Robotic surgery
Robotic surgery or robot-assisted surgery is any type of surgical procedure that is performed with the use of robotic systems. Robotically assisted surgery was developed with the primary goal of overcoming the limitations of pre-existing minimally invasive surgical procedures, alongside enhancing the capabilities of surgeons performing open surgeries.
In the case of robotically assisted minimally-invasive surgery, instead of the surgeon manually moving the surgical instruments, he uses one of two methods to perform dissection, hemostasis, and resection: either a remote manipulator or a computer control system.
- A telemanipulator is a system of remotely controlled manipulators that enables a surgeon to perform the surgery in real-time under stereoscopic vision from a control console separate from the operating table. In this case, the surgical robot is docked next to the patient, while the robotic arms carry out endoscopy-like maneuvers via end-effectors inserted through specially designed trocars. A surgical assistant and a scrub nurse are often still needed scrubbed at the tableside to help switch effector instruments or provide additional suction or temporary tissue retraction using endoscopic grasping instruments.
- In computer-controlled systems, the surgeon uses a computer system to relay control data and direct the robotic arms and their end-effectors, even though these systems still possess the ability to use telemanipulators for their input. One of the primary advantages of using the computerized method is that it does not require the surgeon to be physically present on campus to perform the procedure, leading to the possibility for remote surgery and even AI-assisted or automated procedures.
History
The concept of using standard hand grips to control manipulators and cameras of various sizes down to sub-miniature was described in the Robert Heinlein story "Waldo" in August 1942, which also mentioned brain surgery.The first robot to assist in surgery was the Arthrobot, which was developed and used for the first time in Vancouver in 1983. This robot assisted in being able to manipulate and position the patient's leg on voice command. Intimately involved were biomedical engineer James McEwen, Geof Auchinleck, a UBC engineering physics grad, and Dr. Brian Day as well as a team of engineering students. The robot was used in an orthopaedic surgical procedure on 12 March 1983, at the UBC Hospital in Vancouver. The next important milestone took place in 1985, when the first brain biopsy under CT guidance with the assistance of a robotic arm, PUMA200, was performed. Eventually, over 60 arthroscopic surgical procedures were performed over the period of the first 12 months, while a National Geographic video on industrial robots, The Robotics Revolution, featured the device. Furthermore, among other related robotic devices that were developed at the same time was a surgical scrub nurse robot, which handed operative instruments on voice command, and a medical laboratory robotic arm. A YouTube video entitled Arthrobot – the world's first surgical robot illustrates some of these in operation.
In 1985, a robot, the Unimation Puma 200, was used to orient a needle for a brain biopsy while under CT guidance during a neurological procedure. In the late 1980s, Imperial College London developed a surgical robotic system, PROBOT, which was then used to perform prostatic surgery. Some of the advantages of this robot included its relatively small size, accuracy, and an absence of fatigue for the surgeon. In the 1990s, computer-controlled surgical devices began to emerge, enabling greater precision and control in surgical procedures. One of the most significant milestones in this period was the development of the da Vinci Surgical System, which was approved by the Food and Drug Administration for use in surgical procedures in 2000. The da Vinci system utilizes robotic arms to manipulate surgical instruments, enabling surgeons to perform complex surgical procedures with a significantly higher level of accuracy and control. Additionally, in 1992, the ROBODOC was introduced, eventually revolutionizing orthopedic surgery by being able to assist with hip replacement surgeries. The latter was the first surgical robot to receive the FDA's official approval, which occurred in 2008. The ROBODOC from Integrated Surgical Systems could mill out precise fittings in the femur for hip replacement. The purpose of the ROBODOC was to replace the previous method of carving out a femur for an implant, the use of a mallet and broach/rasp.
Further development of robotic systems was carried out by SRI International and Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system. The first robotic surgery was performed at The Ohio State University Medical Center in Columbus, Ohio, under the direction of a renowned American cardiothoracic surgeon, Robert E. Michler.
When publicly introduced in 1994, AESOP represented a breakthrough in robotic surgery, as it was the first laparoscopic camera holder to be granted the FDA's approval for commercial use. Furthermore, the U.S. government space agency NASA was among companies, governmental institutions, and agencies that provided research funding to the company Computer Motion, which produced AESOP, due to its goal of creating a robotic arm that can be used in space; however, this project eventually moved in the direction of medical science, resulting in the development of a camera used in laparoscopic procedures. In 1996, a voice control system was installed in the AESOP 2000 surgical robot, followed in 1998 by the function of seven degrees of freedom, which enhanced the AESOP 3000 robotic system, effectively enabling it to mimic a functional human hand.
The ZEUS robotic surgical system was commercially introduced in 1998, marking the inception of telerobotics, also known as telepresence surgery, where the surgeon conducts the surgical procedure remotely, navigating the robot through a console, while the robot performs the procedure on the patient. ZEUS was used for the first time during a gynecological surgery in 1997 to reconnect Fallopian tubes in Cleveland, Ohio. Afterwards, it was used on several other surgical procedures, including a beating heart coronary artery bypass graft in October 1999, and the Lindbergh Operation, which was a cholecystectomy performed remotely in September 2001. In 2003, ZEUS made its most prominent mark in cardiac surgery after successfully harvesting the left internal mammary arteries in 19 patients, all of whom had very successful clinical outcomes.
The original telesurgery robotic system that the da Vinci was based on was developed at Stanford Research Institute International in Menlo Park, California, financially supported by DARPA and NASA. A demonstration of an open bowel anastomosis was given to the Association of Military Surgeons of the US. Although the telesurgical robot was originally intended to facilitate remotely performed surgery on the battlefield and in different remote locations or hardly accessible environments to reduce casualties, it turned out to be more useful for minimally invasive on-site surgery. The patents for the early prototype were sold to Intuitive Surgical in Mountain View, California. The da Vinci senses the surgeon's hand movements and translates them electronically into scaled-down micro-movements to manipulate the tiny proprietary instruments. It also detects and filters out any tremors in the surgeon's hand movements, so that they are not duplicated robotically. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console. Compared to the ZEUS, the da Vinci robot is attached to trocars to the surgical table, and can imitate the human wrist. In 2000, the da Vinci obtained FDA approval for general laparoscopic procedures and became the first operative surgical robot in the US. Examples of using the da Vinci system include the first robotically assisted heart bypass in May 1998, and the first performed in the United States in September 1999; and the first all-robotic-assisted kidney transplant, performed in January 2009. The da Vinci Si was released in April 2009 and initially sold for $1.75 million.
In 2005, a surgical technique was documented in canine and cadaveric models called the transoral robotic surgery for the da Vinci robot surgical system, as it was the only FDA-approved robot to perform head and neck surgery. In 2006, three patients underwent resection of the tongue using this technique. The results were more clear visualization of the cranial nerves, lingual nerves, and lingual artery, and the patients had a faster recovery to normal swallowing. In May 2006, the first artificial intelligence doctor-conducted unassisted robotic surgery was successfully performed on a 34-year-old male to correct a heart arrhythmia. The surgery's outcome was rated as better than an above-average human surgeon. The machine had a database of 10,000 similar operations, and so, in the words of its designers, was "more than qualified to operate on any patient." In August 2007, Dr. Sijo Parekattil of the Robotics Institute and Center for Urology performed the first robotic-assisted microsurgery procedure of denervation of the spermatic cord for chronic testicular pain. In February 2008, Dr. Mohan S. Gundeti of the University of Chicago Comer Children's Hospital performed the first robotic pediatric neurogenic bladder reconstruction.
On 12 May 2008, the first image-guided MR-compatible robotic neurosurgical procedure was performed at the University of Calgary by Dr. Garnette Sutherland using the NeuroArm. In June 2008, the German Aerospace Centre presented a robotic system for minimally invasive surgery, the MiroSurge neurosurgical robotic system. In September 2010, the Eindhoven University of Technology announced the development of the Sofie surgical system, the first surgical robot to employ force feedback. In September 2010, the first robotic operation on the femoral vasculature was performed at the University Medical Centre Ljubljana by a team of surgeons led by Dr. Borut Geršak.
In 2017, the first robotic system designed specifically for microsurgery and supermicrosurgery, the , developed by was introduced. It was first used clinically at for procedures in patients with lymphedema.
In 2019 the Versius Surgical System was launched by the British medical device company CMR Surgical. It seeks to challenge the Da Vinci surgical system on the global market, claiming its products are more flexible and versatile, with independent modular arms that are "quick and easy to set up." Versius' small-scale design signifies that the system is suitable for virtually any operating theater and can be operated at either a standing or a sitting position.