Currently one of the most advanced robots in use today is the da Vinci Surgical System. It is an extremely precise tool that has been in use for over ten years. The advantages of surgeries performed using this technology are often shorter recovery times and less discomfort for the patient. Some of the procedures that are commonly performed are prostatectomies, hysterectomies, and bariatric weight loss.
If you would like to schedule an appointment with a surgeon at Flushing Hospital, please call Computer assistance, robotics, automation, and virtual reality are quite new concepts, and more recently they have been applied to healthcare assistance. The last decades have witnessed an exponential growth in medical technology, with the robotic platform applied to surgery one of its most remarkable events. Robots were used in the surgical world more than 30 years ago, and have become a new standard of care, yielding interesting results.
The purpose of this article was to describe the history, evolution, current status, and perspectives of robotic surgery. The idea of creating an automatic machine able to carry out some tasks usually performed by human hands is quite old.
Regarding its surgical applications, its initial concept began more than 60 years ago in the military field. During military combats, hostile environments whose access is difficult and sometimes undesirable are frequent, therefore, lacking proper healthcare assistance. Not rarely, the area with the most limited resources and manpower is the closest to the site of injuries.
Hemorrhagic shock and polytrauma are the most frequent causes of primary death in combat, and therefore, for the military there was an immediate need to provide expert surgical care after major trauma based on damage control surgery 1 1 Zajtchuk R, Rellamy RF, Grande CM, editors.
Anesthesia and perioperative care of the combat casualty. Part IV - surgical combat casualty care. Textbook of Military Medicine.
Another important scenario contributing to robotics and the telepresence concept development was the space race. Not different from warzone, space is the most obvious scenario where human presence demands huge efforts. The necessity for instrument telemanipulation resulted in private and national public engagement for technology development in the area. The virtual reality pioneer Scott Fisher developed the first head mounted display HMD , which immersed the viewer in a three-dimensional 3D virtual environment while the engineer Phil Green developed a system of robotic telemanipulation for microsurgery at the Stanford Research Institute SRI.
Both ideas of telepresence and robotized telemanipulation were essential to assure the concept of telesurgery. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. The development of a surgeon robot for prostatectomies. Proc Inst Mech Eng H. Development of a surgical robot for cementless total hip arthroplasty.
Clin Orthop Relat Res. Allowing the surgeon to optimize the prosthesis size on a patient-specific basis, the Robodoc is currently the only active robotic system cleared by the Food and Drug Administration FDA for the use in orthopedic surgery.
The first model of the robotic arm approved in for usage, the AESOP , was controlled using pedals. When idealized, the robotic AESOP was designed to improve image stability and reduce the medical personnel required in the operating room, showing numerous documented advantages over traditional human-assisted camera holding, especially replacing the need for a surgical assistant who may become fatigued during long procedures 5 5 Kavoussi LR, Moore RG, Adams JB, Partin AW.
Comparison of robotic versus human laparoscopic camera control. J Urol. As a result, Computer Motion, in , presented the Zeus system with arms and surgical instruments controlled by the surgeon, introducing the actual concept of telepresence, in which the surgeon master commands the slave robot.
The ZEUS robot consisted of three arms, each independently attached to a surgical table, having one AESOP arm controlling the scope and two other surgical arms with four degrees of freedom Figure 2. The surgeon console consisted of a video monitor and two handles which are able to manipulate the instruments, providing an enhanced interface and 2-dimensional display. Full robotic assistance for laparoscopic tubal anastomosis: a case report.
One year later, an open-heart grafting of the coronary artery was performed in Canada. In , a major step in robotic surgery took place in what was called the Operation Lindberg. In allusion to Charles Lindberg, the American aviator who performed the first solo transatlantic flight, the Operation Lindberg consisted of a robotic surgery performed using the ZEUS robot and a telecollaboration system SOCRATES that allowed a surgeon using a remote operating station to control the robotic arm located across the Atlantic.
Transatlantic robot-assisted telesurgery. The procedure lasted 54 minutes and had no technical incidents, and with no perception of distance. Figure 2 ZEUS robot consisted of three arms. Years before, in , Frederick H. The patient-side cart of Lenny consisted of 3 separate robotic arms that clamped to the operating table, where two were instrument arms and the third arm held the scope camera 8 8 DiMaio S, Hanuschik M, Kreaden U. The da Vinci Surgical System.
Surgical Robotics: Systems Applications and Visions. Boston, MA: Springer; Telesurgical laparoscopic cholecystectomy. Surg Endosc. Further procedures were achieved such as arteriovenous fistula cases and gastric banding procedures 10 10 Himpens J. The world's first obesity surgery performed by a surgeon at a distance.
Obes Surg. In , Intuitive brought into human use the first system of what would be the most successful robotic surgery platform until now: da Vinci. The procedures were diverse, including thoracoscopic internal mammary harvesting, mitral valve repair, cholecystectomies and Nissen fundoplication 8 8 DiMaio S, Hanuschik M, Kreaden U. The initial commercial sale of the da Vinci was to the Leipzig Heart Center in Germany in late , and with its aid, the surgeons were able to perform a cardiac valve repair and coronary artery bypass graft surgery that were significantly less invasive than the standard sternotomy 12 12 Salisbury JK Jr.
The heart of microsurgery. Without sensations like vibration, static friction, stress, tension, tangential force, etc. When the force feedback was turned off however, high-definition images combined with monocular cues compensated for the lack of tactile information. The SRI system was never intended for human use or commercialization, but as a research prototype developed, the concept proved to be a valid one.
Although funded by external sources, FFRDCs like SRI have numerous exit strategies once a project is ready for commercialization, such as starting a spin-off company or licensing patents. In this case, they chose the latter, and between and efforts were made to pitch the system to venture capitalists. In , Dr. Yulun Wang founded Computer Motion with the goal of creating an endoscopic holder.
While searching for marketable gaps in laparoscopic surgery, Dr. Wang found 2 distinct needs: first, to articulate instrumentation, and, second, to stably hold a laparoscope that could be controlled by the surgeon.
Not only was the technology itself significant as the first voice-controlled equipment approved for use in the OR and the first FDA-approved surgical robot, but Computer Motion used the FDA's K process instead of class III approval, allowing it to be released to the market several years faster and set a precedent for future competition to use. AESOP's success is illustrated by its adoption into more than hospitals and represents the beginning of robotic surgery's global impact.
ZEUS prioritized improving laparoscopic surgery and the original intended use of surgical robotics as a remote surgery system.
Instead of a stereoscopic viewer, the surgeon sat at a monitor with polarizing glasses, much like the SRI system. Early versions had only 6 DOFs, but a seventh was added later.
Motion scaling and tremor elimination were also key features. Computer Motion made cardiothoracic surgery the original target for ZEUS, with particular emphasis on developing a minimally invasive procedure for coronary artery bypass graft surgery CABG. However, there were several difficulties with robotic CABG procedures, predominantly that there still was not enough space to accurately position instruments, even if they were articulated. In the same time frame, catheter procedures were showing efficacy.
ZEUS, much like the later da Vinci, found a market in urologic surgery, although this was short lived, as well as profound telesurgical applications.
Fred Moll, MD, at the time an employee of Guidant, saw an opportunity for growth in laparoscopic surgery. Freund negotiated for SRI's intellectual property, and in Drs.
Moll and Freund were joined by Robert Younge, an electrical engineer who had also departed from Acuson, and founded Intuitive Surgical. Patient-side manipulators were manually attached to the surgical table and had fixed instrumentation.
The patient-side component of Lenny consisted of 3 separate robotic arms that clamped to the operating table. Two were instrument arms, and the third held the endoscopic component.
Part of what enabled this evolution was the addition of exchangeable instrumentation that could be interchanged while maintaining a sterile field. The first procedure attempted was a cholecystectomy performed on a year-old woman on March 3, Himpens operated robotic instruments through two mm ports with an endoscope connected to a third.
Final ports were used for clip placement and liver retraction. Later in the same day, Drs. Himpens and Leman performed a second cholecystectomy as well as an adhesion lysis.
The following day, Marc Bosiers, MD, performed 2 arteriovenous fistula cases for dialysis using Mona. Those interested in publications about the first human trials will be disappointed. Although Dr. Himpens was able to document the event in a letter to the editor featured in Surgical Endoscopy ; submissions were refused by The New England Journal of Medicine and The Lancet , due to the seemingly incredible nature of robots assisting with surgery. Cadiere highlighted 3 points in the piece: that telesurgery is safe and feasible, that it is ergonomically advantageous, and these points are particularly evident in bariatric surgery due to fixed trocars and difficulty in the surgeon's positioning relative to the patient.
Although all the surgeries were successful, they noted that the robot was most beneficial to the procedure when in a confined space or if microsuturing was involved. Several flaws were still evident, including a fragile instrument exchange coupling, inadequate visualization, and unwieldy setup process. The da Vinci's most obvious departure from its predecessors was creation of a stand-alone cart housing patient-side operative components, replacing the necessity for mounting slave manipulators to the table while increasing positioning flexibility from overhead arms.
The da Vinci also had a completely revamped stereoscopic viewer. In the place of single shuttered video displays in combination with glasses, the viewer now had discrete video outputs for each eye, which reduced fatigue and nausea. The master manipulators also progressed from the telescoping system used by SRI to a backhoe design, enabling freer motion. At the patient-side element, the current Welch Allyn endoscope was switched for a custom-built endoscope from Precision Optics Corporation with dual lenses.
This setup resolved some of the issues with video quality and contributed to greater depth perception. Procedures included cholecystectomy, Nissen fundoplication, thoracoscopic internal mammary harvesting, and mitral valve repair. Intuitive had high hopes of marketing the da Vinci for cardiovascular surgeries but, much like ZEUS, hit a flush of success a bit more caudal than they had anticipated.
The Vattikuti Institute of Detroit, Michigan, was the first to document a process for what they called the Vattikuti Institute prostatectomy, which would become commonly known over time as the robotic-assisted prostatectomy. The Vattikuti team had positive outcomes in comparison with the standard radical retropubic approach. This made the procedure difficult to learn, making the open approach more advantageous.
In comparison, one of the main advantages of ZEUS was that it had the experimental capacity for remote surgery which the initial da Vinci did not, because it was only directly connected by cable to the surgeon's console.
There were structural and software differences between the 2 devices, as well. ZEUS mounted a pair of robotic arms to the OR table with the 2 most distal joints passive, allowing the joints to pivot easily for trocar alignment.
In May , Intuitive requested that the U. Although SRI had filed patents on the interferences 6 months before Computer Motion, further conflict soon arose. One year later, Computer Motion sued Intuitive Surgical for infringement on 9 separate patents. The legal battle dragged on for 3 years until the 2 competitors merged in The Silver Falcon had 6 total DOFs: 3 within the base positioner, and another 3 from the wrist, plus the distal grasper. Issues arose from poor structural rigidity, inadequate grip strength for manipulating large needles, and gravitational compensation via counterbalancing.
Their next attempt, the Black Falcon, rectified these concerns while adding another DOF to the wrist and making the end effector detachable although the authors note that it was not easily detachable, and tool exchange was notably tedious.
However, there were several concerns with integrating haptics into a device for clinical applications. The MIT team found that for some tasks, such as suturing, the force reflection offered more hindrance than assistance.
The haptic technology at the time was not sensitive enough for operators to discern when the manipulators came in contact with soft tissue. Attempts to scale up the force to increase the likelihood of sensation only made physical manipulation of the controllers fatiguing. Encouragingly, they found that visualization of deflection in soft tissue occurred before force was a factor.
Similar concerns arose with force feedback from SRI's system, although the illusion from the system of mirrors and stereoscopic vision was more than sufficient to compensate for dismissing the force feedback. Although the early goals of surgical robotics were aimed toward long-distance telesurgery, there are only a few cases where this has actually occurred. Marescaux performed a robotic minimally invasive cholecystectomy between New York City and his patient, a year-old woman in Strasbourg, France.
These events were historic, but media coverage was overshadowed by the terrorist attacks on September 11, The year also saw the initiation of the world's first national telesurgery in Canada with the goal of transmitting from large tertiary hospitals to remote and rural medical centers.
Anvari notes that while surgery may be possible with up to a ms lag, the effects of visual cue and proprioception mismatch at any greater level of lag result in extreme difficulty and even nausea. These successes led to the creative question of whether surgical robotics could be applied in extreme environments.
NEEMO 7 was able to establish that telementoring was achievable in extreme environments. Anvari in Ontario, Canada. One of the main conclusions from NEEMO 9 was that the lag time, especially considering the distance between Earth and the potential space applications, like a manned mission to Mars, were truly detrimental. This was demonstrated by the M7 through a live stream feed to the American Telemedicine Association's annual meeting in by inserting a needle via robotic arm by ultrasound visualization into a mimetic tissue.
The da Vinci followed with experiments in when 4 nephrectomies were completed in anesthetized swine. While the surgeon was located in either Cincinnati, Ohio, or Denver, Colorado, the porcine model was found in a Sunnyvale, California, laboratory. The Denver to Sunnyvale surgeries were successful with round trip delay at ms. This lag was doubled to ms in the Cincinnati to Sunnyvale surgery, which is nearly twice the distance at miles, but had multiple instances of visual packet loss.
Marescaux's earlier success at transatlantic robotic cholecystectomy with Zeus, which traveled round distance nearly 8, miles with a lag time of only ms, there were issues with patient safety and exorbitant cost. In this time frame, the military had renewed interest in telesurgical applications of robotics. Led by Dr. Progress to FDA approval for such a complex system takes an average of 20 years, yet was achieved in little more than a decade Figure The advancement seen to date has truly been remarkable.
While the history of robotics has been well documented, the contributions from living primary sources have added crucial information in creating a definitive documentation. However, the evolution of robotic surgery is far from over, with multiple potential competitors on the horizon.
Not only will there be new tools, but surgeons are continually adapting new procedures and specialties for use with robotics. The developments in patient outcomes, surgical ingenuity, and creative technology will be well worth watching.
Evalyn I. COL Timothy C. National Center for Biotechnology Information , U. Satava , MD. Find articles by Evalyn I. Find articles by Jacques Marescaux. Author information Copyright and License information Disclaimer. Corresponding author. These views are those of the authors and not of the US Department of Defense.
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