by Nikou Kelardashti

Graphic design by Josephine Choi

From the first crude attempts at surgery to the precision of today’s robotic arms, the evolution of surgical technology reflects an unwavering pursuit of perfection in the operating room. 

Historically, open surgery with large incisions was the predominant surgical method. This method allowed the surgeons to directly visualize the surgical site and made the problem more tangible. However, this invasive approach comes with drawbacks such as increased risk of infection, post-surgical pain, increased blood loss, and prolonged recovery time.¹ The invention of video laparoscope in the 1980s marked a pivotal shift towards minimally invasive surgery.¹ Laparoscope, a tube equipped with a camera and a light source, is inserted through a small incision into the abdominal or pelvic cavity. This enables the surgeon to visualize and examine the affected area. Consequently, laparoscopic surgery has gained popularity as a form of minimally invasive surgery. 

Despite overcoming some of the disadvantages associated with open surgery, laparoscopic surgery introduced some of its own challenges. Notably, these include extended procedure times and the necessity for general anesthesia as opposed to local. In addition, a significant drawback of traditional laparoscopic surgery was the counterintuitive movement of surgical instruments, where hand movements were in the opposite direction of instruments’ motion.¹ Moreover, the two-dimensional nature of its video display hindered depth perception. All these factors rendered traditional laparoscopy challenging for inexperienced surgeons. Recognizing these limitations, robotic surgery or robot-assisted surgery has emerged as a novel minimally invasive surgery method aimed at overcoming the setbacks of the previous surgical methods.

Applications of robotic surgery span a wide range of medical specialties. In cardiac procedures like coronary artery bypass surgery and mitral valve replacement, robotic surgery has become a viable option eradicating the need for extensive incisions and ribcage openings. Within the realm of urology, many surgeries including those for prostate, kidney, and bladder can be performed robotically. Similarly, in gynecology, hysterectomy or removal of uterus is among the procedures benefiting from robotic surgery. Beyond these domains, robotic surgery is used in colorectal, general, and thoracic surgeries. The adaptability of robotic systems to various anatomical structures and surgical challenges underscores their potential to redefine the standards of care across a broad spectrum of medical interventions, marking a paradigm shift in the way surgeons approach and execute intricate procedures.

History of Robotic Surgery

The inception of robotic surgery finds its roots in the military domain. This was prompted by challenges faced in military combat zones where access to healthcare assistance is often limited.² Consequently, the concept of teleoperation emerged as a solution. This would have allowed the surgeons to operate a surgical robot from a distance thereby enhancing surgical capabilities in the battlefield. Another catalyst for teleoperation came from the extended stays of astronauts in spaceships, highlighting the anticipated need for surgical expertise in space.² All these underscored the significance of telepresence as a driving force for improving laparoscopic surgeries.

Later on, the concepts developed for military teleoperation found commercial applications making pivotal movement in the evolution of robotic surgery. The first application of a robot in surgery occurred in 1988 when Dr. Kwoh and his team at California’s Memorial Medical Center performed a neurosurgical biopsy using PUMA 560, the first flexible robotic arm.³ This innovation aimed to increase precision and guidance during procedures surpassing the capabilities of the surgeon’s hand. Afterwards, for an extended period of time, the da Vinci system, a robotic-assisted set by Intuitive Surgical (Sunnyvale, CA) dominated the field of robotic-assisted surgery. However, in recent years, other companies have tried to challenge da Vinci’s dominance, introducing an element of competition and choice to the realm of robotic surgery. 

Unveiling Robotic Surgery

Robotic surgical systems are categorized into three primary types: active, semi-active, and master-slave systems.⁴ Active systems are preprogrammed and function autonomously under the supervision of a surgeon. Semi-active systems perform pre-programmed tasks and incorporate a surgeon-driven element. The most prevalent are the master-slave systems which lack any pre-programmed tasks and depend entirely on the surgeon’s control. These systems are composed of three components. The tower (slave) is equipped with multiple arms featuring instruments such as hooks, forceps, and needle-drivers with an additional arm housing a high-resolution camera. The console (master), where the surgeon sits, is placed in the same surgical room. It gives the surgeon the ability to remotely control the tiny laparoscopic surgical instruments with a wide range of motion. The system translates the surgeon’s hand movements at the console in real time offering a 3D high-definition view of surgical site. 

In addition to mitigating the disadvantages associated with open surgery, robotic surgery has many advantages over laparoscopic surgery. These include tremor fixation, a ten-fold magnification capability, stereoscopic vision, heightened precision, and motion scaling.⁴ In addition, robotic surgery puts less physical strain on the surgeon in comparison to the alternative surgical methods.⁴ 

While robotic surgery offers many advantages, its utilization comes with certain drawbacks that warrant consideration. Primarily, the initial cost of purchasing and implementing the robotic systems can be substantial.⁵ The necessity for recurrent maintenance and specialized training of surgeons further amplifies the costs associated with this type of surgery. For example, the da Vinci robot costs US$2 million, rendering it financially inaccessible for many institutions.⁵ Beyond the financial considerations, the large and obstructive nature of robotic arms present practical challenges.³ This complicates surgical procedures even in standard-sized operating rooms, frequently leading to collisions. Additionally, certain procedures require undocking and redocking of robotic arms during surgery, resulting in increased time of surgery and increased anesthesia time.³ Another drawback is the lack of tactile feedback for the surgeon and an inability to regulate the applied force effectively. Moreover, the long-term outcomes of robot-assisted surgeries remain inadequately documented. While preliminary research indicates superior short-term results in cancer operations, such as reduced blood loss and enhanced recovery times, the equivalency of long-term outcomes remains a subject of ongoing investigation.⁵ This highlights the importance of comprehensive research on long-term benefits of robot-assisted surgery. 

Future of Robotic Surgery 

In summary, the evolving trends in robotic surgery indicate a relentless pursuit of innovation in surgical systems. The next generation of robotic platforms is expected to achieve several key objectives including the reduction of instrument and robotic arm sizes, the facilitation of automatic instrument exchange, the integration of tissue feedback technology, and the incorporation of artificial intelligence and machine learning. The integration of artificial intelligence stands to offer various advantages such as providing intraoperative guidance based on real-time surgical data and automating repetitive tasks, enhancing the overall efficiency of surgeons. This convergence of cutting-edge technologies signifies a paradigm shift towards precision and personalized patient care, ushering in a new era in the field of surgery.

References:

1. Gharagozloo F, Najam F. Robotic Surgery. New York, NY: McGraw-Hill Medical; 2008.

2. Morrell ALG, Morrell-Junior AC, Morrell AG, et al. The history of robotic surgery and its evolution: when illusion becomes reality. Rev Col Bras Cir. 2021;48:e20202798. 

3. Kalan S, Chauhan S, Coelho RF, Orvieto MA, Camacho IR, Palmer KJ, et al. History of robotic surgery. J Robot Surg. 2010;4(3):141–7 

4. Bramhe S, Pathak SS. Robotic surgery: A narrative review. Cureus. 2022 Sept 15;14(9).

5. Crew B. Worth the cost? A closer look at the da Vinci robot’s impact on prostate cancer surgery. Nature. 2020;580(7804):S5–7.