WILL OUR FUTURE SURGEONS BE ROBOTS?

By Daniel Kan

1. Introduction

Robotic surgery is the use of mechanical arms carrying surgical instruments that are controlled by a surgeon. Robotic surgery is generally used with minimally invasive surgeries, which use small incisions instead of the traditional open procedures.

2. The History of Robotic Surgery

The first application of robots in surgery was in 1985, when a Programmable Universal Machine for Assembly (PUMA 200) was used to perform a neurosurgical biopsy. [1] It was further adapted by The Robotics Center at Imperial College into the PROBOT [2], which was specifically designed to perform a transurethral resection of the prostate (TURP), a procedure that involves cutting away a section of the prostate. The PROBOT allows a surgeon to specify a volume of the prostate, which would automatically be cut by a rotating blade [3].

In 1992, the ROBODOC system was developed and became the first active robot system to achieve a formal FDA approval. This was used to improve the precision of hip replacement surgery. The ROBODOC system consists of a preoperative surgical planning workstation called ORTHODOC and a five-axis robotic arm to carry out the plan [4].

During the next decade, the field of robotic surgery underwent a paradigm shift in which research was more focused on the “master-slave” concept, where a surgeon would remotely control the movements of a robot from a distant workstation.

In 1989, a company called Computer Motion created a robotic platform called Automated Endoscopic System for Optimal Position (AESOP). This consisted of a robotic arm that held an endoscope which removed the need for an assistant to hold it. This had multiple benefits, such as not fatiginge during long procedures (unlike if an assistant was holding it), more stability, and less personnel required to be present in the operation.

Initially, the AESOP 1000 (approved in 1994) was controlled by pedals, but later the AESOP 2000 could be controlled using a voice control system. The final platform, the AESOP HR, also had voice control of other functions such as operating room lighting and movement of the operating table [5].

In 1998, the AESOP system was modified and relaunched as the ZEUS operating system, which had arms and surgical instruments that could be remotely controlled by the surgeon. The ZEUS operating system had three arms: one was an AESOP camera system that was controlled by voice, the other two arms held surgical instruments that could be controlled using handles. In 2001, the first transatlantic surgery was carried out using the ZEUS system, where a surgeon from New York performed a cholecystectomy (removal of gallbladder) on a patient in France [6].

At the same time that the ZEUS system was being developed, another company called Intuitive Surgical was developing their own surgical robot. Their first prototype was called Lenny and had three arms: two for holding instruments and one for the camera. The second generation of robots was Mona, which was the first robotic surgical system to be used in human trials. However, in 1998, Intuitive surgical developed the da Vinci system, which would later become the most successful robotic surgery platform that is still used to this day. The first da Vinci robot had three arms: one that held the camera and the rest would hold instruments. These arms could rotate with seven degrees of freedom and two degrees of axial rotation – a significant selling point compared to other systems. The two companies Computer Motion and Intuitive Surgical then merged in 2003, discontinued the ZEUS system and worked together to improve the da Vinci system [7]. In 2000, the da Vinci system gained FDA approval for clinical use, and 2 years later a version with 4 arms was also approved. In 2006, the da Vinci S platform was released, with a 3D HD camera and an interactive touch screen display. In 2009, the da Vinci Si platform was released with dual console surgery, allowing two surgeons to operate at once. This optimised each surgeon’s potential as well as introduced a way to train non-expert surgeons. The Si system also had other improvements such as a better image system and real time fluorescence imaging. In 2014, the da Vinci Xi platform was created, as well as the da Vinci SP system, which had a single port and only required one incision.

3. How Does Robotic Surgery Work?

3.1. Robotic Surgery vs Minimally Invasive Surgery vs Open Surgery

Traditionally, open surgery requires the surgeon to make a large incision using a scalpel to view the necessary organs. Minimally invasive surgery (MIS) uses several small incisions and a laparoscope, which has a small camera attached to it, to allow the surgeon to examine the organs. MIS is generally less painful and has a faster recovery period compared to open surgery [8]. Robotic Surgery or Robot Assisted Surgery is generally associated with MIS and uses robotic arms that are controlled by the surgeon. The robotic arms hold a camera and surgical instruments. Robotic surgery has multiple advantages such as a greater range of motion and dexterity(ability to delicately manipulate with hands and fingers) for the surgeon [9]. It usually also has a faster recovery time.

3.2. How current Robotic Surgery works - The da Vinci system

The da Vinci system has 3 components: the surgeon console, the patient cart and the vision cart. These components follow the “master-slave” concept, where the surgeon console is the “master interface” and the patient cart holds the “slave manipulators” that hold the surgical instruments. The vision cart makes communication between components possible and supports the 3D HD vision system [10].

The surgeon console allows the surgeon to see inside the patient and control the manipulators. The stereo viewer gives the surgeon a 3D-HD view which immerses the surgeon in the surgical field, something that was lost when doing traditional minimally invasive surgery. The two master controllers allow the surgeon to control the instruments and endoscope. The surgeon can use their hands to move the master controllers, and the actions will be replicated by the manipulators. The manipulators are designed to allow a natural range of motion, dexterity and ergonomic comfort (when using and holding) [11]. Through these controllers, the surgeon’s hand tremors can be filtered out from the electronic signal or scaled down. The surgeon console also has left side and right side pods, which contain controls such as ergonomic controls, the power button, and an emergency stop button [12]. The surgeon console also has a footswitch panel which allows the surgeon to control different things using their feet without having to remove their head from the 3D viewer.

The Patient cart is the operative component of the system and has four arms that hold all the instruments and endoscope. During the operation, instruments and endoscopes are swapped by the assistant surgeon.

The Vision cart holds electronic equipment for visualisation. It includes a light source to illuminate the surgical site, soft ware processing units to process the video images and send it to the 3D viewer and touchscreen.

3.3. Visualisation

The da Vinci Surgical system uses endoscopes to allow the surgeon to visualise the area they are operating on. These endoscopes transmit white-light to form images that only show the visible surfaces of the organs [13]. Recently, there have been further innovations with other techniques such as the Firefly Fluorescence imaging. This works by injecting a fluorescent agent into the bloodstream which will emit light when excited. This is then excited using a corresponding excitation light source and the fluorescence can be detected using a specific detector. The most widely used fluorescent agent is indocyanine green (ICG), which rapidly binds to plasma proteins in the blood. When the ICG fluoresces, the image detected can be combined with the white light image to allow the surgeon to see vasculature and tissue perfusion. One way that ICG is removed from the blood is by secreting it into bile at the liver. This can allow the surgeon to visualise the structures of the bile duct.

There are many other techniques that can be used for visualisation. Dynamic view expansion or mosaicing can offer a wider field of view [14]. Narrow Band Imaging uses specific filters to modify white light images to increase contrast which allows surgeons to more clearly view a certain part of the tissue [15]. Tomographic imaging can be used before or during surgery which uses penetrating waves to provide cross sectional images beyond the surface tissue.

3.4. The Surgical Instruments

The surgical instruments used by the da Vinci system have an articulated wrist mechanism called EndoWrist which allows it to have more dexterity and a greater range of motion [10]. EndoWrist instruments include endoscopic dissectors, scissors, scalpels, forceps, needle holders, needle drivers, retractors, bipolar and monopolar energy instruments, suction irrigation instruments, staplers, and more [16].

The staplers are used in transection and resection by placing multiple rows of staples then transecting the tissue with a knife blade, cleanly cutting the tissue without any bleeding [13]. The stapler is controlled by the foot pedals at the surgeon console.

There are also instruments that use energy. These are split into monopolar and bipolar instruments. Monopolar is when the current passes from the electrode to the target tissue then to a return pad and back to the generator to complete the circuit. Bipolar is when the current passes from one side of the instrument to the other side of the instrument, and only the tissue between the instrument is affected.

There are three monopolar instruments used in the da Vinci system: the hook, the scissors, and the spatula [16]. The most common monopolar instrument is the hook, which allows the surgeon to dissect and apply energy to a certain area. The scissors allow the surgeon to precisely dissect tissue in restricted spaces. The spatula is used for desiccation (drying out of cells) over a wide area [17].

Several bipolar instruments are used in the da Vinci system. The bipolar grasper is used to grasp and retract tissue, and can also be used for hemostasis of small blood vessels. The bipolar forceps can also be used for hemostasis of small vessels, as well as being used to cut, although this is rarely used [17]. The Vessel sealer extend and Vessel sealer can seal and cut vessels. They do this by precisely applying pressure and energy to control the temperature, causing soft tissue proteins to denature and melting the inside walls of the vessel together. Once the vessel is sealed, a mechanical knife can be used to cut through the vessel. The vessel sealer can also be used for dissection, which decreases operative time by removing the need to change instruments.

SynchroSeal is another instrument that can also seal vessels. It is more efficient than vessel sealer since it only requires a single pedal press to seal and cut as opposed to two pedal presses. However, Vessel sealer extend can seal and cut vessels up to 7 mm in diameter, whilst SynchroSeal can only seal and cut vessels up to 5mm in diameter.

4. Current Appliations of Robotic Surgery

Currently, robot assisted surgery is used across a wide range of surgical specialties. Whilst robotic surgery is most commonly performed in urological, gynaecological and gastrointestinal surgery [18], robotic surgery has also seen use in many other specialties.

4.1. Urological surgery

Due to the depth of the pelvis and small size of the structures [19], prostatectomy was one of the first surgical operations to widely adopt robotic surgery. This allows surgeons to more easily guide the instruments to the required location (eg. prostate, kidneys), which is more advantageous when compared to open surgery or traditional laparoscopic techniques. As well as prostatectomy, robotic surgery has also been used in nephrectomies and adrenalectomies. Overall, robotic surgery has been widely adopted for urologic surgery, especially for performing prostatectomies.

4.2. Gynaecological surgery

Robotic surgery has been used to perform many operations in gynaecology. It is estimated that over 60% of hysterectomy procedures (removal of the uterus) were done robotically [21]. Robotic surgery has also been used in myomectomy (removal of uterine fibroids whilst preserving the uterus), tubal reanastomosis, and pelvic and paraaortic lymph node dissection [21].

4.3. Application in gastrointestinal surgery

The increased quality of the images produced by the endoscope and increased precision of its instrument is important in the treatment of gastrointestinal cancer [22]. This includes removal of cancer in organs such as the stomach, liver, gallbladder, small bladder, adrenal, colon, and others [19].

4.4. Other surgical fields

Robotic surgery has also seen use in other surgical fields. In otolaryngological (head and neck) surgery, robotic surgery allows for smaller incisions whilst still allowing the surgeon to have clear visualisation and dexterity. In neurosurgery, robotic surgery allows surgeons to surpass the limits of human dexterity on a microscopic scale, although it does have its limitations such as speed and lack of sense of touch. In cardiothoracic surgery, robotic surgery has been used for mitral valve surgery, repairing atrial septal defect, anastomosis on an arrested heart, anastomosis on a beating heart, and more [19].

5. Future Applications of Robotic Surgery

5.1. Telerobotic Surgery

Telerobotic surgery, also known as remote surgery, is robotic surgery where the surgeon is in a distant place and communicates through a wireless network. This was initially explored by NASA who wanted a type of surgery that could be performed in space, but it can also be applied on earth so patients do not have to travel long distances [23]. Telerobotic surgery allows surgeons from around the world to perform surgery in rural areas or places with surgeon shortage. It can even allow for collaboration of multiple surgeons which can be used to enhance care, as well as for training [24].

However, latency time (delay) has been a significant drawback, as too much time delay can lead to inaccuracies. Developments in 5G technology can be useful for reducing this. There can also be problems with cyber security, cost, and legal issues across country borders [24].

Despite some of these issues, in 2019 researchers in China successfully performed 12 telerobotic spinal surgeries using 5G, all of which were successful. In all of these, the master surgeon was in a different province to the patient. The researchers concluded that using 5G telerobotic surgery was “accurate, safe, and reliable” [25].

5.2. Nanorobotic surgery

Nanorobots are tiny robots that can move around the patient’s entire body through the bloodstream (including capillaries) to access different cells. This can be used for highly precise surgery down to the cellular level, as well as accessing hard to reach places. Nanorobots can take many forms, such as nanodrillers, micro-grippers, micro bullets, and more [26]. Aside from surgery, nanorobots can also be used for targeted drug delivery, diagnosis, detection, biopsies, imaging, 3D printing, and more [27]. However, nanorobotics is just beginning and there still are many challenges that need to be overcome.

7. Bibiliography

[1] Kwoh, Y.S., et al. “A Robot with Improved Absolute Positioning Accuracy for CT Guided Stereotactic Brain Surgery.” IEEE Transactions on Biomedical Engineering, vol. 35, no. 2, 1988, pp. 153–160., https://doi.org/10.1109/10.1354.

[2] “Probot.” Imperial College London, www.imperial.ac.uk/mechatronics-in-medicine/research/probot/.

[3] “The Method of Cutting the Prostate with the Robot.” Imperial College London, www.imperial.ac.uk/mechatronics-in-medicine/research/probot/cutting/.

[4] Bargar, William L., et al. “Primary and Revision Total Hip Replacement Using the Robodoc?? System.” Clinical Orthopaedics and Related Research, vol. 354, 1998, pp. 82–91., doi:10.1097/00003086-199809000-00011.

[5] MORRELL, ANDRE LUIZ, et al. “The History of Robotic Surgery and Its Evolution: When Illusion Becomes Reality.” Revista Do Colégio Brasileiro De Cirurgiões, vol. 48, 2021, doi:10.1590/0100-6991e-20202798.

[6] Marescaux, Jacques, et al. “Transatlantic Robot-Assisted Telesurgery.” Nature, vol. 413, no. 6854, 2001, pp. 379–380., doi:10.1038/35096636.

[7] Lane, Tim. “A Short History of Robotic Surgery.” The Annals of The Royal College of Surgeons of England, vol. 100, no. 6_sup, 2018, pp. 5–7., doi:10.1308/rcsann.supp1.5.

[8] “Open Surgery vs Laparoscopic Surgery: Which Is the Best Procedure?” Far North Surgery, www.farnorthsurgery.com/blog/open-surgery-vs-laparoscopic-surgery.

[9] “What Is Robotic Surgery?” UCLA Health System, www.uclahealth.org/medical-services/robotic-surgery/what-robotic-surgery.

[10] “About Da Vinci Systems.” Da Vinci Surgery | Da Vinci Surgical System | Robotic Technology, www.davincisurgery.com/da-vinci-systems/about-davinci-systems.

In the future, it is possible that robots will be able to perform surgeries autonomously without the control of a human surgeon. To do this, the robot will have to be able to interpret visual and physical data, then decide what to do and carry it out [28]. It will also need to be able to adapt to different situations in real time. To achieve this, various machine learning algorithms will need to be used for receiving and interpreting data, as well as being “taught” how to actually perform the surgery.

Although current robotic surgeries are still done by humans, recently, a robot successfully performed an intestinal anastomosis on a pig without any direct human assistance using the Smart Tissue Autonomous Robot (STAR) [29].

6. Future Applications of Robotic Surgery

In conclusion, robotic surgery is a type of minimally invasive surgery that uses robotic arms to perform surgery. Currently, it uses the “master-slave” concept where a surgeon directly controls robotic manipulators that hold surgical instruments and an endoscope. There are many benefits of robotic surgery including more dexterity, better visualisation, and faster recovery times. However, robotic surgery is very expensive, which is why it hasn’t been as widely adopted as it could be. Fields where robotic surgery is used the most are: urological surgery, gynaecological surgery, and gastrointestinal surgery. In the future, it could be used for telerobotic surgery where the surgeon controls the robot remotely, nanorobotic surgery where nanorobots move through the bloodstream, or autonomous surgery where the robot performs without any human assistance.

[11] Mishra, R.K., System Components - World Laparoscopy Hospital. www.laparoscopyhospital.com/Book/Ch-03.pdf.

[12] Intuitive Surgical, da Vinci Si surgical system User Manual, Intuitive Surgical

[13] Azizian, Mahdi, et al. “The Da Vinci Surgical System.” The Encyclopedia of Medical Robotics, 2018, pp. 3–28., doi:10.1142/9789813232266_0001.

[14] Lerotic, Mirna, et al. “Dynamic View Expansion for Enhanced Navigation in Natural Orifice Transluminal Endoscopic Surgery.” Medical Image Computing and Computer-Assisted Intervention – MICCAI 2008, 2008, pp. 467–475., doi:10.1007/978-3-540-85990-1_56.

[15] Barbeiro, Sandra, et al. “Narrow-Band Imaging: Clinical Application in Gastrointestinal Endoscopy.” GE - Portuguese Journal of Gastroenterology, vol. 26, no. 1, 2018, pp. 40–53., doi:10.1159/000487470.

[16] Da Vinci X & Da Vinci XI Instrument & Accessory Catalogue - Intuitive.com. Intuitive Surgical, Mar. 2022, www.intuitive.com/en-gb/-/media/ISI/ Intuitive/Pdf/da-vinci-x-xi-instrument-accessory-catalogue-1075017.pdf.

[17] Wikiel, Krzysztof J., et al. “Energy in Robotic Surgery.” Annals of Laparoscopic and Endoscopic Surgery, vol. 6, 2021, pp. 9–9., doi:10.21037/ ales.2020.03.06.

[18] Anderson, Jamie E., et al. “The First National Examination of Outcomes and Trends in Robotic Surgery in the United States.” Journal of the American College of Surgeons, vol. 215, no. 1, July 2012, pp. 107–114., doi:10.1016/j.jamcollsurg.2012.02.005.

[19] Shah, Jay, et al. “The History of Robotics in Surgical Specialties.” American Journal of Robotic Surgery, vol. 1, no. 1, 2014, pp. 12–20., doi:10.1166/ ajrs.2014.1006.

[20] Bharathan, Rasiah, et al. “Operating Room of the Future.” Best Practice & Research Clinical Obstetrics & Gynaecology, vol. 27, no. 3, 21 Dec. 2012, pp. 311–322., doi:10.1016/j.bpobgyn.2012.11.003.

[21] Leddy, Laura, et al. “Robotic Surgery: Applications and Cost Effectiveness.” Open Access Surgery, 2 Sept. 2010, p. 99., doi:10.2147/oas.s10422.

[22] Ohuchida, Kenoki. “Robotic Surgery in Gastrointestinal Surgery.” Cyborg and Bionic Systems, vol. 2020, 2020, pp. 1–7., doi:10.34133/2020/9724807.

[23] Mohan, Anmol et al. “Telesurgery and Robotics: An Improved and Efficient Era.” Cureus vol. 13,3 e14124. 26 Mar. 2021, doi:10.7759/cureus.14124

[24] Choi, Paul J, et al. “Telesurgery: Past, Present, and Future.” Cureus, 2018, doi:10.7759/cureus.2716.

[25] Tian, Wei et al. “Telerobotic Spinal Surgery Based on 5G Network: The First 12 Cases.” Neurospine vol. 17,1 (2020): 114-120. doi:10.14245/ ns.1938454.227

[26] Li, Jinxing et al. “Micro/Nanorobots for Biomedicine: Delivery, Surgery, Sensing, and Detoxification.” Science robotics vol. 2,4 (2017): eaam6431. doi:10.1126/scirobotics.aam6431

[27] Eggleton, Benjamin. “Nanorobotic Surgery.” Nanorobotic Surgery, The University of Sydney, www.sydney.edu.au/nano/our-research/research-programs/nanorobotic-surgery.html.

[28] Panesar, Sandip, et al. “Artificial Intelligence and the Future of Surgical Robotics.” Annals of Surgery, vol. 270, no. 2, Aug. 2019, pp. 223–226., doi:10.1097/sla.0000000000003262.

[29] Saeidi, H., et al. “Autonomous Robotic Laparoscopic Surgery for Intestinal Anastomosis.” Science Robotics, vol. 7, no. 62, 26 Jan. 2022, doi:10.1126/ scirobotics.abj2908.

Figure 1: https://www.researchgate.net/figure/Puma-200-the-first-robot-used-for-assisting-human-neurosurgery-1985-12_fig2_290495998

Figure 2: https://www.researchgate.net/figure/ZEUS-robotic-system-first-robotic-system-to-combine-instrument-and-camera-control_fig3_51437277

Figure 3: http://www.rsalinas.com/davinci-si-1-1

Figure 4: https://www.advancedurologyinstitute.com/da-vinci-surgical-system/

Figure 5: https://www.ourmidland.com/news/article/Firefly-glow-improves-visibility-in-surgery-6946851.php

Figure 6: https://entokey.com/the-da-vinci-system-technology-and-surgical-analysis/

Figure 7 and 8: https://www.intuitive.com/

1. Introduction

Proteins are everywhere, from specifically shaped enzymes that catalyse metabolic processes, to the fibrous, connective tissue made of collagen present in just about every organ in the body, to the body’s chemical messengers, hormones, that are secreted from exocrine glands and travel in the bloodstream. They play an irreplaceably crucial role in our daily lives, impacting our appearance, our actions, and most importantly, our survival!

Hence, AlphaFold is an extremely useful AI, as it can predict how chains of amino acids can fold into complex 3D structures, namely secondary, tertiary and quaternary, as protein functions are highly reliant on their shapes. However, before we go into the specifics of how AlphaFold works, we should understand why it is necessary first.