ROBOTIC SURGERY: THE FUTURE BECKONS...
Guest Blog by
Dr. Soumyadeep Bhaumik MBBS
GP, Independent Researcher and Medical Correspondent
In 1921 Czech playwright Kapel Clark introduced the concept of robots (and in the process coined the term robot too) in his science fiction epic Rossum’s Universal Robots. Domin, the lead character of the play describes the future of robots as, “all work will be done by living machines. Everybody will be free from worry and liberated from the degradation of labour. Everybody will live only to perfect himself.” Ever since then robots have captured the imagination as well as the reality of humans. Robots are used nowadays in specific, precise, speedier and often hazardous work in domains ranging from industries to research to warfare. The entry and progression of robots however has been comparatively slower in the field of medicine.1
Robotic surgery is a new and emerging field that has taken the medical and particularly the surgical community by storm. Robotic surgery is a technique which in the simplest term can be described as a surgeon performing surgery using a computer that remotely controls very small instruments attached to a robot with multiple arms.
History of Surgical robots:
The background of development of robotic surgery is inherently intertwined with the development of minimally invasive surgery (MIS). MIS has various advantages like smaller incisions, lesser infection, shorter hospital stays, quicker discharge from hospital, decreased pain, better cosmesis, and better postoperative immune function2-4 An inherent problem with current laparoscopic equipment is the loss of haptic feedback (force and tactile), natural hand-eye coordination and dexterity1. Moreover laparoscopic instruments have restricted degrees of motion (usually 4) whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization (which is essentially two-dimensional). Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult 5. Most surgeons harped over these limitations and argued the supremacy of traditional surgeries but biomedical engineers collaborated with a handful of surgeons and developed the Puma-650 which was first used in precise neurosurgical biopsies2 and then in Trans-urethral resection of prostate (TURP)6. Robotic surgery gained rapid strides with the development of the PROBOT, ROBODOC, NeuroMate, PAKY-RCM, AcuBot and AESOP 1,7.The da Vinci Surgical System ultimately made the robotic surgical system popular globally. More than 1752 da Vinci systems are already installed in across 44 countries of the world.7
Pros and cons:
Robotic surgery promises to overcome the traditional obstacles of surgery1. They have better geometric accuracy, remain stable and do not get tired, can scale motion and offer more degrees of freedom than the human hand. They are precise and can access spaces or areas which a human hand cannot--thus making micro-anastomoses possible. Unlike humans, robots are not susceptible to radiation/infection or fatigue. Robots eliminate the fulcrum effect and also physiological tremors of the surgeon. Having fewer surgeons in the operating room and allowing doctors the ability to operate on a patient long-distance (tele-surgery) would also lower the cost of healthcare in the long term.7 More over because the surgical cuts are essentially smaller it provides all benefits of MIS, albeit in a greater dimension.
The prime disadvantage as of now with robotic surgery is not technology (which is bound to improve further in the future) but the costs involved. Robotic systems cost a whooping US $ 1 million to procure and recurring costs of $100,000/year. Such huge sums mean a lot if viewed in the light of public health measures in resource-poor developing and underdeveloped nations. Other concerns that have been raised are the requirement of extra staff to operate, steep learning curve and it’s yet to be proven cost-benefit ratio. A major cause of concern is the fact that robots do lack the capacity to earn the trust implicitly assumed in a surgeon-patient relationship8.What would be the psychological state of the patient peri/post operatively when he knows that his body parts is being handled by a machine made of ‘tins and oils’ ? What if the robot malfunctions? What if it is fed with the data for a wrong patient or for that matter even a wrong surgery? Who will be to blame in case something goes wrong?
What the future holds?
In spite of the fact that robotic surgery is fast spreading globally it is important to note that it is still in its infancy. The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, vision beyond the magnified eye, robot accessibility with a reduction of entry ports and miniaturizing the slave robot.7 In the near future robotic systems are expected to integrate various other technologies and modalities that are currently being used in the operating room. Efforts are already on to relay touch sensations from the robots to the surgeon and develop better suture less anastomoses7. Diagnostic modalities like USG, CT scan and MRI will soon be merged with robotic surgical equipments and guide the surgeon in better dissection and pathology identification. Nano-robots too are being developed across the world. Surgical training is also expected to radically change with robotic systems being used to rehearse procedures before doctors actually operate on a patient. Eventually tele-robotics will develop thereby enabling super-speciality surgeons to operate at inaccessible rural location without them being physically present in the operation theatre.
Evaluation of its safety, efficacy and long term effects vide randomised controlled trials is the need of the hour. Efforts to bring down costs should be specifically attempted. Unlike in industries or warfare clinical judgement is way too complex process which takes into account various factors beyond the operation table. The patient's socio-economic background, physico-intellectual status, his aspirations from life, emotional state, and cultural factors are issues which are taken onto account by the surgeon. Owing to the very nascent stage in which artificial Intelligence is currently the view that the automation age in robotic surgery has arrived and " it’s only a matter of time when it will run our lives for us” 8 is but a vision of the very distant future.
Soumyadeep Bhaumik is a blogger and his blog Caffeinated Works & Random Musings is one of the largest healthcare blogs in India
You can get in touch with him via
- Lanfranco AR, Castellanos AE,Desai JP,Meyers WC.Robotic surgery: a current perspective. Ann Surg 2004;239:14-21
- Kim VB, Chapman WH, Albrecht RJ, et al. Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using DaVinci. Surg Laparosc Endosc Percutan Tech 2002;12:34–40.
- Fuchs KH. Minimally invasive surgery. Endoscopy 2002;34:154–159.
- Allendorf JD, Bessler M, Whelan RL, Trokel M, Laird DA, Terry MB et al. Postoperative immune function varies inversely with the degree of surgical trauma in a murine model.. Surg Endosc 1997;11:427–430
- Prasad SM, Ducko CT, Stephenson ER, Chambers CE, Damiano RJ Jr. Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1 year follow-up.Ann Surg. 2001;233:725–732.
- Davies B. A review of robotics in surgery. Proc Inst Mech Eng.2000;214:129–140.
- Wedmid A,Llukani E, Lee DI. Future perspectives in robotic surgery. Brit J Urol Int ;108:1028-1036( Avalilable online http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10458.x/pdf)
- Nath NC.Robotics –the future of surgery. J Ind Med Assoc 2011;109:12-13