HHS Public Access Author manuscript Author Manuscript
Am J Robot Surg. Author manuscript; available in PMC 2015 October 22. Published in final edited form as: Am J Robot Surg. 2014 June 1; 1(1): 1–64.
Robotic Surgery: Applications Tiffany Leung, B.S. and College of Human Medicine, Michigan State University, 1200 East Michigan Avenue, Suite 655, Lansing, MI 48912, USA
Author Manuscript
Dinesh Vyas, MD, MBBS, MS, FICS [Assistant Professor] [Advanced Robotic and GI Surgeon] [Adjunct Professor] [Director] Department of Surgery; Institute of International Health; MS Surgery Clerkship, College of Human Medicine, Michigan State University, 1200 East Michigan Avenue, Suite 655, Lansing, MI 48912, USA
Surgical Specialties
Author Manuscript
In a relatively short amount of time, robots have made its way into both general and subspecialty surgical fields. The da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) has been around for over a decade now. The first da Vinci surgical system came out in 1999 and was FDA approved in 2000. In 2003, a fourth robotic arm was added. The da Vinci S model came out in 2006 and offered improved robotic arm movements, console displays, and simpler set up. As of 2009, the latest model called da Vinci Si, now offers dual consoles so two individuals can collaborate simultaneously. Controls, vision, and ergonomics have been improved as well.
Author Manuscript
The specialties that use the da Vinci system frequently are urological, gynecological, and gastrointestinal surgery (1). In 2010, Intuitive Surgical Inc., the manufacturer of the da Vinci robot, reported that over 70% of robotic procedures were for both prostatectomy and hysterectomy combined (1). Further, robotic technique is the preferred method of performing a radical prostatectomy as the definitive treatment for prostate cancer (2). In gynecology, it is estimated that over 60% of minimally invasive hysterectomies performed in patients with endometrial cancer were done robotically (3). There are several reasons why urologists and gynecologists perform more robotic procedures than their other surgical counterparts. These include balance of surgeon endoscopic skill level, meaning how often endoscopic or laparoscopic techniques are performed in their field; equipment limitations, especially when working with anatomically complex areas; and procedure complexity, taking into account which procedures are better performed open versus minimally invasive versus robotically, the latter having the greatest precision (2). Robotic options do exist for surgical treatment in other specialties although it is used much less frequently. These include cardiothoracic surgery, for cases of coronary bypass and heart defects repairs; general surgical oncology, for esophageal tumors, gastric cancer, colon cancer, thymoma; and pediatrics, to resolve congenital heart diseases, gastroespohageal reflux disease, or uretopelvic junction obstruction (4).
Leung and Vyas
Page 2
Author Manuscript
Development of Robots It cannot be emphasized enough that robotic surgery is a relatively young field, but it is one that has grown at a rapid pace in the past couple of decades. Use of robots in surgery began in 1985 when a group of neurosurgeons were able to perform biopsies with a machine they called Puma 560 (5). Other breakthroughs happened shortly thereafter. In 1988, the first robotic transurethral prostate resection using the same system was accomplished. The PROBOT, a specialized robot designed to perform prostatectomy was then developed by Harris et al. Another company called Integrated Surgical Supplies Ltd. from Sacramento, CA, created ROBODOC, designed for use in hip replacement surgery. This device was the first surgical robot approved by the FDA.
Author Manuscript
The idea of using robots to perform remote operations, otherwise known as telesurgery, first came about in the early 1990’s. Stemming from the concept of virtual reality, researchers at the National Air and Space Administration (NASA) Ames Research Center worked with a team at Stanford University’s Research Institute hoping to develop ways to provide surgical intervention to astronauts from a remote hospital. Their goal was to make the surgeon feel as if he/she were operating directly on a patient even though they were located elsewhere. This idea caught the attention of U.S. Army surgeons who hoped to develop a system for remote operations on wounded soldiers under the direction of a surgeon who would be located in a safe zone.
Author Manuscript
These researchers had the idea of expanding the use of robots to civilian practice as well. In 1993, a company called Computer Motion, Inc., of Goleta, CA, succeeded in creating a robotic camera holder called Automated Endoscopic System for Optimal Positioning (AESOP). Shortly thereafter, the control system for the device, HERMES, came around, which led to a complete functional robotic system called ZEUS. This system, also known as a master-slave device, permitted a surgeon (master) to operate a console and control a robot (slave).
Author Manuscript
In 1995, a company called Intuitive Surgical from Sunnyvale, CA, began working on a combined master-slave system with a three-dimensional vision system and patient safety sensor monitors to create a prototype machine called the da Vinci surgical system. Surgeons in Belgium first utilized the device in 1997 with robotic cholecystectomy and Nissen fundoplication. Its eventual FDA approval came around in 2000. As of 2009, Intuitive Surgical Inc. is now in its fourth generation of the da Vinci robotic system. A four-arm da Vinci robotic system with high definition enhanced visual magnification and dual consoles designed in mind for teaching purposes is being used around the world today in a broad range of specialties as mentioned earlier, and is specifically indicated for micro- and complex-minimally invasive surgeries.
Nanorobotic surgery Robotic surgery has even branched out onto a nanoscale level, where micro-sized robots on the order of 10−9 meters in size are placed into human body cavities. Surgeons have the ability to program and control these devices remotely. Nanorobots permit extreme preciseness in handling minimally invasive imaging techniques in fields such as vascular Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Leung and Vyas
Page 3
Author Manuscript
surgery and neurosurgery. Nanotechnology has provided oncologists with enhanced magnetic resonance imaging, improved drug delivery systems for often toxic chemotherapeutic agents, and precise in vivo targeting and elimination of tumor cells. Nanoparticles have the ability to remain saturated and agglomerate deep into the body. Further, nanorobots have shown usefulness in tissue engineering and organ transplantation. Synthetic grafts composed of carbon nanotubes possess remarkable mechanical strength and thrombo-resistant properties. Such composites have been utilized in endothelial regeneration and bone replacement.
Telerobotics
Author Manuscript
As mentioned previously, the concept of having surgeons operate remotely came from the need to treat wounded soldiers in combat. Since then, advances in communication have enabled telesurgery to be performed on civilian operations across cities, states, and even countries. This has allowed experienced surgeons from around the world to practice on patients without the need for the patient to come to them. The first intercontinental robotic telesurgery case was performed in 2001 and involved surgeons in New York performing a laparoscopic cholecystecomy on a patient located in Paris. Although costly, telesurgery offers several worldwide health advantages in the long run. For example, providing advanced surgical care to rural and underserved populations is now possible. Also, surgeons in training can benefit by distance-learning from highly skilled practitioners employed in the latest techniques. For example, one of the four Robotic arms on the latest da Vinci model can be programmed so that it is being controlled by a different surgeon in a different location. Innovations such as this have made teaching modalities such as telementoring and teleproctoring possible.
Author Manuscript
Economics of robotics
Author Manuscript
Perhaps the major drawback to robotic surgery is its cost. Each da Vinci Surgical System costs around $2 million, with annual maintenance fees totaling about 10% of the initial purchase as well as the costs for disposable equipment. Cost analyses have shown that robotic surgery is more expensive than laparoscopy or conventional open surgery. However, a recent study involving the twelve most common gastrointestinal procedures showed that the total hospitalization costs for the robotic approach is actually less than the laparoscopic or open approach, although procedural costs were higher depending on the type of surgery being performed. When more common robotic procedures from urology, gynecology, nephrology, and cardiology were taken into account, researchers concluded that although robotic procedures cost more, it is associated with a decreased length of hospital stay and decreased odds of death when compared to procedures currently performed using the conventional open method. These analyses have also identified longer operating time as a reason behind the higher cost. However, as more and more surgeons become trained and proficient in robotic techniques, operating time is expected to shorten. In addition, Intuitive Surgical Inc. continues to sell more da Vinci Surgical Systems around the world each year and sales continue to grow steadily. This growth will steadily lower the price of the robot over time. Another study
Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Leung and Vyas
Page 4
Author Manuscript
suggests that costs can be minimized by increasing the number of robotic cases performed, given that higher utilization improves cost effectiveness.
Ethics and robotic surgery
Author Manuscript
Robotic surgery is not without controversy. As of now, there are no other competitors for Intuitive Surgical Inc. and their da Vinci system. The company currently holds many patents to robotic software and components. With high costs and financial limitations in Western countries, this makes robotic surgery a privilege in select public hospitals and private centers. Further, critics state that the advantages of using robots is often exaggerated and that there is a lack of objective, scientific studies that show that robotic surgery is better, particularly in the field of general surgery. Most of the published data for robotic surgery outcomes are for radical prostatectomies which have shown only marginal clinical benefits. However, as mentioned previously, reduced length of hospital stay and an increase in number of procedures performed will compensate for cost in the long run. Also, as patents expire, manufacturers from around the world are expected to join the market and increase competition. Telerobotic procedures also bring forth other ethical issues. Patient confidentiality has to be taken into account when communicating electronically. Medical liability can be another complicated issue. All parties involved, including surgeons, patient, hospitals, and equipment companies need to prepare alternative approaches in the event of a rare but possible systems failure due to the robot itself or the communication lines. Everyone’s responsibilities should be clearly outlined.
Author Manuscript
Finally, robotic operations fulfill the ethical principle of beneficence, in that surgeons are now able to perform procedures in areas where they cannot feasibly travel to. Opponents argue though, that this will result in the migration of physicians into technologically-rich areas and worsen the current shortage of specialists in underserved areas.
Imaging and robotic surgery The da Vinci robot has provided users with high resolution three-dimensional imaging. With that comes the advantage of improved quality, depth perception, and accuracy. A study involving surgical attendings and residents demonstrated improved performance with the da Vinci system in both groups. This was largely attributed to the imaging quality robots are able to offer.
Author Manuscript
Image-guided robotic surgery has been used frequently in neurosurgery and orthopedics. This involves the use of preoperative or intraoperative images along with a tracked device to create an interactive map of deep anatomy, vasculature, and pathology prior to incision. This method of guidance has been of great use particularly in tumor resection where surgical margins can be carefully delineated without damaging benign tissue. Recently, fluorescent imaging was attempted in robotic cholecystecomy and researchers reported clear advantages when it came to visualization of the cystic duct, common hepatic duct, and common bile duct both before and after dissection. Since this is a relatively new
Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Leung and Vyas
Page 5
Author Manuscript
technique only a limited number of fluorescent imaging studies have been conducted and issues such as dye dosing and injection still have to be addressed.
References
Author Manuscript Author Manuscript Author Manuscript
1. Anderson JE, Chang DC, Parsons JK, Talamini MA. The first national examination of outcomes and trends in robotic surgery in the United States. J Am Coll Surg. 2012; 215:107–14. discussion 14-6. [PubMed: 22560318] 2. Barbash GI, Glied SA. New technology and health care costs--the case of robot-assisted surgery. N Engl J Med. 2010; 363:701–4. [PubMed: 20818872] 3. Bharathan R, Aggarwal R, Darzi A. Operating room of the future. Best Pract Res Clin Obstet Gynaecol. 2013; 27:311–22. [PubMed: 23266083] 4. Byrn JC, Schluender S, Divino CM, et al. Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg. 2007; 193:519–22. [PubMed: 17368303] 5. Dickens BM, Cook RJ. Legal and ethical issues in telemedicine and robotics. Int J Gynaecol Obstet. 2006; 94:73–8. [PubMed: 16777109] 6. Freitas RA. Nanotechnology, nanomedicine and nanosurgery. Int J Surg. 2005; 3:243–6. [PubMed: 17462292] 7. Gambadauro P, Torrejon R. The “tele” factor in surgery today and tomorrow: implications for surgical training and education. Surg Today. 2013; 43:115–22. [PubMed: 22836545] 8. Giri S, Sarkar DK. Current status of robotic surgery. Indian J Surg. 2012; 74:242–7. [PubMed: 23730051] 9. Giri S, Sarkar DK. Current status of robotic surgery. Indian J Surg. 2012; 74:242–7. [PubMed: 23730051] 10. Herrell SD, Kwartowitz DM, Milhoua PM, Galloway RL. Toward image guided robotic surgery: system validation. J Urol. 2009; 181:783–9. discussion 9-90. [PubMed: 19091336] 11. Jones A, Sethia K. Robotic surgery. Ann R Coll Surg Engl. 2010; 92:5–8. [PubMed: 20056045] 12. Kalan S, Chauhan S, Coelho RF, et al. History of robotic surgery. Journal of Robotic Surgery. 2010; 4:141–7. 13. Kenngott HG, Fischer L, Nickel F, Rom J, Rassweiler J, Muller-Stich BP. Status of robotic assistance--a less traumatic and more accurate minimally invasive surgery? Langenbecks Arch Surg. 2012; 397:333–41. [PubMed: 22038293] 14. Khawaja AM. The legacy of nanotechnology: revolution and prospects in neurosurgery. Int J Surg. 2011; 9:608–14. [PubMed: 22027280] 15. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective. Ann Surg. 2004; 239:14–21. [PubMed: 14685095] 16. Loizidou M, Seifalian AM. Nanotechnology and its applications in surgery. Br J Surg. 2010; 97:463–5. [PubMed: 20205212] 17. Lowrance WT, Eastham JA, Savage C, et al. Contemporary open and robotic radical prostatectomy practice patterns among urologists in the United States. J Urol. 2012; 187:2087–92. [PubMed: 22498227] 18. Marano A, Priora F, Lenti LM, Ravazzoni F, Quarati R, Spinoglio G. Application of Fluorescence in Robotic General Surgery: Review of the Literature and State of the Art. World J Surg. 2013 19. Martel S. NANOROBOTS FOR MICROFACTORIES TO OPERATIONS IN THE HUMAN BODY AND ROBOTS PROPELLED BY BACTERIA. Facta Univ Ser Mech Autom Control Robot. 2008; 7:1–8. 20. Morris B. Robotic surgery: applications, limitations, and impact on surgical education. MedGenMed. 2005; 7:72. [PubMed: 16369298] 21. Palep JH. Robotic assisted minimally invasive surgery. J Minim Access Surg. 2009; 5:1–7. [PubMed: 19547687] 22. Parekattil SJ, Moran ME. Robotic instrumentation: Evolution and microsurgical applications. Indian J Urol. 2010; 26:395–403. [PubMed: 21116362] Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
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23. Patel HR, Linares A, Joseph JV. Robotic and laparoscopic surgery: cost and training. Surg Oncol. 2009; 18:242–6. [PubMed: 19560913] 24. Pietrabissa A, Vinci A, Pugliese L, Peri A. [Robotic surgery: current controversies and future expectations]. Cir Esp. 2013; 91:67–71. [PubMed: 23265772] 25. Pugin F, Bucher P, Morel P. History of robotic surgery: from AESOP© and ZEUS© to da Vinci©. J Visc Surg. 2011; 148:e3–8. [PubMed: 21974854] 26. Salman M, Bell T, Martin J, Bhuva K, Grim R, Ahuja V. Use, cost, complications, and mortality of robotic versus nonrobotic general surgery procedures based on a nationwide database. Am Surg. 2013; 79:553–60. [PubMed: 23711262] 27. Senapati S, Advincula AP. Telemedicine and robotics: paving the way to the globalization of surgery. Int J Gynaecol Obstet. 2005; 91:210–6. [PubMed: 16213505] 28. Turchetti G, Palla I, Pierotti F, Cuschieri A. Economic evaluation of da Vinci-assisted robotic surgery: a systematic review. Surg Endosc. 2012; 26:598–606. [PubMed: 21993935] 29. Verit A, Rizkala E, Autorino R, Stein RJ. Robotic laparoendoscopic single-site surgery: From present to future. Indian J Urol. 2012; 28:76–81. [PubMed: 22557723] 30. Wilson EB. The evolution of robotic general surgery. Scand J Surg. 2009; 98:125–9. [PubMed: 19799050] 31. Wright JD, Burke WM, Wilde ET, et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol. 2012; 30:783–91. [PubMed: 22291073] 32. Yoshida M, Furukawa T, Morikawa Y, Kitagawa Y, Kitajima M. The developments and achievements of endoscopic surgery, robotic surgery and function-preserving surgery. Jpn J Clin Oncol. 2010; 40:863–9. [PubMed: 20736221]
Author Manuscript Author Manuscript Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Am J Robot Surg. Author manuscript; available in PMC 2015 October 22. Published in final edited form as: Am J Robot Surg. 2014 June 1; 1(1): 1–64.
Robotic Surgery: Applications Tiffany Leung, B.S. and College of Human Medicine, Michigan State University, 1200 East Michigan Avenue, Suite 655, Lansing, MI 48912, USA
Author Manuscript
Dinesh Vyas, MD, MBBS, MS, FICS [Assistant Professor] [Advanced Robotic and GI Surgeon] [Adjunct Professor] [Director] Department of Surgery; Institute of International Health; MS Surgery Clerkship, College of Human Medicine, Michigan State University, 1200 East Michigan Avenue, Suite 655, Lansing, MI 48912, USA
Surgical Specialties
Author Manuscript
In a relatively short amount of time, robots have made its way into both general and subspecialty surgical fields. The da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) has been around for over a decade now. The first da Vinci surgical system came out in 1999 and was FDA approved in 2000. In 2003, a fourth robotic arm was added. The da Vinci S model came out in 2006 and offered improved robotic arm movements, console displays, and simpler set up. As of 2009, the latest model called da Vinci Si, now offers dual consoles so two individuals can collaborate simultaneously. Controls, vision, and ergonomics have been improved as well.
Author Manuscript
The specialties that use the da Vinci system frequently are urological, gynecological, and gastrointestinal surgery (1). In 2010, Intuitive Surgical Inc., the manufacturer of the da Vinci robot, reported that over 70% of robotic procedures were for both prostatectomy and hysterectomy combined (1). Further, robotic technique is the preferred method of performing a radical prostatectomy as the definitive treatment for prostate cancer (2). In gynecology, it is estimated that over 60% of minimally invasive hysterectomies performed in patients with endometrial cancer were done robotically (3). There are several reasons why urologists and gynecologists perform more robotic procedures than their other surgical counterparts. These include balance of surgeon endoscopic skill level, meaning how often endoscopic or laparoscopic techniques are performed in their field; equipment limitations, especially when working with anatomically complex areas; and procedure complexity, taking into account which procedures are better performed open versus minimally invasive versus robotically, the latter having the greatest precision (2). Robotic options do exist for surgical treatment in other specialties although it is used much less frequently. These include cardiothoracic surgery, for cases of coronary bypass and heart defects repairs; general surgical oncology, for esophageal tumors, gastric cancer, colon cancer, thymoma; and pediatrics, to resolve congenital heart diseases, gastroespohageal reflux disease, or uretopelvic junction obstruction (4).
Leung and Vyas
Page 2
Author Manuscript
Development of Robots It cannot be emphasized enough that robotic surgery is a relatively young field, but it is one that has grown at a rapid pace in the past couple of decades. Use of robots in surgery began in 1985 when a group of neurosurgeons were able to perform biopsies with a machine they called Puma 560 (5). Other breakthroughs happened shortly thereafter. In 1988, the first robotic transurethral prostate resection using the same system was accomplished. The PROBOT, a specialized robot designed to perform prostatectomy was then developed by Harris et al. Another company called Integrated Surgical Supplies Ltd. from Sacramento, CA, created ROBODOC, designed for use in hip replacement surgery. This device was the first surgical robot approved by the FDA.
Author Manuscript
The idea of using robots to perform remote operations, otherwise known as telesurgery, first came about in the early 1990’s. Stemming from the concept of virtual reality, researchers at the National Air and Space Administration (NASA) Ames Research Center worked with a team at Stanford University’s Research Institute hoping to develop ways to provide surgical intervention to astronauts from a remote hospital. Their goal was to make the surgeon feel as if he/she were operating directly on a patient even though they were located elsewhere. This idea caught the attention of U.S. Army surgeons who hoped to develop a system for remote operations on wounded soldiers under the direction of a surgeon who would be located in a safe zone.
Author Manuscript
These researchers had the idea of expanding the use of robots to civilian practice as well. In 1993, a company called Computer Motion, Inc., of Goleta, CA, succeeded in creating a robotic camera holder called Automated Endoscopic System for Optimal Positioning (AESOP). Shortly thereafter, the control system for the device, HERMES, came around, which led to a complete functional robotic system called ZEUS. This system, also known as a master-slave device, permitted a surgeon (master) to operate a console and control a robot (slave).
Author Manuscript
In 1995, a company called Intuitive Surgical from Sunnyvale, CA, began working on a combined master-slave system with a three-dimensional vision system and patient safety sensor monitors to create a prototype machine called the da Vinci surgical system. Surgeons in Belgium first utilized the device in 1997 with robotic cholecystectomy and Nissen fundoplication. Its eventual FDA approval came around in 2000. As of 2009, Intuitive Surgical Inc. is now in its fourth generation of the da Vinci robotic system. A four-arm da Vinci robotic system with high definition enhanced visual magnification and dual consoles designed in mind for teaching purposes is being used around the world today in a broad range of specialties as mentioned earlier, and is specifically indicated for micro- and complex-minimally invasive surgeries.
Nanorobotic surgery Robotic surgery has even branched out onto a nanoscale level, where micro-sized robots on the order of 10−9 meters in size are placed into human body cavities. Surgeons have the ability to program and control these devices remotely. Nanorobots permit extreme preciseness in handling minimally invasive imaging techniques in fields such as vascular Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Leung and Vyas
Page 3
Author Manuscript
surgery and neurosurgery. Nanotechnology has provided oncologists with enhanced magnetic resonance imaging, improved drug delivery systems for often toxic chemotherapeutic agents, and precise in vivo targeting and elimination of tumor cells. Nanoparticles have the ability to remain saturated and agglomerate deep into the body. Further, nanorobots have shown usefulness in tissue engineering and organ transplantation. Synthetic grafts composed of carbon nanotubes possess remarkable mechanical strength and thrombo-resistant properties. Such composites have been utilized in endothelial regeneration and bone replacement.
Telerobotics
Author Manuscript
As mentioned previously, the concept of having surgeons operate remotely came from the need to treat wounded soldiers in combat. Since then, advances in communication have enabled telesurgery to be performed on civilian operations across cities, states, and even countries. This has allowed experienced surgeons from around the world to practice on patients without the need for the patient to come to them. The first intercontinental robotic telesurgery case was performed in 2001 and involved surgeons in New York performing a laparoscopic cholecystecomy on a patient located in Paris. Although costly, telesurgery offers several worldwide health advantages in the long run. For example, providing advanced surgical care to rural and underserved populations is now possible. Also, surgeons in training can benefit by distance-learning from highly skilled practitioners employed in the latest techniques. For example, one of the four Robotic arms on the latest da Vinci model can be programmed so that it is being controlled by a different surgeon in a different location. Innovations such as this have made teaching modalities such as telementoring and teleproctoring possible.
Author Manuscript
Economics of robotics
Author Manuscript
Perhaps the major drawback to robotic surgery is its cost. Each da Vinci Surgical System costs around $2 million, with annual maintenance fees totaling about 10% of the initial purchase as well as the costs for disposable equipment. Cost analyses have shown that robotic surgery is more expensive than laparoscopy or conventional open surgery. However, a recent study involving the twelve most common gastrointestinal procedures showed that the total hospitalization costs for the robotic approach is actually less than the laparoscopic or open approach, although procedural costs were higher depending on the type of surgery being performed. When more common robotic procedures from urology, gynecology, nephrology, and cardiology were taken into account, researchers concluded that although robotic procedures cost more, it is associated with a decreased length of hospital stay and decreased odds of death when compared to procedures currently performed using the conventional open method. These analyses have also identified longer operating time as a reason behind the higher cost. However, as more and more surgeons become trained and proficient in robotic techniques, operating time is expected to shorten. In addition, Intuitive Surgical Inc. continues to sell more da Vinci Surgical Systems around the world each year and sales continue to grow steadily. This growth will steadily lower the price of the robot over time. Another study
Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Leung and Vyas
Page 4
Author Manuscript
suggests that costs can be minimized by increasing the number of robotic cases performed, given that higher utilization improves cost effectiveness.
Ethics and robotic surgery
Author Manuscript
Robotic surgery is not without controversy. As of now, there are no other competitors for Intuitive Surgical Inc. and their da Vinci system. The company currently holds many patents to robotic software and components. With high costs and financial limitations in Western countries, this makes robotic surgery a privilege in select public hospitals and private centers. Further, critics state that the advantages of using robots is often exaggerated and that there is a lack of objective, scientific studies that show that robotic surgery is better, particularly in the field of general surgery. Most of the published data for robotic surgery outcomes are for radical prostatectomies which have shown only marginal clinical benefits. However, as mentioned previously, reduced length of hospital stay and an increase in number of procedures performed will compensate for cost in the long run. Also, as patents expire, manufacturers from around the world are expected to join the market and increase competition. Telerobotic procedures also bring forth other ethical issues. Patient confidentiality has to be taken into account when communicating electronically. Medical liability can be another complicated issue. All parties involved, including surgeons, patient, hospitals, and equipment companies need to prepare alternative approaches in the event of a rare but possible systems failure due to the robot itself or the communication lines. Everyone’s responsibilities should be clearly outlined.
Author Manuscript
Finally, robotic operations fulfill the ethical principle of beneficence, in that surgeons are now able to perform procedures in areas where they cannot feasibly travel to. Opponents argue though, that this will result in the migration of physicians into technologically-rich areas and worsen the current shortage of specialists in underserved areas.
Imaging and robotic surgery The da Vinci robot has provided users with high resolution three-dimensional imaging. With that comes the advantage of improved quality, depth perception, and accuracy. A study involving surgical attendings and residents demonstrated improved performance with the da Vinci system in both groups. This was largely attributed to the imaging quality robots are able to offer.
Author Manuscript
Image-guided robotic surgery has been used frequently in neurosurgery and orthopedics. This involves the use of preoperative or intraoperative images along with a tracked device to create an interactive map of deep anatomy, vasculature, and pathology prior to incision. This method of guidance has been of great use particularly in tumor resection where surgical margins can be carefully delineated without damaging benign tissue. Recently, fluorescent imaging was attempted in robotic cholecystecomy and researchers reported clear advantages when it came to visualization of the cystic duct, common hepatic duct, and common bile duct both before and after dissection. Since this is a relatively new
Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Leung and Vyas
Page 5
Author Manuscript
technique only a limited number of fluorescent imaging studies have been conducted and issues such as dye dosing and injection still have to be addressed.
References
Author Manuscript Author Manuscript Author Manuscript
1. Anderson JE, Chang DC, Parsons JK, Talamini MA. The first national examination of outcomes and trends in robotic surgery in the United States. J Am Coll Surg. 2012; 215:107–14. discussion 14-6. [PubMed: 22560318] 2. Barbash GI, Glied SA. New technology and health care costs--the case of robot-assisted surgery. N Engl J Med. 2010; 363:701–4. [PubMed: 20818872] 3. Bharathan R, Aggarwal R, Darzi A. Operating room of the future. Best Pract Res Clin Obstet Gynaecol. 2013; 27:311–22. [PubMed: 23266083] 4. Byrn JC, Schluender S, Divino CM, et al. Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg. 2007; 193:519–22. [PubMed: 17368303] 5. Dickens BM, Cook RJ. Legal and ethical issues in telemedicine and robotics. Int J Gynaecol Obstet. 2006; 94:73–8. [PubMed: 16777109] 6. Freitas RA. Nanotechnology, nanomedicine and nanosurgery. Int J Surg. 2005; 3:243–6. [PubMed: 17462292] 7. Gambadauro P, Torrejon R. The “tele” factor in surgery today and tomorrow: implications for surgical training and education. Surg Today. 2013; 43:115–22. [PubMed: 22836545] 8. Giri S, Sarkar DK. Current status of robotic surgery. Indian J Surg. 2012; 74:242–7. [PubMed: 23730051] 9. Giri S, Sarkar DK. Current status of robotic surgery. Indian J Surg. 2012; 74:242–7. [PubMed: 23730051] 10. Herrell SD, Kwartowitz DM, Milhoua PM, Galloway RL. Toward image guided robotic surgery: system validation. J Urol. 2009; 181:783–9. discussion 9-90. [PubMed: 19091336] 11. Jones A, Sethia K. Robotic surgery. Ann R Coll Surg Engl. 2010; 92:5–8. [PubMed: 20056045] 12. Kalan S, Chauhan S, Coelho RF, et al. History of robotic surgery. Journal of Robotic Surgery. 2010; 4:141–7. 13. Kenngott HG, Fischer L, Nickel F, Rom J, Rassweiler J, Muller-Stich BP. Status of robotic assistance--a less traumatic and more accurate minimally invasive surgery? Langenbecks Arch Surg. 2012; 397:333–41. [PubMed: 22038293] 14. Khawaja AM. The legacy of nanotechnology: revolution and prospects in neurosurgery. Int J Surg. 2011; 9:608–14. [PubMed: 22027280] 15. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective. Ann Surg. 2004; 239:14–21. [PubMed: 14685095] 16. Loizidou M, Seifalian AM. Nanotechnology and its applications in surgery. Br J Surg. 2010; 97:463–5. [PubMed: 20205212] 17. Lowrance WT, Eastham JA, Savage C, et al. Contemporary open and robotic radical prostatectomy practice patterns among urologists in the United States. J Urol. 2012; 187:2087–92. [PubMed: 22498227] 18. Marano A, Priora F, Lenti LM, Ravazzoni F, Quarati R, Spinoglio G. Application of Fluorescence in Robotic General Surgery: Review of the Literature and State of the Art. World J Surg. 2013 19. Martel S. NANOROBOTS FOR MICROFACTORIES TO OPERATIONS IN THE HUMAN BODY AND ROBOTS PROPELLED BY BACTERIA. Facta Univ Ser Mech Autom Control Robot. 2008; 7:1–8. 20. Morris B. Robotic surgery: applications, limitations, and impact on surgical education. MedGenMed. 2005; 7:72. [PubMed: 16369298] 21. Palep JH. Robotic assisted minimally invasive surgery. J Minim Access Surg. 2009; 5:1–7. [PubMed: 19547687] 22. Parekattil SJ, Moran ME. Robotic instrumentation: Evolution and microsurgical applications. Indian J Urol. 2010; 26:395–403. [PubMed: 21116362] Am J Robot Surg. Author manuscript; available in PMC 2015 October 22.
Leung and Vyas
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