Robotic Surgery: A Current Perspective

Anthony R. Lanfranco, BAS; Andres E. Castellanos, MD; Jaydev P. Desai, PhD; William C. Meyers, MD


Annals of Surgery. 2004;239(1) 

In This Article

Background and History of Surgical Robots

Since 1921 when Czech playwright Karel Capek introduced the notion and coined the term robot in his play Rossom's Universal Robots, robots have taken on increasingly more importance both in imagination and reality.[1,2] Robot, taken from the Czech robota, meaning forced labor, has evolved in meaning from dumb machines that perform menial, repetitive tasks to the highly intelligent anthropomorphic robots of popular culture. Although today's robots are still unintelligent machines, great strides have been made in expanding their utility. Today robots are used to perform highly specific, highly precise, and dangerous tasks in industry and research previously not possible with a human work force. Robots are routinely used to manufacture microprocessors used in computers, explore the deep sea, and work in hazardous environment to name a few. Robotics, however, has been slow to enter the field of medicine.

The lack of crossover between industrial robotics and medicine, particularly surgery, is at an end. Surgical robots have entered the field in force. Robotic telesurgical machines have already been used to perform transcontinental cholecystectomy.[3,4] Voice-activated robotic arms routinely maneuver endoscopic cameras, and complex master slave robotic systems are currently FDA approved, marketed, and used for a variety of procedures. It remains to be seen, however, if history will look on the development of robotic surgery as a profound paradigm shift or as a bump in the road on the way to something even more important.

Paradigm shift or not, the origin of surgical robotics is rooted in the strengths and weaknesses of its predecessors. Minimally invasive surgery began in 1987 with the first laparoscopic cholecystectomy. Since then, the list of procedures performed laparoscopically has grown at a pace consistent with improvements in technology and the technical skill of surgeons.[5] The advantages of minimally invasive surgery are very popular among surgeons, patients, and insurance companies. Incisions are smaller, the risk of infection is less, hospital stays are shorter, if necessary at all, and convalescence is significantly reduced. Many studies have shown that laparoscopic procedures result in decreased hospital stays, a quicker return to the workforce, decreased pain, better cosmesis, and better postoperative immune function.[6,7,8] As attractive as minimally invasive surgery is, there are several limitations. Some of the more prominent limitations involve the technical and mechanical nature of the equipment. Inherent in current laparoscopic equipment is a loss of haptic feedback (force and tactile), natural hand-eye coordination, and dexterity. Moving the laparoscopic instruments while watching a 2-dimensional video monitor is somewhat counterintuitive. One must move the instrument in the opposite direction from the desired target on the monitor to interact with the site of interest. Hand-eye coordination is therefore compromised. Some refer to this as the fulcrum effect.[9] Current instruments have restricted degrees of motion; most have 4 degrees of motion, whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization. Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult if not impossible.[10] The motivation to develop surgical robots is rooted in the desire to overcome the limitations of current laparoscopic technologies and to expand the benefits of minimally invasive surgery.

From their inception, surgical robots have been envisioned to extend the capabilities of human surgeons beyond the limits of conventional laparoscopy. The history of robotics in surgery begins with the Puma 560, a robot used in 1985 by Kwoh et al to perform neurosurgical biopsies with greater precision.[6,11] Three years later, Davies et al performed a transurethral resection of the prostate using the Puma 560.[12] This system eventually led to the development of PROBOT, a robot designed specifically for transurethral resection of the prostate. While PROBOT was being developed, Integrated Surgical Supplies Ltd. of Sacramento, CA, was developing ROBODOC, a robotic system designed to machine the femur with greater precision in hip replacement surgeries.[1] ROBODOC was the first surgical robot approved by the FDA.

Also in the mid-to-late 1980s a group of researchers at the National Air and Space Administration (NASA) Ames Research Center working on virtual reality became interested in using this information to develop telepresence surgery.[1] This concept of telesurgery became one of the main driving forces behind the development of surgical robots. In the early 1990s, several of the scientists from the NASA-Ames team joined the Stanford Research Institute (SRI). Working with SRI's other robotocists and virtual reality experts, these scientists developed a dexterous telemanipulator for hand surgery. One of their main design goals was to give the surgeon the sense of operating directly on the patient rather than from across the room. While these robots were being developed, general surgeons and endoscopists joined the development team and realized the potential these systems had in ameliorating the limitations of conventional laparoscopic surgery.

The US Army noticed the work of SRI, and it became interested in the possibility of decreasing wartime mortality by "bringing the surgeon to the wounded soldier-through telepresence."[1] With funding from the US Army, a system was devised whereby a wounded soldier could be loaded into a vehicle with robotic surgical equipment and be operated on remotely by a surgeon at a nearby Mobile Advanced Surgical Hospital (MASH). This system, it was hoped, would decrease wartime mortality by preventing wounded soldiers from exsanguinating before they reached the hospital. This system has been successfully demonstrated on animal models but has not yet been tested or implemented for actual battlefield casualty care.

Several of the surgeons and engineers working on surgical robotic systems for the Army eventually formed commercial ventures that lead to the introduction of robotics to the civilian surgical community.[1] Notably, Computer Motion, Inc. of Santa Barbara, CA, used seed money provided by the Army to develop the Automated Endoscopic System for Optimal Positioning (AESOP), a robotic arm controlled by the surgeon voice commands to manipulate an endoscopic camera. Shortly after AESOP was marketed, Integrated Surgical Systems (now Intuitive Surgical) of Mountain View, CA, licensed the SRI Green Telepresence Surgery system. This system underwent extensive redesign and was reintroduced as the Da Vinci surgical system. Within a year, Computer Motion put the Zeus system into production.