-What is Robotic Surgery

Introduction:

Robotic surgery is the latest evolution of minimally invasive surgical procedures, During surgery, three or four robotic arms are inserted into the patient through small incisions in the abdomen, One arm is a camera, two act as the surgeon’s hands and a fourth arm may be used to move obstructions out of the way.

The patients are surrounded by a complete surgical team, while the surgeon is seated at a nearby console, The surgeon uses a viewfinder which offers a three-dimensional image of the surgical field, the surgeon’s hands are placed in special devices that direct the instruments, 

Robotic arms filter out any tremors in the physician’s hands & increase the physician’s range of motion, This enhanced precision is helpful to the surgeon during delicate portions of procedures.

Robotic surgery is ideal for those more complex & difficult to access surgeries, within the specialty of general surgery, its application is widely developed in oncological surgery of the rectum & esophagus-gastric and also, in the other procedures such as surgery of the morbid obesity & the pelvic floor.

Robotic surgery is a new and exciting emerging technology that is taking the surgical profession by storm. Up to this point, however, the race to acquire and incorporate this emerging technology has primarily been driven by the market. 

In addition, surgical robots have become the entry fee for centers wanting to be known for excellence in minimally invasive surgery despite the current lack of practical applications. Therefore, robotic devices seem to have more of a marketing role than a practical role. 

Whether or not robotic devices will grow into a more practical role remains to be seen.

It is an advanced form of minimally invasive or laparoscopic (small incision) surgery where surgeons use a computer-controlled robot to assist them in certain surgical procedures, 

The hands of the robot have a high degree of dexterity, allowing surgeons to operate in very tight spaces in the body that would otherwise only be accessible through open (long incision) surgery.

The idea of robotics used for surgery began more than 50 years ago, but actual use began in the late 1980s with Robodoc (Integrated Surgical Systems, Sacramento, CA), the orthopedic image-guided system developed by Hap Paul, DVM, and William Bargar, MD, for use in prosthetic hip replacement. 

During the time frame of Drs. Paul and Bargar’s development of Robodoc, Brian Davies and John Wickham were developing a urologic robot for prostate surgery. 

In addition, there were a number of computer-assisted systems being used in neurosurgery (called stereotactic) and otolaryngology. 

These were procedure-specific, computer-assisted, and image-guided systems that proved both the potential and value of robotic surgery systems. 

They also heralded the multipurpose teleoperated robotic systems initially developed by SRI International and the Defense Advanced Research Projects Agency (DARPA) and led to the surgeon-controlled (multifunctional) robotic telepresence surgery systems that have become a standard of care. 

The impetus to develop these systems stemmed from the Department of Defense’s need to decrease battlefield casualties, and DARPA was precisely the agency to conduct such high-risk research and development.

Robotic Surgery

Background and history of surgical robots:

Since 1921 when Czech playwright Karel Capek introduced the notion and coined the term robot in his play Rossum’s Universal Robots, robots have taken on increasingly more important both in imagination and reality. 

Robot, taken from the Czech robota, meaning forced labor, has evolved in meaning from dumb machines that perform menial, repetitive tasks to the highly intelligent anthropomorphic robots of popular culture. 

Although today’s robots are still unintelligent machines, great strides have been made in expanding their utility. 

Today robots are used to perform highly specific, highly precise, and dangerous tasks in industry and research previously not possible with a human work force. Robots are routinely used to manufacture microprocessors used in computers, explore the deep sea, and work in hazardous environment to name a few. Robotics, however, has been slow to enter the field of medicine.

The lack of crossover between industrial robotics and medicine, particularly surgery, is at an end. Surgical robots have entered the field in force. Robotic tele surgical machines have already been used to perform transcontinental cholecystectomy. 

Voice-activated robotic arms routinely maneuver endoscopic cameras, and complex master slave robotic systems are currently FDA approved, marketed, and used for a variety of procedures. 

It remains to be seen, however, if history will look on the development of robotic surgery as a profound paradigm shift or as a bump in the road on the way to something even more important.

Paradigm shift or not, the origin of surgical robotics is rooted in the strengths and weaknesses of its predecessors. Minimally invasive surgery began in 1987 with the first laparoscopic cholecystectomy. Since then, the list of procedures performed laparoscopically has grown at a pace consistent with improvements in technology and the technical skill of surgeons. 

The advantages of minimally invasive surgery are very popular among surgeons, patients, and insurance companies. Incisions are smaller, the risk of infection is less, hospital stays are shorter, if necessary at all, and convalescence is significantly reduced. 

Many studies have shown that laparoscopic procedures result in decreased hospital stays, a quicker return to the workforce, decreased pain, better cosmesis, and better postoperative immune function. 

As attractive as minimally invasive surgery is, there are several limitations. Some of the more prominent limitations involve the technical and mechanical nature of the equipment. Inherent in current laparoscopic equipment is a loss of haptic feedback (force and tactile), natural hand-eye coordination, and dexterity. Moving the laparoscopic instruments while watching a 2-dimensional video monitor is somewhat counterintuitive. 

One must move the instrument in the opposite direction from the desired target on the monitor to interact with the site of interest. Hand-eye coordination is therefore compromised. Some refer to this as the fulcrum effect. 

Current instruments have restricted degrees of motion; most have 4 degrees of motion, whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization. 

Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult if not impossible. 

The motivation to develop surgical robots is rooted in the desire to overcome the limitations of current laparoscopic technologies and to expand the benefits of minimally invasive surgery.

From their inception, surgical robots have been envisioned to extend the capabilities of human surgeons beyond the limits of conventional laparoscopy. The history of robotics in surgery begins with the Puma 560, a robot used in 1985 by Kwoh to perform neurosurgical biopsies with greater precision. 

Three years later, Davies et al performed a transurethral resection of the prostate using the Puma 560. This system eventually led to the development of PROBOT, a robot designed specifically for transurethral resection of the prostate. 

While PROBOT was being developed, Integrated Surgical Supplies Ltd. of Sacramento, CA, was developing ROBODOC, a robotic system designed to machine the femur with greater precision in hip replacement surgeries ROBODOC was the first surgical robot approved by the FDA.

Also in the mid-to-late 1980s a group of researchers at the National Air and Space Administration (NASA) Ames Research Center working on virtual reality became interested in using this information to develop telepresence surgery. 

This concept of telesurgery became one of the main driving forces behind the development of surgical robots. In the early 1990s, several of the scientists from the NASA-Ames team joined the Stanford Research Institute (SRI). Working with SRI’s other robotocists and virtual reality experts, these scientists developed a dexterous telemanipulator for hand surgery.

 One of their main design goals was to give the surgeon the sense of operating directly on the patient rather than from across the room. While these robots were being developed, general surgeons and endoscopists joined the development team and realized the potential these systems had in ameliorating the limitations of conventional laparoscopic surgery.

Current robotic surgical systems:

Today, many robots and robot enhancements are being researched and developed. Schurr at Eberhard Karls University’s section for minimally invasive surgery have developed a master-slave manipulator system that they call ARTEMIS. 

This system consists of 2 robotic arms that are controlled by a surgeon at a control console. Dario et al at the MiTech laboratory of Scuola Superiore Sant’Anna in Italy have developed a prototype miniature robotic system for computer-enhanced colonoscopy. 

This system provides the same functions as conventional colonoscopy systems but it does so with an inchworm-like locomotion using vacuum suction. 

By allowing the endoscopist to tele operates or directly supervise this endoscope and with the functional integration of endoscopic tools, they believe this system is not only feasible but may expand the applications of endoluminal diagnosis and surgery. 

Several other laboratories, including the authors’, are designing and developing systems and models for reality-based haptic feedback in minimally invasive surgery and also combining visual serving with haptic feedback for robot-assisted surgery.

In addition to Prodoc, ROBODOC and the systems mentioned above several other robotic systems have been commercially developed and approved by the FDA for general surgical use. These include the AESOP system (Computer Motion Inc., Santa Barbara, CA), a voice-activated robotic endoscope, and the comprehensive master-slave surgical robotic systems, Da Vinci (Intuitive Surgical Inc., Mountain View, CA) and Zeus (Computer Motion Inc., Santa Barbara, CA).

The da Vinci and Zeus systems:

The da Vinci and Zeus systems are similar in their capabilities but different in their approaches to robotic surgery. Both systems are comprehensive master-slave surgical robots with multiple arms operated remotely from a console with video assisted visualization and computer enhancement. In the da Vinci system. which evolved from the telepresence machines developed for NASA and the US Army, there are essentially 3 components: a vision cart that holds a dual light source and dual 3-chip cameras, a master console where the operating surgeon sits, and a moveable cart, where 2 instrument arms and the camera arm are mounted. 

The camera arm contains dual cameras and the image generated is 3-dimensional. The master console consists of an image processing computer that generates a true 3-dimensional image with depth of field; the view port where the surgeon views the image; foot pedals to control electrocautery, camera focus, instrument/camera arm clutches, and master control grips that drive the servant robotic arms at the patient’s side. 

The instruments are cable driven and provide degrees of freedom. This system displays its 3-dimensional image above the hands of the surgeon so that it gives the surgeon the illusion that the tips of the instruments are an extension of the control grips, thus giving the impression of being at the surgical site.

The Zeus system is composed of a surgeon control console and 3 table-mounted robotic arms. The right and left robotic arms replicate the arms of the surgeon, and the third arm is an AESOP voice-controlled robotic endoscope for visualization. 

In the Zeus system, the surgeon is seated comfortably upright with the video monitor and instrument handles positioned ergonomically to maximize dexterity and allow complete visualization of the OR environment. 

The system uses both straight shafted endoscopic instruments similar to conventional endoscopic instruments and jointed instruments with articulating end-effectors and 7 degrees of freedom.

The da Vinci and Zeus systems

Medical artificial intelligence:

AI in medicine means tasks are completed more quickly, and it frees up a medical professional’s time, so, he can perform other duties that can’t be automated, Artificial intelligence can manage medical records and other Data, 

Robots can collect, store, re-format, and trace data to offer faster & more consistent access, Data management is the most widely used application of artificial intelligence and digital automation.

Medical artificial intelligence refers to the use of AI technology / automated processes in the diagnosis and treatment of patients who require care, Medical records are digitized, appointments can be scheduled online, patients can check into health centers or clinics using their phones or computers.

AI is used for collecting of data through patient interviews and tests, Processing and analyzing results, Using multiple sources of data to come to an accurate diagnosis, Determining an appropriate treatment method, Preparing and administering the chosen treatment method, Patient monitoring & Aftercare, follow-up appointments etc.

Advantages of robot-assisted surgery:

These robotic systems enhance dexterity in several ways. Instruments with increased degrees of freedom greatly enhance the surgeon’s ability to manipulate instruments and thus the tissues. These systems are designed so that the surgeons’ tremor can be compensated on the end-effector motion through appropriate hardware and software filters. 

In addition, these systems can scale movements so that large movements of the control grips can be transformed into micromotions inside the patient.

Another important advantage is the restoration of proper hand-eye coordination and an ergonomic position. These robotic systems eliminate the fulcrum effect, making instrument manipulation more intuitive. 

With the surgeon sitting at a remote, ergonomically designed workstation, current systems also eliminate the need to twist and turn in awkward positions to move the instruments and visualize the monitor.

By most accounts, the enhanced vision afforded by these systems is remarkable. The 3-dimensional view with depth perception is a marked improvement over the conventional laparoscopic camera views. 

Also to one’s advantage is the surgeon’s ability to directly control a stable visual field with increased magnification and maneuverability. 

All of this creates images with increased resolution that, combined with the increased degrees of freedom and enhanced dexterity, greatly enhances the surgeon’s ability to identify and dissect anatomic structures as well as to construct microanastomose

Disadvantages of robotic-assisted surgery:

There are several disadvantages to these systems. First of all, robotic surgery is a new technology and its uses and efficacy have not yet been well established. To date, mostly studies of feasibility have been conducted, and almost no long-term follow up studies have been performed. 

Many procedures will also have to be redesigned to optimize the use of robotic arms and increase efficiency. However, time will most likely remedy these disadvantages.

Another disadvantage of these systems is their cost. With a price tag of a million dollars, their cost is nearly prohibitive. 

Whether the price of these systems will fall or rise is a matter of conjecture. Some believe that with improvements in technology and as more experience is gained with robotic systems, the price will fall.  

Others believe that improvements in technology, such as haptics, increased processor speeds, and more complex and capable software will increase the cost of these systems. Also at issue is the problem of upgrading systems; how much will hospitals and healthcare organizations have to spend on upgrades and how often? 

In any case, many believe that to justify the purchase of these systems they must gain widespread multidisciplinary use.

Another disadvantage is the size of these systems. Both systems have relatively large footprints and relatively cumbersome robotic arms. This is an important disadvantage in today’s already crowded-operating rooms. It may be difficult for both the surgical team and the robot to fit into the operating room. 

Some suggest that miniaturizing the robotic arms and instruments will address the problems associated with their current size. Others believe that larger operating suites with multiple booms and wall mountings will be needed to accommodate the extra space requirements of robotic surgical systems. The cost of making room for these robots and the cost of the robots themselves make them an especially expensive technology.

One of the potential disadvantages identified is a lack of compatible instruments and equipment. Lack of certain instruments increases reliance on tableside assistants to perform part of the surgery.6 This, however, is a transient disadvantage because new technologies have and will develop to address these shortcomings.

Most of the disadvantages identified will be remedied with time and improvements in technology. 

Only time will tell if the use of these systems justifies their cost. If the cost of these systems remains high and they do not reduce the cost of routine procedures, it is unlikely that there will be a robot in every operating room and thus unlikely that they will be used for routine surgeries.

Practical uses of surgical robots:

In today’s competitive healthcare market, many organizations are interested in making themselves “cutting-edge” institutions with the most advanced technological equipment and the very newest treatment and testing modalities. 

Doing so allows them to capture more of the healthcare market. Acquiring a surgical robot is in essence the entry fee into marketing an institution’s surgical specialties as “the most advanced.” It is not uncommon, for example, to see a photo of a surgical robot on the cover of a hospital’s marketing brochure and yet see no word mentioning robotic surgery inside.

As far as ideas and science, surgical robotics is a deep, fertile soil. It may come to pass that robotic systems are used very little but the technology they are generating and the advances in ancillary products will continue.

 Already, the development of robotics is spurring interest in new tissue anastomosis techniques, improving laparoscopic instruments, and digital integration of already existing technologies.

As mentioned previously, applications of robotic surgery are expanding rapidly into many different surgical disciplines. The cost of procuring one of these systems remains high, however, making it unlikely that an institution will acquire more than one or two. 

This low number of machines and the low number of surgeons trained to use them makes incorporation of robotics in routine surgeries rare whether this changes with the passing of time remains to be seen.

The Future of Robotic Surgery:

Robotic surgery is in its infancy. Many obstacles and disadvantages will be resolved in time and no doubt many other questions will arise. Many question have yet to be asked; questions such as malpractice liability, credentialing, training requirements, and interstate licensing for tele-surgeons, to name just a few.

Many of current advantages in robotic assisted surgery ensure its continued development and expansion. 

For example, the sophistication of the controls and the multiple degrees of freedom afforded by the Zeus and da Vinci systems allow increased mobility and no tremor without comprising the visual field to make micro anastomosis possible. 

Many have made the observation that robotic systems are information systems and as such they have the ability to interface and integrate many of the technologies being developed for and currently used in the operating room. 

One exciting possibility is expanding the use of preoperative (computed tomography or magnetic resonance) and intraoperative video image fusion to better guide the surgeon in dissection and identifying pathology. 

These data may also be used to rehearse complex procedures before they are undertaken. The nature of robotic systems also makes the possibility of long-distance intraoperative consultation or guidance possible and it may provide new opportunities for teaching and assessment of new surgeons through mentoring and simulation. 

Computer Motion, the makers of the Zeus robotic surgical system, is already marketing a device called SOCRATES that allows surgeons at remote sites to connect to an operating room and share video and audio, to use a “telestrator” to highlight anatomy, and to control the AESOP endoscopic camera.

Technically, many remains to be done before robotic surgery’s full potential can be realized. Although these systems have greatly improved dexterity, they have yet to develop the full potential in instrumentation or to incorporate the full range of sensory input. 

More standard mechanical tools and more energy directed tools need to be developed. Some authors also believe that robotic surgery can be extended into the realm of advanced diagnostic testing with the development and use of ultrasonography, near infrared, and confocal microscopy equipment.

Much like the robots in popular culture, the future of robotics in surgery is limited only by imagination. Many future “advancements” are already being researched. Some laboratories, including the authors’ laboratory, are currently working on systems to relay touch sensation from robotic instruments back to the surgeon. 

Other laboratories are working on improving current methods and developing new devices for suture-less anastomosis. When most people think about robotics, they think about automation. The possibility of automating some tasks is both exciting and controversial. 

Future systems might include the ability for a surgeon to program the surgery and merely supervise as the robot performs most of the tasks. The possibilities for improvement and advancement are only limited by imagination and cost.

Conclusion: 

Although still in its infancy, robotic surgery has already proven itself to be of great value, particularly in areas inaccessible to conventional laparoscopic procedures. It remains to be seen, however, if robotic systems will replace conventional laparoscopic instruments in less technically demanding procedures.

 In any case, robotic technology is set to revolutionize surgery by improving and expanding laparoscopic procedures, advancing surgical technology, and bringing surgery into the digital age. 

Furthermore, it has the potential to expand surgical treatment modalities beyond the limits of human ability. Whether or not the benefit of its usage overcomes the cost to implement it remains to be seen and much remains to be worked out. 

Although feasibility has largely been shown, more prospective randomized trials evaluating efficacy and safety must be undertaken. Further research must evaluate cost effectiveness or a true benefit over conventional therapy for robotic surgery to take full root.  

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