Robot-Assisted Surgery: Current Applications and Future Trends in General Surgery.

Robotic-assisted bariatric surgery improves accuracy and patient safety

Cost in healthcare is an increasing and justifiable concern that impacts decisions about the introduction of new devices such as the da Vinci(®) surgical robot. Because equipment expenses represent only a portion of overall medical costs, we set out to make more specific cost comparisons between open and robot-assisted laparoscopic surgery. We performed a retrospective, observational, matched cohort study of 146 pediatric patients undergoing either open or robot-assisted laparoscopic urologic surgery from October 2004 to September 2009 at a single institution. Patients were matched based on surgery type, age, and fiscal year. Direct internal costs from the institution were used to compare the two surgery types across several procedures. Robot-assisted surgery direct costs were 11.9% (P=0.03) lower than open surgery. This cost difference was primarily because of the difference in hospital length of stay between patients undergoing open vs robot-assisted surgery (3.8 vs 1.6 days, P<0.001). Maintenance fees and equipment expenses were the primary contributors to robotic surgery costs, while open surgery costs were affected most by room and board expenses. When estimates of the indirect costs of robot purchase and maintenance were included, open surgery had a lower total cost. There were no differences in follow-up times or complication rates. Direct costs for robot-assisted surgery were significantly lower than equivalent open surgery. Factors reducing robot-assisted surgery costs included: A consistent and trained robotic surgery team, an extensive history of performing urologic robotic surgery, selection of patients for robotic surgery who otherwise would have had longer hospital stays after open surgery, and selection of procedures without a laparoscopic alternative. The high indirect costs of robot purchase and maintenance remain major factors, but could be overcome by high surgical volume and reduced prices as competitors enter the market.

The use of robotic and semi-robotic systems in surgery was introduced back in the 1980s, and in orthopedic surgery in the 1990s, but many years passed before it became a significant part of orthopedic surgery. In recent years, robotic surgery, robotic-assisted surgery and advanced technologies have gained popularity and have been integrated as a fundamental part of orthopedic surgery. Adult limb reconstruction, Total Knee Replacement in particular, is probably the highest volume surgery performed in a robotic assisted manner in orthopedic surgery. However, advanced technologies are not limited to knee replacement surgeries. Spine surgery is the second sub-specialty in orthopedics using robotic assistance and navigation in surgery. In recent years we have seen the introduction of advanced technologies into many fields of orthopedic surgery, including foot and ankle surgery, trauma surgery and other subspecialties. In most cases the use of robotic systems is safe, but there are no prospective, long-term high quality studies that indicate a significant advantage for one of the options. There is an abundance of researchers currently investigating this topic. In this article we review the latest uses and developments of robotics and advanced technologies in orthopedic surgery.

Robot-assisted gynaecological cancer surgery—complications and prevention

To investigate the learning curve of robot-assisted vitreoretinal surgery compared to manual surgery in a simulated setting. The study was designed as a randomized controlled longitudinal study. Eight ophthalmic trainees in the 1st or 2nd year of their specialization were included. The participants were randomized to either manual or robot-assisted surgery. Participants completed repetitions of a test consisting of three vitreoretinal modules on the Eyesi virtual reality simulator. The primary outcome measure was time to learning curve plateau (minutes) for total test score. The secondary outcome measures were instrument movement (mm), tissue treatment (mm2 ) and time with instruments inserted (seconds). There was no significant difference in time to learning curve plateau for robot-assisted vitreoretinal surgery compared to manual. Robot-assisted vitreoretinal surgery was associated with less instrument movements (i.e. improved precision), -0.91 standard deviation (SD) units (p < 0.001). Furthermore, robot-assisted vitreoretinal surgery was associated with less tissue damage when compared to manual surgery, -0.94 SD units (p = 0.002). Lastly, robot-assisted vitreoretinal surgery was slower than manual surgery, 0.93 SD units (p < 0.001). There was no significant difference between the lengths of the learning curves for robot-assisted vitreoretinal surgery compared to manual surgery. Robot-assisted vitreoretinal surgery was more precise, associated with less tissue damage, and slower.

The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien–Dindo III–IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.

Training in robotics: The learning curve and contemporary concepts in training

Based on their experience with robot-assisted vascular surgery, the authors present some unique types of procedures they have performed in this area. From November 2005 to February 2022, a total of 560 robotic vascular procedures were performed, of which 70 were orphan operations, corresponding to 12.5%. The most common was robotic decompression of the coeliac trunk (18 times) in Dunbar syndrome, followed by robotic repair of type II endoleak after stent graft implantation (15 times) and robotic repair of splenic artery aneurysm (11 times). Less common were isolated pelvic artery aneurysm surgery (8 times), aortic thromboenderectomy and abdominal aortic patch repair (8 times) and hybrid surgery (6 times). Completely unique are renal artery reconstruction (2 times), operation of internal mammary artery aneurysm (1 time) in a patient with Marfan syndrome and paracaval biopsy (1 time) in a cancer patient. In 3 cases (4.2%) the operation had to be converted to open surgery. Twice in the management of splenic artery aneurysm due to flat adhesions in the abdominal cavity and once in the endoleak operation, when due to the very fragile wall of the dilated and pulsating abdominal aortic aneurysm sac, we considered manipulation with robotic instruments to be highly risky. There was zero mortality in this cohort; one patient had to undergo laparoscopic diaphragm repair for diaphragmatic hernia at another institution after deliberation of the coeliac trunk and in one case open surgery was needed for persistent endoleak. The use of the robotic system can be beneficial also in less frequent procedures, offering the patients all the advantages of robotic surgery. However, the need of extensive experience in robotic surgery should be emphasized because these operations are rare and perfect anatomical knowledge of the area is necessary.

English

Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.

One of the innate qualities of all doctors is the desire to do what is best for the ailing patient. This quality then becomes an objective sought by all clinical physicians to improve medical standards as they try to find better ways of delivering healthcare to their patients. Although incorporation of minimally invasive laparoscopic, robotic, and endo-operative techniques into mainstream care has proved disruptive, our patients are demanding effective yet minimally invasive approaches to their healthcare needs. Accompanying these advances and advantages are the challenges and ethics of applying surgical technology to our respective patients. Currently, in the United States, every individual hospital is required to develop criteria and policies for granting clinical privileges to surgeons operating in their hospital. This task is usually assigned either to the medical director or the chief of each particular surgical service, who verifies whether the respective surgeon is “credentialed” for that procedure. The hospital, compromised by the medical staff office, is, in turn, required by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) to verify the credentials and training of their practitioners to delineate clinical privileges. One areas in which this process came into existence was credentialing aged surgeons. It is well known that fine motor skills wane as one ages. It was, therefore, recommended that “as age advances, a physician should, from time to time scrutinize impartially, the state of his faculties; that he may determine, bona fide, the precise degree in which he is qualified to execute the active and multifarious offices of his profession” [1]. Clearly, the above-mentioned process that materialized, which is generally standard across the nation, was not designed to address the introduction of new revolutionary surgical techniques and machinery. What remains is the question—how do we credential surgeons with new surgical technology, in particular robot assisted surgery? Robot-assisted surgery is the application of advanced computerized technology in the planning, performance, and follow-up of invasive surgical procedures. The Food and Drug Administration (FDA) approved the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) April 2004 for use in several surgical disciplines, including cardiac, urologic, and gynecologic surgery. The da Vinci telerobotic surgical system consists of a three dimensional laparoscopic vision system and two or three robotic arms that can perform high-precision articulating movements with a variety of instruments. Both the vision system and the robotic arms are controlled by the surgeon in a “master/slave” relationship via a remote surgeon’s console that houses the vision system and the telemanipulators for the robotic arms. The technology enables for more precise and anatomical dissection with outcomes equal to or better than conventional techniques in both academic and private practice-based settings [2–6], for both laparoscopic and non-laparoscopic trained surgeons [7, 8]. Robot-assisted surgery is not a mere extension of one’s innate ability to perform open or laparoscopic surgery. The appropriate and safe use of this technology requires specialized training and experience. Although the FDA reviews the results of laboratory, animal, and human clinical testing, it does not develop or test products. The FDA does not, moreover, regulate who buys or uses the product, or whether a physician is qualified to use the equipment. The ability to perform a surgical procedure is regulated by hospital-based credentialing policy. Credentialing is the systematic approach to the collection, review, and verification of a practitioner’s professional qualification. Robot-assisted surgery may not be learned safely during a weekend course. Dedication, commitment, and unique cognitive and technical skills are required to transfer skills from an open or laparoscopic setting to a robotic setting. There are no widely accepted guidelines that define appropriate credentialing for robot-assisted urologic surgery. This group was formed in response to a need to establish prudent and fair guidelines for credentialing robotic surgery at our respective institutions. Electively we tried to formulate a policy for credentialing and maintenance of credentials for robot-assisted radical prostatectomy. The guidelines herein are proposed for obtaining privileges and performing robot-assisted radical prostatectomy using the da Vinci telerobotic surgical system. Use of this technology should be limited to the level of intervention already granted under the same privileges for open and advanced laparoscopic procedures. Special circumstances may arise where robot-assisted surgery may be appropriate for non-laparoscopic open surgical procedures. Credentialing is considered on a case-by-case basis. Our consensus is given in the Appendix. We believe that every institution that invests in the da Vinci telerobotic surgical system should consider establishing a robot-assisted surgical subcommittee of their existing credentialing committee. As with any surgical procedure, credentialing should be dictated by the policies of the local hospital or institution. To the best of our knowledge, most institutions have embarked on robot-assisted surgical programs without the benefit of procedural guidelines for obtaining surgical privileges and credentialing of physicians for robot-assisted surgery because of the newness of the technology. The suggested guidelines can serve as a template to such committees in an effort to provide direction for a successful launch of a new program or facilitation of a successful ongoing program. Based on a collaborative experience of 1,500 cases and numerous proctoring experiences at various institutions, we recommend the following guidelines. A minimum of four cases be proctored before performing robotic surgery independently. Based on consensus opinion four cases seems practical but each credentialing committee should consider a surgeon’s past operative experience and availability of appropriate proctors. More importantly, each proctor and trainee must determine if additional cases may be required before performing these procedures independently. In an era of evidence-based medicine, surgical competence is being defined by some as a measure of quantity by using “volume” of a procedure to ensure acceptable outcomes. In urology, the prototype has been the conventional radical retropubic prostatectomy [9–12]. Occurrence of postoperative and late urinary complications was reduced if the procedure was performed in a high-volume hospital and by a surgeon who performs a large number of such procedures. However, significant variations occurred among surgeons that suggested technical details were critical for favorable outcomes [9, 10, 12]. In addition, post-operative mortality was low and similar among surgeons and hospitals with different volumes of radical prostatectomies [9–12]. Other disciplines require a minimum number of procedures to obtain and/or maintain surgical privileges, because studies demonstrated that a caseload threshold exists whereby surgical outcomes decline for hospitals or surgeons [11, 13–15]. The Society for Bariactric Surgery requires a 150-case minimum per year/per institution and a 50-case minimum per year/per surgeon for recognition as a center of excellence [11, 13–17]. The American Society for Gastrointestinal Endoscopy (ASG guidelines) recommends a minimum number for each endoscopic procedure performed before competence can be assessed [18]. Although many believe there is inherent quality in quantity, the frequency of a procedure is more than just a marker of quality. Experience gained by repetition may be an underrated aspect of a surgeon’s technical ability. We recommend by consensus that a minimum number of robot-assisted cases be performed on an annual basis, although data that enable scientific validation of this opinion are not currently available [12]. Although the benefits of quantity of surgical procedures remain controversial, idle motor skills wane faster than memories. “Pay-for-performance” may soon require that urologists track outcomes. The higher than expected variability in outcome for radical prostatectomy performed by high volume surgeons led to the appropriate recommendation for monitoring of individual surgeon performance [10, 12]. High-quality surgical care is everyone’s objective. Periodic review is mandatory to expose deficiencies and improve quality outcomes. Procedural credentialing is a privilege—not a right that serves to protect patients from practitioners whose skills are less than otherwise available. We suggest these guidelines to assist urologists and their medical institutions with commencing a successful and safe transition from open to robot-assisted radical prostatectomy.

The introduction of the surgical robot resulted in increasing technical difficulty of these robot assisted surgeries (RAS). The qualification and certification of RAS skills are still in a preliminary phase within all surgical specialties, also in urology. New methods of training for novice surgeons (residents and fellows) in these highly specialised techniques should be implemented to guarantee patient safety. The challenge for novice surgeons is how to learn new surgical procedures and once the procedure is learned and they become experts how to analyse past performances and subsequently use this as a lesson for the future in order to improve postoperative outcome. In the first part of this these we explored the best methods to educate surgeons in robotic surgery. By using different modalities of training, (i.e., hands-on training combined with theoretical information of learning) we discovered (chapter 2) novice robot surgeons were too positive in the self-assessment of their own surgical skills after a training in RAS. To prevent overconfidence biases the novice surgeons should be provided with feedback (proctoring) to inform them about their results to enhance learning and inform them of their competence levels. Although results (chapter 3) show there is no significant difference in the acquisition of surgical skills between different types of proctoring provided to novice surgeons the participant satisfaction seems to be higher in the “human proctoring” group. Which could result in additional motivation for the participant to continue training in RAS. Additional research (chapter 4) shows residents in urology are allowed to perform RAS during their residency, but criteria for starting RAS differ significantly among the teaching hospitals. This shows there is a need for the implementation of a (multi-step) training and certification program in the Dutch urology residency curriculum. The long-term effects of the structured fellowship in RAS were investigated in chapter 5. The results of the survey showed that most respondents still perform RAS after the fellowship, which matches results from other research into the impact of RAS fellowships.34,35 A remarkable finding of this study is that a large proportion of respondents is unaware of the oncological (33%) and functional outcomes (66%) of their patients. Thus, participants of RAS fellowships should be coached to review their own results to learn from their past performance and reduce their learning curve. The second part of the thesis focuses the assessment of a robotic surgeon’s surgical performance. Different methods were used to identify which factors should be assed in surgical video analysis in order to ascertain a surgeon’s surgical skills. In robot assisted surgery. (Chapter 6 and 8). In addition, a research protocol is provided by which the non-technical skills can be assed in both laparotomic surgery and robot assisted surgery in order to discover the difference in non-technical skills between the two surgical modalities. The third part of the thesis focusses on the relation between a surgeon’s performance and postoperative outcome of patients. In this part multiple methods of surgical video analysis were used to identify factors which could influence the postoperative outcome of patients (Chapters 9, 10, 11, and 12). Results show the length of the urethral stump after dissection of the prostate could be a significant factor in the recovery of continence after prostatectomy.

Medical robotics, such as the da Vinci Surgical System, Hinotori, and Saroa, has been rapidly expanding in the field of general surgery in recent years. Because of the need for high precision in vitreoretinal surgery, general surgery robots are not applicable; therefore, a variety of robots specifically designed for vitreoretinal surgery have been developed around the world. These robotic systems can be broadly categorized into operation systems, operation assistance systems, and observation systems. The purpose of the operation robots is mainly internal limiting membrane peeling and retinal vascular cannulation. The PRECEYES Surgical System was already approved in the European Union in 2019 on the basis of positive clinical results. The aim of operation assistance robots, such as iARMs, is to suppress tremors. Meanwhile, we have developed an observation robot, an intraocular endoscope-holding robot (OQrimo), which was approved as a medical device in Japan in 2023. This robot allows surgeons to perform intraocular manipulations using both hands during vitreoretinal surgery for proliferative diabetic retinopathy and other intractable retinal diseases and may also make it easier to manipulate the anterior tissues around the ciliary body. In the future, by being combined with artificial intelligence in vitreoretinal clinics, robotic surgery will be applied to preoperative, intraoperative, and postoperative surgical procedure decisions, programs, and education.

Robotic systems have significantly transformed the landscape of minimally invasive surgery, offering enhanced precision, reduced recovery times, and improved patient outcomes. These systems have evolved from simple mechanical tools to sophisticated platforms integrating advanced control algorithms and real-time feedback mechanisms. This paper provides a comprehensive overview of the role of robotic systems in minimally invasive surgery, exploring the various benefits, inherent risks, and the challenges associated with their adoption and development. We examine the technical aspects of robotic control systems, such as kinematics, force control, and haptic feedback, which enable greater surgical accuracy. Despite these advantages, challenges such as system complexity, high costs, and ethical concerns remain significant barriers to widespread adoption. The future of robotic surgery lies in overcoming these obstacles, with advancements in system miniaturization and further refinement of control systems poised to enhance the efficacy and accessibility of robotic platforms. This paper explores the role of robotic systems in minimally invasive surgery, focusing on three key areas: bronchoscopy and ureteroscopy. By reviewing the benefits, risks, case studies, and future directions of these technologies, the paper seeks to provide an in-depth understanding of how robotic systems are shaping the future of surgery. Key words: Robotic Surgery, Minimally Invasive Surgery, Robotic Control Systems, Surgical Precision, PID Control, Kinematics, Inverse Kinematics, Forward Kinematics, Dynamic Control, Force Control, Impedance Control, Surgical Robotics, Haptic Feedback, Robotic Arm, Robotic Surgery Benefits, Robotic Surgery Risks, Robot-Assisted Surgery, Surgeon Console, Real-Time Feedback, Surgical Training, Robotic System Development, System Testing, Clinical Trials, Surgical Robot Performance, Robotics in Urology, Telepresence Surgery, Robotic Surgery Cost, Robotic Surgery Future Directions.

Background: Robotic-Assisted Minimally Invasive Surgery (RAMIS) represents a significant advancement in surgical techniques, leveraging robotic systems to enhance precision, reduce invasiveness, and improve patient outcomes. The da Vinci surgical system has been a leading example, demonstrating the potential of robotic assistance in minimally invasive procedures. Aim: This paper explores the evolution of RAMIS, focusing on technological advancements, integration with Artificial Intelligence (AI), and future directions in surgical robotics. Methods: The study reviews the development and current state of RAMIS technologies, including the historical background, state-of-the-art systems, and emerging innovations. It analyzes data from a range of sources including literature reviews, market reports, and recent research developments. Results: RAMIS systems, particularly the da Vinci surgical system, have achieved widespread adoption due to their advanced features, such as enhanced vision, improved ergonomics, and training programs. Recent advancements include AI integration, new sensor technologies, and enhanced imaging modalities. Despite these improvements, challenges remain in achieving higher levels of autonomy and addressing cost and regulatory issues. Conclusion: RAMIS continues to evolve with significant advancements in AI, haptic feedback, and simulation technologies. Future developments are expected to further enhance surgical precision and outcomes.