Robotic-Assisted Surgery: A Brief History to Understand Today's Practices.

Abstract

Today, OR robots function completely under the direction of the surgical team—never autonomously or independently. The proper word phrasing, therefore, is robotic-assisted surgery (RAS), not “robotic surgery.” In the future, artificial intelligence (AI) may be added to RAS, giving robots the ability to learn from enormous amounts of data to make better decisions.1 Surgical robots embedded with AI are being used in the military, but not yet on civilians. Robotic-assisted surgery is used mostly during minimally invasive surgery (MIS), where rigid or semirigid endoscopes are placed inside cavities via natural orifices (eg, hysteroscopy, cystoscopy, endoscopic sinus surgery) or the abdomen (ie, laparoscopy), thorax (ie, thoracoscopy), or joints (ie, arthroscopy); although they are now also used in open procedures, including orthopedic surgery (eg, hip and knee arthroplasties) and neurosurgery (eg, brain surgery).2 The US Food and Drug Administration (FDA) regulates medical devices, including RAS devices. Through FDA tracking of RAS complaints via medical device reporting, the two most common problems encountered are device malfunctions and image or display issues. These problems are not associated with injuries but can create inefficiencies and increase the length of a surgical procedure.3 Inconveniences or problems associated with robots include the need to undock and redock it when working in different abdominal quadrants and when converting to an open procedure in an emergency, the numerous nooks and crannies to be cleaned and decontaminated in the reprocessing process, and the steep learning curve and expense. Major benefits of surgical robots are that they decrease ergonomic issues for the surgical team; have extreme-angle instrument wrist articulation capabilities in small spaces; and provide excellent magnified, high-definition (HD), three-dimensional (3D) vision for the surgeon. Surgical robot vendor representatives are expected to coordinate training for proper use, troubleshooting, and emergencies with surgeons and surgical teams; facilities usually require surgeons to be credentialed to operate a robot. Surgeons, their assistants, and the OR staff members must be knowledgeable about and competent in using these devices.3 Gynecologists led the way with MIS early in the 20th century2 and continued that trend with RAS; general surgeons joined this endeavor in the mid-1980s.4 Increasingly, RAS has been gaining acceptance across surgical specialties,1 including urology (eg, renal, urogenital, prostate surgery),5 cardiac surgery (eg, thoracoscopic internal mammary harvesting, mitral valve repair),6 general surgery (eg, colon,5 gallbladder,6 Nissen fundoplication6), and gynecology (eg, uterine, ovarian).5 The robotic prostatectomy is an excellent exemplar of the benefits of RAS. Laparoscopic prostatectomies are technically very challenging to perform because the suturing of the urethral stump to the bladder neck must be performed in an inverted direction and in a tight space (ie, deep in the pelvis).1, 4 Not only is this surgery technically difficult to perform, but excising excessive prostatic tissue in any direction may cause bladder incontinence or erectile dysfunction. Robotic-assisted surgery is an improvement over traditional MIS because it provides better internal space access, increases visualization through magnification, and provides surgical instruments more degrees of freedom (DOF).4 When compared with the open and laparoscopic prostatectomy, the RAS prostatectomy results in less blood loss,7, 8 higher discharge hemoglobin levels,8 lower patient mean pain scores,8 shorter duration of urinary catheterization,7 fewer positive margins remaining in situ,7 decreased probability of undetectable prostate-specific antigen levels postoperatively,8 earlier return to continence and erectile function,7, 8 and shorter length of hospitalization.7, 8 The earliest RAS dates back to the late 1950s when Russia became the first country to launch an artificial satellite. Robots were created to repair the satellite while it floated in space—termed telemanipulation. In 1958, the National Aeronautics and Space Administration (NASA) was established to oversee the US civilian space program and aeronautics and space research. In the 1960s, NASA started exploring the concept of “virtual reality” (VR), although this terminology did not yet exist. With VR, an immersive, illusionary environment is created that changes the user’s sense of awareness of their physical surroundings, triggering a “telepresence.” Eventually, VR equipment was adapted into a wearable head-mount display (HMD), and the user donned the DataGlove, an interface tool that uses hand gestures to measure the user’s hand positions and orientations to provide haptic feedback for the wearer.8 The user achieves telepresence by being immersed into a 3D virtual environment6 with the ability to interact with and control images in that environment. The US government created the foundation upon which commercial manufacturers further improved the RAS platform for hospital and surgery center ORs. The number of companies involved with RAS development continues to bloom, as do the number of mergers and acquisitions during this revolution.4 Scientists at SRI International collaborated with the US government to create the first US robotic surgical telepresence system prototype in 1987. They continued their efforts by replacing the HMD with a stereoscopic video monitor at a workstation console with an audio system and also trialed the surgeon wearing passive polarized glasses that created observable 3D images. The DataGlove was also eventually replaced with surgical instrument handles capable of transmitting the surgeon’s hand motions to the remote robotic unit. Surgeons were able to view the surgical instruments’ tips on the video monitor responding to the handles being manipulated (ie, grasping, dissecting, cutting, sewing, cauterizing). High-resolution 3D images provided surgeons with enough information to judge tissue tension without the sense of touch.1 Intuitive Surgical, created in 1995, acquired SRI International’s intellectual property3 and reworked the surgical telepresence system. Their initial robot consisted of two arms to hold surgical instruments and a third arm for the laparoscope and camera.1, 6, 8 Their first prototype, Lenny, had wrists capable of seven DOF. The robotic arms, however, were noninterchangeable and had to be separately attached to the OR bed manually. Intuitive Surgical also changed SRI International’s passive polarized 3D visualization system to an active shutter video display and glasses.1, 6 Lenny was mechanically unstable, however, and did not provide sufficiently high-quality visualization.8 Mona followed Lenny in 1997 and was the first RAS to move to human trials. Mona had “exchangeable instrumentation that could be interchanged while maintaining a sterile field.”8(p8) The instrument engagement failure rate was 20%,9 however, and the bedside assistant had to hold the laparoscope.1 True 3D vision was the result, with greater depth perception and without the need to wear special glasses.6, 8 Although the da Vinci was originally targeted for cardiothoracic surgery, it was most successful in laparoscopic prostatectomies. In fact, 75% of all prostate surgeries are performed with the da Vinci robot.10 Today, the da Vinci is used across most surgical specialties. Additional da Vinci modifications included dual surgeon consoles,1 interactive touch screens,6 and multiquadrant capability,1 which were included in successive da Vinci models. The da Vinci Xi was added in 2014. It provides a stable, immersive, highly magnified 3D and HD view of the surgical field that incorporates “table motion,” by which patients can be dynamically positioned intraoperatively without removing instruments or undocking the robot.6 It also allows for setup automation. The cart can now be docked from any angle, which improves access to any abdominal quadrant, and the redesigned arms allow for greater internal range of motion while improving patient access and minimizing external collisions. The newest robot added to the portfolio in 2019 was Ion, a percutaneous lung biopsy system. Computer Motion’s first robot, conceived with the support of NASA and DARPA, was Automated Endoscopic System for Optimal Positioning (AESOP), the first surgical robot to receive FDA clearance.1, 8, 10 The initial AESOP was designed with pedals and a voice-controlled robotic arm equipped with an endoscope. Computer Motion collaborated with Stryker Endoscopy in 1996 to introduce the Highly Efficient Robotic Mechanisms and Electromechanical System (HERMES) Control Center,8 which provided an integrated, computerized OR (eg, OR lighting, insufflation, OR bed positioning) with voice control and feedback. The ZEUS Robotic Surgery System (ZRSS) was also introduced in 1996. It had three robotic arms independently attached to the OR bed and the surgeon wore polarizing glasses while working at a two-dimensional video monitor. It used the same software and platform as AESOP’s robotic arm but also incorporated laparoscopic instrumentation controlled by the surgeon. The focus of this platform was to use robots as remote surgery systems (ie, telepresence).8 The next generation, the SOCRATES Telecollaboration System, received FDA approval in 2001 and allowed for telementoring between hospitals.8 Both ZRSS and SOCRATES were used jointly during the first trans-Atlantic commercial robotic surgery completed in New York City on a 68-year-old woman undergoing a robotic laparoscopic cholecystectomy in Strasbourg, France. The procedure lasted 54 minutes without any perceptions of distance or technical difficulties. Surgery was incredibly expensive, however, with more than $1 million attributed just to the telecommunications cost.6, 8 The evolution of the software and hardware components of surgical robots will include smaller instruments, automatic sterile instrument exchanges, less intrusive robotic arms, down-sized carts, faster docking, better haptics and tissue-sensing technology, and the elimination of energy cords. Ultimately, richer VR experiences will add to the surgical team’s participation and lead to an augmented reality experience. The future integration of AI is around the corner as well—robot decision making based on large amounts of data is expected to be the next revolution in surgery.1 The ability to perform telesurgery is another hot commodity, although it requires major telecommunication network improvements before it can be deemed worthwhile. A solution is first needed to create inexpensive long-distance networks with minimal delay times to transmit large amounts of continuous data. Telesurgery will open the door for telementoring experiences for surgeons in rural areas as well as patients who choose to undergo surgery performed by a surgeon located in another state or country.1 As the robotics market becomes more competitive with new companies entering the field, costs will be driven down, leading to wider adoption1 and allowing for newer products with more accessible robotic platforms.4, 10 And, similar to the MIS trajectory, over time RAS will improve and surgery will take less time. If the number of articles written on RAS is any indication of where this market is headed, it is already growing: the number of articles indexed on PubMed increased from approximately two to eight per year before 2000 to more than 700 per year in 2017 and 2018.1, 4 Surgery accounts for $500 billion of health care spending, with 5% to 10% of the market allocated to robotics.10 This robotics issue introduces three important topics for novice and experienced perioperative nurses. “The role of the robotics coordinator: improving efficiency in a robotic surgery program”11 by Chuck Lawrence provides insight for nurses interested in becoming involved in RAS on an administrative level. The author discusses the challenges and solutions found in scheduling RAS procedures, designing room layouts, providing accurate and slimmed-down preference lists, performing inventory management, and improving team communication. In “Robotic-assisted lumbar fusion: an effective technique for pedicle screw placement”12 and “Care of the patient undergoing robotic-assisted brain biopsy with stereotactic navigation: an overview,”13 Beth Karasin et al offer articles on RAS during spine surgery and brain surgery—two of the newer procedures where robotic surgery is finding a home and is performed in tandem with other new technology, such as the navigation system. The authors discuss the disease processes, how RAS is used intraoperatively, and the perioperative course for the patient from the RNFA perspective. Enjoy these offerings and get ready for an explosion in the future for robotic-assisted surgery! Editor’s notes: DARPA is a registered trademark of the Defense Advanced Research Projects Agency, Arlington, VA. SRI International is a registered trademark of SRI International, Menlo Park, CA. Intuitive Surgical and da Vinci Xi are registered trademarks of Intuitive Surgical Operations, Inc, Sunnyvale, CA. PubMed is a registered trademark of the US National Library of Medicine, Bethesda, MD. Debra Dunn, MSN, MBA, RN, CNOR, was an education specialist in the OR at Holy Name Medical Center, Teaneck, NJ, at the time this article was written. Ms Dunn has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.