Friday, 15 November 2013

Group Presentations 2

Brief Overview/ Introduction
This session marked the end of TWC sessions. It was surprising how rapidly these past 13 weeks flew by. In this session, the remaining four groups, including mine, presented the websites that they have created for the project.

Interesting Observations & Ideas:
The first group was Jamie’s group, which presented on the topic of min-controlled prosthetics. It is really amazing how much prosthetics has evolved over the years, due to technology, this certainly reminds one the wonderful impacts and benefits continually developing and improving technology can bring to mankind. I liked how the group mentioned the need for the sense of touch in current prosthetics, as I had never considered that disadvantage before. It would be very beneficial indeed, if future prosthetics come with the ability to feel, so that users can better communicate and interact with their fellow humans without the need to worry of unintentionally hurting them. Users would also be able to undertake delicate tasks requiring soft, controlled and restrained handling, or touch, thus not severely limiting them in any way.

The second group was Alister’s group on Transhumanism. Their presentation was a real eye-opener as I had never heard of the term transhumanism before ahahha. One thing that I really liked about their website, was the user-friendly and interesting timeline of the development in non-human body parts. I found the benefits of transhumanism very promising and fascinating, and especially beneficial to those that are dis-abled. However, for perfectly abled humans…I can’t seem to accept the idea of their unnecessarily substituting their perfectly-fine limbs for non-human limbs, despite the multiple advantages, right now ahahahha. Nevertheless, it was a very thought-provoking and interesting presentation, and I really liked the design of their website, it appeared as though they really put in a lot of effort in designing the layout.

After my group’s presentation on food for the future, Sylvester’s group was next to present on the definitely attention-capturing (hoho) topic of sex and advertising. Indeed, the increasing portrayal of women as object for mere sexual pleasure is troubling, especially with the potential image that could be portrayed to susceptible young children, especially since they would be our future generations and the continuation of the human race. Already there is an alarmingly rapid growth in the numbers of teen-pregnancy and especially rape. The increasing application of sex ads could accelerate the growth in those areas even more…especially with the invention of 3-D sex ads. These concerning side-effects have opt be considered really carefully before companies push out more and more sex ads.

Finally, the last group, Clara’s group, presented on the topic of virtual reality, mainly focusing on the 2 types of augmented reality and simulation virtual reality. Although the topic of virtual reality had been discussed before in one of the previous session, the group’s presentation was nevertheless still interesting and exciting. I especially liked the live demonstration the group did, it was very innovative and attention-grabbing. I also felt that the group did a good job in researching and investigating the different applications, implication, and potential of virtual reality.

Session Rating: 9/10

It is really amazing how time can really fly by, it really feels as though it was only recently that I attended the first TWC session. Throughout these 13 weeks, I have undoubtedly gained numerous knowledge and information that will continue to be useful to both my personal life and future career. Had I not taken TWC, I would still be in my own little world, unknown to the mind-boggling wonders of technology, and unable to appreciate its worth.

Group Presentations 1

Brief Overview/ Introduction
The weeks of 11 and 12 were dedicated to my fellow classmates’ group presentations, so instead of the usual routine of Prof heading the session, we got to see the various websites that the group have created. It was rather exciting to see what the groups had come up with, and it proved to be an interactive and interesting experience.

Interesting Observations & Ideas:
Prashant’s group was the first to bring us through their website on Futuristic Buildings. Overall, I really liked their group’s presentation, as it was obvious that they really went in-depth into the topic of future buildings, and I especially liked the fact that they actually went to build a miniature of their building concept, it shows that they did put in a lot of effort into their project.
The group delved into the various infrastructural aspects of futuristic buildings, namely, susceptibility, sustainability, space, speed and design. I especially liked the group’s idea for ensuring the sustainability of their future building. Sustainable construction of future buildings is a very important part of future buildings, due to the crucial need to preserve the Earth’s precious resources. As the population continues to increase, there is a constant need for more and more buildings, and this makes the sustainability of buildings even more important. Pranshant’s group not only captured this need, they came up with what I felt was a sound and innovative method for the construction of their futuristic building.

Grace’s group was the second to present, and for their project, they delved into the different types of clean energy that are expected to come of age soon. I felt that their group chose a very pertinent and important topic. Given the limited state of the earth’s resources, like fossil fuels for example, and their shockingly rapid depletion, we, let alone our future generations, face the dire threat of having insufficient resources for future development and survival. Hence there is an undeniable need for clean, sustainable energy for both our own future development, and that of our future generations. Out of all the different possible sources of clean energy, I felt that solar energy and the use of solar panels would be the most efficient for resource-scarce, especially land, small, and densely populated Singapore.

Like the first group, it was obvious to me that this group had conducted a very thorough and in-depth research in the various aspects of clean energy. Their website contained all the results of their research, which are, the different types of clean energy and their respective histories, pros and cons, the implications of clean energy on the areas of health, environmental and economic, and even future considerations. I liked how the website even featured various case studies of countries that have been successful in implementing some of the various types of clean energy sources. All in all, the group did a good job in studying the topic of clean energy, however, I felt that they could probably concise the information in their website more, as some of the sections were a little too wordy and too small. Nevertheless, I trust that it was because they were pressed for time, due to the busy few weeks I trust everyone has been having. Another suggestion would be that perhaps they could have given their thoughts and opinions, about the possible future plan they think would be most suitable and viable for Singapore under the thoughts section of the website.

The last group, Wei Yang’s group, presented their website on nanotechnology. Again, their group seemed to have done a very thorough job in canvassing the areas of nanotechnology. I like how they included videos in their website, as it made their website more interesting.  I also liked how they had added navigation buttons here and there to facilitate easy and convenient user navigation.
Lastly, it was an interactive presentation by Wei Yang’s group on nanotechnology. I enjoyed how they formed a very balanced presentation on both the pros and cons of nanotechnology, especially with reference to the part on hydrophobic particles where they were extremely transparent about the potential carcinogenic properties of such particles if ingested. Beyond the unintended side effects of using nanotechnology, I liked how they showed the possible intentional abuse of such technology by making nanotechnology a weapon as well. What especially stood out, for me, was the section dedicated to nanotechnology in cancer treatments.

Cancer is fast becoming the number one assassin globally, and although the current possible medical treatments available, they have numerous unforgiving side-effects, like the case of chemotherapy. In addition, many cancer cases are still incapable of being treated, as such, there is a constant need for the invention and development of a better and more effective solution, and nanotechnology shows very promising capability of assuming that role. I felt that this group did well in mentioning the possible cons and dangers of nanotechnology too though, as it gave the audience a very balanced viewpoint. Indeed, the nature of human hearts differ from person to person, and with the massive capability of nanotechnology, many negative side-effects could come up, and this possibility would definitely have to be taken into consideration when considering whether or not to develop the technologies mentioned.

Session Rating: 8/10

All in all, I enjoyed viewing the different websites and their diverse information in today’s group presentations, and found the session very interesting and eye-opening. 

Wednesday, 6 November 2013

Individual Topical Review Paper

Robotic Surgery: The New Future of Surgery?[1]
Suherman Kartika Sari (kssuherman.2013@business.smu.edu.sg), 1st Year student, Bachelor of Business Management, Singapore Management University

1.      Executive Summary

Considering the presently known advantages of robotic surgery, it clearly has the potential to become a revolutionary technology which will bring about further colossal changes in the way surgical procedures are performed. This paper serves to evaluate the potential success of this technology, by first examining the history and initial development of robotically-assisted surgery, together with the major achievements and breakthroughs it has since contributed to the area of surgery. Subsequently, this paper delves into the current application and reception of the technology in the medical field, as well as its present advantages and limitations. The paper also addresses whether those limitations can be overcome. Finally, the various possibilities that await the development of robotic surgery, and the resulting changes to the surgical field will be touched upon and explained in the future considerations section of the paper.


2.      Introduction

Technology has impacted the world in numerous ways, with technological advancement and innovation playing major parts in diversifying and improving human activities and capabilities, including the medical field. Over the years, technological advancements have continuously shaped and changed the variety of medicine and medical procedures performed. Currently, one of the most innovative and potentially revolutionary technology raging in the medical field is: Surgical Robots.

Robotic surgery is a type of surgical procedure where robotic systems are employed to carry out surgical procedures (Mayo Clinic, n.d.). Generally, in robotically-assisted surgeries, a surgeon conducts an operation through a computer which controls the movements of multiple minute surgical tools attached to a robot. This innovative surgical method was initially developed and introduced with the aim of replacing minimally-invasive surgery, or laparoscopy, by making up for the latter’s limitations, as well as to enhance surgeons’ capabilities in cases of open surgery. (AAGL, 2013) As such, there are presently 2 types of surgical situations where these robotic systems are used: i) robotically-assisted minimally-invasive surgery and ii) enhanced open surgery.

For that of a robotic minimally-invasive surgery, robotic systems were incorporated with the purpose of overcoming the limitations of the popular minimally-invasive surgery. Laparoscopy was first introduced in 1987, and has steadily gained the favour of surgeons and patients alike, by bringing advantages such as smaller incisions and wounds, lower risk of infections, shorter recuperation and resource employment period (The University of Chicago Medical Center, 2013). However, its limitations has hindered its successful application in more serious and complex surgical procedures. These limitations are mostly centred on the dexterity and coordination of its technical and mechanical nature, such as hand-eye coordination and restricted degrees of motion, thereby limiting its adoption in delicate and complex procedures. Surgical robots were hence developed to overcome these limitations, and extend the scope of application of conventional laparoscopy. As for enhanced open-surgery, traditional steel surgical instruments are replaced by autonomous robotic instruments capable of performing several procedures and actions much smoother and better-controlled than the human hand. This effectively decreases tissue trauma.

The several advantages of using robotic systems in surgical processes are just a few of the numerous benefits of the technology. These other benefits will be further elaborated in the later sections of the paper, along with the present limitations of the technology. However, before the paper explores those areas, it will first introduce the historical developments and progress of the technology, and well as the achievements that have since been realized. This will then be followed by the estimation of the potential of the said technology.

2.1.Limitations of Report

One of the limitations of the report would be the absence of statistical evidence of the success and adoption of robotic surgery throughout the world. Furthermore, were it not for length constraints, this paper could have examined the historical origins of laparoscopic and its development in order to better explain the inspiration for the idea of incorporating robots into the surgical process. Similarly, the paper could have perhaps delve into the multiple types of robotic surgical systems that were developed over the years, together with their corresponding achievements, to date, in greater detail.


3.      Historical Perspective

The Information Age has brought about numerous additions to the range of human activities and capabilities. Just like how technology has revolutionised various fields such as manufacturing and production, it has similarly made significant contributions to the area of medicine. As mentioned previously, the limitations of laparoscopic surgery spurred the research and development of a better technology, i.e. robotic surgery. Seeing how robots have been successfully introduced and incorporated into other areas, in manufacturing for example, innovators have since sought to do the same for the medical field.

The year of 1985 saw the very first documented use of robotics in surgery, when the PUMA 560 surgical arm, an originally standard industrial robotic arm was modified and used by Kwoh et al. in a neurosurgical biopsy with the aid of a computed tomography (CT). The PUMA robotic arm is conjoined to a 1980 series controller which uses a programming language, VALII, to translate simple commands into electrical signals that drives the robot (Rutherford, 2012).  The robotic arm was adapted to hold a fixture beside the head of a patient so drills and biopsy needles could be implanted with greater precision into the desired location during brain biopsies (Albani, 2007). Despite the successful preliminary results which showed that the robot could perform brain biopsies with greater precision, the company selling the PUMA 560 protested the usage of the robot for surgical purposes, stating that it unsafe as it was originally intended to be within a barrier preventing any human contact. (Gupta)

Nevertheless, the encouraging 1985 surgery results eventually led to the first robotically-assisted laparoscopic surgery in 1987. The following year, in 1988, the PUMA 560 was again employed, this time by Davies et al. for a prostate surgery. This consequently spurred the development of the PROBOT, a robotic surgical system specifically designed for prostate surgery purposes, in 1992 at the Imperial College London. The PROBOT was the world’s first pure robotic surgery, but it failed to gain the approval of the Food and Drug Administration (FDA). In the meantime, another robot, ROBODOC, was in the midst of development, carried out by Integrated Surgical Supplies Ltd. for the purpose of performing hip replacement surgeries with greater precision. This time, the FDA finally approved of the ROBODOC, and it thus became the first certified surgical robot. (Mishra, 2011)

Amidst the continuous research and development of robots for surgical purposes, from the middle to the late 1980s, a party of the National Air and Space Administration (NASA)-Ames Research Center researchers, who were then researching on virtual reality, were keen on using the information on robotic surgery to invent tele-presence surgery, or tele-surgery (Lanfranco et al 2004). Tele-surgery allows a surgeon to perform surgery from a location that is geographically removed from the actual surgical site, by manipulating a robotic surgical system at the remote site (Sherk, n.d.). Spurred by the massive potential of tele-surgery, a few of the scientists from the NASA-Ames team joined forces with researchers from the Stanford Research Instistute (SRI), along other experts in robotics and virtual reality, to continue the development of surgical robots.  The US Army subsequently became interested in this development, as it presented the possibility of conducting surgeries on wounded soldiers without having to take the risk of transporting surgeons over to the war-site. With the financing from the US Army, a robotic machine which enabled a soldier to undergo an operation, remotely performed by a doctor at a nearby Mobile Advanced Surgical Hospital (MASH), was successfully developed. This system was expected to help decrease the likelihood of wounded soldiers dying from blood loss before reaching the hospital. (Lanfranco et al 2004)

Several members of the team who developed the robotic system for the US Army saw that the system possessed great potential commercial value, and thus through forming several commercial ventures, they pioneered the introduction of robotics to the civilian medical society. Over time, the numerous research and development carried out on the area of robotic surgery led to 3 noteworthy inventions, namely, the AESOP, the Zeus system, as well as the Da Vinci surgical system. The AESOP, or the Automated Endoscopic System for Optimal, is a voice-commanded robotic arm that manipulates an endoscopic camera that was developed by Computer Motion Inc. The Da Vinci and Zeus surgical system, developed by Intuitive Surgical, Inc. and Computer Motion, Inc. respectively, have similar capabilities whereby both are master-slave machine, i.e. not a pure robot with incorporated intelligence, consisting of multiple robotic arms that are manipulated from a removed computer-enhanced console consisting of video-assisted visualization.

Out of the three, the Da Vinci surgical system is the more frequently utilised to date, as it was officially approved by the FDA for use in most types of laparoscopic surgery in July 2000 (Mishra, 2011). Examples of its applications will be covered under the following section. The Da Vinci system comprises of 4 interactive robotic arms, 3 for surgical tools and 1 for an endoscopic camera, manipulated by the surgeon through a single master console. It is presently the only commercially available robotic surgical system that gives a surgeon the dexterity, control, and precision of conventional open surgery while merely needing 1-2cm incisions. (Intuitive Surgical, 2013)


4.      Current Situation

As seen from the previous section, these past few decades have seen advancements in robotic surgery that has led to countless breakthroughs and advancements in the surgical field. Likewise, the usage of robotic surgery has also been steadily increasing vis-à-vis the development of the procedure. The popularity and receptivity of this technology, among surgeons and patients alike, has rapidly escalated over the years, especially in the US. More and more surgeons recommend the use of robotic surgery to patients due to the advantages over traditional procedures, and patients themselves, too, often enquire and request for this option whenever possible. In the US alone, the total number of robotically-assisted operation shot up from 80,000 in 2008 to 205,000 in 2010. (Lipschitz, 2010) Some of the surgeries which employs robotic systems will explained in detail in the subsection below. 

4.1.Applications of Robotic Surgery

Initially, robotic surgery was more commonly used for the removal of gall bladders, but today, robots are employed in a variety of operations, namely:
4.1.1.      General Surgery
The Da Vinci surgical robot has been employed in several common general operations, such as in esophageal and pancreatic surgery, and even in liver transplants. This robotically-assisted procedure provides the advantages of laparoscopic surgery, for example decreased pain and scarring, as well as make up for its limitations.

4.1.2.      Cardiovascular surgery
Figure 1: Full Da Vinci S surgical system. Reproduced from Intuitive Surgical. (n.d.)
At present, robotic surgery is frequently applied to these 3 types of heart surgery: Coronary artery bypass, atrial septal defect repair, and Mitral valve repair. An atrial septal defect repair is conducted to resolve a hole in the middle of the 2 upper heart chambers, while a mitral valve repair involves the restoration of the valve that serves to avert the backflow of blood into the upper heart chambers in heart contractions. A coronary artery bypass is for the removal of blockage in the coronary arteries.

4.1.3.      Gastrointestinal surgery
There are numerous types of gastrointestinal operations where robotic systems are used, such as in gastric bypass surgeries, which reduces the amount of food absorbed during the digestive process by stitching a part of a patient’s stomach together to make it smaller. Robotic surgery is also applied in operations for the treatment of gastroesophageal reflux (i.e. acid reflux) and colon resection surgeries. The Da Vinci robot and ZEUS system are typical used for these procedures, although the latter has been recently phased out. 

4.1.4.      Gynaecology
One of the most common and rapidly growing application of robotic surgery is in gyneocology, such as in gynecology and gynecologic oncology. The Da Vinci surgical system is usually used for such surgeries. The robotically-assisted procedure eliminates the need for large abdominal incisions, and is applied to treat endometriosis, pelvic prolapse, abnormal periods, fibroids, and even female cancers. Furthermore, gyneocologists are able to use the system to perform hysterectomies, myomectomies, and lymph node biopsies as well.

4.1.5.      Neurosurgery
Several robotic systems for use in neurosurgery have been developed and marketed in the past few years, beginning with the NeuroMate in 1997, which has since been used in 8000 brain surgeries over the US, Europe, and Japan, by 2009. Others include the Rosa, Renaissance, and NeuroArm, the world’s 1st MRI-compatible robot to be commercialised internationally.

4.1.6.      Orthopaedics
The Renaissance robot mentioned above is also employed in surgeries involving the spine, such as spinal deformity corrections and fusion, in multiple countries. Other orthopaedic operations with robotic assistance are hip and knee replacements, as well as ligament reconstructions. The robotic surgical systems allow greater precision in bone-cutting procedures for these surgeries.

4.1.7.      Paediatrics
Surgical robots have even been employed in various operations for children as well. The Children’s Hospital in Boston was the 1st paediatric hospital to procure a robotic surgical system back in 2001, and has since used the technology in more operations compared to any other hospital in the world. The surgeons in their Centre for Robotic Surgery possess high-level of expertise paediatric robotic surgery, and even conduct trainings for surgeons from other countries on the procedures. 

4.1.8.      Radiosurgery
Robotic surgery has even been used in radiosurgery to treat cancers and tumours. One example is the CyberKnife Robotic Radiosurgery System which enables the treatment of tumours in any part of the body by sending numerous high-energy radiation beams directly to the tumour (Accuray Incorporated, n.d.). This robotic system allows the delivery of radiation beams from multiple directions without having to move either the patient or the radiation source, which is required in traditional procedures.

4.1.9.      Urology
Urology is another field in which robotically-assisted procedures have gained popularity in usage, especially in the US. It is most commonly used in prostate cancer operations, due to the difficult anatomical access in traditional open-surgery methods. Robotic systems are used in kidney cancer and bladder operations too.




4.2.Advantages

The widespread application of this technology, as shown above, is due to its abundant advantages, for both surgeons and patients, over tradition open-surgery procedures. Each of the current advantages of robotic surgery will be covered in detail in the respective subsections below:

4.2.1.      Increased precision & accuracy
One of the main benefits of robotically-assisted surgery would be the greater level of precision and accuracy of the robotic systems give to surgeons, compared to traditional surgical instruments. For example, in the ZEUS as well as Da Vinci surgical systems, one of the robotic arms is a 3D camera, or Automated Endoscopic System for Optimal Positioning (AESOP). This gives surgeons a more real-life image, compared to 2D images using normal endoscopic procedures. Furthermore, AESOP is conveniently adjusted through voice command, by either zooming in or out. The magnifying capability of the device is especially beneficial to surgeons with poor vision, or in surgeries involving miniscule or microscopic parts, such as veins or nerves. With this enlarging function, a millimetre-wide vein, for example, can be magnified into as big as a pencil. Also, the motions of the other robotic arms wielding surgical instruments can be scaled according to the desired scale, which means, for example, that a surgeon’s 1cm movement can be adjusted to result in a 1mm movement. (ThinkQuest, n.d.)

4.2.2.      Greater dexterity & accessibility
The 3D camera mentioned above is small and flexible, and thus enables surgeons to see regions that are usually obstructed to the human eye in open-surgeries. The other robotic arms are extremely thin, flexible, and dexterous, thereby allowing greater accessibility and mobility in tight areas, especially in children operations, that are traditionally only accessible by making long incisions.

4.2.3.      Minimally invasive
Figure 2: Minimally Invasive Surgery. Reproduced from Mayo Clinic. (n.d.)
Additionally, due to the thinness and flexibility of the robotic arms, only small incisions are needed. For example, in a traditional heart-surgery, in order to get to the heart, the surgeon would have to make a very long 25-30cm cut, as well as splitting the breast bone and parting the rib cage. With robotic surgery, these procedures are redundant, for heart-bypass surgery can now be done on a closed and beating chest, which is an enormous achievement in the medical field. This minimally invasive procedure are far less painful, and not to mention, leave much smaller scars. (Cavayero, 2013)


4.2.4.      Risk reduction & faster recuperation
Furthermore, the smaller required incisions result in decreased blood loss and fewer blood transfusion requirements. In addition, robots can remain in a sterile environment and minimize bacteria exposure, unlike humans, thereby decreasing the risk of infections. This not only benefits the surgeons, but patients too, with regards to minimal pain, speedier recovery, and rapider return to normal activities. The briefer hospital stays help reduce the number of staff required for after-operation nursing care. By freeing up hospital resources, more patients and surgeries can be handled during a particular period. This likewise leads to lower hospital costs for patients and hospital alike. (ThinkQuest, n.d.)

4.2.5.      Human error reduction
Another clear advantage in robotically-assisted surgeries is in long operations, especially those involving miniscule or microscopic parts, like tissue or nerve reconstruction, and long complex operations. A typical coronary bypass lasts as long as 3-6 hours. Surgeons often get tired during such lengthy surgeries, and this affects their concentration level, judgment, stability and accuracy, which are all very vital in any surgery. Conversely, the robotic systems do not tire like humans, and can therefore operate within long periods of time without compromising precision and stability, thereby reducing human error, risk, and increasing chances of success. Furthermore, in robotic surgeries, surgeons can remain seated rather than stand, and the magnifying capability of the telescopic camera decreases the strain on their eyes as well.

4.3.Disadvantages

Despite the plentiful benefits of robotic surgery, there are several drawbacks to the technology that limit its widespread application and reception. These drawbacks will be explained below:

4.3.1.      Higher costs
One of the frequently cited disadvantages of robotic surgery is the hefty additional costs incurred for both hospitals and patients. The purchase cost of some robotic surgical systems can go up to as much as $1 million, with maintenance costs generally amounting up to $100,000 a year. In 2011, the latest Da Vinci surgical robot was selling for $1.8 million, with annual maintenance costs at approximately $140,000. The replacement cost of each of the four arms of the robot was around $1,000 (Smith, 2011). In addition, operating the robotic system require surgeons to have a specific degree of expertise, in which they would have to go for a series of rigorous specialized training before they can be fully certified to use the equipment. Hospitals would have to bear these additional training costs required, as well as the opportunity cost incurred in terms of time lost that could have been better used to operate on patients. Often, hospitals would then make up for these extra costs by increasing the cost of hospital bills for patients. The higher cost of robotically-assisted operations are also not usually covered by patients’ health insurance or Medicare. On this basis, critics of robotic surgery often argue that in spite of the benefits conferred by the technology, the higher medical costs involved limit its benefit to the small group of affluent patients who can afford it. Whereas patients who cannot afford to bear extra costs are not able to benefit from the use of the technology.

However, although the initial absolute costs of robotic surgery is higher than that of conventional procedures, the major portion of these additional costs is due to the large purchase cost of the equipment, and the annual maintenance costs. These factors are attributed to the relatively new stage of the technology, and thus are projected to decrease significantly as the technology advances further. Moreover, the savings hospitals can obtain from reductions in operative time, hospital stays, and personnel costs, will duly compensate the hospital for its initial investment in the technology in the long run. (Lanfranco et al 2004)


4.3.2.      Steeper & longer learning curve
As mentioned earlier, surgeons are required to possess specialised skills to master the use of the technology and thereby qualified to perform a robotically-assisted operation. Learning how to use the robotic systems takes a long period of time, usually requiring at least hundreds of both simulated and real operations before surgeons can honestly express that they have mastered the technology. The benefits of robotic surgery cannot be fully realised if surgeons have not truly mastered the procedure yet, as a result, patients sometimes bear the consequences of the learning curve, as seen from the slightly less-than-satisfactory successful robotic surgery results. Also, most of the surgeons who are qualified to learn the skills required are well-experienced and established in their surgical fields, which means that they generally have very little time to undergo training. Not to mention, the opportunity costs incurred, in terms of serving other patients or training to enhance a surgeon’s skill in traditional surgeries, is very high. Additionally, as the technology is still considered to be at its initial stages, proper training curricula have yet to be optimally developed, thus at present, surgeons face a very steep learning curve. (Satava, n.d.)

Nevertheless, like the preceding argument, given the eventual further advancements and developments of the technology, more effective and appropriate surgical curricula and simulations are bound to be drawn up, which would ultimately offset this disadvantage.


4.3.3.      Risk of system malfunction
Just like any other technology or electronic device, there is always a possibility of the robotic systems malfunctioning or experiencing device-related complications in the midst of an operation. This is especially so given the higher complexity of robotic surgeries compared to traditional operations. Once again, just like any other technology, this risk can be gradually reduced as further developments in the robotic systems are made. (Johns Hopkins, 2013) Furthermore, hospitals can put in place back-up procedures and policies in anticipation of any possible complication, by having a secondary robot ready, or requiring surgeons to continue the surgery using conventional procedures.



5.      Future Considerations

Robotic surgery has just been around for slightly more than 10 years, yet the advantages attached to it has led to its rapidly gaining popularity over traditional open surgery in many areas of surgery. The amazing part about this revolutionary technology is the fact that it is just at its initial stages of development. It has massive potential to completely change the way surgeries are performed, and there are still so many possibilities just waiting to be discovered and explored.
5.1.Automated surgical robots
It was said earlier on that presently employed robotic systems are master-slave robots that are unable to make decisions independently, like the Da Vinci system for example. These type of robots require a surgeon to be present at the master console to give the system commands that will accordingly dictate their actions. However, there is a possibility that the developments of the technology will introduce a new generation of robotic systems that are capable of making decisions and performing procedures independently and automatically in the near future. Robotic surgeons might even substitute human surgeons, thereby eliminating human error and increasing efficiency. Their greater precision, sterility, and lower invasiveness will increase the likelihood of success for simple and complex procedures alike.

The higher success rate would mean that less lives will be lost due to human carelessness and mistake. Also, the greater degree of sterility in surgeries would help to push the rate of infection down, and the lower invasiveness would contribute by accelerating patients’ recuperation periods. In short, automated surgical robots have the potential to raise the standards of healthcare services even higher, increasing overall standard of living. The consequent benefits are not just confined to patients alone, these automated robotic robots will take over the manual jobs of surgeons, and reduce or even eliminate the number of assistant medical personnel needed to standby during surgeries. This thereby decreases the strain on surgeons and nurses alike, and they can then focus their efforts on other critical tasks.

5.2.Tele-presence surgery
One of the major anticipated contributions that robotic surgery will bring to the area of medicine is the development in tele-presence surgery, or tele-surgery. Earlier in the paper, it was mentioned that the US Army invested heavily into the development of robotic surgery, as they hoped that it would make tele-surgery possible, and allow them to deliver timely medical assistance to wounded field soldiers. However, the geographical distance between the place of actual surgery and the surgeon was not very far in their case.
Now, as continuous improvements are made over time, doctors are expecting the expansion of this geographical distance, whereby surgeons could operate on a patient from a different city, country, or even continent. Imagine the substantial benefits that would bring to patients all around the world. There will be greater accessibility to medical assistance and solutions for even the most rural and desolated of villages. This would in turn help to significantly decrease world mortality rates that are associated with the lack of timely or appropriate medical solutions, and raise healthcare standards in less-developed countries.
In fact, a long-distance surgery has already been conducted in 2001, between New York and Strasbourg, France, for gallbladder removal. Although “Operation Lindbergh”, as the surgery was dubbed, was successful, the delay caused by lag time due to telecommunications made the surgery unfeasible (Polland, 2012). Nonetheless, given the rapid improvements of the internet and wireless technology, this is but a small problem that can be easily surmounted.

5.3.Single-incision ports & Nanosurgery
A different surgical method that robots are expected to bring about is the single-incision port. Currently, robotic systems used in laparoscopic surgeries employ a minimally-invasive method where only a few small incisions need to be made, through which the flexible robotic arms are inserted. In the case of a single-incision port, as the name suggests, only one incision is needed for the robotic arms to go through. That would definitely reduce the risk of blood loss, infection, pain, and recovery time even more significantly (Polland, 2012), ultimately raising the quality of healthcare services to a whole new level for patients.   

Additionally, there is the emerging research and development of nanosurgery which involves the use of nanorobots, robots with sizes ranging from 0.1-10 micrometres with nanoscale (10−9 metres) components that have the thinness of human hair, in surgical procedures. This would introduce a whole new level of precision and accessibility in the field of robotic surgery, and likewise cause great advancements in the quality and standards of medical solutions and services. For example, in cancer surgeries, according to Associate mechanical and industrial engineering Professor, Nader Jalili, of Northeastern University, Boston, in the areas within the body where traditional surgical instruments are unable to access, say within a millimeter of a tumor, a nanorobot can be precisely directed to the location and show images of the tumor that could never be seen before. (Northeastern University, 2009)

5.4.Greater competition & higher education standards
With the development and implementation of tele-surgery, other than reducing the distance between patients and doctors, it would similarly raise the degree of competition between doctors who are competing for surgical bids and patients worldwide. Patients will have the ability to choose from a whole range of medical practitioners from all over the world and pick the best from the market. Consequently, the standards and quality of medical services would inevitably be pushed considerably up, and doctors have to continually improve their skills in order to not get left behind.
Another area that will receive potential improvement is in the standards of surgical education. As mentioned, the learning curve of robotic surgery for surgeons is very steep. Besides the complexity and uniqueness of the skills needed to operate the systems, there is a lack of educational materials and medical curricula available as well, due mainly to the newness of the technology. Nevertheless, as more medical institutes come to realise the great potential of robotic surgery, more effort will be put into developing the educational curriculum and training required to carry out robotically-assisted surgeries for interested and qualified surgeons. (Ryerson, 2013)
In fact, robotic surgery could even improve the learning curve for surgeons for all types of surgical procedures in the future. The technology could be used to generate simulations or reconstructions that emulate real operations for surgeons under training. Besides helping to shorten the learning time for surgeons-in-training, it could also increase the effectiveness of training exercises, thereby lessening surgical errors and improving patients’ safety. (Lanfranco et al 2004)

5.5.Possible social costs
However, although the adoption of robots in surgery may be advantageous to the surgical training process in the long term, the steep learning curve of the technology might present some social costs in the near future. As mentioned previously, due to the limited time and inadequate training curriculum available to surgeons who are interested in learning the technology, most surgeons have yet to fully master the technology before they perform actual robotically-assisted operations. This poses a threat to the safety of the patients they operate on, for their inexperience increases the risk of errors. The lack of knowledge on the technology may also contribute to the poor safety management and monitoring of robotic surgeries. Besides this, robotic systems are prone to occasional malfunctions too, especially when the development of the technology is still relatively new.

Consequently, patients’ safety are at a higher stake than what would have been in a conventional procedure serving the same purpose. To put it simply, patients have to bear the brunt of the development process of robotic surgery. This is especially so with complicated surgeries, like life-and-death emergency cases where the risk involved is much higher. It would not be comforting to either the patient’s relatives or surgeons themselves, to know that the results might have turned out better, or mistakes avoided, had traditional procedures been used instead. Nonetheless, nothing is perfect; even though 85 deaths and 245 Da Vinci-related injuries have been reported since 2000, the figures correspond to 1.5million robotic procedures that have been performed during the same period. The statistical insignificance of the causality rate thereby presents an optimistic forecast of the future contributions of robotic surgery. (Greenberg, 2013)
Another possible social problem is that the high cost of robotically-assisted operations limits its accessibility to patients with lower income. Robotic surgery costs around $1,500-$2,000 more than conventional procedures, a hefty difference a lot of patients may not be able to afford. (Andrews, 2013) And though the costs of present robotic solutions will most likely decrease vis-à-vis its advancement and improvements, the costs of the more advanced robotic systems developed along the way will always remain high, given the general perception that new is always better. The rate of increment in its price is likely to accelerate as the systems gets more and more advanced with increasing technological knowledge. This rise in the prices of surgical systems could very well raise the overall costs of healthcare across the medical industry, as hospitals are likely to compensate their higher expenses by increasing their medical fees. Considering so, there is a high chance of a widening gap with regards to society’s access to healthcare services. The lower income group in society would continue to face increasing difficulty in affording medical solutions, whereas the more affluent group will always be able to freely enjoy and benefit from the increasing quality of medical services. This means that the unfair distribution of healthcare in society can only henceforth become more difficult to eradicate.
The relatively new stage of the technology might also impede on its efficiency and scale of contributions in the near future. As the robotic systems are far more complicated to use than conventional equipment that surgeons are much experienced and familiar in using, robotic procedures often take a longer time than traditional operations, particularly for non-complex cases. (Schwitzer, 2011) Furthermore, surgeries performed by inexperienced surgeons or those who are still undergoing training require intensive surveillance and guidance from surgeons who are experts on the use of robotic surgical equipment. Meaning that besides the longer time involved, which necessarily increases the stake on patients’ lives, more medical personnel might be required than in traditional operations. Therefore instead of relieving the present strain on the medical infrastructure, robotic surgery could very well double surgeons’ burdens.

5.6.Suggestions for minimising current drawbacks
As stated previously, one of the major drawbacks of this promising technology which presently fetters the scope of its beneficial contributions would be the high purchase cost of the technology. However, there has been several suggestions that increasing the number of manufacturers and investors of the technology would be the key instigator of the eventual reduction in its price (Pietrabissa et al, 2013).Given so, the author suggests that government authorities could consider offering more incentives to hospitals that wish to purchase and invest in the technology, as well as to manufacturers that are interested in innovating and producing robotic systems. This could help to increase the scope of adoption and volume of robotic systems in the healthcare market, which would accordingly help to push the cost of the technology down. As to the limitation attributed to the substantial learning curve surgeons face, the author likewise feels that the joint effort of government authorities and health institutions in pushing for standardised robotic surgery training and credential programs, as well as in developing more comprehensive and better training curricula, could perhaps help to ease the learning curve. Lastly, regarding the inevitable malfunction risk of the surgical systems, this author believes that this risk would most likely decrease significantly with the eventual advancements in and greater knowledge of the technology, therefore making the incentives and investments from government authorities even more necessary. Nevertheless, regardless of how safe the robotic systems may get, medical institutions should never leave anything to chance and always put in place back-up policies and plans for all robotic surgeries performed.  



6.      Conclusion

In summary, as seen from the historical and current situation of the technology, the substantial time and effort used in developing robotic surgery has been duly recompensed by the countless benefits and achievements it has brought to the world of surgery. The technology’s employment in the various areas of surgery have not only reshaped the way surgical procedures are performed, it has also made possible countless breakthroughs in the realm of medicine and improved the overall quality of medical services available to patients. Limitless possibilities await the development of robotic surgery, and its further progress is set to completely reshape the way surgeries are performed in the future. It would only be unwise to ignore its massive potential. 


7.      References

AAGL. (2013). Robotic-assisted laparoscopic surgery.Journal of Minimally Invasive Gynecology,20(1), 2-9. Retrieved from http://www.aagl.org/wp-content/uploads/2013/03/aagl-robotic-position-statement.pdf
Accuray Incorporated. (n.d.). Cyberknife:what is cyberknife?. Retrieved from http://www.cyberknife.com/cyberknife-overview/what-cyberknife.aspx?langtype=1033
Andrews, M. (2006, July 23). A guiding hand. U.S. News & World Report, Retrieved from http://health.usnews.com/usnews/health/articles/060723/31robot_3.htm
Andrews, M. (2013, April 23). Questions arise about robotic surgery’s cost, effectiveness. Retrieved from http://www.kaiserhealthnews.org/features/insuring-your-health/2013/042313-michelle-andrews-robotic-surgery.aspx
Albani, J. M. (2007). The role of robotics in surgery: A review. Missouri Medicine, 104(2), 166. Retrieved from http://www.urologyspecialistskc.com/sites/default/files/pdf/missouri_med.pdf
Cavayero, C. (2013). A practicality analysis pertaining to minimally invasive robot-assisted urologic surgery.Undergraduate Research Journal, 6(2), 45-55. Retrieved from http://www.urj.ucf.edu/docs/cavayero.pdf
Figure 1. Full Da Vinci S Surgical system. Intuitive Surgical, Inc. da Vinci S system. (n.d.) Retrieved from http://intuitivesurgical.com/company/media/images/davinci_s_images.html
Figure 2. Minimally invasive heart surgery. Mayo Clinic. Minimally Invasive Heart Surgery. (n.d.) Retrieved from http://www.mayoclinic.org/minimally-invasive-heart-surgery/enlargeimage5773.html
Gupta, S. (n.d.). Developments in robotic surgery and types of robotic surgery machines. Retrieved from http://bme240.eng.uci.edu/students/10s/sgupta1/Developments.html
Greenberg, H. (2013, March 19). Robotic surgery: Growing sales, but growing concerns. Retrieved from http://www.cnbc.com/id/100564517
Johns Hopkins. (2013, September 3). Robotic surgery complications underreported, Johns Hopkins study suggest. Retrieved from http://www.hopkinsmedicine.org/news/media/releases/robotic_surgery_complications_underreported_johns_hopkins_study_suggests
Lanfranco, A. R., Castellanos, A. E., Desai, J. P., & Meyers, W. C. (2004). Robotic surgery a current perspective. Annals of Surgery, 239(1), 14-21. doi: 10.1097/01.sla.0000103020.19595.7d
Lipschitz, D. (2010). Robotic surgery is all the rage, but price is high. Retrieved from http://www.creators.com/health/david-lipschitz-lifelong-health/robotic-surgery-is-all-the-rage-but-price-is-high.html
Mayo Clinic. (n.d.). Robotic surgery at mayo clinic. Retrieved from http://www.mayoclinic.org/robotic-surgery/
Mishra, R. K. (2011, October 7). History of robotic surgery. Retrieved from http://www.laparoscopyhospital.com/history_of_robotic_surgery.htm
North Shore-LIJ Health System. (2013). What is robotic surgery?. Retrieved from http://www.northshorelij.com/hospitals/robotic-surgery
Northeastern University. (2009, December 21). The next medical frontier: nano-surgery. Retrieved from http://phys.org/news180637694.html
Pietrabissa, A., Vinci, A., Pugliese, L., & Peri, A. (2013). Robotic surgery: Current controversies and future expectations. Cirugía Española91(2), 67-71. doi: 10.1016/j.cireng.2012.07.002
Polland, J. (2012, August 1). Watch: this robot is poised to change surgery forever. Retrieved from http://www.businessinsider.com/the-future-of-robotic-surgery-2012-7
Polland, J. (2012, August 2). Get Ready for the Next Big Steps in Robotic Surgery. Retrieved from http://www.businessinsider.com/robotic-tele-surgery-and-snake-holes-2012-7#ixzz2j0ILw4k2
Rutherford, J. (2012). Using the puma 560 robot. Retrieved from http://rutherford-robotics.com/PUMA/USING THE PUMA ROBOT.pdf
Ryerson, N. (2013, May 16). Dr. vipul patel on the future of robotic surgery. Retrieved from http://www.dotmed.com/news/story/20841?p_begin=1
Satava, R. M. (n.d.). Ethical dilemmas in laparascopic, robotic, and advanced surgical technology. Retrieved from http://laparoscopy.blogs.com/prevention_management_3/2010/10/ethical-dilemmas-in-laparoscopic-robotic-and-advanced-surgical-technology.html
Sherk, S. D. (n.d.). Tele-surgery. Retrieved from http://www.surgeryencyclopedia.com/St-Wr/Tele-surgery.html
Smith, A. (2011, January 4). Growing number of medical operations in Syracuse are done with da vinci surgical robot. The Post-Standard. Retrieved from http://blog.syracuse.com/cny/2011/01/growing_number_of_medical_operations_in_syracuse_are_done_with_da_vinci_surgical_robot.html
Schwitzer, G. (2011, July 30). Surgeon blogs that robotic surgery is all hype and no substance. Retrieved from http://www.healthnewsreview.org/2011/07/surgeon-blogs-that-robotic-surgery-is-all-hype-and-no-substance/
The Associated Press. (2009, October 14). Robotic prostate surgery riskier: study. CBC News. Retrieved from http://www.cbc.ca/news/technology/robotic-prostate-surgery-riskier-study-1.844265
The Robotic Surgery Center (2012). What is robotic surgery?. Retrieved from http://www.robotic-surgery.med.nyu.edu/for-patients/what-robotic-surgery
ThinkQuest. (n.d.). Advantages of robotic surgery. Retrieved from http://library.thinkquest.org/03oct/00760/Advantages of Robotic Surgery.htm
The University of Chicago Medical Center. (2013). Benefits of minimally invasive procedures. Retrieved from http://www.uchospitals.edu/specialties/minisurgery/benefits/
Valeo, T. (2010, April). Scarless surgery: The benefits and drawbacks of robotic thryroidectomy. ENTtoday, Retrieved from http://www.enttoday.org/details/print/684941/April_2010.html
VCU School of Medicine. (2012, September 26). Robotic surgery at vcu urology. Retrieved from http://www.vcu.edu/urology/robotics/history.html
Wrongdoctors. (2010, May 2). [Web log message]. Retrieved from http://wrongdoctors-diseases.blogspot.sg/2010/05/da-vinci-robotic-surgery-pros-and-cons.html





[1] This paper was reviewed by Jamie Teo and Chong Hui Qi.