Robotic Surgery: The New Future of Surgery?
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.
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. 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. As such, there are presently 2 types of surgical situations where these robotic systems are used: i) robotically-assisted minimally-invasive surgery & ii) enhanced open surgery.
In the case of robotically-assisted 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. 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.
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.
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 being developed 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, in the mid-to-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. 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). Spurred by the massive potential of tele-surgery, a few of the scientists from the NASA-Ames team joined forces with researches from the Stanford research Instisture (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 funding of the US Army, a robotic system which enabled a soldier to be remotely operated on by a surgeon at a nearby Mobile Advanced Surgical Hospital (MASH) was successfully developed. It was hoped that this system would help to decrease the likelihood of wounded soldiers dying from blood loss before reaching the hospital. (Lanfranco, Castellanos, Desai & Meyers, 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 Da Vinci surgical system, as well as the Zeus 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 ZEUS and Da Vinci surgical systems, developed by Computer Motion, Inc. and Intuitive Surgical, 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 3, the Da Vinci surgical system is the more commonly used robotic surgical system 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, controlled 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 traditional open surgery while merely requiring 1-2cm incisions. (Intuitive Surgical, 2013)
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-Ã -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.
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:
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.
Cardiovascular surgery
At present, robotic surgery is frequently applied to these 3 types of heart surgery: Atrial septal defect repair, mitral valve repair, and coronary artery bypass. An atrial septal defect repair involves the mending of a hole between the 2 upper heart chambers, while a mitral valve repair involves the restoration of the valve that prevents blood from flowing back into the upper heart chambers during heart contractions. A coronary artery bypass is for the removal of blockage in the coronary arteries.
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.
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.
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.
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.
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 acquire a robotic surgical system back in 2001, and has since used the technology in more operations than 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.
Radiosurgery
Robotic surgery have 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 delivering numerous high-energy radiation beams directly to the tumour. 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.
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.
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:
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 both the ZEUS and 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)
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.
Minimally invasive
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)
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, faster recovery, and quicker return to normal activities. The shorter 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)
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.
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:
Higher costs involved
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 cost 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. Replacing each of the four arms of the robot cost 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, Castellanos, Desai & Meyers, 2004)
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 take 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)
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.
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.
Future Considerations
Robotic surgery has only been around for slightly more than a decade, 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.
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.
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 impractical. Nonetheless, given the rapid improvements of the internet and wireless technology, this is but a small problem that can be easily surmounted.
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)
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 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)
Higher medical quality & 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 before, 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, Castellanos, Desai & Meyers, 2004)
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.
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