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Frontiers in Robotic Surgery

By SAM ATALLAH, MD and JORGE TRILLES

For contemporary readers and practicing physicians, the term 'robotic surgery' may conjure up thoughts of mechanical anthropomorphic beings armed with artificial intelligence quickly rendering the human surgeon obsolete. Yet, this forethought stands in contrast to the current prevailing paradigm for robotic surgery: the master-slave layout, where an experienced surgeon exerts full control over a surgical robot in a symbiotic relationship of sorts that ultimately aims to improve patient outcomes in surgery. In this article, I will offer insights on key advantages and limitations of robotic surgery, shed light on some of the more recent advances in this quickly evolving field, and discuss future directions.

The da Vinci Surgical System, designed and manufactured by Intuitive Surgical in 1997, and approved by the FDA for use in the U.S. in 2000, remains the most commonly used robotic surgical system to this day. It is classified as a telesurgical system, where a surgeon fully controls a robot situated over a patient on an operating table, but does so from a remote console, usually within close vicinity of the operating room. Key differences for the surgeon between the robotic vs. open surgery format are that the surgeon is no longer at the bedside, giving up tactile feedback and direct visualization of the anatomy, and instead secondary visualization is achieved via a specialized fiberoptic lens that feeds to 3D digital imaging display.

Although robotic surgery was originally seen as an evolution of laparoscopic surgery, and physicians initially attempted to compare the two techniques against each other, it is probably best to view these as having a divergent evolution, with each technique retaining unique functionalities and indications in future surgical practice. While both employ CO2 for exposure and secondary visualization via a lens and imaging display, laparoscopic procedures keep surgeons at the bedside.

Robotic surgery, like traditional laparoscopic surgery, is a minimally invasive surgical technique--it allows for a smaller number and length of incisions, resulting in less trauma to achieve a surgical outcome. Advantages include less pain, faster recovery and lower incidence of infection. In certain subsets of patients, the use of robotic surgery has been shown to improve the quality of cancer resection (negative margin rate) and decrease operative morbidity (Ramsay, et al, Health Technol Assess Winch Engl.; 2012). Another key advantage of robotic surgery is exposure--the instruments are much smaller, being able to get into and work in small spaces with stable 3D visualization and up to 12x magnification capability (essentially, the system can thus be used to perform intricate operations within a focused field analogous to microsurgery). Lastly, robots allow for extreme precision in the operating room--a robot's hands simply won't tremble the way even the best surgeon's hands might, and the robot is able to ignore any tremor in an operator's hands. Ultimately, the objective is to better much mimic the movement capabilities of a human wrist than any traditional laparoscopic instrument. This allows surgeons to preserve natural motion mechanics while operating in spaces that their hands would never be able to fit into.

Limitations of robotic revolve around cost and training. The approximate 2019 cost for some systems is $2 million (USD) and annual maintenance fees can add up to several hundred thousand dollars, arguably making it more expensive than open or laparoscopic equivalents. It's possible that robotic surgery could be a cost-effective option if capital costs were to decrease (increased competitors in the market for surgical robots) or a sufficient caseload could be maintained. Furthermore, the rest of the surgical support staff must also receive varying degrees of training in order to efficiently and effectively carry out these procedures. Lastly, surgical robots occupy a large physical footprint and are cumbersome to set up, adding to the time it takes to prepare a room and patient prior to surgery, and adding to the clutter in an already congested operating room.

Next generation robotic systems will incorporate other, non-surgical tools to assist the surgeon in precision surgery. For example, near-infrared fluorescence imaging can be used to help surgeons evaluate blood vessels and tissue perfusion in real time. Other interesting advancements include the SOFIE surgical robot, developed in 2010 at Eindhoven University of Technology. It is the first of its kind to provide haptic feedback--recreating the tactile sensation that a surgeon would normally experience when operating with standard tools for open procedures and supplements visual feedback. Unfortunately, the SOFIE surgical robot has not yet been commercialized, but it does serve as a promising preliminary proof of concept.

As for the future of robotics in medicine, it's predicted to grow tremendously over the next decade. Does this mean open and laparoscopic procedures will become obsolete? No--there will always be a place for these procedures. Next-generation surgical innovation will look to do things otherwise not possible with traditional laparoscopy, relying more on informatics and the concept of Digital Surgery--the platform for this innovation will almost certainly be robotic surgery. According to an industry report by MarketsandMarkets published December of 2018, the surgical robot's market is expected to grow from $3.9 billion (USD) in 2018 to $6.5 billion by 2023, with other analysts estimating growth to upwards of $20 billion. Analysts indicate that key drivers of growth include improving technology, availability of R&D capital, increasing applicability of robotic surgery and wider adoption of these systems by hospitals and other surgical centers.

I leave you with some conceptual food for thought: In 2015, a team of researchers at Vanderbilt University successfully constructed a prototype wrist (diameter = 1.16 mm) for needle-sized surgical robots that can rotate and has an actuation tendon that permits it to bend up to 90 degrees, possibly paving the way for surgeons to access previously inaccessible areas of the body with robotic surgery. In 2016, the Smart Tissue Autonomous Robot (STAR) was able to suture in an ex vivo and in vivo setting and quantitatively outperformed surgeons in formal studies; and lastly, Elon Musk's latest project, Neuralink, recently unveiled its research on computer-brain interfacing, including the development of a microsurgical robot with enhanced optics that allows it to implant electrodes into the brain with extreme precision, avoiding blood vessels in the process, and potentially ushering in a new standard for tomorrow's minimally invasive surgery.

Sam Atallah, MD, is a Colorectal Surgeon and Director of Research and Clinical Trials at Digestive and Liver Center of Florida. He pioneered robotic transanal surgery and was the first in the world to perform this technique. He is one of the leaders in advanced technology for rectal cancer surgery and has developed the technique of stereotactic navigation for transanal total mesorectal excision (taTME) -- an important step forward in the evolution of computer-assisted surgery. Visit https://www.DLCFL.com

Jorge Trilles is a third-year medical student at the UCF College of Medicine and is set to graduate as part of the Class of 2021. UCF's medical school requires all of its students to conduct research during their training, so they play a part in contributing new scientific and medical knowledge.



 
 
 
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