgery in all tasks during the two trials. However, these results were more noticeable for LN. These results suggest that robotic surgery can be easily learned without laparoscopic experience because of its technical advantages. However, further experimental trials are needed to investigate the advantages of robotic surgery in more detail.

소화기 영역의 로봇 수술

형우진 ( Woo Jin Hyung ) 대한소화기학회 2007 대한소화기학회지 Vol.50 No.4

Robotic surgery is an emerging technology. After adoption of robotic surgery for cholecystectomy in 1997, various general surgical procedures have been performed using surgical robot. In general surgery, robotic surgery is applied to wide range of procedures, however, it is still in its early years. Cholecystectomy, Nissen fundoplication, Heller myotomy, and Roux-en-Y gastric bypass are the most frequently performed robotic operations. Most reports proved that application of robotic technology for general surgery is technically feasible and safe with the help of improved dexterity, better visualization, and high level of precision. However, still the absence of tactile sense and extremely high costs are the problems to be solved. Although robotic surgery has demonstrated some clear benefits compared to conventional surgeries including laparoscopy, it remains to be seen whether these benefits will outweigh the associated disadvantages or problems of robot surgery. Therefore, more prospective randomized study comparing the shot-term and long-term surgical outcomes between robotic and conventional laparoscopic surgery is needed to further define the impact of robotic surgical technology in general surgery. (Korean J Gastroenterol 2007;50:256-259)

lymphREVIEW ARTICLE : The Feasibility and Future Prospects of Robot-Assisted Surgery in Gastric Cancer: Consensus Comments from the National Evidence-based Collaborating Agency Round-Table Conference

( Eunhee Shin ),( Jieun Choi ),( Seongwoo Seo ),( Seonheui Lee ) 한국보건행정학회 2015 보건행정학회지 Vol.25 No.2

To establish an appropriate policy for robotic surgery in Korea, the National Evidence-based Collaborating Agency (NECA) and the Korean Society of Health Policy and Administration held a round-table conference (RTC) to gather opinions through a comprehensive discussion of scientific information in gastric cancer. The NECA RTC is a public discussion forum wherein experts from diverse fields and members of the lay public conduct in-depth discussions on a selected social issue in the health and medical field. For this study, representatives from the medical field, patient groups, industry, the press, and policy makers participated in a discussion focused on the medical and scientific evidence for the use of robotic surgery in gastric cancer. According to the RTC results, robotic surgery showed more favorable results in safety and efficacy than open surgery and it is similar to laparoscopy. When the cost-effectiveness of robotic surgery and laparoscopy is compared, robotic surgery costs are higher but there was no difference between the two of them in terms of effectiveness (pain, quality of life, complications, etc.). In order to resolve the high cost issue of the robotic surgery, a proper policy should be implemented to facilitate the development of a cost-effective model of the robotic surgery equipment. The higher cost of robotic surgery require more evidence of its safety and efficacy as well as the cost-effectiveness issues of this method. Discussions on the national insurance coverage of robotic surgery seems to be necessary in the near future.

부인과 질환의 치료에 있어서 로봇수술의 적응증과 효용성

CHUNG YOUN JEE,김미란 대한의사협회 2012 대한의사협회지 Vol.55 No.7

T he development of robotic technology has facilitated the application of minimally invasive techniques for complex gynecologic surgery. Some major advantages of robotic surgery are three-dimensional magnification and articulation beyond normal manipulation. It also detects and filters out any tremors in the surgeon’s hand movements, so that they are suitable for microsurgery. Compared to laparotomy, robotic gynecological cancer surgery results in improved clinical outcomes and comparable lymph node yields. Radical trachelectomy is an alternative therapy in early cervical cancer in women who wish to retain fertility. Anatomic restriction to the vaginal approach such as lack of pelvic descent is overcome using the robotic technique. This also enables preservation of the uterine vessels and increased precision and visualization during surgery. Robotic and conventional laparoscopic hysterectomy are equivalent regarding surgical and clinical outcomes. Operating times are longer and costs are significantly higher for the robotic procedure. Robotic surgery has the potential to become an enabler for gynecologic minimally invasive surgery, especially suture-intensive operations such as myomectomy. Patients who underwent robot-assisted laparoscopic myomectomy had significantly decreased blood loss,complication rates, and length of stay. The ultimate role of robot-assisted laparoscopic myomectomy is to supplant open myomectomy as the standard of care for conservative surgical treatment of myomas. Robot-assisted treatment of deep infiltrating endometriosis is feasible and safe. Robotic sacrocolpopexy demonstrated similar short-term surgical outcome compared with abdominal sacrocolpopexy, with longer operative time, less blood loss, and a shorter length of stay. Except for its higher cost, robotic surgery in gynecology is feasible with a low complication rate and comparable surgical outcomes.

Robotic surgery for colorectal disease: review of current port placement and future perspectives

이종률,Hassan A. Alsaleem,Jin Cheon Kim 대한외과학회 2020 Annals of Surgical Treatment and Research(ASRT) Vol.98 No.1

Purpose: As robotic surgery is increasingly performed in patients with colorectal diseases, understanding proper port placement for robotic colorectal surgery is necessary. This review summarizes current port placement during robotic surgery for colorectal diseases and provides future perspective on port placements. Methods: PubMed were searched from January 2009 to December 2018 using a combination of the search terms “robotic” [MeSH], “colon” [MeSH], “rectum” [MeSH], “colorectal” [MeSH], and “colorectal surgery” [MeSH]. Studies related to port placement were identified and included in the current study if they used the da Vinci S, Si, or Xi robotic system and if they described port placement. Results: This review included 77 studies including a total of 3,145 operations. Fifty studies described port placement for left-sided and mesorectal excision; 17, 3, and 7 studies assessed port placement for right-sided colectomy, rectopexy, transanal surgery, respectively; and one study assessed surgery with reduced port placement. Recent literatures show that the single-docking technique included mobilization of the second and third robotic arms for the different parts without movement of patient cart and similar to previous dual or triple-docking technique. Besides, use of the da Vinci Xi system allowed a more simplified port configuration. Conclusion: Robot-assisted colorectal surgery can be efficiently achieved with successful port placement without movement of patient cart dependent on the type of surgery and the robotic system

Robotic Colorectal Surgery

백승혁 연세대학교의과대학 2008 Yonsei medical journal Vol.49 No.6

Robotic colorectal surgery has gradually been performed more with the help of the technological advantages of the da Vinci(R) system. Advanced technological advantages of the da Vinci(R) system compared with standard laparoscopic colorectal surgery have been reported. These are a stable camera platform, three-dimensional imaging, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling, and instruments with multiple degrees of freedom. However, despite these technological advantages, most studies did not report the clinical advantages of robotic colorectal surgery compared to standard laparoscopic colorectal surgery. Only one study recently implies the real benefits of robotic rectal cancer surgery. The purpose of this review article is to outline the early concerns of robotic colorectal surgery using the da Vinci(R) system, to present early clinical outcomes from the most current series, and to discuss not only the safety and the feasibility but also the real benefits of robotic colorectal surgery. Moreover, this article will comment on the possible future clinical advantages and limitations of the da Vinci(R) system in robotic colorectal surgery.