Laparoscopic and Robotic Surgery in Turkey

Laparoscopic and robotic surgery are modern surgical methods performed using minimally invasive techniques and causing less tissue damage in patients. These approaches are applied through small incisions using special cameras and surgical instruments, and they accelerate the recovery process.

Within the scope of minimally invasive surgical methods, laparoscopic surgery is performed with high-resolution cameras that allow visualization of the intra-abdominal organs. This technique reduces postoperative pain, lowers the risk of infection, and significantly shortens the length of hospital stay.

Robotic surgery systems, on the other hand, provide the surgeon with three-dimensional imaging and highly precise movement capability, allowing complex operations to be performed in a more controlled manner. Robot-assisted systems are especially widely preferred in the fields of urology, gynecology, and general surgery.

Among the advantages of laparoscopic and robotic surgery are smaller surgical scars, a rapid recovery process, and low complication rates. While increasing patient comfort, these methods also raise surgical success rates and have now become the standard approach in many surgical procedures.

How Did the Transformation of Laparoscopic and Robotic Surgery in Medicine Begin?

Looking at the history of surgical sciences, it is seen that for many years the basic rule was to make a sufficiently large incision to reach the diseased organ. In the past, it was necessary to make large incisions in the abdominal area or around the waist to reach the kidney, prostate, or bladder. These large scars meant severe pain for patients after surgery, risks of wound-site infection, hospital stays lasting for weeks, and major difficulties in returning to daily life. During the recovery period, patients had to remain on prolonged bed rest and stay away from their loved ones and working lives.

By the 1990s, however, laparoscopic methods, also known as “keyhole surgery,” began to enter the field of urology. Instead of making large incisions in the body, this method turned into reality the idea of operating through only a few millimeter-sized small holes into which thin tubes called “ports” were inserted. The inside of the abdomen was gently inflated with a special gas to create a working space, and organs began to be operated on using long, thin instruments with light and a camera at the tip. This created incredible excitement in the surgical world because patients could get out of bed the day after even major surgeries.

However, laparoscopy also had its own technical limitations. The surgical field had to be viewed in two dimensions, that is, without a sense of depth, just like a television screen. The instruments used were in the form of straight rods and could not imitate the wrist movements of the human hand. It was exactly at this point that, with technology advancing at an incredible pace, robotic surgery systems took their place in operating rooms at the beginning of the 2000s. While preserving the advantage of small incisions offered by laparoscopy, robotic systems provided an extraordinary three-dimensional image that gave a sense of depth and robotic arms capable of agile movements that even the human hand could not perform. Thus, a completely new era in medicine began.

What Are the Main Differences Between Open, Laparoscopic, and Robotic Surgery?

To better understand these three different methods, it is necessary to consider the surgeon’s angle of vision during the operation and the way they use their hands. In open surgery, the tissues are contacted directly. Visibility depends entirely on the ambient light and the capacity of the human eye. Reaching organs such as the prostate, especially those located deep within the male pelvic bone, is like reaching into a narrow and dark well. The hands are quite restricted while working in this confined space.

In laparoscopic surgery, large incisions disappear, and the inside is illuminated with a camera, but the image is two-dimensional. The surgeon has to create the sense of depth in their own brain. Imagine threading a needle with one eye closed; that is the kind of mastery and difficulty involved in operating in a deep, complex area on two-dimensional screens. The rod-shaped instruments used can only rotate around their own axes and can move to the right or left at limited angles.

Robotic surgery completely removes these limitations. Thanks to the special dual-lens cameras used, a true three-dimensional (3D) and high-resolution image is obtained. This image is much larger than what can be seen with the naked eye. The finest capillaries and nerve networks that are difficult to distinguish with the eye almost reach enormous dimensions on the screen. This tremendous clarity and magnification prevent damage to the healthy tissues in the surgical area. In terms of freedom of movement, robotic arms are designed to comfortably perform all the maneuvers the human hand can make and much more.

What Are the Main Components of the Robotic Surgery System?

The systems that make robotic surgeries possible consist of certain technological components.

The main parts of this advanced technology system are as follows:

• Surgeon console
• Patient-side unit
• Imaging tower
• Optical cameras
• Robotic arms
• Foot control pedals
• Hand sensors

What Are the Advantages of Robotic Surgery Arms Compared to the Human Hand?

A very common myth in society is that in robotic surgery, the robot performs the operation on its own. This is a completely wrong perception. The system itself cannot make any autonomous decisions or make an incision on its own by being pre-programmed. The system is an extremely advanced guidance platform that transmits the surgeon’s finger movements to the instruments inside the patient with millimetric precision. Control is completely in the surgeon’s hands every second.

At the heart of this technology lies the robotic wrist mechanism called “Endowrist.” Although the human hand is an extraordinary structure, it has some physical limitations when it comes to surgery. For example, the human wrist can bend only up to a certain angle. However, the tips of robotic instruments have the ability to rotate up to 540 degrees around themselves. Imagine having to place a stitch at a reverse angle inside a very narrow tube; while this is very difficult or impossible with the human hand, robotic arms do it with incredible elegance and ease.

In addition, the system has a wonderful safety filter. No matter how skilled they are, every human hand may have a natural and microscopic level of tremor. This tremor is a disadvantage especially in very delicate vascular suturing. Computer software instantly filters out even the slightest possible tremor in the hand of the surgeon sitting at the console and absolutely does not transmit it to the robotic arms inside. The arms inside are always as steady as a rock. In addition, thanks to motion scaling, the surgeon’s large finger movements outside are transformed into much more miniature movements on the organ, bringing the margin of error close to zero.

Why Is Robotic Surgery Preferred in Prostate Cancer?

The treatment of prostate cancer, one of the most important problems threatening men’s health, is an extremely delicate process due to anatomical difficulties. The prostate gland is an organ located at the lowest point of the pelvic bone, just below the bladder. This area resembles a narrow funnel. Not only is it narrow, but the immediate surroundings of the prostate are also encircled by very dense and complex vascular and nerve networks that control male sexual functions and the urinary continence mechanism.

The main purpose of the surgery is, of course, to completely rid the body of cancerous tissue. However, the goal of modern medicine is not only survival but also to ensure that the patient maintains a good quality of life after surgery. In the open surgeries performed in the past, because the area was very narrow and dark and the procedure involved a lot of bleeding, it was extremely difficult to protect these delicate nerve networks around the prostate while removing it. Patients who were cured of cancer could remain dependent on urinary incontinence pads for the rest of their lives or permanently lose their sexual functions.

This is where robotic surgery illuminated this dark picture. The area around the prostate is examined in enormous detail with three-dimensional high-resolution cameras. The nerves responsible for erection are preserved by being peeled away from the surface of the prostate with great precision as a membrane-thin layer of tissue. Thanks to the excellent maneuverability provided inside by the robotic arms, bleeding becomes almost negligible, which ensures that the field of vision remains perfectly clean at all times.

Which Functions Are Preserved After Robotic Surgery for the Prostate?

While the prostate is removed with this delicate surgical method, very important structures that determine the patient’s quality of life are secured.

The main anatomical and functional structures carefully preserved during surgery are as follows:

• Urinary continence muscles
• Nerves responsible for erection
• Bladder neck
• Length of the urinary tract
• Pelvic floor muscles

After the prostate is separated from the body, the bladder and the urinary tract must be sutured back together. This suturing must be flawless and watertight. The robotic arms smoothly unite these two structures by placing extraordinarily delicate stitches in a very narrow area. Thanks to all these protective steps, patients begin to hold their urine comfortably a very short time after their catheters are removed.

How Do Laparoscopic and Robotic Surgery Save the Organ in Kidney Tumors?

The kidneys are our body’s blood filtration facilities. In current approaches, in patients in whom a mass or tumor is detected in the kidney, the highest priority is to protect the healthy kidney by removing only the diseased tissue instead of sacrificing the entire kidney. This organ-preserving approach is of vital importance, especially in masses that have not grown very large. Because leaving healthy kidney tissue in place incredibly reduces the likelihood that the patient will experience heart, vascular, and kidney failure problems in later life.

However, by nature, the kidney is an organ with a very rich blood supply. Cutting out only the tumor from this organ creates a serious risk of bleeding. To stop this bleeding, the main blood vessel going to the kidney must be clamped temporarily during the operation. This is the most stressful moment of the surgery, a race against time. When blood flow is interrupted, healthy kidney cells are deprived of oxygen. It is very important that this period does not exceed safe limits so that the organ does not lose its vitality.

In kidney-preserving surgeries performed by laparoscopic or open methods, after the tumor is removed, suturing the kidney and stopping the bleeding is a very time-consuming and laborious task. This is where the incredible suturing speed and maneuverability of robotic surgery come into play. The tumor is carefully separated from the healthy tissues around it, and the remaining kidney tissue is repaired by being sutured firmly within seconds thanks to the robotic arms. Thus, blood flow to the kidney is restarted in a very short time, and damage to the organ is prevented.

What Are the Advanced Robotic Surgery Technologies Used in Kidney Operations?

Some additional technologies that make organ-preserving surgeries even safer have been successfully integrated into robotic systems.

The technological tools that guide surgeons during the operation are as follows:

• Fluorescent dye imaging
• Infrared light filters
• Three-dimensional navigation
• Digital magnification lenses
• Smart vessel sealers
• Ultrasonic cutters

Among these technologies, the use of fluorescent dye is especially groundbreaking. A special dye substance is administered to the patient through the vein, and the infrared light of the camera is turned on. At that moment, the healthy kidney tissue nourished by blood turns a bright green color on the screen, while the cancerous tumor remains dark. This visual distinction allows the surgeon to cut out the tumor from its boundaries with millimetric precision, neither sacrificing too much healthy tissue nor leaving a dangerous cell behind. In much larger giant tumors that have spread to the main vessels of the kidney, when the entire kidney must be removed, closed methods come into play. By entering through three or four small holes, the vessels around the kidney are safely controlled, and the diseased organ is removed from the body in a closed bag.

Is It Possible to Create a New Bladder with Robotic Surgery in Bladder Cancer?

Bladder cancer, especially when it progresses into the muscle tissue, requires a very major and complex surgical treatment. In advanced stages, the entire bladder, the surrounding lymph nodes, and depending on the situation, the prostate or uterus must be removed from the body as a whole. Performing such a major procedure with traditional open surgery means a huge incision extending all the way along the abdominal area, very painful and taking weeks to heal.

Today, even such a major operation can be performed completely with closed methods through small holes opened in the abdominal area. After the diseased bladder and surrounding tissues are removed with great precision, the patient needs a new storage area to be able to urinate after surgery. With advanced robotic techniques, a certain piece of the patient’s own small intestine is taken and shaped into a brand-new spherical bladder.

The most impressive part is that this new bladder is built not outside the body but completely inside the closed abdominal cavity (intracorporeally). The fact that the intestines remain inside the abdomen without coming into contact with open air prevents postoperative bowel sluggishness (ileus). Patients begin eating and regain normal bowel movements a very short time after surgery. The newly created bladder is sutured precisely to the natural urinary tract. Because nerve-sparing techniques are applied, patients can urinate normally with their new bladders and continue their lives comfortably.

How Is Robotic Surgery Applied in Congenital Narrowing of the Kidney Canal?

Closed surgical methods are life-saving not only in cancer diseases but also in congenital or acquired structural disorders of the urinary tract. Narrowing at the very exit point of the thin channels called ureters, which carry the urine produced by the kidney to the bladder, from the renal pelvis is a very common problem. Because of this narrowing, urine accumulates in the kidney, the organ swells, and over time it begins to decay by losing its function.

The permanent treatment of this condition is to cut out and remove the narrowed part and suture the healthy channel back to the kidney in a wider manner. Since this operation is a reconstruction procedure, it requires flawless and very delicate sutures. Thanks to the tremendous magnification provided by robotic surgery and the wrist movements in the arms, this procedure is performed with extraordinary success. After the narrowed part is cleaned, the new connection is formed in a watertight manner.

This technique is applied extremely safely not only in adults but also in babies and children. Considering the physical and psychological traces that open surgery would leave in children, solving this problem permanently for a lifetime through only a few tiny holes is invaluable comfort for both families and patients.

What Patient Characteristics Are Evaluated Before Laparoscopic and Robotic Surgery?

Although these modern and comfortable surgical methods offer many advantages, the patient’s individual characteristics are examined meticulously to achieve a successful result.

The main elements evaluated in the patient before the decision for surgery are as follows:

• Body mass index
• Advanced age status
• Heart and lung capacity
• Previous abdominal surgeries
• Bleeding disorders
• Stage of the disease
• Anatomical structure

Each surgery has its own specific requirements. Since the inside of the abdomen is inflated with gas in minimally invasive surgeries, a certain pressure is created on the heart and lungs. In addition, in pelvic surgeries, the patient may need to be laid head-down. For this reason, patients with heart failure or serious respiratory problems are evaluated in great detail together with anesthesia teams, and the most appropriate method is chosen.

Are Closed Surgery Methods an Obstacle in Obesity or Advanced Age?

There is a common but incorrect belief in society that being overweight or old age is an obstacle to these advanced technology surgeries. On the contrary, obesity is one of the situations in which the advantages of minimally invasive surgery are most evident.

Performing open surgery on an overweight patient is very difficult for the surgical team. To pass through the thick fat layer and reach the organ deep inside, very large and wide incisions must be made. After surgery, the risk of that large wound becoming infected, opening up, or turning into a hernia is quite high. It is also much more painful for overweight patients to get up and walk after open surgery.

However, in laparoscopic and robotic methods, when the inside is inflated with gas, a wide, clear, and spacious working room is formed under the thick fatty tissues. Thanks to the camera, fatty tissues cease to be an obstacle, and the targeted organ is reached directly. Likewise, for elderly patients, the bodily trauma caused by large surgical incisions is very severe. Being operated on through only a few millimeter-sized holes minimizes postoperative pain in elderly patients, almost eliminates blood loss, and saves them from being dependent on the bed. For elderly patients, this also prevents fatal risks that may develop due to prolonged lying down, such as pneumonia or vascular occlusion.

What Are the Advantages of the Recovery Process After Laparoscopic and Robotic Surgery?

Minimizing bodily trauma allows patients to feel the difference from the moment they leave the operating room.

The main advantages experienced by patients after surgery are as follows:

• Low blood loss
• Minimum pain
• Low risk of infection
• Short hospital stay
• Fast return to daily life
• Small surgical scars

After open surgeries, patients generally need to receive blood from outside, whereas in closed methods this need disappears because bleeding is very low. Since the muscles and tissues are not injured by large incisions, patients feel much less pain. Most of the time, standard painkillers are sufficient for their relief. Compared to the difficult hospital stays of five to seven days after open surgeries, many patients who undergo robotic surgery can be discharged comfortably on foot at the end of the first or second day. The time to return to work, social life, and loved ones is shortened by weeks.