Robots revolutionising surgery

The United States Food and Drug Administration (FDA) have approved voice activated robotic arms and master slave robotic systems that has the potential to impact most areas of surgery. From their inception, surgical robots has been designed and developed to enhance surgeon’s abilities in terms of vision, sensing and instrument manipulation. New robotically assisted surgery methods and systems are pushing the boundaries of medicine.

Robot-Assisted Surgery
Surgical Robotics is one of the most intensely researched areas in the medical devices industry that is primarily market driven. They have been developed to automate the process of imaging, navigation and communication for surgeries. Robotic automation of surgical systems is offering crucial improvements in terms of accuracy and repeatability of the surgical procedure. The demand for faster recovery, reduced hospital stay and better aesthetics post-surgery is also advancing the surgical robotics field. Robotic systems are being developed for fewer incisions, increased precision and versatility to make surgery safer and more efficient for patient.

Operative procedures carried out with the assistance of robotic technology are termed as robot-assisted surgery (RAS). Robotic technology is used for surgical imaging to obtain images for planning, navigating and confirming the position of surgical instruments and implants. They are used for interventional surgical strategy, real time intra-operative imaging, and articulation of the surgical instruments beyond normal manipulation and for navigating the instruments for the procedure. Robotics surgery uses computer assisted systems between the surgeon and the surgical tools which mean that there is no complete elimination of the surgeons but the incorporation of the latest advances in robotics, computing, imaging and navigation for assisting the surgical procedure. The da Vinci Robotic Surgery System from Intuitive Surgical (Sunnyvale, California) was the first surgical robot approved by FDA for assisting laparoscopic surgery. With its first mover advantage, the company is recognised as the global leader in robot assisted minimally invasive surgery. 

Robotic surgical machines have a number of other advantages. Surgical robots can provide higher magnification with an immersive view of the surgical operative field. They offer unsurpassed visual clarity for precisely visualising target anatomy within the surgical space and improve depth perception. Companies are working on additional visual enhancements for the surgeon’s vision that will enable even real-time molecular imaging and microscopy. The supposed increased efficiency and reliability of imaging from robot assisted surgeries will promote the use of robotic technology for almost all types of surgical procedures, such as transplanting organs, shrinking stomachs,  fixing heart valves and so on.

Current robotic systems provide miniaturised endo wrist instruments that can mimic surgeons’ natural hand and wrist motions intuitively similar to an open surgery. Development initiatives in this direction are looking into imparting higher degrees of freedom for the instruments that can rival surgeon capabilities. Motion scaling and tremor reduction are other features of surgical robots that enables seamless adjustments of hand to instrument movement ratios in tight surgical spaces.

Surgical robots can offer interactive interfaces which is a much sought after aspect in robot assisted surgery. A multitude of technology developers within this space are researching on natural visual interaction, holograms and augmented reality for better human machine interfaces.

Robotic systems are being developed with simulator environments that can import patient specific data and for rehearsal of patient specific surgical procedures. This is used for training surgeons, reducing complication rates and also for maintaining robotic surgery skills. Surgical simulators are offering surgical learning experience to lower the learning curve for surgeons to adopt surgical robots.  They remaining adjunct in the training of surgeons and it is seen that leading and upcoming companies are looking into capturing the data regarding surgeons’ performance which can even be used to train the surgical robots to perform similar independent tasks.

These advantages will translate into better adoption of surgical robots by hospitals and healthcare facilities to overcome the limitations of higher patient and shortage of trained professional staff. More organisations and surgeons will be investing in robot assisted surgery for overcoming surgeon fatigue, improving ergonomics and communicating clinical excellence.

Targeting wide range of Surgical Disciplines
The growth of the surgical robotics since the latter half of the 1980s has been striking. From a few initial efforts for laparoscopic surgery, endoscopic surgery and stereo tactical surgery, the field has expanded to various disease states. In the realm of surgery, robotic technology is at the cutting edge of precision and miniaturisation; this transverses to wide application areas of minimally invasive procedures for neurosurgery, urology, gynecology, cardiothoracic, orthopedic, laparoscopic and even oncology. A number of robotic systems are currently approved by the FDA for specific surgical procedures.

Neurosurgery was one of the first surgical disciplines for robotic technology, due to the need for high precision to localise and manipulate instruments within the brain and the cranial anatomy. Neuromate System from Renishaw PLC (London, UK) and Rosa Robotic System from Medtech Innovative Surgical Technology (MontPellier, France) have been clinically approved for neurological procedures such as deep brain stimulation (DBS), stereotactic surgery, brain tumor, epilepsy surgery and craniotomy surgery. Urologists have found applications for surgical robots in laparoscopical nephrectomy, pyeloplasty, adrenalectomy and radical prostatectomy. Cholecystectomy, Nissen fundoplication, Heller myotomy, pancreatectomy, gastric banding and distal gastrectomy are some of the laparoscopic gastrointestinal procedures performed using surgical robots. Laparoscopic surgeries have been revolutionized with surgical robot technology and the da Vinci system is the widely used surgical robot within this discipline. Emerging opportunities for this discipline includes surgical robots that makes of natural orifices or ultra-small incisions. In this regard, Titan Medical (Torronto, Canada) is developing the SPORT™ Surgical System that will make use of natural orifices or small skin incisions of just 25 mm for laparoscopic surgeries.

Robotic surgery is also widely accepted in the orthopedics sector as it is well suited for operating on bones, offering increased accuracy for knee, hip and spinal procedures. The MAKOplasty from Mako Surgical Corp (Fort Lauderdale, FL), Renaissance system from Mazor Robotics, Ltd. (Orlando, Florida) and Navio Orthopedic Surgical System from Blue Belt Technologies (East Taunton, Massachusetts) are the dominating surgical robots for orthopedic surgery.

Minimally invasive cardiac surgery is an area where robotic surgery is transforming medicine. Several research groups are developing robotic procedures that will expand laparoscopic techniques for cardiac surgery which was previously unexplored. Heart Lander is a mobile miniature robot currently in development at The Robotics Institute of Carnegie Mellon University (Pittsburgh, PA) for delivering minimally invasive therapy to the surface of a beating heart. They are called snake robots that will be used to access difficult anatomical spaces of the heart through small ports when large body openings are unavailable or inconvenient. The da Vinci system is also currently being studied for endoscopic cardiac surgeries. Another use for robotic technology being investigated is for pediatric laparoscopic surgery.

Robotic systems appeal to various specialists and hospitals because of its application in various clinical areas. The da Vinci system has been approved for urological, general laparoscopic, non-cardiovascular thoracosopic and thoracoscopically-assisted cardiotomy procedures. The system has been adopted by more than 2,025 academic and community hospitals for approximately 1.5 million for various surgical procedures as of 2013. The number and types of surgeries being performed with surgical robots is increasing rapidly with even ocular microsurgery being considered.

Industry Challenges
The biggest challenge within the surgical robotics industry is the extremely high initial cost of acquiring and maintaining the robotic systems that has been restraining adoption. The substantial cost disadvantage for using the surgical robots has prompted companies to develop systems with low cost. This has led established market players to work on offering significantly low-cost solutions for maintenance and disposable instruments of the systems that will provide a positive attribute when catering to a highly priced surgical robotics industry. Despite many studies evaluating the feasibility of robotic surgery, there is still much to be desired. More high-quality clinical trials needs to conducted to assess the efficacy of robotic surgery. The level of clinical evidence to support the economic efficiency, improved ergonomics and reduced surgeon fatigue has to be increased before full potential of these systems can be realised.
Even with the lack of robust clinical data supporting the efficacy and safety, robotic surgery has proven itself to be of great value, particularly for performing conventional laparoscopic procedures in inaccessible anatomical locations. It is expected that the current advantages of surgical robotic systems will be expanded upon in the next generation of robots. Next generation surgical robotic technology, focusing on ultra-minimally invasive surgery, haptics feedback and augmented reality will improve and expand the use of surgical robots as well as bring surgery into the digital age.