Actas Urol Esp. 2012;xxx(xx):xxx--xxx -

Actas Urológicas Españolas


Robotic surgery: History and teaching impact
R. Valero a,b,c , Y.H. Ko a,d , S. Chauhan a , O. Schatloff a , A. Sivaraman a , R.F. Coelho a,e , F. Ortega f,c , K.J. Palmer a,b , R. Sanchez-Salas f,b , H. Davila b , X. Cathelineau f , V.R. Patel a,∗

Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, United States Departamento de Urología, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela c Robotic Fellow, Confederación Americana de Urología (CAU), Miami, FL, United States d Departamento de Urología, Escuela Universitaria Coreana de Medicina, Seúl, South Korea e Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Divisão de Urologia, São Paulo, Brazil f Departamento de Urología, Lˇ iInstitut Mutualiste Montsouris, París, France

Received 29 March 2011; accepted 9 April 2011

Robotics; Surgery; History; Surgical systems; AESOP; ZEUS; Teaching; Future

Abstract Context: The purpose of this article is to review the history of robotic surgery, its impact on teaching as well as a description of historical and current robots used in the medical arena. Summary of evidence: Although the history of robots dates back to 2000 years or more, the last two decades have seen an outstanding revolution in medicine, due to all the changes that robotic surgery has made in the way of performing, teaching and practicing surgery. Conclusions: Robotic surgery has evolved into a complete and self-contained field, with enormous potential for future development. The results to date have shown that this technology is capable of providing good outcomes and quality care for patients. © 2011 AEU. Published by Elsevier España, S.L. All rights reserved.

Robótica; Cirugía; Historia; Sistemas quirúrgicos; AESOP; ZEUS; Ense˜anza; n Futuro

Cirugía robótica: Historia e impacto en la ense˜anza n
Resumen Contexto: El objetivo de este artículo es hacer una revisión de la Historia de la cirugía robótica, su impacto en la ense˜anza, así como una descripción de los robots antiguos y actuales usados n en el campo médico. Resumen de evidencia: Aunque la historia de la robótica tiene 2.000 a˜os o más, las últimas n dos décadas han mostrado una marcada revolución en Medicina, debido a todos los cambios que la cirugía robótica ha provocado en la manera de hacer, ense˜ar y practicar cirugía. n

Please cite this article as: Valero R, et al. Cirugía robótica: Historia e impacto en la ense˜anda. Actas Urol Esp.2011;35:540--545. n Corresponding author. E-mail address: vipul.patel.md@flhosp.org (V.R. Patel).

2173-5786/$ – see front matter © 2011 AEU. Published by Elsevier España, S.L. All rights reserved.

ACUROE-306; No. of Pages 6

replicating a task previously only performed by humans3 (Fig. Conclusiones: La cirugía robótica ha evolucionado hasta ser un campo aparte. Todos los derechos reservados. CA) is the only one of its kind to be approved by the Food and Drugs Administration (FDA). arms and neck was designed by Leonardo da Vinci in 1495 and was named the Metal-Plated Warrior (Fig. Attaching this wheel to a feather pen. Marescaux performed the first telerobotic surgery (telerobotic = surgeon console and patient cart are not in the same place) using ZEUS® surgical system: a transatlantic Figure 2 ‘‘The Writer’’. precision surgery and improved results for patients.6 However. ‘‘The Writer’’ was able to make complete sentences. © 2011 AEU.1. is changing the way we practice and teach surgery. such as 3D vision. the first robot that imitated human movements of the jaw. in turn. These advantages translate into a more delicate treatment of tissues. 2 Introduction Robotic surgery has been considered by some authors as the future of surgery due to the dramatic changes and impact that it has shown in the last two decades. 2).L. The da Vinci® Robotic Surgical System (Intuitive Surgical Sunnyvale. developed by Jaquet-Droz in 1772. autonomously operated machines can be dated from 400 BC when Archytas of Arentum developed a steam-driven. elimination of fulcrum effect. dexterity. S.+Model ARTICLE IN PRESS R. spacing between words and lines. tremor filtration and an ergonomic position for the surgeon. meaning ‘‘labor’’.2 The word robot comes from the Czech word ‘‘robota’’. articulated instruments. which.3---5 Though robotics is a relatively new term. In 2001. It offers several advantages over conventional laparoscopic surgery. The purpose of this article is to describe the history of robotic surgery including its evolution and improvements in teaching and practicing surgery. Los resultados muestran hasta ahora que esta tecnología es capaz de ofrecer buenos resultados y un adecuado tratamiento a los pacientes. Figure 1 Leonardo da Vinci’s ‘‘Metal-Plated Warrior’’. increased range of motion. It has had a rapid development and has shown numerous advantages of enhancing surgical techniques. Jaquet-Droz’s first android. was the first robot with a programmable wheel used to write whatever the user desired. Dr. in 1942. con un enorme potencial para su futuro desarrollo. Valero et al. This invention served as an inspiration to Gianello Torriano. Isaac Asimov inspired by Capek’s works defined the term ‘‘robotics’’ and wrote the three rules of robotics in his books Runaround and I Robot. Publicado por Elsevier España.7 ‘‘The Writer’’. 1). self-propelling wooden bird capable of flying 200 m. Robotic history Karel Capek in 1921 introduced the notion and the term robot in his play Rossom’s Universal Robots. Later. . who created a robotic mandolin-playing lady in 1540. and even place periods after sentences. The impact of robotics on medicine has created new aspects of medicine such as telesurgery (surgery performed with the surgeon and the patient in different locations).

CA and approved in 1994.8---10 Later in 1988. it also caused collision of the arms when trocars were misplaced.12. the main one is still size. it limits the space in the operating room. Robotic surgery: History and teaching impact operation performing a cholecystectomy in a 62 year-old patient with cholelithiasis with the surgeons in New York (EEUU) and the patient in Strasbourg (France). The da Vinci® Robotic Surgical System also has limitations. The right and left robotic arms replicate the arms of the surgeon. The console is composed of two ‘‘masters’’ that control the robotic arms with seven degrees of freedom. in 1985 in a very precise way. USA) is another type of current robot that became commercial in 1998 and introduced the idea of telerobotics or telepresence to robotic surgery. created two models with similar characteristics: PROBOT® . we must emphasize and focus on the major robotic surgical systems that have contributed in the development of current systems. An infrared sensor detects when the surgeon’s head is placed into the console and subsequently triggers activation of the two masters and. thus. many robots and robot enhancements are being researched and developed. . It consists of 3 components: a vision cart that holds a dual light source and dual 3-chip cameras. When we talk about robotics. thus. a robot used to perform neurosurgical biopsies by Kwoh et al. a computer and a 3D imaging system. increasing operative and anesthesia times. CA.1.3 Today. a robot designed specifically for transurethral resection of the prostate and ROBODOC® .13.16 The main disadvantage of the ZEUS® system was the large size of the robotic arms.8 Current robots The modern history of robotics in surgery begins with the Puma 560® . ZEUS® The Zeus® system (Computer Motion. Moreover.3 It is composed of a surgeon control console with a 3D imaging system which is at a distance from the robot and 3 table-mounted robotic arms with Figure 3 Mimic’s dV-TrainerTM . da Vinci Surgical System® This is the most complete and evolved major robotic surgical system. some procedures such as bowel resections that require access to one or more abdominal quadrants mean that the robotic arms need to be undocked and redocked. 3). a master console where the operating surgeon sits.1 This last one was the first surgical robot approved by the FDA. and a moveable cart where 3 instrument arms and the camera arm are mounted. It is basically a robotic arm that holds a laparoscopic camera and can be controlled by voice commands. moreover.10. Santa Barbara. which limited space in operating rooms. Davies et al. a robotic system designed to machine the femur with greater precision in hip replacement surgeries. Santa Barbara. performed a transurethral resection of the prostate using the same system. the robotic arms (Fig.3 designed by Computer Motion. of Sacramento. Figure 4 Laparoscopic single site surgery da Vinci® platform.11 Integrated Surgical Supplies Ltd.17 AESOP® The Automated Endoscopy System for Optimal Positioning (AESOP® ) was the first robot to be approved by the FDA for abdominal surgical procedures. it has a lot of delicate connections that are inside the operating room that may cause accidents or can be damaged if not used adequately. and the third arm is an AESOP® voice-controlled robotic endoscope for visualization. 4).+Model ARTICLE IN PRESS 3 4 degrees of freedom. the need to wear special glasses made it cumbersome to perform surgery without them. Furthermore. The latest generations added seven degrees of freedom to mimic the human hand14.15 (Fig.

Impact on urology and other specialties Although robotic surgery was developed initially for cardiovascular surgery. Robotic surgery and surgical education Despite numerous technological advances. tactile sensation). it has reached many other fields such as general surgery. Robotic surgery may soon represent a new surgical standard of care for the treatment of localized prostate cancer. 3). is one of the companies that is working on robotic virtual training and has developed systems such as: Mimic’s dV-TrainerTM .+Model ARTICLE IN PRESS R. providing close-to-life experience of working on the master console of da Vinci® Surgical System.18.28 Few academic centers have developed formal didactics to train teams in robotic surgery.18. most residency programs in the United States have not placed adequate emphasis on training in robotic surgery.22---24 Telepresence surgery (surgery using virtual telepresence in another physical location by means of telecommunication technology) has been successfully used in teaching basic surgical skills to third-year medical students guiding them through telementoring classes. the number of robotic prostatectomies performed was estimated to exceed 60.27 In 2003. thoracic surgery. and compromises patients’ safety. prolongs surgical training.. driven by physician enthusiasm. another survey by the same group showed that although 57% of surgical residents demonstrated high interest in robotic surgery. neurosurgery. used to teach surgery and practice on 3D virtual models instead of practicing on patients. It has also been included in surgery programs around the globe. the use of MISTELS tasks can be adapted for the da Vinci® platform. the majority (80%) did not have a robotic training program at their institutions. Valero et al. Inc. ENT. ProMIS® [PM]. partial nephrectomy. promise. but in fact. effective marketing. more than 85% of all radical prostatectomies performed in the US are done with robotic assistance. results in several procedures such as radical prostatectomy.21 Image-guided simulations will allow surgeons to practice procedures on 3-dimensional reconstructions of a targeted anatomy scheduled for surgery the next day.18.34 There are also publications about using laparoscopic simulation programs adapting virtual reality trainers improving their capability to develop surgical skills. present a randomized controlled trial using LapSim® [LSM].26 Robotic technology is expected to play an increasingly important role in the future of surgery. virtual-reality simulators and soft-tissue models that recreate the texture of human tissue through force feedback (haptics refers to the sense of touch.33 RoSSTM is another robotic surgical simulator from Simulated Surgical Systems LLC. However. By 2009.31 Nowadays. 4 Teaching impact Robotic surgery has not just changed the way to perform surgery. more standardized credentials will be required to obtain robotic surgical privileges.35 Additionally. showing excellent . or marketing. This approach makes surgical training completely dependent on the actual case load.19 Robotic surgery will create a new medium for acquiring surgical skills through simulation of all operations that can be done via the robot. Feifer et al. Surgeons can use surgical robots to practice operations on 3-dimensional. gynecology. with certain benefits of decreased blood loss and lower morbidity.29 Ensuring competency to perform robotic procedures is left to individual hospitals. live donor nephrectomy. It has reformed the way to teach and learn surgery. and pyeloplasty among many others. Mimic Technologies. the most dramatic impact has been in urology with enormous progression. and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills® (MISTELS) utilizing a hybrid augmented reality trainer.19 A survey in 2002 showed that only 23% of surgery program directors had plans to incorporate robotics into their programs.18.18. There are a few simulators and software that allow surgeons to practice surgical procedures as many times as they need before actually performing it on a real patient. Surgeons in training have always had to gain operative experience through ‘‘supervised trial and error’’ on real patients. a ‘‘flight simulator’’ for robotic surgery designed to allow efficient on-demand training for surgeons learning to use the da Vinci® Surgical System31 (Fig. including open surgery and robotics with a high quality force feedback and little computational overhead to your host PC.32 Urology is just one surgical specialty that has been highly impacted by robotics. these applications will be integral to the training and licensing of surgeons and will provide objective means for assessment of surgical skills.25 These systems are expected to significantly enhance the learning curve.32 but there are still some skeptics of the technique that have emphasized that the robotic approach needs to show that it is a safe and effective procedure supported by evidenced-based outcomes which go beyond mere speculation. allowing trainees to acquire surgical skills in a short period of time while improving patients’ safety by reducing surgical errors. which uses virtual reality to introduce the user to the operation and feel of a robotic surgical console. surgical training has stayed more or less unchanged for more than a century. However. robotic-assisted laparoscopic radical prostatectomy has rapidly become the most commonly performed surgical technique for prostate cancer. It is expected that as formal training in robotic surgery develops. patient interest. cardiac surgery.20. a rapidly growing body of evidence is showing that the robotic approach measures up to the past and present standards for radical prostatectomy and.30 Virtual training in robotic surgery Another aspect to consider is that robotics is being used for virtual training. and aggressive. Mimic’s Mantis DuoTM is a truly unique twohanded haptic system that can be used for a wide range of simulation applications. In less than a decade. orthopedic and ophthalmologic surgery.19 Ultimately.000. 2010.

3. 6. Astounding science fiction. 7. LESS is evolving. 2. In 2010. 4). developed a much more compact surgical robot called Sophie. there are new challenges to come and the next step to reach could be the use of nanorobots. there appear new aspects and robot models that actually improve current robotic systems. 2007.+Model ARTICLE IN PRESS 5 gle session (Duke Robot Biopsy Guided by 3-D Ultrasound). Other benefits include three-dimensional visualization. Linda van den Bedem. Simone M. It has also been able to facilitate and increase the uses of minimally invasive surgery allowing surgeons to use technology like LESS in many procedures. The evolution of and early experience with robot assisted mitral valve surgery.without human assistance -. which means that the surgeon is unable to know and feel the amount of force needed to pull or grasp tissue without breaking or damaging it. and virtual training. 1988. 10. Surg Laparosc Endosc Percutan Tech. CT: Fawcett. robotics has shown results that are changing the way of performing and teaching surgery. Robotic surgery: History and teaching impact Robotics for laparoendoscopic single-site surgery (LESS) Laparoendoscopic single-site surgery (LESS) is a new vision of surgery that provides the ability to perform major surgery with minimal incisions and nearly scar-free results. and force feedback. Felger JE. a 4-armed robotic surgical system. - . IEEE Trans Biomed Eng. Conflict of interest The authors declare that they have no conflicts of interest. 2002.12:58--63. this is not the end of this futuristic race. adrenalectomy. Nifong L. motion scaling. London: Springer.12:6--16. Asimov I. Runaround. et al.can locate a manmade or phantom lesion in simulated human organs. It enables the elimination and correction of one of the biggest challenges that still remains in current robotic systems: the absence of haptics. Coelho R. Greeenwich. establishing new standards of treatment and demonstrating that it is here to stay and evolve. New York: Street & Smith Publications Inc. or pick up toxic radicals.235:487--92.36 Conclusions The history of robotics has shown a rapid evolution in the last decade.35:153--61. and tremor filtration36. Ann Surg. imaging symbiosis. The researchers believe that as technology is developed. n 1982. robot. Leroy J. repair tissues. Palmer K. guide a device to the lesion. and gynecology. Kalan S. Los relojes y autómatas de Juanelo Turriano. which uses ‘force feedback’ to allow the surgeon to feel what he or she is doing. Robotic surgery has developed and enhanced several surgical techniques in specialties such as urology. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. varicocelectomy. et al. Madrid: Tempos Fugit. Jonckheere E. p. 8. The primary advantage of the da Vinci® Surgical System for LESS includes easier articulation using EndoWrist instruments. 2002.38 Force feedback is an outstanding and unique characteristic of this robotic surgical system. There is still much in the horizon to study and develop in robotic surgery but the results obtained are encouraging and it seems to be just a matter of time until robotic surgery becomes the new standard of treatment in a significant amount of surgical procedures.4:141--7. general surgery. J Robotic Surg. Titan Medical Inc. renal cryoablation. p. is a Canadian company. 2002. 9. I. radical prostatectomy. 5. García-Diego JA. partial nephrectomy. Kwoh Y. 2. Smith M. Rubino F. Transcontinental robot-assisted remote telesurgery: feasibility and potential applications. in robotic surgery it does not seem to be that way.40 However. 55--60. This technology has been responsible for establishing new concepts such as telesurgery. 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