REVIEW ARTICLE
The use of robotics in surgery: a review A. Hussain,1 A. Malik,1 M. U. Halim,1 A. M. Ali1,2
1
John Radcliffe Hospital, University of Oxford, Oxford, UK 2 Harvard University, Cambridge, MA, USA Correspondence to: Azhar Hussain, Magdalen College, Oxford, OX1 4AU, UK Tel.: + 447838084966 Email: azhar.hussain@doctors. org.uk
Disclosure We have no conflict of interest to declare.
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SUMMARY
Review criteria
Importance: There is an ever-increasing drive to improve surgical patient outcomes. Given the benefits which robotics has bestowed upon a wide range of industries, from vehicle manufacturing to space exploration, robots have been highlighted by many as essential for continued improvements in surgery. Objective: The goal of this review is to outline the history of robotic surgery, and detail the key studies which have investigated its effects on surgical outcomes. Issues of cost-effectiveness and patient acceptability will also be discussed. Results and conclusion: Robotic surgery has been shown to shorten hospital stays, decrease complication rates and allow surgeons to perform finer tasks, when compared to the traditional laparoscopic and open approaches. These benefits, however, must be balanced against increased intraoperative times, vast financial costs and the increased training burden associated with robotic techniques. The outcome of such a cost-benefit analysis appears to vary depending on the procedure being conducted; indeed the strongest evidence in favour of its use comes from the fields of urology and gynaecology. It is hoped that with the large-scale, randomised, prospective clinical trials underway, and an ever-expanding research base, many of the outstanding questions surrounding robotic surgery will be answered in the near future.
We searched MEDLINE and Google Scholar using the terms ‘robotic surgery’, ‘robot-assisted surgery’ and ‘robotic-assisted surgery’ and manually searched references to identify papers in the English language.
Message for the clinic Robotic surgery confers a number of benefits including technical precision, faster recovery times and reduced complication rates, and it has been avidly adopted by several surgical specialties. Prohibitive costs and lack of familiarity with robotic systems remain important problems. However, current research seems set to yield more costeffective, smaller and precise robots that could accelerate the adoption of robotic surgery and expand its potential uses.
Introduction
A brief history of robotic surgery
Over the last decade, the use of robot-assisted surgery has increased dramatically. Urology and then gynaecology were the earliest specialties to adopt robotics in surgery, and many more specialties have since followed suit. This review examines the history of robotic surgery, the benefits of this technology and its use in different surgical procedures, followed by a discussion of cost-effectiveness and patient acceptability. The word ‘robot’ was first coined by the Czech playwright Karel Capek in 1921 (1). Since then, the field of robotics has expanded exponentially, particularly in industrial processes where robots are used to perform precise, repetitive and even hazardous tasks. Given the drive for technological innovation which healthcare has experienced over recent years, robots are now also being increasingly incorporated into many core surgical procedures. While the USA has been the main adopter of robotic systems, there are now several centres in the UK which incorporate robotic surgery into routine practice.
The drive to develop robotic surgical systems initially stemmed from the need to improve the accuracy and precision of surgical techniques. Indeed, one of the first surgical robots, PUMA 200, was developed in 1985 to allow neurosurgeons to increase their positioning accuracy for stereotactic CT-guided brain surgery (2). A few years later, the already established computeraided design and computer-aided manufacture (CADCAM) system was used by Integrated Surgical Systems to develop a surgical robot called ROBODOC (3). This device found use in orthopaedics, where three-dimensional (3D) imaging relayed to the robot enabled it to accurately fashion the implant cavity in knee and hip arthroplasty procedures, resulting in more accurate placement of the prosthesis as compared with the previous mallet and broach method. The real breakthrough in robotic surgery came in the 1990s, however, when robotic systems were able to process continuous input from surgeons and translate them into movements in real time. In the early 1990s, to reduce wartime mortality, the USA Army funded projects to develop systems whereby
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wounded soldiers could be placed in specialised vehicles and operated on remotely by surgeons (1). Many of the engineers and surgeons working for the Army then went on to develop ‘telepresence’ robotic systems for the civilian population. In 1994, one of the first telesurgical robots to be approved by the FDA was called AESOP (Automated Endoscopic System for Optimal Positioning), a USA Army-funded device developed by Computer Motion Inc. that allowed surgeons to control the position of the endoscope using either voice commands or a foot pedal. Further advances led to the development of the ZEUS robotic system (also by Computer Motion Inc.), which incorporated AESOP technology (4). This was the first ‘master-slave’ system that allowed a surgeon to remotely control the manipulator arms of the robot while seated at a special console. Although robotic surgery was still in its infancy, it was not long before rival manufacturers began filing lawsuits against one other for patent infringement (5). In 2003, two of the biggest rival companies, Computer Motion Inc. and Intuitive Surgical Inc., merged together and combined efforts to promote their ‘da Vinci’ system, in turn resulting in the discontinuation of the ZEUS robot.
The da Vinci Surgical System The da Vinci Surgical System is a comprehensive master-slave surgical robot which has emerged as the telesurgical system of choice in today’s practice. It comprises four arms, three of which carry surgical equipment, and a fourth which holds an endoscopic camera with dual lenses to generate stereoscopic 3D vision for the surgeon. The system can replicate the operating surgeon’s exact hand movements via the controls located on the console using EndoWrist Technology (6). The da Vinci system gained FDA approval in 2000 for general laparoscopic surgery, followed by approval in 2001 for radical prostatectomy and in 2005 for urological procedures. It has since been approved for gynaecological laparoscopic surgical procedures, general thoracoscopic surgical procedures and thoracoscopically assisted cardiotomy procedures (6). As of June 2013, 2799 da Vinci systems have been installed worldwide – 2001 in the USA, 442 in Europe and 356 in the rest of the world (7). Globally, they were used to perform nearly 500,000 operations in 2012, with almost 350,000 of those being in the fields of urology and gynaecology (7).
From the shadow of laparoscopy The current rise in the use of robotic devices for surgical procedures abroad and in the NHS mirrors ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
the steady implementation of other novel surgical techniques, such as minimally invasive surgery. Although the first laparoscopic cholecystectomy, performed in 1987, was initially met with a great deal of skepticism by the surgical community, minimally invasive surgery has since been warmly welcomed by patients and surgeons alike. Numerous studies have shown that laparoscopic procedures result in shorter hospital stays, fewer complications, decreased pain and better outcomes (8). However, despite these advantages there are several limitations which are inherent in laparoscopy, and the development of robotic surgical systems was largely born out of a desire to overcome these limitations while retaining the advantages that laparoscopy has to offer. Perhaps the greatest barrier surgeons had to overcome when training for laparoscopic procedures was the disruption of natural hand-eye co-ordination. Robotic surgery offers 3D visualisation as well as limiting the fulcrum effect which exaggerates tremors in laparoscopic surgery. Furthermore, the fact that the arms of the robotic system can be angulated in almost any direction enables the robot to provide more degrees of freedom than can be achieved by laparoscopic instruments. Certain specialties have failed to adopt laparoscopic surgery despite evidence showing clear benefits because of the sheer difficulty in becoming proficient at such procedures (9). The learning curve for robotic-assisted surgery on the other hand seems to be substantially easier. Marecik et al. found suturing to be significantly easier and more precise in surgical residents compared with open and laparoscopic methods (10). In addition, Ahlering et al. demonstrated successful transfer of surgical skills from an open to a laparoscopic environment using a robotic interface in surgeons without previous laparoscopic experience (11). Despite these advantages, robotic surgery is not as established as one might expect. Arguably the largest obstacle for widespread adoption is the high setup cost, but there are other barriers too. Notable examples include the inability to reposition the docked arms and the loss of haptic feedback. However, these issues are rapidly being addressed by engineers and have even led to the development of sensory systems that feedback to the surgeons’ hands (12).
Applications of robotic surgery Robotic surgical technology has found a particular stronghold in two specialties: urology and gynaecology. Indeed, as previously mentioned, of the 500,000 operations performed to date using the Da Vinci sys-
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tem almost 350,000 have been in one of those fields (5). Robotic assistance has been shown to improve the safety and the performance of intracorporeal suturing, which are heavily required in urological and gynaecological procedures (13). It is therefore no surprise that such surgeons have been enthusiastic in implementing robotic assistance in their procedures. The next section will focus on the effectiveness and outcomes in these specialties, where the richest supply of data is available.
Robotic surgery in urology Urology has been the speciality most keen to adopt robot-assisted surgery, and indeed it is now expected that robots will be used routinely in radical prostatectomy in the USA (14). Since the first robot-assisted laparoscopic prostatectomy (RALP) in 2000, RALP has now become by far the most commonly performed robotic operation (15). As such, multiple trials have been conducted evaluating its effectiveness over open and laparoscopic radical prostatectomy (LRP). Tewari et al. performed a meta-analysis of 167,184 open, 57,303 LRP, and 62,389 RALP procedures, adjusting for age, prostate-specific antigen levels and pathological characteristics (16). They found that RALP conferred many advantages over open and LRP procedures, including a lower estimated blood loss and shorter length of stay (LOS). These are summarised in Table 1. Furthermore, RALP had lower rates of readmissions, nerve injury, reoperations, deep vein thrombosis and sepsis compared with LRP (p < 0.003), as well as superior continence rates and return of sexual function (17–19). In addition, Sukumar et al. evaluated oncological outcomes in 5152 patients undergoing RALP in the largest report of its kind to date. They demonstrated effective long-term biochemical control in a high-volume tertiary center, offering further support for RALP (20). The adoption of robotic surgery has been slower in Europe than in the USA, however in the UK urologists have found substantial use for this technology, especially for RALP. Within just a decade, RALP has achieved similar, if not better, outcomes than open
and laparoscopic approaches. This may be surprising given the relatively short time for which robotic surgery has been available, however a study by Hakimi et al. has provided an explanation. In a case series of over 300, they found that superior results were obtained with the first 75 RALP cases as compared with the last 75 LRP cases, and indeed similar findings have been reported elsewhere, demonstrating the shorter learning curve of the robotic as opposed to the laparoscopic approach (21,22). This, along with the growing body of support for the efficacy and safety of RALP, lends credence to the notion that the robotic approach will become the method of choice for prostatic cancer surgery in the near future.
Robotic surgery in gynaecology In 2005 the FDA approved robot-assisted surgery for radical hysterectomy for endometrial and cervical cancer, 5 years after its initial approval for use in urology (23). Since then, the robot-assisted procedure has been widely adopted in the USA. However, unlike RALP, there has been a considerable lack of randomized controlled trials despite radical hysterectomies being the second most common robotassisted procedure performed in the USA. Kruijdenberg et al. reviewed robot assisted radical hysterectomy (RRH) vs. total laparoscopic hysterectomies (TLRH) by analysing data largely from individual case series, with 342 RRH patients and 914 TLRH patients. Although fewer blood transfusions were needed by patients in RRH compared with TLRH (5.4% vs. 9.7%, p < 0.05) and LOS was significantly shorter in RRH patients (3.3 vs. 6.2 days; p < 0.05), major postoperative complications were more frequent in RRH patients than TLRH (9.6%, 5.5% respectively; p < 0.05). However, the authors did conclude that the RRH studies had a smaller population and that experience with the new surgical devices beyond the initial learning phase may well reduce the complication rate (24). Two recent, though small, RCTs have shed further light on the outcomes of robotic vs. laparoscopic hysterectomy. Using 95 patients, Sarlos et al. com-
Table 1 Summary of main benefits of RALP over open radical prostatectomy and LRP
Perioperative outcomes
Estimated blood loss (ml) Length of stay, USA (days) Length of stay, non-USA (days)
RALP minus open radical prostatectomy
562.5 (95% CI 1.69 (95% CI 3.65 (95% CI
485.2, 639.8; p < 0.0001) 1.5, 1.9; p < 0001) 2.8, 4.5; p < 0.0001)
RALP minus LRP
127.8 (95% CI 0.78 (95% CI 1.04 (95% CI
95.4, 160.2; p < 0.0001) 0.5, 0.9; p < 0.001) 0.3, 1.8; p = 0.005)
Adapted from Tewari et al. (16).
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pared conventional laparoscopic hysterectomy vs. robot-assisted laparoscopic hysterectomy (25). After controlling for age, BMI and uterus weight, the total operating time was significantly higher for the robotic group than the conventional group (106 vs. 75 min respectively, p < 0.05). Complications and blood loss were not significantly different between the groups, although postoperative quality of life index was better in the robotic group. A similar randomized controlled trial by Paraiso et al. with 62 patients reached the same conclusions (26). These data however, need to be considered in the light of their relatively small sample sizes and the fact that a new procedure was being compared with one the operating surgeon was already very familiar with. In a large cohort study of 264,758 women across 441 hospitals in the USA from 2007 to 2010, Wright et al. report that that robotically assisted procedures increased from 0.5% in 2007 to 9.5% in 2010 of all hysterectomies performed (27). This is although, apart from a reduced LOS, overall complication rates and transfusion requirements were similar for both RRH. The lack of large RCTs, combined with the relatively recent (2005) FDA approval for gynecological surgery, make it difficult to comment on the effectiveness of robotic surgery in this specialty. However, as surgeons become more adept at using such technology and overcome the initial learning curve, a clearer picture will emerge.
Robotic surgery in other specialties Robotic surgery has been approved for use in various other specialties including paediatric surgery, cardiac surgery and general surgery. However, in these fields it has been met with less enthusiasm and has been adopted to a much lesser degree.
General surgery Although advances in laparoscopic surgery were largely driven by general surgeons, the use of robotics in general surgery has been surprisingly low. The areas with the greatest interest in robotic assisted procedures are foregut surgery, hepatobiliary surgery, bariatric surgery, colorectal surgery and endocrine surgery (10). In foregut surgery, trials comparing laparoscopic vs. robotic Nissen fundoplication show similar outcomes (28). Robot-assisted Heller myotomy for achalasia has also been studied, and has been found to have very low perforation rates (29). Many of the authors have commented on the potential use of robotic surgery in more complicated cases, though further study is needed before firm conclusions can be drawn. In bariatric surgery, gastric banding has ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
been performed robotically with little benefit as compared with laparoscopy (30). However, some have suggested that robotic surgery may improve outcomes for more complex bariatric procedures which require intracorporeal suturing (31). The cautious approach by the general surgeons to embrace this new technology may have resulted from several factors. For simple procedures, the use of complex robotics seems unwarranted. On more complex procedures the robot is limited, particularly in procedures where movement into several quadrants is required. Furthermore, the lack of an instrument for bowel stapling, sealing and cutting also makes the adoption very difficult, although a solution to this problem could conceivably be developed.
Costs of robotic surgery Robotic surgery is an expensive endeavour (32). In assessing the cost-effectiveness of robotic surgery, one must balance the potential benefits, such as reduced hospital stay and reduced complication rates, with the costs, which include the need for additional surgical training, the cost of equipment, its maintenance and repair, and increased operating room setup time. Robot-assisted surgery has been reported favourably in gastrointestinal surgery, thoracic surgery, urology and gynaecological surgery, to list just a few examples (33). For example, in a randomised controlled trial comparing laparoscopic and robotassisted radical prostatectomy, reduced long-term complications were reported, namely urinary incontinence and erectile dysfunction, 1 year postsurgery in the robot-assisted group (34,35). Furthermore, in the latter group rates of readmission were lower. Similarly, despite the direct procedural costs of robotassisted Roux-en-y gastric bypass being higher than its non-robot assisted laparoscopic counterpart, a recent study examined the total costs of each procedure, factoring in the cost of complications and hospitalization time as well as the direct cost of the procedure itself (36,37). Robot-assisted surgery was found to be $2334 and $3637 cheaper than laparoscopic surgery and open surgery, respectively. Robotic surgery does not always confer costadvantage, however; this is variable according to the procedure and the specialty. For example, robotassisted transaxillary thyroidectomy compared with the traditional cervical approach showed no difference in rates of temporary hoarseness, bleeding, infection, seroma, numbness and length of hospital stay (38). Furthermore, the cost of setting up a robotic surgical unit is significant, ranging from $1 million to $2.5 million (39). Maintenance costs are reported to be $138,000 per annum and robot-
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of scientific evidence on the use of robot-assisted laparoscopic surgery. Surg Endosc 2014; 28(4): 1388–98. Porpiglia F, Morra I, Lucci Chiarissi M et al. Randomised controlled trial comparing laparoscopic and robot-assisted radical prostatectomy. Eur Urol 2013; 63: 606–14. Lim SK, Kim KH, Shin T, Rha KH. Current status of robot-assisted laparoscopic radical prostatectomy: how does it compare with other surgical approaches? Int J Urol 2013; 20: 271–84. Curet M, Curet MJ, Solomon H, Lui G, Morton JM. Comparison of hospital charges between robotic, laparoscopic stapled, and laparoscopic handsewn roux-en-Y gastric bypass. J Robotic Surg 2009; 3: 75–8. Hagen ME, Pugin F, Chassot G et al. Reducing cost of surgery by avoiding complications: the model of robotic roux-en-Y gastric bypass. Obes Surg 2012; 22: 52–61. Landry CS, Grubbs EG, Warneke CL et al. Robot-assisted transaxillary thyroid surgery in the united states: is it comparable to open thyroid lobectomy? Ann Surg Oncol 2012; 19: 1269–74. Barbash GI, Glied SA. New technology and health care costs – the case of robot-assisted surgery. N Engl J Med 2010; 363: 701–4. Amodeo A, Linares Quevedo A, Joseph JV, Belgrano E, Patel HRH. Robotic laparoscopic surgery: cost and training. Minerva Urol Nefrol 2009; 61: 121–8. Patel HRH, Linares A, Joseph JV. Robotic and laparoscopic surgery: cost and training. Surg Oncol 2009; 18: 242–6. Ahmed K, Ibrahim A, Wang TT et al. Assessing the cost effectiveness of robotics in urological surgery – a systematic review. BJU Int 2012; 110: 1544–56. van der Sluis PC, Ruurda JP, van der Horst S et al. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial). Trials 2012; 13: 230. Collinson FJ, Jayne DG, Pigazzi A et al. An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis 2012; 27: 233–41. Jackson NR, Yao L, Tufano RP, Kandil EH. Safety of robotic thyroidectomy approaches: meta-analysis and systematic review. Head Neck 2014; 36(1): 137–43 Barbosa JA, Kowal A, Onal B et al. Comparative evaluation of the resolution of hydronephrosis in
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children who underwent open and robotic-assisted laparoscopic pyeloplasty. J Pediatr Urol 2013; 9: 199–205. Xu J, Dailey RK, Eggly S, Neale AV, Schwartz KL. Men’s perspectives on selecting their prostate cancer treatment. J Natl Med Assoc 2011; 103: 468– 78. White E. Molecular neurosurgery: vectors and vector delivery strategies. Br J Neurosurg 2012 Dec; 26: 798–808. Latt WT, Newton RC, Visentini-Scarzanella M et al. A hand-held instrument to maintain steady tissue contact during probe-based confocal laser endomicroscopy. IEEE Trans Biomed Eng 2011; 58: 2694–703. Martirosyan NL, Cavalcanti DD, Eschbacher JM et al. Use of in vivo near-infrared laser confocal endomicroscopy with indocyanine green to detect the boundary of infiltrative tumor. J Neurosurg 2011; 115: 1131–8. Shang J, Noonan DP, Payne C et al. An articulated universal joint based flexible access robot for minimally invasive surgery. Proc IEEE Int Conf Robot Autom 2011; 1147–52. McLeod IK, Mair EA, Melder PC. Potential applications of the da Vinci minimally invasive surgical robotic system in otolaryngology. Ear Nose Throat J 2005; 84: 483–7. Weinstein GS, O’Malley BW, Snyder W, Sherman E, Quon H. Transoral robotic surgery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg 2007; 133: 1220–6. Weinstein GS, O’Malley BW, Magnuson JS et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope 2012; 122: 1701–7. Dallan I, Castelnuovo P, Vicini C et al. The natural evolution of endoscopic approaches in skull base surgery: robotic assisted surgery? Acta Otorhinolaryngol Ital 2011; 31: 390–4. AlAsari SF, Lim D, Kim NK. Robotic hemi-levator excision for low rectal cancer: a novel technique for sphincter preservation. OA Robotic Surg 2013; 1(1): 3. Motkoski J, Yang F, Lwu S, Sutherland G. Toward robot-assisted neurosurgical lasers. IEEE Trans Biomed Eng 2012; 99: 1. Marcus H, Nandi D, Darzi A, Yang GZ. Surgical robotics through a keyhole: from today’s translational barriers to tomorrows disappearing robots. IEEE Trans Biomed 2013 Eng 2013; 60(3): 674–81.
Paper received March 2014, accepted June 2014
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paved the way for novel surgical approaches which have hitherto been impossible because of the limitations of the human hand, particularly in confined spaces. Unsurprisingly, otolaryngoligist have enthusiastically welcomed robotics because of the greater freedom of movement and an enhanced 3D view of the surgical bed. (52,53). Previously, surgical management of head and neck cancers faced criticisms because of the need for access which often requires lip-splitting or mandibulotomy. Initial reports of Transoral Robotic Surgery demonstrated a very high safety and efficacy profile, and has led to the reemergence of surgical therapy and individual treatment protocols for patients with newly diagnosed oropharyngeal cancers (54). Other surgical disciplines have also benefitted by the creation of novel surgical corridors and improved visualisation, such as skull base surgery and sphincter preservation procedures in low rectal cancer (55,56). Furthermore, technical advances such as the development of robotic surgical laser technology offer improvements over simple electrocautery. By preferentially delivering energy dependent upon the wavelength of different tissue types (fat, protein or water), they can minimise collateral tissue damage in neurosurgical resections (57). Apart from cost, one of the key barriers to the successful translation of robotic advances into clinical practice has been the large and imposing nature of the system. Repositioning of the camera and the arms of the robot can be time-consuming and cumbersome. However, robotics is still in its infancy and improvements in technology will undoubtedly yield
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robots that are smaller, more powerful and cheaper to maintain, analogous to the way digital computing has progressed over the last few decades. A close partnership between clinicians and engineers, however, is crucial to the development of novel instruments that are both technically impressive and clinically effective (58). Over time it is likely that a range of smaller robotic systems, each encompassing specific robotic capabilities, will replace the multipurpose systems of today.
Conclusions Given the success with which robotics has been implemented in a number of different fields, from vehicle manufacturing to space exploration, and given the ability of robotics to perform fine, precise tasks, there has been a considerable impetus to utilise this technology within the surgical arena. As with all innovations in healthcare, however, robotic surgery has faced numerous barriers, notably questions regarding efficacy, safety and cost-effectiveness. In time, however, an expanding research base will provide us with answers to the many questions that remain surrounding robotic surgery and allow us to make key decisions regarding if, when and in what settings it should best be used.
Funding No external funding was required for this research.
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21 Hakimi AA, Blitstein J, Feder M, Shapiro E, Ghavamian R. Direct comparison of surgical and functional outcomes of robotic-assisted versus pure laparoscopic radical prostatectomy: single-surgeon experience. Urology 2009; 73: 119–23. 22 Schroeck FR, Palha de Sousa CA, Kalman RA et al. Trainees do not negatively impact the institutional learning curve for robotic prostatectomy as characterized by operative time, estimated blood loss, and positive surgical margin rate. Urology 2008; 71: 597–601. 23 Advincula AP, Song A. The role of robotic surgery in gynecology. Curr Opin Obstet Gynecol 2007; 19: 331–6. 24 Kruijdenberg CBM, Van Den Einden LCG, Hendriks JCM, Zusterzeel PLM, Bekkers RLM. Robot-assisted versus total laparoscopic radical hysterectomy in early cervical cancer, a review. Gynecol Oncol 2011; 120: 334–9. 25 Sarlos D, Kots L, Stevanovic N, Von Felten S, Sch€ar G. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol 2012; 120: 604–11. 26 Paraiso MFR, Ridgeway B, Park AJ et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Obstet Gynecol 2013; 208: 368.e1–7. 27 Wright JD, Ananth CV, Lewin SN et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA 2013; 309: 689–98. 28 M€ uller-Stich BP, Reiter MA, Wente MN et al. Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled trial. Surg Endosc Other Interv Tech 2007; 21: 1800–5. 29 Galvani C, Gorodner MV, Moser F, Baptista M, Donahue P, Horgan S. Laparoscopic heller myotomy for achalasia facilitated by robotic assistance. Surg Endosc Other Interv Tech 2006; 20: 1105–12. 30 M€ uhlmann G, Klaus A, Kirchmayr W et al. DaVinci robotic-assisted laparoscopic bariatric surgery: is it justified in a routine setting? Obes Surg 2003; 13: 848–54. 31 Yu SC, Clapp BL, Lee MJ, Albrecht WC, Scarborough TK, Wilson EB. Robotic assistance provides excellent outcomes during the learning curve for laparoscopic roux-en-Y gastric bypass: results from 100 robotic-assisted gastric bypasses. Am J Surg 2006; 192: 746–9. 32 Herron DM, Marohn M, Advincula A et al. A consensus document on robotic surgery. Surg Endosc Other Interv Tech 2008; 22: 313–25. 33 Heemskerk J, Bouvy ND, Baeten CGMI. The end of robot-assisted laparoscopy? A critical appraisal
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of scientific evidence on the use of robot-assisted laparoscopic surgery. Surg Endosc 2014; 28(4): 1388–98. Porpiglia F, Morra I, Lucci Chiarissi M et al. Randomised controlled trial comparing laparoscopic and robot-assisted radical prostatectomy. Eur Urol 2013; 63: 606–14. Lim SK, Kim KH, Shin T, Rha KH. Current status of robot-assisted laparoscopic radical prostatectomy: how does it compare with other surgical approaches? Int J Urol 2013; 20: 271–84. Curet M, Curet MJ, Solomon H, Lui G, Morton JM. Comparison of hospital charges between robotic, laparoscopic stapled, and laparoscopic handsewn roux-en-Y gastric bypass. J Robotic Surg 2009; 3: 75–8. Hagen ME, Pugin F, Chassot G et al. Reducing cost of surgery by avoiding complications: the model of robotic roux-en-Y gastric bypass. Obes Surg 2012; 22: 52–61. Landry CS, Grubbs EG, Warneke CL et al. Robot-assisted transaxillary thyroid surgery in the united states: is it comparable to open thyroid lobectomy? Ann Surg Oncol 2012; 19: 1269–74. Barbash GI, Glied SA. New technology and health care costs – the case of robot-assisted surgery. N Engl J Med 2010; 363: 701–4. Amodeo A, Linares Quevedo A, Joseph JV, Belgrano E, Patel HRH. Robotic laparoscopic surgery: cost and training. Minerva Urol Nefrol 2009; 61: 121–8. Patel HRH, Linares A, Joseph JV. Robotic and laparoscopic surgery: cost and training. Surg Oncol 2009; 18: 242–6. Ahmed K, Ibrahim A, Wang TT et al. Assessing the cost effectiveness of robotics in urological surgery – a systematic review. BJU Int 2012; 110: 1544–56. van der Sluis PC, Ruurda JP, van der Horst S et al. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial). Trials 2012; 13: 230. Collinson FJ, Jayne DG, Pigazzi A et al. An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis 2012; 27: 233–41. Jackson NR, Yao L, Tufano RP, Kandil EH. Safety of robotic thyroidectomy approaches: meta-analysis and systematic review. Head Neck 2014; 36(1): 137–43 Barbosa JA, Kowal A, Onal B et al. Comparative evaluation of the resolution of hydronephrosis in
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children who underwent open and robotic-assisted laparoscopic pyeloplasty. J Pediatr Urol 2013; 9: 199–205. Xu J, Dailey RK, Eggly S, Neale AV, Schwartz KL. Men’s perspectives on selecting their prostate cancer treatment. J Natl Med Assoc 2011; 103: 468– 78. White E. Molecular neurosurgery: vectors and vector delivery strategies. Br J Neurosurg 2012 Dec; 26: 798–808. Latt WT, Newton RC, Visentini-Scarzanella M et al. A hand-held instrument to maintain steady tissue contact during probe-based confocal laser endomicroscopy. IEEE Trans Biomed Eng 2011; 58: 2694–703. Martirosyan NL, Cavalcanti DD, Eschbacher JM et al. Use of in vivo near-infrared laser confocal endomicroscopy with indocyanine green to detect the boundary of infiltrative tumor. J Neurosurg 2011; 115: 1131–8. Shang J, Noonan DP, Payne C et al. An articulated universal joint based flexible access robot for minimally invasive surgery. Proc IEEE Int Conf Robot Autom 2011; 1147–52. McLeod IK, Mair EA, Melder PC. Potential applications of the da Vinci minimally invasive surgical robotic system in otolaryngology. Ear Nose Throat J 2005; 84: 483–7. Weinstein GS, O’Malley BW, Snyder W, Sherman E, Quon H. Transoral robotic surgery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg 2007; 133: 1220–6. Weinstein GS, O’Malley BW, Magnuson JS et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope 2012; 122: 1701–7. Dallan I, Castelnuovo P, Vicini C et al. The natural evolution of endoscopic approaches in skull base surgery: robotic assisted surgery? Acta Otorhinolaryngol Ital 2011; 31: 390–4. AlAsari SF, Lim D, Kim NK. Robotic hemi-levator excision for low rectal cancer: a novel technique for sphincter preservation. OA Robotic Surg 2013; 1(1): 3. Motkoski J, Yang F, Lwu S, Sutherland G. Toward robot-assisted neurosurgical lasers. IEEE Trans Biomed Eng 2012; 99: 1. Marcus H, Nandi D, Darzi A, Yang GZ. Surgical robotics through a keyhole: from today’s translational barriers to tomorrows disappearing robots. IEEE Trans Biomed 2013 Eng 2013; 60(3): 674–81.
Paper received March 2014, accepted June 2014
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
The use of robotics in surgery: a review A. Hussain,1 A. Malik,1 M. U. Halim,1 A. M. Ali1,2
1
John Radcliffe Hospital, University of Oxford, Oxford, UK 2 Harvard University, Cambridge, MA, USA Correspondence to: Azhar Hussain, Magdalen College, Oxford, OX1 4AU, UK Tel.: + 447838084966 Email: azhar.hussain@doctors. org.uk
Disclosure We have no conflict of interest to declare.
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SUMMARY
Review criteria
Importance: There is an ever-increasing drive to improve surgical patient outcomes. Given the benefits which robotics has bestowed upon a wide range of industries, from vehicle manufacturing to space exploration, robots have been highlighted by many as essential for continued improvements in surgery. Objective: The goal of this review is to outline the history of robotic surgery, and detail the key studies which have investigated its effects on surgical outcomes. Issues of cost-effectiveness and patient acceptability will also be discussed. Results and conclusion: Robotic surgery has been shown to shorten hospital stays, decrease complication rates and allow surgeons to perform finer tasks, when compared to the traditional laparoscopic and open approaches. These benefits, however, must be balanced against increased intraoperative times, vast financial costs and the increased training burden associated with robotic techniques. The outcome of such a cost-benefit analysis appears to vary depending on the procedure being conducted; indeed the strongest evidence in favour of its use comes from the fields of urology and gynaecology. It is hoped that with the large-scale, randomised, prospective clinical trials underway, and an ever-expanding research base, many of the outstanding questions surrounding robotic surgery will be answered in the near future.
We searched MEDLINE and Google Scholar using the terms ‘robotic surgery’, ‘robot-assisted surgery’ and ‘robotic-assisted surgery’ and manually searched references to identify papers in the English language.
Message for the clinic Robotic surgery confers a number of benefits including technical precision, faster recovery times and reduced complication rates, and it has been avidly adopted by several surgical specialties. Prohibitive costs and lack of familiarity with robotic systems remain important problems. However, current research seems set to yield more costeffective, smaller and precise robots that could accelerate the adoption of robotic surgery and expand its potential uses.
Introduction
A brief history of robotic surgery
Over the last decade, the use of robot-assisted surgery has increased dramatically. Urology and then gynaecology were the earliest specialties to adopt robotics in surgery, and many more specialties have since followed suit. This review examines the history of robotic surgery, the benefits of this technology and its use in different surgical procedures, followed by a discussion of cost-effectiveness and patient acceptability. The word ‘robot’ was first coined by the Czech playwright Karel Capek in 1921 (1). Since then, the field of robotics has expanded exponentially, particularly in industrial processes where robots are used to perform precise, repetitive and even hazardous tasks. Given the drive for technological innovation which healthcare has experienced over recent years, robots are now also being increasingly incorporated into many core surgical procedures. While the USA has been the main adopter of robotic systems, there are now several centres in the UK which incorporate robotic surgery into routine practice.
The drive to develop robotic surgical systems initially stemmed from the need to improve the accuracy and precision of surgical techniques. Indeed, one of the first surgical robots, PUMA 200, was developed in 1985 to allow neurosurgeons to increase their positioning accuracy for stereotactic CT-guided brain surgery (2). A few years later, the already established computeraided design and computer-aided manufacture (CADCAM) system was used by Integrated Surgical Systems to develop a surgical robot called ROBODOC (3). This device found use in orthopaedics, where three-dimensional (3D) imaging relayed to the robot enabled it to accurately fashion the implant cavity in knee and hip arthroplasty procedures, resulting in more accurate placement of the prosthesis as compared with the previous mallet and broach method. The real breakthrough in robotic surgery came in the 1990s, however, when robotic systems were able to process continuous input from surgeons and translate them into movements in real time. In the early 1990s, to reduce wartime mortality, the USA Army funded projects to develop systems whereby
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382. doi: 10.1111/ijcp.12492
The use of robotics in surgery
wounded soldiers could be placed in specialised vehicles and operated on remotely by surgeons (1). Many of the engineers and surgeons working for the Army then went on to develop ‘telepresence’ robotic systems for the civilian population. In 1994, one of the first telesurgical robots to be approved by the FDA was called AESOP (Automated Endoscopic System for Optimal Positioning), a USA Army-funded device developed by Computer Motion Inc. that allowed surgeons to control the position of the endoscope using either voice commands or a foot pedal. Further advances led to the development of the ZEUS robotic system (also by Computer Motion Inc.), which incorporated AESOP technology (4). This was the first ‘master-slave’ system that allowed a surgeon to remotely control the manipulator arms of the robot while seated at a special console. Although robotic surgery was still in its infancy, it was not long before rival manufacturers began filing lawsuits against one other for patent infringement (5). In 2003, two of the biggest rival companies, Computer Motion Inc. and Intuitive Surgical Inc., merged together and combined efforts to promote their ‘da Vinci’ system, in turn resulting in the discontinuation of the ZEUS robot.
The da Vinci Surgical System The da Vinci Surgical System is a comprehensive master-slave surgical robot which has emerged as the telesurgical system of choice in today’s practice. It comprises four arms, three of which carry surgical equipment, and a fourth which holds an endoscopic camera with dual lenses to generate stereoscopic 3D vision for the surgeon. The system can replicate the operating surgeon’s exact hand movements via the controls located on the console using EndoWrist Technology (6). The da Vinci system gained FDA approval in 2000 for general laparoscopic surgery, followed by approval in 2001 for radical prostatectomy and in 2005 for urological procedures. It has since been approved for gynaecological laparoscopic surgical procedures, general thoracoscopic surgical procedures and thoracoscopically assisted cardiotomy procedures (6). As of June 2013, 2799 da Vinci systems have been installed worldwide – 2001 in the USA, 442 in Europe and 356 in the rest of the world (7). Globally, they were used to perform nearly 500,000 operations in 2012, with almost 350,000 of those being in the fields of urology and gynaecology (7).
From the shadow of laparoscopy The current rise in the use of robotic devices for surgical procedures abroad and in the NHS mirrors ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
the steady implementation of other novel surgical techniques, such as minimally invasive surgery. Although the first laparoscopic cholecystectomy, performed in 1987, was initially met with a great deal of skepticism by the surgical community, minimally invasive surgery has since been warmly welcomed by patients and surgeons alike. Numerous studies have shown that laparoscopic procedures result in shorter hospital stays, fewer complications, decreased pain and better outcomes (8). However, despite these advantages there are several limitations which are inherent in laparoscopy, and the development of robotic surgical systems was largely born out of a desire to overcome these limitations while retaining the advantages that laparoscopy has to offer. Perhaps the greatest barrier surgeons had to overcome when training for laparoscopic procedures was the disruption of natural hand-eye co-ordination. Robotic surgery offers 3D visualisation as well as limiting the fulcrum effect which exaggerates tremors in laparoscopic surgery. Furthermore, the fact that the arms of the robotic system can be angulated in almost any direction enables the robot to provide more degrees of freedom than can be achieved by laparoscopic instruments. Certain specialties have failed to adopt laparoscopic surgery despite evidence showing clear benefits because of the sheer difficulty in becoming proficient at such procedures (9). The learning curve for robotic-assisted surgery on the other hand seems to be substantially easier. Marecik et al. found suturing to be significantly easier and more precise in surgical residents compared with open and laparoscopic methods (10). In addition, Ahlering et al. demonstrated successful transfer of surgical skills from an open to a laparoscopic environment using a robotic interface in surgeons without previous laparoscopic experience (11). Despite these advantages, robotic surgery is not as established as one might expect. Arguably the largest obstacle for widespread adoption is the high setup cost, but there are other barriers too. Notable examples include the inability to reposition the docked arms and the loss of haptic feedback. However, these issues are rapidly being addressed by engineers and have even led to the development of sensory systems that feedback to the surgeons’ hands (12).
Applications of robotic surgery Robotic surgical technology has found a particular stronghold in two specialties: urology and gynaecology. Indeed, as previously mentioned, of the 500,000 operations performed to date using the Da Vinci sys-
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tem almost 350,000 have been in one of those fields (5). Robotic assistance has been shown to improve the safety and the performance of intracorporeal suturing, which are heavily required in urological and gynaecological procedures (13). It is therefore no surprise that such surgeons have been enthusiastic in implementing robotic assistance in their procedures. The next section will focus on the effectiveness and outcomes in these specialties, where the richest supply of data is available.
Robotic surgery in urology Urology has been the speciality most keen to adopt robot-assisted surgery, and indeed it is now expected that robots will be used routinely in radical prostatectomy in the USA (14). Since the first robot-assisted laparoscopic prostatectomy (RALP) in 2000, RALP has now become by far the most commonly performed robotic operation (15). As such, multiple trials have been conducted evaluating its effectiveness over open and laparoscopic radical prostatectomy (LRP). Tewari et al. performed a meta-analysis of 167,184 open, 57,303 LRP, and 62,389 RALP procedures, adjusting for age, prostate-specific antigen levels and pathological characteristics (16). They found that RALP conferred many advantages over open and LRP procedures, including a lower estimated blood loss and shorter length of stay (LOS). These are summarised in Table 1. Furthermore, RALP had lower rates of readmissions, nerve injury, reoperations, deep vein thrombosis and sepsis compared with LRP (p < 0.003), as well as superior continence rates and return of sexual function (17–19). In addition, Sukumar et al. evaluated oncological outcomes in 5152 patients undergoing RALP in the largest report of its kind to date. They demonstrated effective long-term biochemical control in a high-volume tertiary center, offering further support for RALP (20). The adoption of robotic surgery has been slower in Europe than in the USA, however in the UK urologists have found substantial use for this technology, especially for RALP. Within just a decade, RALP has achieved similar, if not better, outcomes than open
and laparoscopic approaches. This may be surprising given the relatively short time for which robotic surgery has been available, however a study by Hakimi et al. has provided an explanation. In a case series of over 300, they found that superior results were obtained with the first 75 RALP cases as compared with the last 75 LRP cases, and indeed similar findings have been reported elsewhere, demonstrating the shorter learning curve of the robotic as opposed to the laparoscopic approach (21,22). This, along with the growing body of support for the efficacy and safety of RALP, lends credence to the notion that the robotic approach will become the method of choice for prostatic cancer surgery in the near future.
Robotic surgery in gynaecology In 2005 the FDA approved robot-assisted surgery for radical hysterectomy for endometrial and cervical cancer, 5 years after its initial approval for use in urology (23). Since then, the robot-assisted procedure has been widely adopted in the USA. However, unlike RALP, there has been a considerable lack of randomized controlled trials despite radical hysterectomies being the second most common robotassisted procedure performed in the USA. Kruijdenberg et al. reviewed robot assisted radical hysterectomy (RRH) vs. total laparoscopic hysterectomies (TLRH) by analysing data largely from individual case series, with 342 RRH patients and 914 TLRH patients. Although fewer blood transfusions were needed by patients in RRH compared with TLRH (5.4% vs. 9.7%, p < 0.05) and LOS was significantly shorter in RRH patients (3.3 vs. 6.2 days; p < 0.05), major postoperative complications were more frequent in RRH patients than TLRH (9.6%, 5.5% respectively; p < 0.05). However, the authors did conclude that the RRH studies had a smaller population and that experience with the new surgical devices beyond the initial learning phase may well reduce the complication rate (24). Two recent, though small, RCTs have shed further light on the outcomes of robotic vs. laparoscopic hysterectomy. Using 95 patients, Sarlos et al. com-
Table 1 Summary of main benefits of RALP over open radical prostatectomy and LRP
Perioperative outcomes
Estimated blood loss (ml) Length of stay, USA (days) Length of stay, non-USA (days)
RALP minus open radical prostatectomy
562.5 (95% CI 1.69 (95% CI 3.65 (95% CI
485.2, 639.8; p < 0.0001) 1.5, 1.9; p < 0001) 2.8, 4.5; p < 0.0001)
RALP minus LRP
127.8 (95% CI 0.78 (95% CI 1.04 (95% CI
95.4, 160.2; p < 0.0001) 0.5, 0.9; p < 0.001) 0.3, 1.8; p = 0.005)
Adapted from Tewari et al. (16).
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
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pared conventional laparoscopic hysterectomy vs. robot-assisted laparoscopic hysterectomy (25). After controlling for age, BMI and uterus weight, the total operating time was significantly higher for the robotic group than the conventional group (106 vs. 75 min respectively, p < 0.05). Complications and blood loss were not significantly different between the groups, although postoperative quality of life index was better in the robotic group. A similar randomized controlled trial by Paraiso et al. with 62 patients reached the same conclusions (26). These data however, need to be considered in the light of their relatively small sample sizes and the fact that a new procedure was being compared with one the operating surgeon was already very familiar with. In a large cohort study of 264,758 women across 441 hospitals in the USA from 2007 to 2010, Wright et al. report that that robotically assisted procedures increased from 0.5% in 2007 to 9.5% in 2010 of all hysterectomies performed (27). This is although, apart from a reduced LOS, overall complication rates and transfusion requirements were similar for both RRH. The lack of large RCTs, combined with the relatively recent (2005) FDA approval for gynecological surgery, make it difficult to comment on the effectiveness of robotic surgery in this specialty. However, as surgeons become more adept at using such technology and overcome the initial learning curve, a clearer picture will emerge.
Robotic surgery in other specialties Robotic surgery has been approved for use in various other specialties including paediatric surgery, cardiac surgery and general surgery. However, in these fields it has been met with less enthusiasm and has been adopted to a much lesser degree.
General surgery Although advances in laparoscopic surgery were largely driven by general surgeons, the use of robotics in general surgery has been surprisingly low. The areas with the greatest interest in robotic assisted procedures are foregut surgery, hepatobiliary surgery, bariatric surgery, colorectal surgery and endocrine surgery (10). In foregut surgery, trials comparing laparoscopic vs. robotic Nissen fundoplication show similar outcomes (28). Robot-assisted Heller myotomy for achalasia has also been studied, and has been found to have very low perforation rates (29). Many of the authors have commented on the potential use of robotic surgery in more complicated cases, though further study is needed before firm conclusions can be drawn. In bariatric surgery, gastric banding has ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
been performed robotically with little benefit as compared with laparoscopy (30). However, some have suggested that robotic surgery may improve outcomes for more complex bariatric procedures which require intracorporeal suturing (31). The cautious approach by the general surgeons to embrace this new technology may have resulted from several factors. For simple procedures, the use of complex robotics seems unwarranted. On more complex procedures the robot is limited, particularly in procedures where movement into several quadrants is required. Furthermore, the lack of an instrument for bowel stapling, sealing and cutting also makes the adoption very difficult, although a solution to this problem could conceivably be developed.
Costs of robotic surgery Robotic surgery is an expensive endeavour (32). In assessing the cost-effectiveness of robotic surgery, one must balance the potential benefits, such as reduced hospital stay and reduced complication rates, with the costs, which include the need for additional surgical training, the cost of equipment, its maintenance and repair, and increased operating room setup time. Robot-assisted surgery has been reported favourably in gastrointestinal surgery, thoracic surgery, urology and gynaecological surgery, to list just a few examples (33). For example, in a randomised controlled trial comparing laparoscopic and robotassisted radical prostatectomy, reduced long-term complications were reported, namely urinary incontinence and erectile dysfunction, 1 year postsurgery in the robot-assisted group (34,35). Furthermore, in the latter group rates of readmission were lower. Similarly, despite the direct procedural costs of robotassisted Roux-en-y gastric bypass being higher than its non-robot assisted laparoscopic counterpart, a recent study examined the total costs of each procedure, factoring in the cost of complications and hospitalization time as well as the direct cost of the procedure itself (36,37). Robot-assisted surgery was found to be $2334 and $3637 cheaper than laparoscopic surgery and open surgery, respectively. Robotic surgery does not always confer costadvantage, however; this is variable according to the procedure and the specialty. For example, robotassisted transaxillary thyroidectomy compared with the traditional cervical approach showed no difference in rates of temporary hoarseness, bleeding, infection, seroma, numbness and length of hospital stay (38). Furthermore, the cost of setting up a robotic surgical unit is significant, ranging from $1 million to $2.5 million (39). Maintenance costs are reported to be $138,000 per annum and robot-
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21 Hakimi AA, Blitstein J, Feder M, Shapiro E, Ghavamian R. Direct comparison of surgical and functional outcomes of robotic-assisted versus pure laparoscopic radical prostatectomy: single-surgeon experience. Urology 2009; 73: 119–23. 22 Schroeck FR, Palha de Sousa CA, Kalman RA et al. Trainees do not negatively impact the institutional learning curve for robotic prostatectomy as characterized by operative time, estimated blood loss, and positive surgical margin rate. Urology 2008; 71: 597–601. 23 Advincula AP, Song A. The role of robotic surgery in gynecology. Curr Opin Obstet Gynecol 2007; 19: 331–6. 24 Kruijdenberg CBM, Van Den Einden LCG, Hendriks JCM, Zusterzeel PLM, Bekkers RLM. Robot-assisted versus total laparoscopic radical hysterectomy in early cervical cancer, a review. Gynecol Oncol 2011; 120: 334–9. 25 Sarlos D, Kots L, Stevanovic N, Von Felten S, Sch€ar G. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol 2012; 120: 604–11. 26 Paraiso MFR, Ridgeway B, Park AJ et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Obstet Gynecol 2013; 208: 368.e1–7. 27 Wright JD, Ananth CV, Lewin SN et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA 2013; 309: 689–98. 28 M€ uller-Stich BP, Reiter MA, Wente MN et al. Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled trial. Surg Endosc Other Interv Tech 2007; 21: 1800–5. 29 Galvani C, Gorodner MV, Moser F, Baptista M, Donahue P, Horgan S. Laparoscopic heller myotomy for achalasia facilitated by robotic assistance. Surg Endosc Other Interv Tech 2006; 20: 1105–12. 30 M€ uhlmann G, Klaus A, Kirchmayr W et al. DaVinci robotic-assisted laparoscopic bariatric surgery: is it justified in a routine setting? Obes Surg 2003; 13: 848–54. 31 Yu SC, Clapp BL, Lee MJ, Albrecht WC, Scarborough TK, Wilson EB. Robotic assistance provides excellent outcomes during the learning curve for laparoscopic roux-en-Y gastric bypass: results from 100 robotic-assisted gastric bypasses. Am J Surg 2006; 192: 746–9. 32 Herron DM, Marohn M, Advincula A et al. A consensus document on robotic surgery. Surg Endosc Other Interv Tech 2008; 22: 313–25. 33 Heemskerk J, Bouvy ND, Baeten CGMI. The end of robot-assisted laparoscopy? A critical appraisal
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of scientific evidence on the use of robot-assisted laparoscopic surgery. Surg Endosc 2014; 28(4): 1388–98. Porpiglia F, Morra I, Lucci Chiarissi M et al. Randomised controlled trial comparing laparoscopic and robot-assisted radical prostatectomy. Eur Urol 2013; 63: 606–14. Lim SK, Kim KH, Shin T, Rha KH. Current status of robot-assisted laparoscopic radical prostatectomy: how does it compare with other surgical approaches? Int J Urol 2013; 20: 271–84. Curet M, Curet MJ, Solomon H, Lui G, Morton JM. Comparison of hospital charges between robotic, laparoscopic stapled, and laparoscopic handsewn roux-en-Y gastric bypass. J Robotic Surg 2009; 3: 75–8. Hagen ME, Pugin F, Chassot G et al. Reducing cost of surgery by avoiding complications: the model of robotic roux-en-Y gastric bypass. Obes Surg 2012; 22: 52–61. Landry CS, Grubbs EG, Warneke CL et al. Robot-assisted transaxillary thyroid surgery in the united states: is it comparable to open thyroid lobectomy? Ann Surg Oncol 2012; 19: 1269–74. Barbash GI, Glied SA. New technology and health care costs – the case of robot-assisted surgery. N Engl J Med 2010; 363: 701–4. Amodeo A, Linares Quevedo A, Joseph JV, Belgrano E, Patel HRH. Robotic laparoscopic surgery: cost and training. Minerva Urol Nefrol 2009; 61: 121–8. Patel HRH, Linares A, Joseph JV. Robotic and laparoscopic surgery: cost and training. Surg Oncol 2009; 18: 242–6. Ahmed K, Ibrahim A, Wang TT et al. Assessing the cost effectiveness of robotics in urological surgery – a systematic review. BJU Int 2012; 110: 1544–56. van der Sluis PC, Ruurda JP, van der Horst S et al. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial). Trials 2012; 13: 230. Collinson FJ, Jayne DG, Pigazzi A et al. An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis 2012; 27: 233–41. Jackson NR, Yao L, Tufano RP, Kandil EH. Safety of robotic thyroidectomy approaches: meta-analysis and systematic review. Head Neck 2014; 36(1): 137–43 Barbosa JA, Kowal A, Onal B et al. Comparative evaluation of the resolution of hydronephrosis in
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children who underwent open and robotic-assisted laparoscopic pyeloplasty. J Pediatr Urol 2013; 9: 199–205. Xu J, Dailey RK, Eggly S, Neale AV, Schwartz KL. Men’s perspectives on selecting their prostate cancer treatment. J Natl Med Assoc 2011; 103: 468– 78. White E. Molecular neurosurgery: vectors and vector delivery strategies. Br J Neurosurg 2012 Dec; 26: 798–808. Latt WT, Newton RC, Visentini-Scarzanella M et al. A hand-held instrument to maintain steady tissue contact during probe-based confocal laser endomicroscopy. IEEE Trans Biomed Eng 2011; 58: 2694–703. Martirosyan NL, Cavalcanti DD, Eschbacher JM et al. Use of in vivo near-infrared laser confocal endomicroscopy with indocyanine green to detect the boundary of infiltrative tumor. J Neurosurg 2011; 115: 1131–8. Shang J, Noonan DP, Payne C et al. An articulated universal joint based flexible access robot for minimally invasive surgery. Proc IEEE Int Conf Robot Autom 2011; 1147–52. McLeod IK, Mair EA, Melder PC. Potential applications of the da Vinci minimally invasive surgical robotic system in otolaryngology. Ear Nose Throat J 2005; 84: 483–7. Weinstein GS, O’Malley BW, Snyder W, Sherman E, Quon H. Transoral robotic surgery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg 2007; 133: 1220–6. Weinstein GS, O’Malley BW, Magnuson JS et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope 2012; 122: 1701–7. Dallan I, Castelnuovo P, Vicini C et al. The natural evolution of endoscopic approaches in skull base surgery: robotic assisted surgery? Acta Otorhinolaryngol Ital 2011; 31: 390–4. AlAsari SF, Lim D, Kim NK. Robotic hemi-levator excision for low rectal cancer: a novel technique for sphincter preservation. OA Robotic Surg 2013; 1(1): 3. Motkoski J, Yang F, Lwu S, Sutherland G. Toward robot-assisted neurosurgical lasers. IEEE Trans Biomed Eng 2012; 99: 1. Marcus H, Nandi D, Darzi A, Yang GZ. Surgical robotics through a keyhole: from today’s translational barriers to tomorrows disappearing robots. IEEE Trans Biomed 2013 Eng 2013; 60(3): 674–81.
Paper received March 2014, accepted June 2014
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
The use of robotics in surgery
paved the way for novel surgical approaches which have hitherto been impossible because of the limitations of the human hand, particularly in confined spaces. Unsurprisingly, otolaryngoligist have enthusiastically welcomed robotics because of the greater freedom of movement and an enhanced 3D view of the surgical bed. (52,53). Previously, surgical management of head and neck cancers faced criticisms because of the need for access which often requires lip-splitting or mandibulotomy. Initial reports of Transoral Robotic Surgery demonstrated a very high safety and efficacy profile, and has led to the reemergence of surgical therapy and individual treatment protocols for patients with newly diagnosed oropharyngeal cancers (54). Other surgical disciplines have also benefitted by the creation of novel surgical corridors and improved visualisation, such as skull base surgery and sphincter preservation procedures in low rectal cancer (55,56). Furthermore, technical advances such as the development of robotic surgical laser technology offer improvements over simple electrocautery. By preferentially delivering energy dependent upon the wavelength of different tissue types (fat, protein or water), they can minimise collateral tissue damage in neurosurgical resections (57). Apart from cost, one of the key barriers to the successful translation of robotic advances into clinical practice has been the large and imposing nature of the system. Repositioning of the camera and the arms of the robot can be time-consuming and cumbersome. However, robotics is still in its infancy and improvements in technology will undoubtedly yield
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robots that are smaller, more powerful and cheaper to maintain, analogous to the way digital computing has progressed over the last few decades. A close partnership between clinicians and engineers, however, is crucial to the development of novel instruments that are both technically impressive and clinically effective (58). Over time it is likely that a range of smaller robotic systems, each encompassing specific robotic capabilities, will replace the multipurpose systems of today.
Conclusions Given the success with which robotics has been implemented in a number of different fields, from vehicle manufacturing to space exploration, and given the ability of robotics to perform fine, precise tasks, there has been a considerable impetus to utilise this technology within the surgical arena. As with all innovations in healthcare, however, robotic surgery has faced numerous barriers, notably questions regarding efficacy, safety and cost-effectiveness. In time, however, an expanding research base will provide us with answers to the many questions that remain surrounding robotic surgery and allow us to make key decisions regarding if, when and in what settings it should best be used.
Funding No external funding was required for this research.
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children who underwent open and robotic-assisted laparoscopic pyeloplasty. J Pediatr Urol 2013; 9: 199–205. Xu J, Dailey RK, Eggly S, Neale AV, Schwartz KL. Men’s perspectives on selecting their prostate cancer treatment. J Natl Med Assoc 2011; 103: 468– 78. White E. Molecular neurosurgery: vectors and vector delivery strategies. Br J Neurosurg 2012 Dec; 26: 798–808. Latt WT, Newton RC, Visentini-Scarzanella M et al. A hand-held instrument to maintain steady tissue contact during probe-based confocal laser endomicroscopy. IEEE Trans Biomed Eng 2011; 58: 2694–703. Martirosyan NL, Cavalcanti DD, Eschbacher JM et al. Use of in vivo near-infrared laser confocal endomicroscopy with indocyanine green to detect the boundary of infiltrative tumor. J Neurosurg 2011; 115: 1131–8. Shang J, Noonan DP, Payne C et al. An articulated universal joint based flexible access robot for minimally invasive surgery. Proc IEEE Int Conf Robot Autom 2011; 1147–52. McLeod IK, Mair EA, Melder PC. Potential applications of the da Vinci minimally invasive surgical robotic system in otolaryngology. Ear Nose Throat J 2005; 84: 483–7. Weinstein GS, O’Malley BW, Snyder W, Sherman E, Quon H. Transoral robotic surgery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg 2007; 133: 1220–6. Weinstein GS, O’Malley BW, Magnuson JS et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope 2012; 122: 1701–7. Dallan I, Castelnuovo P, Vicini C et al. The natural evolution of endoscopic approaches in skull base surgery: robotic assisted surgery? Acta Otorhinolaryngol Ital 2011; 31: 390–4. AlAsari SF, Lim D, Kim NK. Robotic hemi-levator excision for low rectal cancer: a novel technique for sphincter preservation. OA Robotic Surg 2013; 1(1): 3. Motkoski J, Yang F, Lwu S, Sutherland G. Toward robot-assisted neurosurgical lasers. IEEE Trans Biomed Eng 2012; 99: 1. Marcus H, Nandi D, Darzi A, Yang GZ. Surgical robotics through a keyhole: from today’s translational barriers to tomorrows disappearing robots. IEEE Trans Biomed 2013 Eng 2013; 60(3): 674–81.
Paper received March 2014, accepted June 2014
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, November 2014, 68, 11, 1376–1382
