| ROBOTIC OPERATION | Overview | OPERATIONAL EQUIPMENT | Brief History | How Robotic Surgery Will Work | Supervisory-controlled Robotic Surgery Systems | Dr. that testified the importance of Robotic Operation | PATIENT'S TESTIMONIAL | TESTIMONIALS: ROBOTIC PROSTATE CANCER SURGERY | Practical uses of Robotic Operation today | Advantages of Robotic Surgery | Social Benefits in ROBOTIC OPERATION: | A Consensus Document on Robotic Surgery | | I. Surgeon Training and Credentialing | II. Clinical Applications | | III. Cost/Benefit Analysis of Robotic Surgery | | IV. Research | | Safety and Documentation of Outcomes | Robotic Surgery Systems (Shared-control) | Survey on Robotics Surgery | Robotic Surgery Gains Acceptance as Experimentation Continues | References:


Using robots in the operating room to assist the surgeon in performing surgery. The surgeon views the patient via a terminal and manipulates robotic surgical instruments via a control panel. Views of the organs being worked on are transmitted from tiny cameras inserted into the body. Such robots are considerably less invasive than normal operating room procedures because the instruments can be inserted into much smaller incisions in the human body. This type of "laparoscopic" surgery means less pain and less scarring, and patients recover much faster.



The observatory was designed from the beginning to support robotic operation. This means both that it is possible to operate it remotely, and also that observing sessions can be automated and carried out with little or no human oversight.

Cabling is a key part of the system. There is a lot of electronics on the telescope, and therefore a lot of wires that need to be routed from moving to stationary parts. This needs to be done very carefully, both to eliminate changing forces that can interfere with smooth tracking and to avoid interference that could be disastrous in an unattended setting.



A medical technology developed by SRI International that allows a surgeon to operate long distance. By combining advances in imaging, video, robotics and sensory devices, the system gives doctors the full sensory experience of hands-on surgery. Wearing a pair of specially polarized glasses and sitting before a console showing a high-resolution 3D image of the patient, the surgeon is actually doing the operation. Also called "telepresence surgery. operation. Also called "telepresence surgery.

The Preparation:

  1. The surgeon and the team prepare for the operating room in the same manner as in non-robotic surgeries, except that the machine requires extensive sterilization and set-up.
  2. The nurses and surgcal assistants will set up and test the procedure of the robotic system before the surgery. That will take at least 15mins.
  3. The patient, already anesthetized, is bought into OR and positioned under the robotic arms.
  4. The surgeon then enters, is seated at the console interface and after brief communication with the assistants at the table, begins directing the robot in the procedure.
  5. Throughout the surgery, the surgeon does not aproach the table or patient.

{Video of Robotic Operation Should Be Put Here}

The operating theatre is dimly lit and completely silent apart from the gentle beep of the heart monitor. The patient lies strangely angled with his feet in the air, his head near the ground. Around him are seven nursing and medical staff and three raised video screens, revealing the intimacies of his organs. And above him looms a large spider-like object wrapped in transparent plastic, its arms passing into small holes in his abdomen.
I'm witnessing surgery conducted by the amazing Da Vinci robotic surgeon at Addenbrookes Hospital, Cambridge. Despite its forbidding appearance, it is the most advanced piece of surgical equipment in the UK, offering the man on the table a chance of recovery from prostate cancer that he would never have had five years ago. He is having his prostate gland removed because of a cancerous growth. But there is no need for the patient to be “opened up”. The three abdominal holes accommodate Da Vinci's camera arm and two operating arms. To the side of them, two more abdominal holes allow nurses to drain fluids, feed in clips to stem bleeding and push organs out of the way.

Controlling the robot at a console four metres from the patient is the cancer surgeon Professor David Neal, his head pressed against stereoscopic eyepieces conveying 3-D pictures of the abdomen's contents from the central camera leg of Da Vinci: the robot's eyes are his eyes throughout the surgery. Professor Neal tells me it's like having your head inside the patient. His hands are swivelling, tweaking and pinching joystick-style controls, controlling the tiny robotic hands at the end of Da Vinci's two other arms. He looks more like a seamstress than a surgeon.
Every movement he makes is scaled down into the far smaller, shakeless, movements made by the 7mm, multijointed pincers, deep inside the patient's abdomen. You can see everything in high magnification on those screens above, though to the untrained eye it's hard to tell bladder from bowel, a bit of fatty tissue from a major vein.
Professor Neal, a Cancer Research UK professor of surgical oncology, is working his way down from the middle of the abdomen, past the bladder, to its deepest recesses in the pelvis, where the prostate is located. Gravity has pushed the upside-down patient's bowels out of the way, up under the ribcage.
There's the occasional magnified whoosh of red as Professor Neal nicks a blood vessel and, more surprisingly, little puffs of smoke. The little robotic hands have super-heated edges, which mean they burn through tissue (rather than actually cutting it) and cauterise veins as they go. It's quite overwhelming on the senses. The burning tissue looks like pork crackling and there's a whiff of burnt meat. My vision starts to bleach and my head begins to whirl. I have to sit down for a minute.

Prostate removal can cause impotence
Eventually, an hour into the operation, the prostate is revealed, a crimson globe sitting behind a deflated bladder. Now comes the tricky bit. Traditionally, one of the great problems of removing a prostate gland affected by cancer is that the nerves controlling urination and penile erection are tightly and intricately wrapped around it. Removing the prostate the conventional way means cutting nerves, often resulting in impotence or incontinence.
But so dextrous are Da Vinci's cutting hands, and so clearly visible is the noodle-like mesh of nerves attaching to the prostate, that it can be detached intact before the prostate is removed. “Outcomes aren't great when you remove the prostate using conventional open surgery,” says Professor Neal. “After four years, half of men will have lost erections, or continence, or their cancer will have returned. But with this type of surgery, 90 per cent of patients are completely dry. The finer dissection that robotic surgery allows means that patients are more comfortable after the operation, there are fewer complications and they get better more quickly.”
Professor Neal has conducted 230 radical prostatectomies at Addenbrookes using Da Vinci since it was bought three years ago. Remarkably, half of Professor Neal's prostate operation patients go home the next day. “My star patient was back on his tractor in a week.”
This is one of only six Da Vinci machines in the NHS, compared with 350 operating in the United States. If such surgery were to become more widely available, the implications for men with prostate cancer could be profound. On diagnosis, only 20 per cent of men opt for prostate removal. Because many tumours are slow growing, specialists often recommend watching and waiting, and not risking the permanent sexual and urinary problems that surgery can bring. But this causes uneasiness in many men, who simply want to be rid of the cancer. Da Vinci changes the odds, and makes prostate removal a more feasible “play it safe” option.

The patient loses only a glassful of blood
Now Professor Neal is pushing, dabbing and stroking the prostate as he cuts it away, detaching it from the urethra (which passes through it), pushing it away from the big veins coming up from the penis. Finally, it's released. “Just pop it up under the ribs for now,” he tells the nurses, and using keyhole probes, they manipulate it into a plastic bag, and push it up out of sight of the camera. (After the operation, they will pull it out, through one of the keyholes.)
Meanwhile, Professor Neal has more intricate work to do. He has to remove lymph tissue in case there are any cancer cells there and, finally, stitch the bladder back to the urethra. It's incredibly fiddly work, but the tiny robotic hands, holding a needle and winding thread into loops and knots, work fast. Robotic surgery minimises blood loss and transfusions are rarely required. The patient lying in front of me has lost less than 100ml of fluids - just a small wine glass full - during the operation.
After an intense two hours, the operation over, Professor Neal takes me for a cup of tea and a biscuit - his lunch before the next Da Vinci operation begins in just over an hour.

Michael Mills, 65, a building contractor from Cambridge
“The prostate cancer was picked up after a routine health check. The specialists said I might be OK for 15 years and there didn't seem to be any spread outside the prostate, but I didn't want it hanging over me. When I was told that recovery was quicker with robotic surgery, I thought that was a good reason to go for it.
“I went in to hospital on Monday, had the operation on Tuesday, and went home on Wednesday lunchtime. I've had no pain at all and not a single painkiller. It was a little uncomfortable where the holes
in my abdomen were. The only problem I've had is controlling my urine, but that seems to be getting better.
“I was back to work in three weeks. To be honest, I feel as if nothing has happened.

Brief History


Application on Module:

The invention of Robotic Operation are great help in Science and Technology and it is proven how the technology increases and continue to improve throughout the society. The rationality that led us to invent and to discover, and the tools and techniques that come out of our search-the machines, the processes, in short, the technologies, derive their moral goodness from their uses. True, these technologies can be used both for the good and the bad, but they do not have inherent, or intrinsic, moral values. They are just tools
.(pg.11 STS Module)

How Robotic Surgery Will Work

Just as computers revolutionized the latter half of the 20th century, the field of robotics has the potential to equally alter how we live in the 21st century. We've already seen how robots have changed the manufacturing of cars and other co nsumer goods by streamlining and speeding up the assembly line. We even have robotic lawn mowers and robotic pets. And robots have enabled us to see places that humans are not yet able to visit, such as other planets and the depths of the ocean.

In the coming decades, we may see robots that have artificial intelligence. Some, like Honda's ASIMO robot, will resemble the human form. They may eventually become self-aware and conscious, and be able to do anything that a human can. When we talk about robots doing the tasks of humans, we often talk about the future, but robotic surgery is already a reality. Doctors around the world are using sophisticated robots to perform surgical procedures on patients.
Not all surgical robots are equal. There are three different kinds of robotic surgery systems: supervisory-controlled systems, telesurgical systems andshared-control systems. The main difference between each system is how involved a human surgeon must be when performing a surgical procedure. On one end of the spectrum, robots perform surgical techniques without the direct intervention of a surgeon. On the other end, doctors perform surgery with the assistance of a robot, but the doctor is doing most of the work [source: Brown University].

While robotic surgery systems are still relatively uncommon, several hospitals around the world have bought robotic surgical systems. These systems have the potential to improve the safety and effectiveness of surgeries. But the systems also have some drawbacks. It's still a relatively young science and it's very expensive. Some hospitals may be holding back on adopting the technology.

Supervisory-controlled Robotic Surgery Systems

Of the three kinds of robotic surgery, supervisory-controlled systems are the most automated. But that doesn't mean these robots can perform surgery without any human guidance. In fact, surgeons must do extensive prep work with surgery patients before the robot can operate.

That's because supervisory-controlled systems follow a specific set of instructions when performing a surgery. The human surgeon must input data into the robot, which then initiates a series of controlled motions and completes the surgery. There's no room for error -- these robots can't make adjustments in real time if something goes wrong. Surgeons must watch over the robot's actions and be ready to intervene if something doesn't go as planned and the reason surgeons might want to use such a system is that they can be very precise, which in turn can mean reduced trauma for the patient and a shorter recovery period. One common use for these robots is in hip and knee replacement procedures. The robot's job is to drill existing bone so that an implant fits snugly into the new joint. Because no two people have the exact same body structure, it's impossible to have a standard program for the robot to follow. That means surgeons mustmap the patient's body thoroughly so that the robot moves in the right way. They do this in a three-step process called planning, registration and navigation. In the planning stage, surgeons take images of the patient's body to determine the right surgical approach. Common imaging methods include computer tomography (CT) scans, magnetic resonance imaging (MRI) scans, ultrasonography, fluoroscopy and X-ray scans. For some procedures, surgeons may have to place pins into the bones of the patient to act as markers or navigation points for the computer. Once the surgeon has imaged the patient, he or she must determine the surgical pathway the robot will take.
Dr. Scott J. Boley demonstrates a robotic surgery system at the Montefiore Institute for Minimally Invasive Surgery in New York City.

Price of ROBOTICS:

The most in demand in the Market today for ROBOTIC Science that affordable are the Human Touch Massage System and its very helpful to the Physical Therapist. The massage mechanics combined a curved track massage system that follows the spine's nature curves with massaging modalities that imitate the techniques of back care professionals such as massage therapists.

The price is estimate : $2,000 to $ $,4000
More prices:
Other Robotic machines on url (

Lower Cost, Portable Surgical Robots Could Be Smooth Operators

March 2, 2006
WEST LAFAYETTE, Ind. – A mechanical engineer at Purdue University is teaming up with medical doctors in research aimed at developing less expensive, portable and versatile surgical robots that could become more common in operating rooms.
The researchers also are trying to incorporate tactile sensors into the robots to enable surgeons to feel tissue and better diagnose medical conditions.
"Robots don't perform the surgeries, but they are tools that give the surgeon more dexterity," said William Peine, an assistant professor of mechanical engineering. "They let you get into confined spaces. You can eliminate hand tremor, and you can be very precise and delicate. It's as if the tips of the instruments become your fingertips."

Peine, whose research involves creating both software and hardware for surgical robots, helped form a company called Pressure Profile Systems, located in California, which develops and markets tactile medical devices. He also is affiliated with Purdue's Regenstrief Center for Healthcare Engineering at Discovery Park, the university's hub for interdisciplinary research.
"The Regenstrief Center's mission statement is to design, implement and sustain interdisciplinary solutions to transform health-care delivery systems," Peine said. "We emphasize that solutions and new technology should improve the quality, efficiency, safety and accessibility of health care.
"Surgical robotics has the potential to do this because less expensive robots reduce costs and make the technology available to more hospitals, while the quality and safety of care would improve by including a computer in the loop with the surgeon."
The only surgical robot currently on the market costs about $1 million, but researchers are trying to create alternatives that cost about $250,000.

Dr. that testified the importance of Robotic Operation

Chitwood: Medical things that can be done with these robotics tele-presence devices so that a lower level technologist, maybe not a surgeon, would be able to insert the probes and have a surgeon at a distance perform and emergency operation. The robots nimble hands clip out the offending part of the leaking valve. A plastic support is sewn in. And the whole procedure takes only slightly longer than traditional surgery. More testimony: (

Dr. Moll, 56, is a soft-spoken man who can look uncomfortable on stage. Yet his role in founding Intuitive Surgical, the company that now dominates the field, and his current involvement with three other robotics companies, has kept him in the sights of investors, health care providers and fellow entrepreneurs.
He’s now best known as chief executive of Hansen Medical, a publicly traded robotics company focused on minimally invasive cardiac care. But he’s also an investor in and a board member of Mako Surgical, an orthopedics robotics company that recently went public, and he is a co-founder and chairman of Restoration Robotics, a start-up company focused on cosmetic surgery.
Dr. Moll says robotics will ultimately advance on still other fronts, largely because it can help doctors of varying ability perform at the level of the world’s top surgeons.
“The public has no idea of the extent of difference between top surgeons and bad ones,” he said. “Robots are good at going where they are supposed to, remembering where they are and stopping when required.”


“The prostate cancer was picked up after a routine health check. The specialists said I might be OK for 15 years and there didn't seem to be any spread outside the prostate, but I didn't want it hanging over me. When I was told that recovery was quicker with robotic surgery, I thought that was a good reason to go for it.
“I went in to hospital on Monday, had the operation on Tuesday, and went home on Wednesday lunchtime. I've had no pain at all and not a single painkiller. It was a little uncomfortable where the holes in my abdomen were. The only problem I've had is controlling my urine, but that seems to be getting better.
“I was back to work in three weeks. To be honest, I feel as if nothing has happened.

-- Michael Mills, 65, a building contractor from Cambridge, UK


Mission Statement:
Our mission is to provide the highest quality urological care for our patients in a compassionate, ethical and confidential manner.



Dr. Scott Tully:

Dr. Tully is one of the original founders of the robotic program at Urology Centers of Alabama and the first to perform a robotic radical prostatectomy in Alabama in 2002. He has performed over 1500 robotic radical prostatectomies and routinely does eight to ten procedures per week. He has been a pioneer in the development and refinement of the procedure and has instructed numerous surgeons in the technique. Currently, UCA is one of the busiest robotic radical prostatectomy programs in the world, leading the way in robotic surgery.
Dr. Tully is the past Secretary-Treasurer and President of the Birmingham Urology Club, and he is past Secretary-Treasurer and President of the Alabama Urology Society.
Dr. Tully is an active member of the American Urologic Association and Medical Association of the State of Alabama. He has served on the Board of the Southeastern Urological Society for two years. He has been on the Board of the Jefferson County Medical Society and served a three-year term as the Treasurer of the Jefferson County Medical Society.
Dr. Tully is certified by the American Board of Urology and a Fellow of the American College of Surgeons.
Dr. Scott Tully is a graduate of the University of Alabama School of Medicine, Birmingham, Alabama. Dr. Tully completed his internship and residency in surgery and urology at Emory University in Atlanta, Georgia.
Dr. Tully is Board Certified.

Dr. Vincent Michael Bivins:

Dr. Bivins' interests include robotic prostatectomy, laparoscopy, urology oncology, female pelvic floor reconstruction, reconstruction for complex urethra stricture disease and stone disease. He is the only urologist in the state that performs robotic reconstruction procedures, including sacrocolpopexy, Burch and paravaginal repairs. He also uses minimally invasive procedures for benign prostate hyperplasia including microwave and laser treatment and other minimally invasive urologic procedures.
Dr. Bivins received his undergraduate degree from the University of Alabama. He received his medical doctorate from the University of Alabama School of Medicine. He completed his surgical internship at Vanderbilt Medical Center. He received his urology training from the University of Oklahoma. He completed a urology oncology fellowship from the University of Washington. He is cerified by the American Board of Urology. He is also a major in the United States Air Force Reserve.
Dr. Bivins is board certified.

Dr. Charles Edward Bugg, Jr.:

Dr. Eddie Bugg has been a member of our robotic team since 2003. He has performed over 1,000 procedures doing 6-10 robotic prostatectomies a week. He uses the daVinci robotic system at St. Vincent's and Trinity Hospital.
Currently, this is one of the busiest centers in the world. Our surgical technique has been modified through the years to improve patient outcomes. Dr. Bugg is also involved in teaching other physicians how to perform robotic and laparoscopic surgery. He also does robotic kidney surgery.
As a board certified urologist, Dr. Bugg's clinical interests include not only minimally invasive prostate and kidney cancer, but also include stone disease and infertility.
He is certified by the American Board of Urology and is a member of the Southeastern Urological Society and the American Urological Association.
Dr. Bugg received his BS degree from The University of Alabama and graduated Magna Cum Laud in 1993. Dr. Bugg completed two years of general surgery and a residency in Urology at The University of Alabama Medical School, Birmingham, Alabama.
Dr. Bugg is board certified.

Dr. Thomas Douglas Holley:

Dr. Thomas Douglas Holley is a graduate of the University of Alabama School of Medicine in Birmingham, AL. He completed his internship and residency in surgery and urology at Alton Ochsner Medical Foundation Hospital in Louisiana.
He is a member of Phi Beta Kappa and was awarded the Dr. Earle Drennen scholarship to medical school.

Dr. Eric Brewer:

Dr. Eric Brewer is a native of Birmingham, AL and a graduate of the University of Alabama. He obtained his medical degree in 2004 from the University of Alabama School of Medicine in Birmingham. Dr. Brewer then went on to complete an internship in Surgery and residency in Urology at the University of Tennessee Medical Center, Knoxville.
Dr. Brewer has published several manuscripts in the Urology literature regarding urologic trauma, erectile dysfunction, and urinary stone disease. His interests include laparoscopic and robotic surgery, minimally invasive treatment of BPH, treatment of all urologic cancers, complex reconstructive procedures, stone disease, male infertility, and the treatment of incontinence.

David Brown:

I was surprised when a routine blood test associated with an annual physical indicated my PSA had jumped to 5.4, but the real shock came later when 3 of 8 “sticks” in a follow-up prostate biopsy were found to contain cancer cells!
With the help of my local urologist and a host of friends I began the learning process and started considering treatment options. Radical prostatectomy quickly became my choice, but just as I was preparing to see my local urologist about scheduling conventional open surgery two new pieces of information came along that changed everything: 1) I got a tip that led to a chat with a distant stranger in Michigan who was elated about the results of his own recent robotic prostate surgery and 2) I read an article in the December 12, 2005, issue of Newsweek Magazine giving more details about Intuitive Surgical’s new da Vinci robot.
On Intuitive Surgical’s website I found information about the institutions / locations where their da Vinci robots were operating, and as I started looking at the web sites of those institutions I also found lists of the doctors who were using them for prostate surgery. In so doing, I quickly learned of Dr. Scott Tully's work at St. Vincent's Hospital in Birmingham and read some of their research in the Journal of Urology. It was quickly apparent to me I wanted to make an appointment with Dr. Tully at Urology Centers of Alabama and see what he and the robot could do for me.
The rest is history now. While I must admit I slept through the whole episode, Dr. Tully, the support staff and the robot performed their magic on me March 29, 2006. I was released from the hospital the next morning, returned to Birmingham to get the catheter removed on April 7, and was absolutely surprised to learn both my urinary continence and erectile functions were normal just two days later! Within one month after my surgery, I have resumed all my normal routines. Thanks to Dr. Scott Tully, and all the wonderful people at St. Vincent's and The Urology Centers of Alabama, and that fantastic robot from Intuitive Surgical I have my life back already!
David S. Brown, Ph.D.
Athens, GA

Bruce Patrick:

After learning I had prostate cancer, my doctor recommended a new hi-tech surgery: Robotic Laparoscopic Prostate Surgery. He recommended the team of doctors at Urology Centers of Alabama in Birmingham. I was given the names of local men who had gone to them and had successful prostate robotic laparoscopic surgery. Talking with them gave me to confidence to go ahead with this new type of surgery.
My new doctor, Eddie Bugg, would sit in front of a computer, away from me; he would operate controls that a computer would transfer his motions to control the small robot instruments operating inside my body.
I was operated on the morning of March 31; five small cuts were made in my lower front abdomen during a four hour surgery. The prostate was removed and found to have all of the cancer still inside its tissue. By mid day of April 1, I was released to go home from the hospital. I wore a catheter for 7 days and after two or three weeks of rest I will be able to go back to work. I will not have to take any radiation treatments. I was the 1020th patient to receive the robotic laparoscopic radical prostatectomy from the caring people at Urology Centers of Alabama.
Urology Centers of Alabama has not only completed over 1,000 successful procedures, they are #1 volume in the Southeast and top 5 volume in the country. They have treated patients from 5 countries, 19 states and 336 cities so far.
I hope after reading this that middle age men will get that PSA checked each year so you will have the same second chance that I have been given.
The star wars equipment is great, the Urology Centers of Alabama doctors and hospital staff at St Vincent's are very skilled and good at what they do.
Bruce Patrick
Ethelsville, AL

Patients Testimonial:

John Story:

In Mid-December 2005, an annual physical with my Internist showed that my PSA was 4.0. My wife is an RN which translates into the fact that within 3 days I was visiting a urologist.
My urologist told me that I had prostatitis and that it could cause the elevation. He gave me an antibiotic to take for 10 days but told me before leaving that even if the PSA came down after the antibiotic he would suggest a biopsy. He was right, the PSA came down to 1.6 but I followed his advice and had the biopsy. I had 3 positives out of 18 samples taken. My results were given to me Friday January 13.
Over the weekend I read the book Prostate Cancer for Dummies. This is an excellent easy to read book written by a Urologist who himself has undergone the OPEN procedure. It compares all 3 treatment options very thoroughly. During the following week I talked with folks who had undergone all 3 treatments - OPEN, ROBOTIC and RADIATION. I did extensive research on the Internet. I posted the results of this research on my website at under the MEDICINE category. My research led me to choose the ROBOTIC procedure performed by the surgical team at Urology Centers of Alabama.
On January 20, one week after diagnosis I met with Dr. Eddie Bugg and we scheduled the surgery for February 28. Physicians recommend that you wait at least a month after a biopsy before initiating any treatment. I used this time to perform daily muscle exercises which helped me get bladder control back faster after surgery.
I entered St. Vincent’s at 5 am the day of surgery. I had surgery at 7 am and was back in my room by noon. I lost only 33 cc of blood during surgery. They had me up and walking that afternoon and night. The next morning at 7 am, Dr. Bugg released me to go home. At 11:30 am I walked from my room to the car and came home. I came home with a catheter in place. I also had a device that resembles a fanny pack attached around my waist. It contained pain medication that was automatically dispensed into two of the five incision holes. My medication ran out on the fourth day home and my wife removed the device. The On-Q Pain Buster is one marvelous device. It totally controlled my pain. I took only five of thirty pills for pain that I brought home. I took none after the seventh day.
Forty six days after diagnosis, my problem had been removed. Eight days after surgery, I returned and had the catheter removed and the following day I was driving myself to the barber shop, bank and a restaurant.
After four weeks, I was down to changing out one small pad during the day and I used one brief type pad for sleeping at night. After six weeks I dropped the brief pad altogether. Your bladder’s control comes back first when lying down, then while sitting and lastly standing or walking.
I worked in the yard for almost two hours on day 12 after surgery. I had bypass heart surgery four years ago and compared to that, this procedure is about like a root canal.
John Story
Birmingham, AL

Da Vinci robot is a lifesaver:

As a prostate cancer survivor, I think the Da Vinci robot, recently purchased by the Infirmary Foundation and the University of South Alabama Mitchell Cancer Institute, is one of the greatest medical advancements in our lifetimes. This machine, in the hands of trained medical providers, can cure early diagnosed prostate cancer with fewer side effects.
Men who receive the recommended PSA screening and/or biopsy have an excellent chance of an early diagnosis. The earlier prostate cancer is found, the better the chances are that it will be contained within the prostate. Inversely, if the screening tests are neglected, the chances are greater that the cancer will have spread before it is diagnosed.
The two big fears, beyond the cancer itself, are loss of bladder control and loss of erectile function. The Da Vinci robot is so precise that a skilled surgeon can preserve nerves, etc., to improve the patient's chance of retaining normal functions.
When I was diagnosed with prostate cancer in April 2005, my treatment of choice was radioactive seed implants. Thank God, my cancer was contained within the prostate. My doctors performed a volume study to determine the feasibility. Because my prostate was too enlarged to receive the seed, I was given five monthly hormone injections.
Another volume study was also unsuccessful. This left me looking at other treatment options. External radiation and/or surgery seemed to be the best known available treatment. Yet, I was not happy with either. The radiation would take about seven or eight weeks and appeared uncertain. Open surgery can have a lot of complications and healing time.
Dr. Douglas Turnbull, my urologist who faithfully monitored me through the years and caught the cancer early before it could spread, told me about the Da Vinci robotic option at St. Vincent's Hospital in Birmingham. An appointment was made for me to see Dr. Scott Tully.
I elected to have this surgery. I had a total of three trips to Birmingham: one initial office visit, the hospital time for the surgery, and one follow-up office visit. St. Vincent's facility was great; it has a lodge (extra cost) connected to the hospital by an enclosed walkway for families of out-of-town patients.
Letters to the Editor
Monday,July 24, 2006
Edition: 05, Section: A, Page 06
James J. Kirkey

Practical uses of Robotic Operation today

In today’s competitive healthcare market, many organizations are interested in making themselves “cutting-edge” institutions with the most advanced technological equipment and the very newest treatment and testing modalities. Doing so allows them to capture more of the healthcare market. Acquiring a surgical robot is in essence the entry fee into marketing an institution’s surgical specialties as “the most advanced.” It is not uncommon, for example, to see a photo of a surgical robot on the cover of a hospital’s marketing brochure and yet see no word mentioning robotic surgery inside.As far as ideas and science, surgical robotics is a deep, fertile soil. It may come to pass that robotic systems are used very little but the technology they are generating and the advances in ancillary products will continue. Already, the development of robotics is spurring interest in new tissue anastomosis techniques, improving laparoscopic instruments, and digital integration of already existing technologies.As mentioned previously, applications of robotic surgery are expanding rapidly into many different surgical disciplines. The cost of procuring one of these systems remains high, however, making it unlikely that an institution will acquire more than one or two. This low number of machines and the low number of surgeons trained to use them makes incorporation of robotics in routine surgeries rare. Whether this changes with the passing of time remains to be seen.

Advantages of Robotic Surgery

In today's operating rooms, you'll find two or three surgeons, an anesthesiologist and several nurses, all needed for even the simplest of surgeries. Most surgeries require nearly a dozen people in the room. As with all automation, surgical robots will eventually eliminate the need for some personnel. Taking a glimpse into the future, surgery may require only one surgeon, an anesthesiologist and one or two nurses. In this nearly empty operating room, the doctor sits at a computer console, either in or outside the operating room, using the surgical robot to accomplish what it once took a crowd of people to perform.

In today's operating rooms, you'll find two or three surgeons, an anesthesiologist and several nurses, all needed for even the simplest of surgeries. Most surgeries require nearly a dozen people in the room. As with all automation, surgical robot will eventually eliminate the need for some personnel. Taking a glimpse into the future, surgery may require only one surgeon, an anesthesiologist and one or two nurses. In this nearly empty operating room, the doctor sits at a computer console, either in or outside the operating room, using the surgical robot to accomplish what it once took a crowd of people to perform. The use of a computer console to perform operations from a distance opens up the idea of telesurgery, which would involve a doctor performing delicate surgery miles away from the patient. If the doctor doesn't have to stand over the patient to perform the surgery, and can control the robotic arms from a computer station just a few feet away from the patient, the next step would be performing surgery from locations that are even farther away. If it were possible to use the computer console to move the robotic arms in real-time, then it would be possible for a doctor in California to operate on a patient in New York. A major obstacle in telesurgery has been latency -- the time delay between the doctor moving his or her hands to the robotic arms responding to those movements. Currently, the doctor must be in the room with the patient for robotic systems to react instantly to the doctor's hand movements.


These robotic systems enhance dexterity in several ways. Instruments with increased degrees of freedom greatly enhance the surgeon’s ability to manipulate instruments and thus the tissues. These systems are designed so that the surgeons’ tremor can be compensated on the end-effector motion through appropriate hardware and software filters. In addition, these systems can scale movements so that large movements of the control grips can be transformed into micromotions inside the patient.6Another important advantage is the restoration of proper hand-eye coordination and an ergonomic position. These robotic systems eliminate the fulcrum effect, making instrument manipulation more intuitive. With the surgeon sitting at a remote, ergonomically designed workstation, current systems also eliminate the need to twist and turn in awkward positions to move the instruments and visualize the monitor.By most accounts, the enhanced vision afforded by these systems is remarkable. The 3-dimensional view with depth perception is a marked improvement over the conventional laparoscopic camera views. Also to one’s advantage is the surgeon’s ability to directly control a stable visual field with increased magnification and maneuverability. All of this creates images with increased resolution that, combined with the increased degrees of freedom and enhanced dexterity, greatly enhances the surgeon’s ability to identify and dissect anatomic structures as well as to construct microanastomoses.

Disadvantages of Robotic Surgery
  1. Since it's a new technology, it's uses and efficacy have not yet been well established. Mostly, studies of feasibility have been conducted, and almost no long term follow-upstudies have been performed.
  2. Their cost is nearly prohibitive. Whether the price of these systems will fall or rise is a matter of conjecture. Also at issue is the problem of upgrading system. How much will hospitals and healthcare organizations have to spend on upgrades and how often?
  3. The size of the system. It may be difficult for both the surgical team and the robot to fit into the operating room.
  4. Lack of compatible instruments and equipments. Lack of certain instruments increases reliance on tableside assistants to perform part of the surgery.

Social Benefits in ROBOTIC OPERATION:

  1. Smaller incisions
  2. Less pain and scar
  3. Decreased blood loss
  4. Fewer complications
  5. Shorter hospital stay
  6. Faster return to activity
  7. Reduced trauma

The benefits of robotic surgery, however, can carry a hefty price tag. The initial cost of each da Vinci Surgical System (a teleoperative machine designed by the company Intuitive Surgical of Sunnyvale, CA., for areas such as cardiac, urologic, gynecologic and general surgery) is 1.5 million dollars, with annual upkeeps costing approximately $100,000. On average, the use of robotic technology increases the surgical costs in increments of thousands of dollars, where the increase in cost is relative to both the complexity of the procedure and risk associated with that surgery. However, many would argue that the need for less medication and a shorter hospital stay offsets the total expenditure for the patient.

Shared-control Robotic Surgery Systems

A Consensus Document on Robotic Surgery

Prepared by the SAGES-MIRA Robotic Surgery Consensus Group
This project was funded in part by a grant from the Defense Advanced Research Project Agency (DARPA). The views and opinions, and/or findings contained in this report are those of the author(s) and should not be construed as an official Department of the Army position, policy, or decision, unless so designated by the other documentation.


Robotic surgical devices have developed beyond the investigational stage and are now routinely used in minimally invasive general surgery, pediatric surgery, gynecology, urology, cardiothoracic surgery and otorhinolaryngology. Robotic devices continue to evolve and – as they become less expensive and more widely disseminated – will likely become more frequently utilized in surgical procedures. The leadership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Minimally Invasive Robotic Association (MIRA) felt that guidelines for the usage of robots in surgery were lacking, and that the surgical community would benefit from a consensus statement on robotic surgery including guidelines for training and credentialing.
To accomplish this task, SAGES and MIRA assembled an international multidisciplinary consensus group to draft a consensus statement. The SAGES-MIRA Robotics Consensus Conference was convened at Mount Sinai Medical Center in New York City on June 2-3, 2006. The task force addressed four distinct questions it felt were central to the use of robots in surgery:
  • Training and credentialing: How should training for robotic surgery be accomplished? What is the appropriate process for credentialing robotic surgery?
  • Clinical applications of robots in surgery: What are the appropriate clinical applications for robotic surgery; has efficacy been demonstrated for these applications?
  • Risks of Surgery and Cost-Benefit Analysis: What are the physical risks of robotic surgery to the patient? What financial costs are involved in robotic surgery and are these costs justified?
  • Research: What are the important unanswered questions in robotic surgery? What direction should future research take?
After meeting and presenting data regarding these issues in a didactic forum, the Robotic Task Force faculty was divided into 4 working groups to address these issues separately. The faculty then reconvened to review the working groups’ conclusions and arrive at a generalized consensus. The results of these proceedings are presented in this document.


“Robotic surgery” is an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted. The term refers to surgical technology that places a computer-assisted electromechanical device in the path between the surgeon and the patient. A more scientifically accurate term for current devices would be “remote tele-presence manipulators” since available technology does not generally function without the explicit and direct control of a human operator. For the purposes of the document, we define robotic surgery as a surgical procedure or technology that adds a computer technology enhanced device to the interaction between a surgeon and a patient during a surgical operation and assumes some degree of control heretofore completely reserved for the surgeon.
As an example, in laparoscopic surgery the surgeon directly controls and manipulates tissue, albeit at some distance from the patient and through a fulcrum point in the abdominal wall. This differs from current robotic devices, where the surgeon sits at a console – typically in the operating room but outside the sterile field – directing and controlling the movements of one or more robotic arms. While the surgeon still maintains control over the operation, the control is indirect and is effected from an increased distance.
This definition of robotic surgery encompasses micromanipulators as well as remotely-controlled endoscopes in addition to console-manipulator devices. The key elements are enhancements of the surgeon’s abilities, be they vision, tissue manipulation, or tissue sensing, and alteration of the traditional direct local contact between surgeon and patient.

Clinical Environment

Surgical robots are considerably more complex, both electrically and mechanically, than traditional devices used in the operating room environment. In addition, they involve direct contact with the patient, both externally and internally. These important features differentiate surgical robots from other equipment such as operating microscopes, intraoperative imaging devices and traditional operating room instruments.
In addition to the surgeon and surgical assistant, all personnel in the operating room must be appropriately trained to handle this equipment. There are currently no standard criteria set forth for registered nurses, operating room technicians, or surgeons with respect to appropriate training for managing these instruments in the operating room. However, at a minimum, operating room personnel should be trained according to the manufacturer’s training guidelines, and should have the opportunity to be “doubled up” with an experienced nurse or operating room technician during their early experience.
It is highly recommended that teams using such instruments – surgeons, technicians, nurses, and possibly manufacturing representative – meet on a periodic basis to stay current in their training and to learn of updates or changes to the hardware or software. In this way, emerging problems may be quickly identified and addressed.

I. Surgeon Training and Credentialing

In order to maintain the highest levels of patient care today and in the future, we must ensure that surgeons are adequately trained in the use of surgical robots prior to clinical use. Training and credentialing are separate but intimately related issues. Credentialing can only be granted by the individual institutions where surgeons work. We have included formal guidelines for credentialing in Appendix I of this document and guidelines for robotic surgery training in Appendix II.
There are two broad aspects to training with robotic systems. The first is technical training and capability. The surgeon must have both a knowledge base and a practical working familiarity with these complex devices before clinical use. In addition to all standard operating procedures, this training must include how to safely and rapidly remove the device in an emergency, what to do if the system stops responding, and how to respond if the system makes movements that are potentially unsafe to the patient. All such reasonably foreseeable situations must be anticipated, practiced and understood. Currently, the FDA has in place a mandate that companies provide at least some of this training. Thus, at a minimum, surgeons must be trained to meet these FDA standards.
The second aspect of training involves the use of the robot for specific operations. The simplest situation exists when a fully trained and competent laparoscopic surgeon begins to use a robotic system clinically. In this case, it is merely a matter of adding the specific knowledge of robotic technology to an existing set of clinical skills. A more complex situation is presented by the surgeon who elects to begin his or her minimally invasive endeavors using the robot. In this situation, the amount of learning required may be substantially greater. Full credentialing guidelines that address these situations are presented in Appendix I.
SAGES and MIRA recognize that surgical simulators may play an increasingly large role in surgical training in the future. However, at present there are no simulators that provide training equivalent to that obtained in a formal clinical setting. Thus, at present, simulators must remain an adjunct in the training of robotic surgeons.

II. Clinical Applications

The goal of the Clinical Applications subgroup was to focus on the status of robotic surgery applications as of June, 2006. Although robotic surgery has shown great promise across a broad range of surgical disciplines, no level I data exist at this time to strongly support robotic surgery; conversely, no studies or anecdotal reports exist to suggest any increase in complication rates compared to conventional open or laparoscopic surgery.
In general, the literature regarding robotic surgery lags behind the clinical experience by several years. Current literature suggests that the primary clinical advantages of currently available robotic systems, compared to conventional open or laparoscopic surgery, include:
  • Superior visualization including 3-dimensional imaging of the operative field
  • Stabilization of instruments within the surgical field
  • Mechanical advantages over traditional laparoscopy
  • Improved ergonomics for the operating surgeon
Across multiple surgical specialties, robotic surgery was felt to offer the greatest advantage in complex reconstructive processes.
Limitations of current robotic technology include,among other technical constraints, lack of haptics (force feedback), size of the devices, instrumentation limitations (both size and variety), lack of flexibility of certain energy devices, and problems with multi-quadrant surgery (current devices are deployed typically for single quadrant application).
Overall, the technically exceptional laparoscopic surgeon may derive little benefit from robotic surgery. However, surgical robots may serve as an “enabling technology” for many surgeons, allowing them to provide complex minimally invasive procedures to a broad range of patients. The potential advantages of robotic surgery extend across many different surgical subspecialties.

Pediatric Surgery: Over 50 different types of abdominal and thoracic procedures have been performed in pediatric patients. Neonates and infants have also undergone robotic procedures safely and with excellent results. In particular, robotic surgery may present advantages for the Kasai procedure, choledochal cyst repair, and thoracic tumor excision. It may also be beneficial in abdominal and thoracic procedures requiring reconstruction. The major limitation is the size of the robotic instruments in relation to the pediatric patient.
Gynecology: Robotic surgery has shown promise in hysterectomy for both benign and malignant disease, as well as myomectomy. In myomectomy, the robot may provide substantial benefit by allowing minimally invasive fertility sparing options. It is also beneficial for tubal reconstruction. The robot may provide potential advantages for pelvic reconstructive surgery.
General Surgery: With present technology, robotic surgery is best suited to procedures limited to one quadrant of the abdomen that present challenging access: specifically those requiring fine dissection, micro-suturing or reconstruction. Reports have been published with use for cholecystectomy, but with no findings of improved outcomes nor safety. Reports for solid organ surgery, as adrenalectomy, have not found particular advantage, noted increased cost, but did prove feasibility. Procedures where it may be of particular value include Heller myotomy, paraesophageal hernia repair, gastric bypass, gastric resection for neoplasm, biliary reconstructive surgery, transhiatal esophagectomy, transthoracic esophageal surgery, distal pancreatectomy with splenic preservation, and selected colorectal procedures. It may hold promise for pancreatic head resection and hepatectomy, but experience to date is limited. In resections for neoplasm, robotic surgery may help to enhance the completeness of lymph node dissection.
Although there is a substantial cost disadvantage to using the robot for simple procedures such as cholecystectomy and fundoplication, these procedure may present an excellent opportunity for surgeons early in their robotic learning curve to acquire increasingly more advanced skills.
Urology: Robotic surgery has been shown to offer substantial advantages over conventional minimally invasive surgery in several urological procedures. While the most mature outcomes data in the field of robotics are for radical prostatectomy, robotics may also offer advantages for cystectomy, pyeloplasty, nephrectomy (partial, complete and donor) and ureteral reimplantation. Resection of bladder neoplasm may also be approached robotically with a lower incidence of postoperative ileus. Robotic surgery may ultimately replace open surgery for some complex urological procedures.
Thoracic Surgery: Robotic surgery offers clear benefits in the resection of solid thoracic tumors, particularly those located in the apex of the chest. Esophageal tumors such as leiomyomas may also be resected robotically.
Otorhinolaryngology/Head and Neck Surgery: Transoral robotic surgery is presently under study. Preliminary data indicate utility for transoral resections of benign and malignant lesions of the pharynx and larynx. Oncologic resections of the supraglottis, tonsil and tongue base have been shown to be feasible with potential advantages compared to traditional approaches. Preliminary evidence indicates that these advantages may include avoidance of mandibulotomy, avoidance of tracheostomy, decreased operative time, reduced requirements for complex reconstructions, and avoidance of external excisions.
Limitations of the present technology preclude transnasal and otologic procedures because of instrument size and functionality. Current otorhinolaryngology procedures are performed under IRB approval as FDA approval is still pending. Further use of robotic surgery in the head and neck will await the development of smaller instruments and more flexible robotic tools.
Limitations across specialties: Overall, the Clinical Applications subgroup felt that the 3 major impediments to the clinical use of robots are cost, training issues and lack of outcomes data. Among the previously mentioned technical limitations, the primary technical limitation of robotic surgery is the difficulty in performing procedures that extend over a large area, such as multiquadrant abdominal surgery. These limitations will likely ease as robotic devices evolve.
The use of surgical registries will be important in future studies of robotic surgery, particularly those evaluating short- and long-term surgical outcomes.

III. Cost/Benefit Analysis of Robotic Surgery

The cost/benefit analysis of robotic surgery involves a complex combination of numerous variables. Costs of the surgical robot include capital acquisition, limited use instruments, team training expenses, equipment maintenance, equipment repair, and operating room setup time. At present it is unknown whether robotic surgery will affect complication rate, length of stay, or length of patients’ convalescence. Any analysis of robotic surgery must ensure that an appropriate comparison to alternative therapies is being made. In some cases robotic surgery should be compared to open surgery while in others to laparoscopic or alternative minimally invasive techniques.

Capital Acquisition Cost

The treatment of the capital acquisition cost will vary across institutions. In some cases the cost analysis will not include the capital purchase cost, while in others the allocation of this investment and depreciation will be assessed on a per case basis. Donations, institutional technology investment decisions, or marketing programs may or may not enter the cost analysis. Multidisciplinary team training is an up front investment that can be capitalized and requires inclusion in the initial analysis.


The number of different robotic instruments utilized varies from case to case. Current instruments are limited to a fixed number of uses, unrelated to instrument wear. Since repeated reuse of instruments lowers the per case cost, an important future goal should be indefinitely reusable instruments.

Equipment Maintenance and Repair

The cost of maintaining, servicing, and repairing these highly complex devices represents a significant portion of the yearly cost. We estimate that the sum of these costs each year is approximately 10% of the capital acquisition cost. Reducing this expense should be an important goal of future device development.

Operating Room Time

The cost analysis of operating room time includes multiple variables: room setup time, time for draping and docking the robot, skin to skin procedure time, undocking/storage time, and room turnover time. These factors are improved by effective team training, attention to efficient procedures, surgeon and team experience, and initial patient selection. Small increases in overall operating room time become significant only when additional personnel are required, overtime is paid, or fewer cases per shift can be accomplished.

Complication Rates

Complications have been shown to have a significant impact on the cost of care. It is generally felt that the use of robotics shortens the learning curve for acquiring complex minimally surgical skills. At present, there are no studies suggesting that robotic procedures performed by experienced robotic surgeons have different complication rates either better or worse than other comparable techniques.

Length of Stay

Comparison of robotic surgery to alternative techniques requires procedure by procedure analysis since there will be instances where robotic surgery is appropriately compared to minimally invasive techniques and others where it is compared to open techniques. Also, it should be remembered that length of stay affects cost centers outside the operating room. Decreased length of stay will counterbalance some of the increased operating room expenses associated with all forms of MIS. Length of stay may be affected by postoperative pain, intraoperative blood loss and complication rates. The differences between robotic and conventional surgery in these categories has not yet been adequately studied.

General Benefits

The desirable characteristics of current therapeutic robotic systems include platform stability, motion scaling, tremor reduction, excellent visualization, and articulating end effectors. Taken in combination these characteristics create a highly effective therapeutic system for performing surgical procedures. Robotics have made minimally invasive techniques accessible to patients in whom the procedures could not be performed using conventional laparoscopic techniques. Furthermore, enhancements in precision may aid in the conduct of a variety of advanced MIS procedures.


Both open and laparoscopic surgical procedures may be physically strenuous and have been associated with surgeon morbidity from repetitive use injury. Since the robotic surgeon sits comfortably in an ergonomically-designed workstation, the conduct of robotically-controlled procedures is generally more ergonomic for the operating surgeon. However, this benefit may not apply to the patient-side assistant. Such ergonomic differences will be magnified for lengthier procedures.

Learning Curve

Technically complex surgical tasks such as suturing present a substantial learning curve. These may be facilitated by the additional degrees of freedom inherent in articulated-arm robotic operating systems. Thus, articulated arm robots will potentially reduce technical skill acquisition time. They may enable surgeons to access difficult anatomic regions more easily, potentially speeding the introduction and clinical adoption of new MIS techniques.

Patient Return to Usual Activity

Some robotic surgical procedures may have better patient outcomes than their open or standard minimally invasive counterparts. Return to work benefits will vary based on the type of procedure and the population served

Risks of Robotic Surgery

Current surgical robots are continuously controlled by the surgeon and do not move autonomously. They possess neither artificial intelligence nor independent functioning. The robot remains a high-level, sophisticated tool used by the surgeon in the conduct of an operative procedure. Risks of robotic surgery can be categorized into those pertaining directly to the use of the robotic system and the general risks of the operative procedure.
Theoretically, the lack of haptic feedback in current robotic systems could lead to an increased risk of inadvertent tissue injury. However, to date, robotically performed operations have not been associated with higher clinical complication rates than their standard laparoscopic or open counterparts in experienced hands. In certain instances evidence exists that robotically performed procedures may be associated with a lower complication rate.
Robotic telesurgery, in which the surgeon may be located at some distance from the patient, poses unique risks. For example, precise control of the robot will be dependent upon the quality of the data connection between the surgeon’s console and the operating room robot. Issues pertaining to the quality and maintenance of such data connections may be beyond the control of the surgical team, but still represent a risk management challenge.

Mechanical Risks

All mechanical and electronic devices are subject to failure. Surgical robots – complex systems relying on a delicate interplay of hardware and software – are no exception. Current systems are designed with features intended to minimize the potentially deleterious effect of such failures on patients. Such features include system redundancy, so called “graceful” performance degradation or failure, fault tolerance, just-in-time maintenance, and system alerting. These are standards to which all high level systems should be held.

Institutional Risks

Healthcare institutions that employ high level technology as surgical robots in clinical practice need to develop and follow credentialing guidelines. The initiation of a robotic surgical program is similar to the introduction of any other novel, high-level, direct patient care technology, and should require appropriate training and credentialing (see Appendix I and II). In addition, each institution needs to develop a consistent policy concerning the nature of the procedures to be performed with regard to the need for IRB oversight. Such policy must take into account the nature of the proposed procedure itself. The institution also has an obligation to maintain the system consistent with manufacturer’s guidelines.

IV. Research

Surgical robots are now in their infancy. At present, there is only 1 commercially available general surgery robot in the United States. The robot does not perform any independent actions, but rather serves as a direct extension of the surgeon’s own hand. In this sense, current robots are more correctly described as electromechanical surgical actuators. These devices faithfully reproduce a surgeon’s action, as a ‘mimic’, but with no artificial intelligence nor automated subroutines. Since the term “robot” has come into general use in both the lay press and professional literature, and it is certainly a less cumbersome descriptor, we have used it throughout this document.
The present paradigm for surgical robotics is a limited one. A surgeon sits at a console, and his or her physical motions are translated via an elaborate electromechanical linkup to surgical instruments in the operative field. This paradigm does provide certain advantages in manipulating tissue, such as motion scaling and elimination of hand tremor. Current technology also has disadvantages, such as loss of haptic feedback. There is a significant amount of research and development that is evolving to bring us smaller, cheaper, faster, and safer devices with improved feature sets, such as haptic feedback. It is critical that future research in surgical robotics should not be tethered to the surgeon-at-a-console paradigm. Rather, research and development endeavors should address broader goals of a “grand vision” of computer/robotic assisted surgery. Some of these goals are enumerated below.


Current robotic instruments have evolved to provide a miniaturized ‘endowrist’ with degrees of freedom rivaling human capability. Future instrumentation will evolve in size and variety to further expand surgical capability.
‘Smart instruments’ are evolving so that dissection instruments can be imbued with capability to provide the user not only with mechanical dissection and retraction capabilities, but with ‘smart sensing’ capabilities, to provide the surgeon with information about tissue oxygenation, blood flow, molecular information, even tumor margin information.


Computer enhanced vision has already restored 3-dimensional vision. Additional visual enhancement systems can further enhance the operator’s vision, importing anatomic overlays, even ‘help’ heads-up displays. Visual system enhancements can also offer an array of ‘optical biopsy’ capabilities, as confocal microscopy, optical coherent tomography (OCT), and others, which can further enhance computer assisted visualization, enabling real-time microscopy, even molecular imaging.

Integrated Surgery

Robotic surgery presents an excellent opportunity to integrate anatomic and physiologic data into the operative field. Preoperative or even intraoperative imaging (e.g., CT, MRI, or ultrasound imaging) can reveal the three-dimensional topology of the operative field even before tissue is disturbed. Since the spatial coordinates (x, y, z axis) of the surgical instruments are “known” at all times by the surgical robot, the robotic interface provides an excellent platform through which this information can be integrated, registered, with the surgical device, so that the imaging information can be fused with the computer visual field, providing the potential for visual overlays of anatomy, function, even tumor mapping, such that the surgeon could ‘see into’ the tissues. Virtual barriers could be mapped into the operative field, identifying danger, or ‘no fly zones’, with the computer helping guide the surgeon away from potential hazard. This information could be used to guide surgical procedures intraoperatively, or even to simulate a proposed procedure before it is carried out. One of the more exciting potential areas of computer assisted interventional research relates to integrating imaging with interventional platforms.


Robot workstations can serve as both consoles controlling robotic systems, but can also have potential to serve as simulator environments, with the capability to import patient specific information and allow rehearsal of patient specific procedures toward reduction in complications rates, learning curves, even development of new technical approaches.
In addition to providing input integration of imaging registered with an interventional robotic platform, robots can capture data regarding how a surgeon performs specific tasks. These ‘black box’ data could be used for quality control, teaching purposes, or even to “train” the computer to perform similar tasks independently.


Future electromechanical technology may allow robots to be miniaturized to the point where they can enter the human body and perform surgery by remote control, or even autonomously. Such robots would potentially permit novel access paths to internal organs and could substantially decrease the invasiveness of surgical procedures. If such miniaturization is extended down to the level of “micro-machines”, then surgery could theoretically be performed at the cellular level. Such extreme miniaturization, while beyond current realization, would require extensive reworking of current surgical paradigms. However, the potential for new minimally invasive approaches is great.
In the near term, robotic platforms and instrumentation may evolve to enable single access port (SAP) surgery, with a device, that once deployed, provides, through a single port, a multi-capable platform providing vision and multiple effectors devices.

Improved Mobility

Current robots work best when the surgical field is limited to a relatively small area, such as a single quadrant of the abdomen. Future devices will need improved flexibility so that they can easily be deployed to access entire body cavities without reconfiguration. Mobility of the robotic device itself is also an issue – current devices are large and difficult to move, and do not lend themselves to use outside an operating room environment, such as in the battlefield. Mobility of robotic devices will improve as they miniaturization improves and the footprint of the devices becomes smaller.

True Independent / Autonomous Robotic Surgery

Current devices do not exercise independent logic or reason and do not even serve to automate repetitive tasks in the way that a sewing machine does. A first step in this direction for future robots would be the automation of routine tasks such as sewing; i.e. the surgeon indicates a start point and a finish point and the robot completes the suture line. Robots could use “artificial intelligence” to learn from the surgeon operating the device. Thus, robots could move from telemanipulators to skilled assistants in the future. If a robot acquired technical or cognitive knowledge from a large group of surgeons, it could ultimately serve as a computerized “colleague” to provide technical assistance in routine or unusual operative situations.

Safety and Documentation of Outcomes

Ultimately, all research in surgical robots must be undertaken with the goal of improving patient care and safety. Patient safety and clinical outcomes must remain foremost in future research efforts.
To adequately assess the risks and benefits of robotic surgery now and in the future, and to assist in guiding future research efforts, it will be essential to have outcomes registries for robotic surgery. Only through such registries will it be possible to accurately compare robotic surgery to traditional approaches, to document quality of outcomes, and to help identify needed no directions for development.

Surgical Team Robotic Augmentees

Just as current surgical robots can enhance human surgeon performance, devices already exist to enhance the surgical team. ‘Penelope’ is a commercially available robot to replace the scrub technicians. Next generation devices under development can enhance the work of scrub nurses, supply workers, among others. Future devices can further augment human capability, task performance, and enhance the surgical team.

Operating Room Integration

Just as an imaging system as a CT scanner is a computer with eyes, and a robot is a computer with arms, an operating room can become a computer system, with surgical robots integrated into perioperative workflow and process. Integrated computerized tracking of surgical activity, workflow, use of materials, devices, consumables, can enhance task performance, quality of care, and ultimately patient safety. Key will be standards development, ‘plug and play’ interoperability, modularity, and better understanding of human-system integration and limitations.

Enabling steps

To fully realize the future of computer assisted intervention/ robotics evolution, we will need transdisciplinary collaboration across not only surgical, interventional, and imaging disciplines, but with engineers and computer experts, backed with significant funding to realize the potential of the human-system interface. The prospects for enhancing patient care, quality, and safety are substantial. Further consensus efforts will be needed to define ‘white papers’ to serve as roadmaps for future research and development.


Robotic Surgery Systems (Shared-control)

Shared-control robotic systems aid surgeons during surgery, but the human does most of the work. Unlike the other robotic systems, the surgeons must operate the surgical instruments themselves. The robotic system monitors the surgeon's performance and provides stability and support through active constraint.

Active constraint is a concept that relies on defining regions on a patient as one of four possibilities:
safe,close, boundary or forbidden. Surgeons define safe regions as the main focus of a surgery. For example, in orthopedic surgery, the safe region might be a specific site on the patient's hip. Safe regions don't border soft tissues.

In orthopedic surgery, a close region is one that borders soft tissue. Since orthopedic surgical tools can do a lot of damage to soft tissue, the robot constrains the area the surgeon can operate within. It does this by providing
haptic responses, also known as force feedback. As the surgeon approaches the soft tissue, the robot pushes back against the surgeon's hand.

As the surgeon gets closer to soft tissue, the instrument enters the boundary region. At this point, the robot will offer more resistance, indicating the surgeon should move away from that area. If the surgeon continues cutting toward the soft tissue, the robot locks into place. Anything from that point on is the forbidden region.


Like the other robots we've looked at, shared-control system robots don't automatically know the difference between a safe region versus a forbidden region. The surgeons must first go through the planning, registration and navigation phases with a patient. Only after inputting that information into the robot's system can the robot offer guidance.

Survey on Robotics Surgery

Are U.S. Residency Training Programs Ready for Robotic Surgery ?
by The Physician Team
Posted: October 1, 2004

Dr Hratch Karamanoukian and colleagues at the University at Buffalo, School of Medicine and Biomedical Sciences, have looked at the influence of robotic technology upon the training of the next generation of surgeons in the United States.
Robotic and minimally invasive surgery represents the future of modern surgical care. However, the role of robotics in the training of current and future surgical residents has not been fully studied, "until now", according to the lead author, Dr. Yatin Patel.
A previous study conducted by this group surveyed program directors at accredited general surgery training programs in the United States to determine the prevalence and application of robotics in their residency training rograms.
This current study is a follow-up survey sent to residents across the United States to see whether they were being adequately trained and exposed to robotic surgery during their training. The goal was to determine the prevalence of robotics exposure in the training of U.S. surgical residents today.
A survey was sent to 1800 general surgery residents, and their responses were tabulated and analyzed. Twenty-three per cent of the 1800 residents responded to the survey. An overwhelming 57 per cent of the responders indicated a high interest in robotic surgery. However, 80 per cent of the responders indicated not having a robotic training program.
Dr. Patel stated that "it is imperative for current trainees in general surgery and the surgical specialties to be exposed to the newest technologies available on the market." Robotic surgery has led to many promising advancements within the surgical subspecialties. With this emerging technology comes the need for a greater emphasis on the training of surgeons in robotics during their residency.
Editor's Note:
The limiting factors for wide dissemination of this technology is the small number of surgeons who can teach these techniques to the current trainees. In cardiac surgery, less than a dozen surgeons in the U.S. are well versed with robotic surgery. Dozens more have just begun to use these devices in the clinical setting. Another limitation is their high cost and need for frequent upgrades, which have shown to be quite expensive for cash strapped university or private hospitals.
A limited recent survey of this same topic (January 2004) by our group to program directors in the U.S. has shown that the issues have changed somewhat with an emphasis to procure robotic systems for residency training in general surgery. The prohibitive cost remains a major issue.
For a related TV story regarding this subject, click on the link below.

Are you ready to become a robo-surgeon?,

American Surgeon; 69:599-603
Date of Article Publication:
Web Site:
Additional Notes:
Original article was written on August 28, 2003 and updated on September 30,2004.

Robotic Surgery Gains Acceptance as Experimentation Continues

By Robin Hohman
Part of the ECT News Network
08/09/06 4:00 AM PT
As physicians become more familiar with the systems' advantages, drawbacks and overall capabilities, robots may become more prevalent in the operating room. For now, healthcare professionals see the need for more research and experimentation.

Robotic surgery is a rapidly growing field that has the potential to change the way we think about healthcare for so-called "remote" communities, from the ocean depths to outer space.
This developing medical technology field employs robots to hold the instruments while a surgeon operates a console to manipulate video-game-like controls. The robot typically includes robotic arms that hold miniature cameras and surgical tools to do all of the things a surgeon normally does directly -- but with much more precision and in much smaller areas. With such a system, the surgeon may never actually touch the patient.
The surgeon's console is usually a few feet away from the patient; however, in the future, the doctor and patient could be separated by a vast distance.

Futuristic Treatment

Dr. Dave Williams of the Canadian Space Agency tested this idea in April when he took part in NEEMO, or NASA Extreme Environment Mission Operations. The program tested robotic surgery precedures taking place 62 feet below the ocean surface -- 3.5 miles off the coast of Key Largo in the Florida Keys National Marine Sanctuary, a marine habitat about the same size as the service module of the International Space Station.
Williams, also an astronaut, is scheduled to travel on the space shuttle in May 2007. His mission will include up to three spacewalks. Although NASA has no plans to test robotic surgery on any of the next few shuttle missions, Williams would like to see it done one day in the future. NASA has performed standard open surgery on animals in space.
Canada, in particular, is invested in robotic surgery, specifically telesurgery, because of the country's vast land mass, which includes many remote rural communities. "Depending upon where you are on Earth, there's a difference in the level of healthcare that exists -- in many cases, just due to the geographic isolation of the area that you're in," Williams told TechNewsWorld.
Telesurgery uses satellites to relay the signals needed to connect the surgeon's console to the robot, which means a surgeon could feasibly operate on a patient located just about anywhere those signals could be received. For right now, robotic surgery is limited to the traditional setting of a hospital operating room. It's gaining widespread acceptance for certain procedures, particularly prostatectomies, in which the entire prostate is removed.
When Samuel Morley was diagnosed with prostate cancer in February 2004, for instance, doctors presented him with several options. One of those options was to do nothing, he was told, because prostate cancer is a slow-growing cancer. He could also implant radioactive seeds in the hope they would kill the cancer, undergo standard open surgery, or try robotic surgery.

Less Invasive

He decided to have the robotic surgery, because "it's not nearly as invasive. The surgeon can see a lot better what's doing inside the body," he said. Open prostatectomy, on the other hand, is a deep and bloody surgery, where "often by mistake, nerves are cut, [or] the ureter is cut, which can cause incontinence," he said.
With robotic surgery, there is a lot less bleeding, the 3D cameras can see a lot further into the dark recesses of the open cavity, and the cuts can be made with much greater precision.
Morley, a 72-year-old economist, was operated on by Dr. Jason Engel, director of robotic urologic surgery and vice chair of the department of urology at George Washington University Hospital in Washington, D.C. Engel has performed over 300 prostatectomies using the da Vinci surgical system developed by Intuitive Surgical (Nasdaq: ISRG). Engel is a big advocate of the technique.
He prefers it over open surgery for prostatectomies, which have become the most common robotic surgical application, because their clinical outcome is clearly superior to that of standard open surgery.
While robotic surgery results in less pain, less bleeding and offers a faster recovery time, that's not the main reason doctors use it. The clinical differences result in a smaller chance of incontinence and erectile dysfunction. "We can try to get [the patient's] life back as close to what it was before -- that's the real purpose of the exactness and the preciseness of it," Dr. Engel said.
The biggest problem with robotic surgery at the moment is the cost -- not so much the cost to purchase the system, which is approximately US$1.5 million for the da Vinci, but rather cost per use for the doctors and their patients. Health insurers typically reimburse patients for the same amount whether he or she chooses open or robotic surgery. So far, hospitals have been picking up the difference in costs in order to get their staff trained on the systems.
As the field is relatively new, few vendors currently sell robotic surgical systems, so hospitals have few choices if they are interested in purchasing the equipment. Intuitive Surgical is one. Also, MacDonald Dettwiler and Associates makes a robotic surgery system known as the "neuroArm," designed for use in intra-cranial and spinal surgery. This system was developed in collaboration with the University of Calgary/Foothills Hospital in Calgary, Alberta.

Not Always Appropriate

Meanwhile, robotic surgery can provide many advantages for certain conditions, but as yet it's not the preferred surgical treatment for all health issues.
The technique is used in some heart surgeries, lung surgeries, and for a few other treatments, but it isn't compatible with all types of surgery. "It really is only a useful tool where you need it, such as places where you really have sort of a technical dissection with the nerves, or places where you have a lot of reconstruction and sewing," Engel noted. "If you're just removing an organ like a kidney, I don't use it for that. It's not necessary for that."
As physicians become more familiar with the systems' advantages, drawbacks and overall capabilities, robots may become more prevalent in the operating room. For now, healthcare professionals see the need for more research and experimentation. "We need to understand what tasks a robot can do really well and what tasks a human can do really well," said Dr. Williams. external image end-enn.gif

US: 50% vote for robotics surgery

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