Robotics in Medicine: The Rise of Robotic Surgery

Introduction

In the 1950s, robots were envisioned as large, hulking devices with relatively limited capabilities. But "robot," taken from the Czech robota, meaning "forced labor," has evolved in meaning from dumb machines that perform menial, repetitive tasks to the highly intelligent anthropomorphic robots of popular culture (Lanfranco, "Robotics"). Similarly, in the 1980s, video games were primitive and allowed users to manipulate images on a screen with halting, sticky joysticks. Today, it is common to play relatively sophisticated video games via the Internet from around the world. Fusing the modern capabilities of robots and computers has yielded one of the most important developments in modern medicine in recent years: robotic surgery.

Robotics can offer people potentially life-saving, less invasive surgery. One day, having surgery performed by a doctor in another country may become commonplace. The use of robotic surgery is likely to increase in the future of medicine. This paper details the history of robotic surgery, some common procedures and surgical systems, a cost-benefit analysis, and the future outlook of robotics in medicine.

History of Robotics in Medicine

The origins of modern robotic surgery can be traced back to 1987 in the form of the first laparoscopic surgeries. This was deemed a breakthrough because laparoscopic surgery allowed for less invasive procedures and shorter hospital stays, along with a marked reduction in the risk of infection. However, there were also some drawbacks. "The equipment requires a surgeon to move the instruments while watching a video monitor. The surgeon must move in the opposite direction from the target on the monitor to interact with the correct area on the patient, so hand-eye coordination, tactile and force feedback, and dexterity aren't compromised" ("History of robotic surgery"). The surgeon, unfortunately, lacks the "feel" and tactile feedback provided by conventional surgery. "Moving the laparoscopic instruments while watching a 2-dimensional video monitor is somewhat counterintuitive. One must move the instrument in the opposite direction from the desired target on the monitor to interact with the site of interest. Hand-eye coordination is therefore compromised" (Lanfranco, "Robotics").

Research on how to improve robotic surgery continued. "Telepresence surgery combined virtual reality, robots, and medicine. In the early 1990s, scientists from the NASA-Ames team joined the Stanford Research Institute (SRI) to develop a telemanipulator for hand surgery" ("History of robotic surgery"). The U.S. Army became especially interested in robotic surgery, as there was hope it could bring expert assistance to wounded soldiers on the battlefield. This resulted in the development of the first non-laparoscopic robot — named the Puma 560 — which was used to perform neurosurgical biopsies ("History of robotic surgery").

These efforts to improve surgery for the Army began to translate into commercial uses, beginning with Computer Motion, Inc., which developed the Automated Endoscopic System for Optimal Positioning (AESOP) — "a robotic arm controlled by the surgeon's voice commands to manipulate an endoscopic camera" (Lanfranco, "Robotics"). This was followed by other popular forms of robotic surgery, including the Da Vinci and Zeus robotic systems used today (Lanfranco, "Robotics"). The use of robotic surgery expanded across procedure types, and today robotics is employed for surgeries as diverse as coronary artery bypasses, gallbladder removal, hysterectomies and tubal ligation, kidney removals and transplants, some forms of heart surgery, radical prostatectomy, and hip replacements, among others (Liou, "Robotic surgery"). "The number and types of surgeries being performed with robots is increasing rapidly as more institutions acquire these systems. Perhaps the most notable use of these systems, however, is in totally endoscopic coronary artery grafting, a procedure formerly outside the limitations of laparoscopic technology" (Lanfranco, "Robotics").

According to the National Institutes of Health (NIH), robotic surgery retains certain advantages similar to laparoscopic surgery while also featuring important improvements. "It can be performed through smaller cuts than open surgery. The small, precise movements that are possible with this type of surgery give it some advantages over standard endoscopic techniques" (Liou, "Robotic surgery"). The surgeon can make much more precise cuts, once again reducing healing time. Furthermore, with the use of robotics "it is easier for the surgeon to use the surgical tools than with laparoscopic surgery through an endoscope. The surgeon can also see the area where the surgery is performed more easily. This method lets the surgeon move in a more comfortable way, as well," reducing physical fatigue (Liou, "Robotic surgery").

How Robotic Surgery Is Performed Today

Different robotic systems have slightly different methods, but a common setup is the so-called "master-slave" system. With this method, "multiple arms [are] operated remotely from a console with video-assisted visualization and computer enhancement" (Lanfranco, "Robotics"). For example, in the Zeus system "there are essentially three components: a vision cart that holds a dual light source and dual 3-chip cameras, a master console where the operating surgeon sits, and a moveable cart where two instrument arms and the camera arm are mounted" (Lanfranco, "Robotics"). The images generated by the dual cameras are entirely three-dimensional in terms of depth. This "gives the surgeon the illusion that the tips of the instruments are an extension of the control grips, thus giving the impression of being at the surgical site" (Lanfranco, "Robotics").

With the Da Vinci system, another widely used platform, "the surgeon works from a computer console in the operating room, controlling miniaturized instruments mounted on three robotic arms to make tiny incisions in the patient" while looking through a 3-D camera magnifying the surgical site ("Robotic surgery program," UC Health). The surgeon's movements are transmitted through the computer system attached to the robot while the surgical team supervises ("Robotic surgery program," UC Health). With all systems, many of the traditional problems associated with laparoscopic surgery are eliminated. In fact, with enhanced vision capabilities and the elimination of surgeon's tremor through the devices, some surgeons have come to prefer robotic-assisted over conventional laparoscopic approaches.

Despite these benefits, there are also some disadvantages: "with a price tag of a million dollars, their cost is nearly prohibitive. Whether the price of these systems will fall or rise is a matter of conjecture. Some believe that with improvements in technology and as more experience is gained with robotic systems, the price will fall" (Lanfranco, "Robotics"). The systems are also large and cumbersome. "It may be difficult for both the surgical team and the robot to fit into the operating room. Some suggest that miniaturizing the robotic arms and instruments will address the problems associated with their current size. The cost of making room for these robots and the cost of the robots themselves make them an especially expensive technology" (Lanfranco, "Robotics").

Conclusion

Despite these concerns, the use of robotics in surgery will likely expand as the price of the technology continues to drop. Machines will grow more sophisticated and less cumbersome over time. The need for telemedicine will likely further spur the use of robotic surgery, and the desire of younger physicians to use familiar technology will result in a broader shift in favor of these systems. According to one urological surgeon: "We've found that younger surgeons who have experience with video games picked it up quicker than older surgeons" (Pollard, "Watch"). Video games and surgery have both come a long way in the last thirty years.