The future of medicine is a primary concern for everyone. Medical providers are concerned with providing the most up to date and beneficial treatment to patients, and patients are concerned with receiving the best, most appropriate care from medical providers. This is the driving force behind why continued research and advancements are being made every day in the field of medicine. One of the important fields in the discussion of medical advancements and future directions is surgical robotics. According to Gomes (2011), the use of surgical robotics has the potential of increased accuracy, reduced procedure lengths, “patient demand, reduction of surgical errors, augmenting surgical capabilities and enabling MIS” (para. 3). Gomes (2011) defines MIS as “any procedure which is less invasive than open surgery for the same purpose” (para. 4). The origin of surgical robotics dates back to the 1980s and since then numerous advancements have been made popularizing its utilization in various areas of medicine (Lanfranco, Castellanos, Desai, & Meyers, 2004). This paper will provide a brief overview of the history of robotic surgery, a review of the developments that have been made to shape the utilization of robotics in surgery, compare operative outcomes between robotics and other surgical procedure methods, and lastly, mention some of the future directions of surgical robotics.
History of Robotic Surgery
Before their emergence into the field of medicine robotics had been developed and used in many other settings including computer systems and exploration of the deep sea (Lanfranco et al., 2004). One of the first steps toward the popularization and utilization of robotics in surgery was the introduction of laparoscopic surgery in 1987, through the first successful completion of a laparoscopic cholecystectomy (Lanfranco et al., 2004). The desire to reduce infection rates, recovery time, and smaller incision sites were all motivating factors for the development of laparoscopy, all of which are driving factors for surgical robotics as well. As the field of laparoscopy grew the limitations of the procedures were made apparent and the desire to overcome these limitations opened the door for further development of surgical robotics (Lanfranco et al., 2004). Lanfranco et al. (2004) lists the limitations to laparoscopic surgery as:
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“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” (para. 5).
Many of these limitations are directly related to human limitation, thus making robotics an attractive development in medicine. Thus, developers kept these limitations in mind while developing robotic systems (Lanfranco et al., 2004).
A second important vision in the development of surgical robotics is their utilization in telepresence procedures (Lanfranco et al., 2004). This vision started in a group of researchers at the National Air and Space Administration (NASA) in the mid-to-late 1980s. The NASA research group joined hands with a Stanford Research Institute (SRI) team and from this partnership they developed a “dexterous telemanipulator for hand surgery” (Lanfranco et al., 2004, para. 7). Another important aspect of this research team was the inclusion of general surgeons and endoscopists, who aided in the development and who realized the potential impact that robotics could have for in-person and telemedicine in the field of surgery (Lanfranco et al., 2004).
A third important organization to become involved in the early developments of surgical robotics was the United States Army (Lanfranco et al., 2004). Like the research team at NASA the possibility of telepresence appealed to the US Army. The US Army saw telemedicine as a way to treat soldiers in the field of duty without having to transport a surgeon to the soldier’s location, thus having the potential to improve response times and the care of injured soldiers. Other organizations that were involved in funding and developments in early surgical robotics were Computer Motion, Inc of Santa Barbara, CA and Integrated Surgical Systems of Mountain View, CA. These groups worked together to design and integrate the higher processing surgical robotics seen in practice today (Lanfranco et al., 2004).
The first robot used in surgery was the Puma 200 to obtain brain biopsy using CT guidance in April of 1985 in California (Gomes, 2011). Once in place the surgical robot was quickly powered down in order to create a fixed position so that the surgeon could collect the brain biopsy. At the time the gold standard for this type of brain biopsy was to use a manually adjustable stereotactic frame. The robot allowed this fixed position to be more quickly and accurately obtained, the CT guidance allowed for placement without damage to vital surround structures. The next milestone of surgical robotics occurred in April of 1991 in London. At this time a Probot was used to perform a transurethral radical prostatectomy (TURP) (Gomes, 2011). The practice of using robotics to perform radical prostatectomy is the standard of care today (Callan & Chen, 2013). With the help of early developments various companies have worked to expand the use of robotics in surgery and medicine, new machines have been developed and additional FDA approvals have been granted for various surgical procedures on multiple organ systems (Gomes, 2011).
It is important to understand the history of surgical robotics in order to appreciate the advancements that have been made thus far. Perhaps, even more important to understand is the original motivations of robotic developments, as these motivations are still important today because they continue to guide equipment and technology developments and the expansion of the application of this equipment. A brief review of surgical robotic developments over the years is discussed in the following section.
Developments in Robotic Surgery
The continued developments in surgical robotics has led to the expansion of their use into other medical specialties and other organ systems. There are three main groups of surgical robotics continually being researched and developed today (Gomes, 2011). The first of these is autonomous robotics, which allow for the robot to carry out tasks automatically at certain stages of the procedure, without surgeon intervention. The second major group is dedicated to the development of assistive and collaborative robots. This group of robotics are designed to reproduce the surgeons hand motions, these machines traditionally have no autonomy. The third group consists of small, special purpose surgical robots (Gomes, 2011). Each group serves various purposes throughout differing surgical procedures, specific examples of robots and their uses within each group are further discussed in this section.
The first robotic surgeries ever performed were with autonomous robots in 1985 and 1991 (Gomes, 2011). In 1992, Japan developed the SCARA robot for use in total hip arthroplasties. The United States Food and Drug Administration (FDA) did not approve its use until 1998. Another orthopedic robotic system, the Robodoc Surgical system was developed for total knee arthroplasty (TKA) and became FDA approval in 2009, since its approval it is estimated that the Robodoc has assisted more in 24,000 surgeons in joint replacement procedures in the U.S., Europe, Japan, Korea, and India. Another commonly used robot is the CyberKnife system designed for use in radiosurgery to administer radiation to tumor cells, while also minimizing the amount of radiation delivered to surrounding structures. A third orthopedic robotic system, the BRIGHT robot was developed for use in TKA and was designed to allow for the robot to be positioned specifically related to patient need as determined by the surgeon, the system was placed on the market in 2007, but as of 2011, there are no reports of its use in clinical practice. There were other autonomous surgical robotic systems, such as the BRIGHT robot, that were designed but were never adopted in clinical practice (Gomes, 2011).
One the most well-known robot’s, the da Vinci robot falls into the second category of robotics, the assistive/collaborative robots (Gomes, 2011). This device takes the surgeons hand movements and scales them down to the robotic instruments inside the patient, which filters out any tremors that may occur in the surgeon. The da Vinci also provides a 3-dimensial image of the surgical field and either three or four instrument arms, at the surgeon’s discretion (Gomes, 2011). The da Vinci robot has been utilized in various cardiac procedures such as mitral valve repair, ASD closure, LV pacing lead implantation, among others (Porrett, 2016). The Sensei robotic catheter system was FDA approved in 2007 and is another assistive robot that is utilized in interventional cardiology (Gomes, 2011). An important aspect of the Sensei robotic catheter is that the surgeon is not exposed to radiation when performing the heart catheterization, thus making it a safer option for the surgeon. A third assistive robot is the Acrobot Sculptor which was designed to be utilized in TKA procedures in crowded operating theaters. This device has both a synergistic device and a spherical manipulator These features allows for a more bone conserving joint replacement and resurfacing, and a more responsive reaction to low force movements made by the surgeon. Another unique feature of the Acrobot is that the robot utilizes preset boundaries set via CT scanning, in which the robotic arms are free to move throughout these boundaries and when they reach the outer edges they then become stiff in order to prevent them from leaving the “safe” region. A second assistive robot used for joint replacement is the Robotic arm Interactive Orthopedic system (RIO) approved by the FDA in 2005. As of 2010, there were 36 RIO systems in operation and over 2,000 procedures had been performed in a short four year period (Gomes, 2011). These assistive robots appear to be the most commonly utilized and favored robotic systems.
At the time of the Gomes (2011) project the final group of robotics had yet to be defined, however their direction was thought to be to design “smaller, special purpose, lower cost, possibly disposable robots, providing alternatives to the current large, versatile and expensive systems” (para. 26). There are several proposed designs for robotics in this area for specific procedures and patients. One example of a device being developed at the time of the Gomes (2011) research is the HeartLander. Gomes (2011) explains that this device is a “miniature mobile robot that delivers minimally invasive therapy to the surface of the beating heart” (para. 30). The primary appeal of this device is that it reduces the damage that another method would require in order to access the heart. The importance of this group of robotics is the vast potential that it has for growth and advancements in medicine (Gomes, 2011).
The developments made throughout the history of surgical robotics have shaped the directions of the field today and will continue to shape its future directions. Additionally, these developments have improved patient care in various aspects. The following section discusses the outcomes of robotic surgery in comparison to open and laparoscopic methods of surgery.
Comparing Robotic Surgery to other Surgical Techniques
In order to determine the usefulness of robotic surgery one must consider the outcomes of this method of surgery in numerous patients. Many studies have sought to provide evidence that proves one method of surgery to be superior to another. However, as each patient is different this is a difficult determination to make. Each surgeon must weigh the risks and benefits of each procedure method to determine which will provide the best outcome to the patient. This section provides evidence from two different articles that compared the outcomes of open, laparoscopic, and robotic surgical methods in patients undergoing a radical prostatectomy and a radial hysterectomy.
Tewari et al. (2012) compared surgical outcomes of open, laparoscopic, and robotic radical prostatectomy (RP). The results of this study found that laparoscopic RP had the highest rates of positive surgical margins. However, both laparoscopic and robotic RP resulted in lower levels of total blood loss and transfusions needed during the procedure, and shorter hospital stay compared to open RP. The complication rates related to the procedure were lowest in robotics RP. Finally, Tewari et al. (2012) found that “rates for readmission, reoperation, nerve, ureteral, and rectal injury, deep vein thrombosis, pneumonia, hematoma, lymphocele, anastomotic leak, fistula, and wound infection showed significant difference between groups, generally favoring RALP [robotic RP]” (abstract). From these results if the surgeon wants to ensure clear margins, reduce blood loss during procedure, and reduce postoperative hospital stay the best option is robotic RP.
A second study performed by Magrina, Kho, Weaver, Montero, and Magtibay (2008) compared perioperative and postoperative results from robotic, laparoscopic, and laparotomy techniques in patients undergoing a radial hysterectomy. This study found that on average the laparotomy took the least amount of time. The robotic technique had almost half the amount of average blood loss to that of laparoscopy and approximately 30% of the average blood loss during an open procedure. The postoperative hospital stay was found to be the shortest in robotic surgery. However, this study did not find any significant differences in complications between the surgical methods, both during and after the procedure. Although, the laparotomy is the fastest procedure, both laparoscopy and robotics take roughly the same amount of time and the advantages of decreased average blood loss make them preferable procedure modalities (Magrina, Kho, Weaver, Montero, & Magtibay, 2008).
In general, it can be accepted that minimally invasive procedures promise the possibility of decreased hospital stay and minimal scaring, two of the reasons that make this type of surgical technique appealing to patients. The Tewari et al. (2012) and the Magrina et al. (2008) studies provide agreeable evidence that robotic surgery also provides the possibility of the least amount of blood loss when compared to open procedures. Additionally, the Tewari et al. (2012) study found a significantly lower complication rate in robotic procedures. Again, the procedure method should be determined by the surgeon as the best option for the patient in question. While this data provides evidence to support robotic surgery being superior in multiple aspects, it is not the right method for every patient. The following section aims to provide insight into the future directions that surgical robotics aspire to achieve.
Future Directions of Robotic Surgery
The medical field is one of the fastest changing fields as medical advancements are being made every day. Less than 50 years ago surgical robotics was a new medical advancement and today surgical robots can be found all across the world. Research is being aimed at answering questions about complication rates, cost, usability, etc. associated with surgical robotics, which will help shape the future of surgical robotics.
Cresswell, Cunningham-Burley, and Sheikh (2018) performed a qualitative interview study in which individuals from various backgrounds shared their opinion of surgical robotics in order to determine if there were any overarching themes or barriers to its use in the medical field today. Interestingly, this study found that the advancements and integration of electronic health records created a sort of hiatus in the investments in robotics. The study also found numerous barriers to the integration of surgical robotics. One of these barriers was determined to be concerns of the public, patient, and health care providers. One example of these concerns involves the physician patient relationship and how robotics opposes the relationship that people have strived to build. Another barrier found through the study was the fear of robotics. Individuals expressed concerns about robots being human like and the lack of trust that some individuals possess toward robotics. A third barrier is new ethical and liability questions that the integration of robotics raises which requires further developments to be made to determine what qualifies as human responsibility and what qualifies as technological autonomy (Cresswell et al., 2018). A fourth barrier to the utilization of surgical robotics is the amount of training and practice that a surgeon needs in order to become proficient in the use of the device (Callan & Chen, 2013). Taking into account all of these barriers, the field of surgical robotics is still making advancements and the front runner in these advancements is the field of urology (Callan & Chen, 2013).
Urology utilizes robotic surgery for radical prostatectomies, radical cystectomies, surgical nerve grafting, and pyeloplasty (Callan & Chen, 2013). This in part stems from the aforementioned decreased rates of surgery related complications, and in part because of the advantages of “greater accuracy, flexibly, smoother actions, and greater range of motion” (Callan & Chen, 2013, para. 1) that robotics provides. Callan and Chen (2013) mentions that one important area of needed improvements in robotics is the integration of real-time imaging performed intra-operatively with autonomous computer controlled systems, like the surgeon controlled systems currently operate with. The article states that integrating this real time imagining would allow for adjustments to be made during surgery, when the pre-operative imaging prove to be inaccurate. Another specific area of improvement is integrating the information gathered from systems about instrument deflection and tissue movement to allow for changes in position throughout surgery. This practice is currently used in Direct Image guided Intervention (DIGI) robots but is not commonplace among all robotics. A third area of improvement is haptics, which includes tactile and kinesthetic feedback during surgery. The lack of haptics is predominantly seen in complex tasks where it is difficult to identify tissue consistency. The reason that more precise haptics have not already been integrated into practice is due to the fact that the technology necessary to do so is extremely complex and while there are several proposed methods to accomplish this there have been limitations in applying the technology to the robotics used in operative theaters today. While there are numerous other possible advancements to be made, Callan and Chen (2013) define these as the most pressing.
Although barriers exist against the usage of surgical robotics, the drive to provide the best medical care to each and every patient will continue to motivate further advancements in technologies and surgical robotics. Advancements in both imaging integration of computer controlled systems and the advancements of haptics throughout all systems of surgical robotics will inevitabily achieve better patient outcomes. The field of surgical robotics has undergone much growth since its inception less than 50 years ago, there is no doubt that this growth will continue and will help shape the future of medicine.
While patients continue to demand the best and safest surgical methods, medical research will continue to determine what exactly those methods are. Surgical robotics allows another minimally invasive option that corrects for certain surgeon related errors, such as tremors. Additionally, robotics aims to complete a more accurate procedure, in less time, with less bleeding, and a shorter hospital stay compared to other popular surgical methods. However, it is important to keep in mind that each patient and each surgeon may not be best suited for a robotic procedure. The field of surgical robotics has made great advancements in a short amount of time, a trend that will likely continue as the field develops more precise methods to perform surgical procedures. The primary goal of surgical robotics is the same goal throughout the other aspects of the medical field, to provide the best equipment available in order for medical providers to provide the best patient care possible.
- Callan, L., & Chen, N. (2013). The future of surgical robotics. University of Western Ontario Medical Journal, 82(1), 22-23. Retrieved from https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1009&context=uwomj#page=24.
- Cresswell, K., Cunningham-Burley, S., & Sheikh, A. (2018). Health care robotics: Qualitative exploration of key challenges and future directions (Preprint). Journal of Medical Internet Research, 20(7), 408-417. https://doi: 10.2196/10410
- Gomes, P. (2011). Surgical robotics: Reviewing the past, analysing the present, imagining the future. Robotics and Computer-Integrated Manufacturing, 27(2), 261-266. https://doi:10.1016/j.rcim.2010.06.009
- Lanfranco, A. R., Castellanos, A. E., Desai, J. P., & Meyers, W. C. (2004). Robotic surgery. Annals of Surgery, 239(1), 14-21. https://doi:10.1097/01.sla.0000103020.19595.7d
- Magrina, J. F., Kho, R. M., Weaver, A. L., Montero, R. P., & Magtibay, P. M. (2008). Robotic radical hysterectomy: Comparison with laparoscopy and laparotomy. Gynecologic Oncology, 109(1), 86-91. https://doi:10.1016/j.ygyno.2008.01.011
- Porrett, P. M., Drebin, J. A., Atluri, P., Karakousis, G. C., & Roses, R. E. (2016). The surgical review: An integrated basic and clinical science study guide (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
- Tewari, A., Sooriakumaran, P., Bloch, D. A., Seshadri-Kreaden, U., Hebert, A. E., & Wiklund, P. (2012). Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: A systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. European Urology, 62(1), 1-15. https://doi:10.1016/j.eururo.2012.02.029