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Surg Clin N Am 86 (2006) 927–936

Robotics in Colorectal Surgery:


Telemonitoring and Telerobotics
Richard M. Satava, MD
Department of Surgery, University of Washington Medical Center,
1959 Pacific Street NE, Seattle, WA 98195, USA

Robotics was introduced into the surgical world in 1996 when Computer
Motion, Inc. (Goleta, California) produced the first surgical robot called
Aesop, a device to control the position of a laparoscopic camera, and later,
Zeus, a full-function teleoperated robotic system. Shortly thereafter, Intui-
tive Surgical, Inc. (Menlo Park, California) introduced the DaVinci system.
The result was a flurry of specialties that investigated which procedures
would benefit from the advantages of robotics. Initially, cardiac surgery
benefited the most, first by using the enhanced dexterity and tremor reduc-
tion to perform the arterial anastomoses of coronary artery bypass grafting
(CABG); later, cardiac surgeons explored the use in many different proce-
dures, such as mitral valve replacement and atrial septal defect. Urology
also discovered the advantages in applying robotics to radical prostatec-
tomy, while a few gynecologists began using it for hysterectomy. Surpris-
ingly, general surgeons have been slow to pick up robotic surgery,
possibly because they had had more than a decade of experience with lapa-
roscopic surgery. This experience, along with the fact that most procedures
did not require the high precision of anastomoses of CABG or radical pros-
tatectomy, has resulted in a slow adoption within general and gastrointesti-
nal surgery.

The opinions or assertions contained herein are the private views of the author and are
not to be construed as official, or as reflecting the views of the Departments of the Army,
Navy, or Air Force, the Defense Advanced Research Projects Agency, or the Department of
Defense.
This is a declared work of the US Government and as such is not subject to copyright
protection in the United States.
E-mail address: rsatava@u.washington.edu

0039-6109/06/$ - see front matter. Published by Elsevier Inc.


doi:10.1016/j.suc.2006.05.005 surgical.theclinics.com
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Uses of robotics in surgery


Robotics in colorectal surgery is beginning to gain acceptance slowly.
Most of the common procedures have been reported. There are numerous
reasons why robotic procedures are not more widespread, including cost,
time for set-up, applicability for all cases, and learning curve. Like general
surgery, the high precision in anastomosing millimeter and submillimeter
structure is required infrequentlydcolorectal surgery is more on a macro
scale than on the micro scale that benefits greatly from robotic enhance-
ment. Additionally, there is not a single ‘‘work space’’ because the colon is
distributed throughout the abdomen, and, hence, requires repositioning dur-
ing surgery. Several surgeons question whether the postoperative recovery is
improved significantly over laparoscopic or even open procedures. Yet for
those surgeons who have accepted robotic systems, there is strong advocacy.
Other applications for robotics invoke the ‘‘tele’’ part of telerobotics,
which permits viewing, monitoring, collaborating, and even performing sur-
gery from a distance. Teleconsultation was the first to be used, which per-
mits a centrally located expert surgeon at a medical center to provide
assistance or collaboration during a difficult procedure to a less experienced
surgeon at a remote site. There are a few such programs that are thriving,
especially in regions where there are underserved populations. It was envi-
sioned that robotics would be used in telementoring, telemonitoring, and tel-
eproctoring to help train and certify surgeons in the new robotic procedures.
The reports of these applications have been rather sporadic, and the much
anticipated use in teleproctoring for new procedures has not materialized.
This is likely due to the amount of time that is required by the centrally lo-
cated proctor, as well as to the cost of the equipment.
The use for robotics to perform surgery at a distant location (telesurgery)
was developed experimentally in the 1990s by Satava and Green [1] and Bo-
wersox and colleagues [2], and was demonstrated clinically first in Septem-
ber, 2001 by Jacques Marescaux of Strasbourg, France. While sitting at the
surgical console in New York City, he performed a telerobotic cholecystec-
tomy on his patient in Strasbourg, who was 4000 km away [3]. This truly
was a technical tour de force that required an enormous amount of planning
and execution to keep the latency (time from hand motion to actual cutting)
to within acceptable limitsdcertainly not a procedure that was able to be
reproduced for daily use. There is one remarkable success in actual telesur-
gery by Mehran Anvari, a general surgeon at McMasters University in
Hamilton, Ontario, Canada. On a routine basis Dr. Anvari performs remote
surgery in advanced minimal access procedures with a colleague in North
Bay, Ontario Canadadapproximately 300 miles away [4]. One factor that
contributes to this success is that the Canadian health care system provides
appropriate reimbursement for the procedure, whereas the system in the
United States has a complex arcane reimbursement system that discourages
the use of such new advanced systems.
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The most common use of telerobotic surgery is during medical confer-


ences. It has become commonplace to have a live video session of a robotic
procedure, frequently with interactive audience participation through asking
questions of the surgeon during the procedure. The educational value is un-
questionable, and, invariably, these sessions are attended heavily.
One use that has not migrated into the colorectal surgery specialty is image-
guided surgery. This is common in neurosurgery, urology (kidney and pros-
tate), general surgery (liver and breast), endovascular surgery (carotid, aortic
other vessels), and other specialties in which high precision is required for solid
organ surgery or precise intravascular localization, usually combined with ab-
lation (eg, thermal, cryo, high-intensity focused ultrasound) or interventional
catheter procedures (eg, balloons, stents). The most likely potential use by co-
lorectal surgeons would be for liver metastases, although one might speculate
that image guidance could be of value in endoluminal surgery.

Concepts in robotic surgery


One of the most important, but least appreciated, aspects of robotics is its
underlying fundamental principle. Most people perceive robots as a machine
that is computer controlled. A robot is not a machine: it is an information
system with arms (manipulators), legs (locomotion), eyes (vision systems),
and so forth. This fact gives robots their enormous value, for as an informa-
tion system a robot can integrate all of the aspects of operative procedures.
While sitting at the surgical console, the surgeon is not looking at the pa-
tient, instead one is looking at a video image, which is an information rep-
resentation of the patient. When the handles are moved, the surgeon is not
cutting the patient, one is sending information (electronic signals) to the re-
mote manipulators with the instruments that are doing the cutting. (Because
the robotic surgical systems send the information from surgeon to manipu-
lator, the computer can enhance and tremor reduce the signals, which gives
the surgeon capabilities that are beyond human physical limitations.) Thus,
all of a surgical procedure becomes various aspects of information. For ex-
ample (Fig. 1), from the surgical console, the surgeon can perform open sur-
gery, minimally invasive surgery, remote telesurgery, and image-guided
surgery (by importing CT or MRI scans and fusing them with the video im-
age). One can telementor, telemonitor, and teleproctor. By importing graph-
ical images, the robotic console becomes a surgical simulator and training
can be done. Likewise, the hand motions of the surgeon can be recorded
(Fig. 2) for feedback to the student, for quality assurance for the practicing
surgeon, or potentially as an objective assessment tool for performance as-
sessment and certification. Patient-specific images (eg, CT, MRI) also can be
used for preoperative planning or rehearsing a complicated surgical proce-
dure (see later discussion). All of these functions are performed at the con-
sole, and integrated as a seamless whole. Additionally, other information
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Fig. 1. The integration of surgery as an information system.

(eg, radiographs, laboratory tests, history and physical, pathology reports)


can be accessed on-screen during the procedure. This is the power of robots,
well beyond their mechanical and telecapabilities.
These capabilities can be augmented because more patients are receiving
total body scans. These scans become the information representation of the

Fig. 2. The ‘‘signature’’ of hand motions as recorded with a tracking device. (Courtesy of Sir
Ara Darzi, MD, FRCS, Imperial College, London, UK.)
ROBOTICS IN COLORECTAL SURGERY 931

patient: a holographic medical electronic representation or holomer. This


holomer soon will become the electronic health record, which provides
text and image as the medical record, and is viewed by the patient and sur-
geon as a full three-dimensional interactive image of the person. Health care
has been the only major industry without a computer representation of their
‘‘product’’dthe patient. The billions of dollars in hardware and software
that are used in other industries cannot be applied in surgery. Sophisticated
computer-aided design/computer-aided manufacturing (CAD/CAM) pro-
grams permit other professionals to design, plan, and prototype their new
products, then to test and evaluate the new product virtually before building
the first product. Any errors are made on the image, not on the final prod-
uct. They can rehearse how to use the product, and get consultation on the
design or implementation before performing those expensive actions in the
real world. Surgeons could learn to do the samedto do preoperative plan-
ning, test and evaluate the plan, perform a surgical rehearsal of the proce-
dure, and make mistakesdon the virtual patient rather than upon the real
patient. All the while, the robotic system is recording the performance.
This cannot be done with any other nonrobotic surgical system that exists
today. Surgery has been fragmented for centuries; the surgeon must look
at the radiograph, plan the procedure, and operate upon the patient using
different mediums and at varying times and places, and the surgeon must
perform the procedure correctly the first time, or the patient suffers the con-
sequences. With the robotic system the surgeon can plan and rehearse the
procedure (on the patient’s own image) until (s)he is convinced that the pro-
cedure can be performed without mistake. This has been done for decades in
other industries; it is time for health care to join the Information Age.

Emerging and future surgical robotic systems


The future of robotics in colorectal surgery is mainly potential that has
yet to be realized. Although there are a few brave pioneers who are pushing
the boundaries of what is possible, most ‘‘pioneers’’ have vested heavily in
laparoscopic colorectal surgery. Many surgeons want to join the minimally
invasive surgery revolution through the use of the ‘‘conventional’’ laparo-
scopic approach, frequently with the idea that performing laparoscopic sur-
gery is a preliminary step toward robotic surgery. This is a misconception in
some part. True, most robotic surgery is performed through minimally inva-
sive ports like laparoscopic surgery; however, the hand motions in robotic
surgery are not ‘‘backward’’ as in laparoscopic surgery. The computer of
the robotic system compensates for the fulcrum effect, and hand motions
are the same as in performing an open procedure. Therefore, the learning
curve for robotic surgery is much shorter than for laparoscopic surgery,
and more importantly, expertise in laparoscopic surgery is not a prerequisite
for performing robotic surgery.
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Many emerging surgical systems revolve around the ‘‘operating room


(OR) of the future,’’ which is where robotic surgery will be performed. There
are three variations on planning what the new ORs should be: (1) multifunc-
tional ORdthe blending of open, laparoscopic, and image-guided surgery
into a single ‘‘flexible’’ OR; (2) perioperative ORdthe incorporation of
new information systems into the entire operating experience, from preoper-
ative holding and anesthesia, to postoperative recovery; and (3) robotic
ORdan OR with no people, in which robot and computer-assisted systems
are integrated highly and controlled from just outside of the OR. Each sys-
tem has decided advantages, and many hospitals are investigating how to
incorporate one or more of these new approaches into new or renovated
ORs.

Multifunctional operating rooms


Most surgeons who are advocating the multifunctional nature of ORs are
focusing on the emerging image-guidance nature of interventional proce-
dures. For solid organ surgery, neurosurgeons, urologists, and general sur-
geons require the use of real-time imaging (eg, CT or MRI scanning) to
localize disease precisely within a solid structure, such as brain, kidney,
prostate, liver, or breast. Frequently, the use of imaging is during an open
surgical procedure, although interventional radiologists often use image
guidance for these procedures without performing an incision. The common
need is to confirm the placement of a needle, probe, or other instrument be-
fore performing the therapy, such as ablation or excision. Thus, the chal-
lenge is to develop an OR that can accommodate a huge imaging system
and the needs of a surgical procedure (anesthesia, operating table, surgeon,
scrub nurse, surgical instruments). There are pioneering efforts by Taylor
and colleagues of Johns Hopkins to incorporate the use of a precision-
guided robot with a CT scanner for prostate surgery and ablative pro-
cedures [5]. A feature in common to these procedures is the preoperative
planning and surgical rehearsal before bringing the patient to the OR,
and the need to update the CT or MRI image at the time of the procedure
to correspond with the preoperative images and plan. Ferenc Jolesz [6] of
Brigham Women’s Hospital is basing the OR upon the imaging system,
such as open MRI, with the approach being the capability of performing
surgery in a radiology suite (rather than imaging within an OR).

Perioperative operating rooms


This emerging concept principally is about the integration of the entire
surgical event, from admission to the preoperative holding area until dis-
missal from the postoperative recovery room, through the use of computers,
robotics, and information systems. The pioneers are Sandberg of Brigham
and Womens’ Hospital and Ganous of University of Maryland Hospital
[7]. They view the entire operating area as a single information system
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process, and look to industry and their current methodologies of efficiently


integrating complex systems. Using business and management practices
from aviation, retail, and delivery (Federal Express), the patient is viewed
as a single ‘‘information object’’ that must be ‘‘moved’’ through flow of
a complex process. This integration includes not only the patient and the
data about the patient, but shares information among other computers,
equipment (eg, OR lights, anesthesia machines), and devices (eg, surgical ro-
bots, delivery robotic systems). The technologies to support this revolution
include (1) new software management systems, such as just-in-time inven-
tory control, supply chain management, inventory tracking and (2) hard-
ware, such as radiofrequency identification (RFID) tags, standard bar
codes, robotic supply dispensers, surgical robots, and intelligent OR tables
and lights. A typical scenario includes a patient arriving at the ambulatory
surgery desk, registering, and receiving their plastic RFID bracelet. From
this moment on, the entire operating theater (and theoretically anywhere
in the hospital) could have protected access to the patient’s information
and location. For example, once the RFID is activated, the laboratory
would be notified of the patient’s registration, would check which labora-
tory tests still needed to be completed, detect the patient location in the pre-
operative holding area, and send an alert message for a technician to draw
blood to complete all of the necessary testsdinstantly and without a single
phone call being placed. Because all patients, personnel, equipment, devices,
and supplies are ‘‘tagged’’ with an RFID or barcode, there is instant and
continuous accountability. The head nurse for the OR can track the loca-
tions of the scrub and circulatory nurses, anesthesiologists, resident, and
surgeon anywhere in the hospital and have all paged simultaneously.
When the patient arrives in the OR the camera above the operating table
notices that the bed is green (from clean OR sheets); however, when the
patient transfers to the OR table, the camera detects the change from solid
green to multiple colors and shapes of the patient with standard image-
recognition software, and automatically notifies everyone that the patient
is on the OR table. By this time the robotic delivery system will have deliv-
ered the surgeon’s ‘‘pick list’’ of instruments, checking to be sure they all are
accounted for. Throughout the procedure the RFID tracks the instrument
use, supply use, surgeon’s hand motions, and so forth for quality assurance,
training, and eventually maintenance of certification for surgical procedures.
At any time all of this information is available through telemonitoring or
telemedicine from anywhere within the hospital. At the completion of sur-
gery, there is automatic sponge and instrument count (because everything
is labeled and tracked to a location), so no sponges or instruments should
be left in the patient. All of this information is collected automatically, con-
tinuously, transparently, and unobtrusively so that the operating team can
concentrate upon the critical issues of performing a surgical procedure.
Thus, the integration of sophisticated sensors, software analysis programs,
tracking and location devices, robotics, and better business and supply
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management processes become a single ‘‘symphony’’ of surgical information


exchange.

Robotic operating room


A third vision of the OR of the future is proposed by Satava [8], and fo-
cuses upon the technical challenge of replacing all of the systems inside of
the OR with robotic systems. This approach is based upon currently avail-
able robotic systems in other industries. In those settings, the robots do not
have people changing tools or dispensing supplies like nuts and bolts; in-
stead there is an automatic tool changer and a parts dispenser. These robotic
subsystems to the main robot perform some of the same tasks that scrub and
circulating room nurses perform, especially the simple handing of instru-
ments to the surgeon or bringing sterile supplies to the scrub nurse. Michael
Treat [9] of Columbia University is performing clinical trials on Penelope
(Fig. 3), a robotic scrub nurse that responds to voice commands and hands
instruments to the surgeon during open surgery. Research in a military med-
ical program, called ‘‘Trauma Pod,’’ is developing an ambitious project
to incorporate tool changers and parts dispensers with the DaVinci surgical
robotic system. The result would be an OR with no people other than the
patient. The surgeon and anesthesiologist would be just outside of the
OR behind a glass window, controlling the robotic systems and performing
surgery on the patient in the isolated sterile OR. A plausible scenario is as
follows. The patient is brought to the preoperative anesthesia area, anesthe-
tized, and placed in the proper position for surgery on an intelligent OR
table. A body scan is performed and the patient is taken to the sterilization
area; meanwhile, the patient image is sent to the surgeon’s console to per-
form preoperative planning and (in the case of complicated surgical pro-
cedure) surgical rehearsal of the procedure on the patient’s own

Fig. 3. Robotic surgical scrub nurse ‘‘Penelope,’’ handing an instrument to Dr. Michael Treat,
MD, PhD. (Courtesy M. Treat, New York, NY).
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three-dimensional body scan, visualizing the complete anatomy and making


any errors on the patient’s image before operating on the patient. The pa-
tient is brought into the isolated OR, the OR table docks onto and ‘‘commu-
nicates’’ with the robotic surgical system to update all of the information for
the surgeon. During the surgical procedure, the surgeon operates as during
open surgery and requests (voice activation) surgical instruments or sup-
plies, but from the tool changer and parts dispenser instead of nurses. Every
time a supply is used, three things occur simultaneously: the patient is billed,
the OR instrument pick list is updated, and a request is sent to order new
supplies or instrumentsdall within 50 milliseconds and with 99.99% accu-
racy. This is standard in many industries. In the ‘‘background’’ on the hos-
pital information system are all of the intelligent systems from the
perioperative OR project that integrates the processes with the software, de-
vices, personnel, and equipment to provide immediate and continuous qual-
ity assurance. Because the robotic systems are controlled from outside of the
OR, this scenario could be performed as indicated, or could be used for tele-
surgery and telementoring to remote locations, such as the battlefield or un-
derserved populations.
The above technologies exist and require a significant engineering effort
to bring them to fruition; however, there are even greater challenges to suc-
cess from nontechnical issues, such as acceptance by surgeons and other
health care providers, cost-effectiveness, and legal and regulatory compli-
ance. It is unlikely that the scenarios depicted above will occur exactly as
written; however, it is highly likely that many of the components will find
usefulness and acceptance in one form or another.

Summary
Surgery has just passed through the laparoscopic surgery revolution, with
validation of the advantages for the patient evaluated painstakingly; how-
ever, laparoscopy is a transition phase to fully information-based surgery,
which only can be accomplished when hand motions are converted to infor-
mation through robotic surgery systems. The main advantage is using such
systems to integrate the entire surgical process. The components that will al-
low such a transition exist in other industries that use robotics, so it is more
a matter of applying these engineering principles to surgery, rather than in-
venting new technologies. Robotics cannot only improve the performance of
surgery, but is providing access to surgical expertise in remote and under-
served areas through telementoring, teleconsultation, and telesurgery. Colo-
rectal surgeons should seize the opportunity to begin to use surgical robotic
systems in those niche areas and procedures that have proven to be of
significant benefit to the patient and are cost-effective. Over time, with the
development of even more advanced systems it will become more advanta-
geous to use robotics on a routine basis.
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