Surg Clin N Am 88 (2008) 1121–1130

Robotic Surgery
Dmitry Oleynikov, MD
Minimally Invasive and Computer Assisted Surgery,
983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA

The minimally invasive surgical revolution of the early nineties ushered in

an era in which a surgeon did not have to have his or her hands directly on
the human body. Once long instruments were placed between the surgeon
and the patient, robotic integration became inevitable. If one can reach
for a small incision with a long instrument, why cannot one do that with
a robotic arm? Commercial robotic systems followed shortly thereafter.
The concept behind robotics was to improve the surgeon’s sense of touch
characteristics and to allow more fluid, minimally invasive surgical proce-
dures to be performed; however, with any new technologies, increased costs
and difficulty of use arise. The next generation of robots are being built
smaller, smarter, and less expensively.
This article discusses the developments that led up to robotic surgical sys-
tems as well as what is on the horizon for new robotic technology. Topics
include how robotics is enabling new types of procedures, including natural
orifice translumenal endoscopic surgery (NOTES) in which one cannot
reach by hand under any circumstances, and how these developments will
drive the next generation of robots.

Commercial systems
The daVinci Surgical System (dVSS) was developed by Intuitive Surgical
(Sunny Valley, California). It became the first surgical robotics system
cleared in 2000 by the US Food and Drug Administration (FDA) for use
in general laparoscopic surgery. After several years the FDA also approved
the dVSS for thorascopic, urologic, and gynecologic surgeries, as well as an
adjunct to some cardiac procedures. Currently, over 800 dVSS are installed
in hospitals worldwide.

E-mail address: doleynik@unmc.edu

0039-6109/08/$ - see front matter. Published by Elsevier Inc.

doi:10.1016/j.suc.2008.05.012 surgical.theclinics.com
1122 OLEYNIKOV

The system has three-dimensional visualization of the operating field,

a 7-degree range of motion, tremor elimination, and comfortable seated
operating posture [1]. These advantages allow surgeons handlike dexterity
and enhanced precision through minimally invasive techniques. The short-
comings of surgical robotics are the lack of haptic feedback while operating,
the inability to switch instruments as well as operating field during the
procedure, the large size of the robot with bulky arms, and the high cost
of the technology [2]. Nevertheless, the dVSS has proved useful for a wide
variety of applications in cardiothoracic, urologic, and general surgery [3–5].
Urologists have been especially pleased with the added dexterity provided
by the dVSS in removal of the prostate. The operative field is typically in the
deep pelvis, and the need for wristlike dexterity is hard to duplicate with
conventional laparoscopic techniques. Suturing is especially challenging in
the narrow male pelvis, and the dVSS excels in the area. Multiple studies
have shown that, with enough experience, robotic prostatectomy is safe
and effective for men who have prostate cancer [6].
Other robotic systems on the market today include RoboDoc, an ortho-
pedic surgery system developed at the University of California Davis and
commercialized by Integrated Surgical Systems (Sacramento, California).
The implementation of this device gave orthopedic surgeons improved accu-
racy of drilling the femur shaft from 75% to 96% while preparing the bones
for prosthetic implants. A similar system known as the Acrobat has been
designed by Limited (London, England) for complicated total knee arthro-
plasty. The significant difference made by these devices led to the acceptance
and realization that information technology could be applied to other fields
in surgery.
There is a long delay between the idea and commercialization of prod-
ucts, and robotic surgery is only in its infancy. Several fascinating new
developments may change how we use the robotics in the near future. These
new technologies are still in an experimental stage but offer a glimpse of
what the next generation of robots will offer. Miniaturization of robotic
technology appears to be the theme of the new generation of devices. Robots
that are smaller than current systems have a natural advantage because they
are easier to deploy and can be used in more settings. The University of
Washington group has developed a smaller prototype machine that has
the capability of being mounted on the patient and controlled remotely
(Fig. 1). This robot, named RAVEN, has been prototyped and tested in
the field. Due to its smaller size and updated enhancements it can be de-
ployed in remote areas and teleoperated [7]. Other robotic technology allows
the surgeon to make rounds while sitting in a remote location. This device
developed by Dr. Yulun Wang is called the RP-7 (In Touch Health, Santa
Barbara, California) and is a mobile robotic platform that enables the
physician to be remotely present by controlling robot movements via the
Internet. Patients surveyed felt that the encounter was a positive one and
were able to completely believe that they were communicating with their
 ROBOTIC SURGERY 1123

Fig. 1. University of Washington RAVEN.

physician in person even if the physician was far removed from the patient’s
bedside [8].
Robotics provides a unique possibility of separating the surgeon from the
patient. This separation can be measured in feet or in thousands of miles.
Telesurgery along with telementoring has been now been tested in several
environments and has been shown to be feasible and beneficial. The removal
of a gallbladder across the Atlantic Ocean and the mentoring of surgeons in
Canada [9] are examples of how technology is rapidly approaching the day
when any surgeon can be connected to a number of colleagues who may be
able to consult and in some cases assist during complex surgical procedures.
As minimally invasive surgical techniques continually develop toward re-
ducing the invasiveness of surgical procedures, robotics technology becomes
more crucial. Natural orifice translumenal endoscopic surgery (NOTES) is
a new approach to abdominal surgery that promises to further reduce inva-
siveness by accessing the peritoneal cavity from a natural orifice. Theoreti-
cally, the elimination of external incisions avoids wound infections, further
reduces pain, and improves cosmetics and recovery times [10]. NOTES is
currently being demonstrated in human studies. The first transvaginal assis-
ted cholecystectomy in the United States was performed in March 2007 [11].
Subsequently, the first transgastric cholecystectomy, also in the United
States, was performed in June 2007 using the EndoSurgical Operating Sys-
tem (USGI Medical, San Capistrano, California) [12]. Significant limitations
have been identified with the use of conventional endoscopic tools. For
example, it is difficult to perform NOTES procedures using a limited two-
dimensional image of the surgical environment when the exact orientation
of the flexible endoscope is not intuitively obvious. Furthermore, the lack
of triangulation between the image and the tools limits depth perception
1124 OLEYNIKOV

and reduces surgical dexterity [13]. New tools are needed to perform such
procedures because simply slipping a hand inside is not possible. Robotics
offers the best solutions under these circumstances.

Flexible endoscopy platform

A flexible endoscopy platform for natural orifice surgery with robotic
actuation and visualization enhancement is the next area of development.
Work has been performed toward the development of an endoluminal
robotic system for providing visualization and dexterous instrumentation
for the performance of endoluminal surgeries [14]. A first-generation device
for teleoperated endoluminal surgery, the ViaCath System, has been devel-
oped by EndoVia Medical (Norwood, Massachusetts). The device consists
of a console and two flexible instruments located alongside a standard
endoscope. Each instrument, together with the positioning arm, provides
7 degrees of freedom. Several end effectors have been developed specifically
for this device, including a needle holder, grasper, scissors, and electrocau-
tery knife. A second-generation robotics system shown in Fig. 2 is currently
being developed at Purdue University.
A four-channel platform scope (TransPort, USGI Medical, San Capi-
strano, California) based on the ShapeLock locking overtube has been
developed [15]. This device incorporates independent steering of the distal
tip such that, once the endoscope is positioned, the base of the endoscope
can be frozen while still allowing four-way movement of the tip. Further-
more, the sizing of the working channels allows for the insertion of 5 mm
graspers, similar to those used with existing laparoscopic tools, for a more
aggressive retraction of organs. The EndoSurgical Operating System,
including the TransPort Multi-lumen Operating Platform, is currently

Fig. 2. Robotic endoluminal surgical system being developed at Purdue University. (From
Abbott DJ, Becke C, Rothstein RI, et al. Design of an endolumenal NOTES robotic system.
In: Proceedings of the IEEE/RSJ International Conference on Intelligent Robots and Systems.
San Diego, CA: October 29-November 2, 2007. p. 412; with permission. Copyright Ó 2007 IEEE.)
 ROBOTIC SURGERY 1125

available commercially. Instruments based on the robotic flexible endoscopy

platform demonstrate the potential for improving surgical dexterity for
natural orifice procedures; however, these devices remain constrained by
the size of the natural orifice and do not provide a sufficient platform for
visualization and application of off-axis forces.

Miniature robot platform

Miniaturization of robotic tools and the ability to place robots entirely
inside the peritoneal cavity offers significant benefits in natural orifice pro-
cedures. Once inserted, the robots can be used inside the peritoneum without
the typical constraints of an externally actuated flexible endoscopic device.
The robots can be positioned to provide visualization and tissue manipula-
tion within each quadrant of the peritoneal cavity. Multiple miniature
robots can be placed inside the peritoneal cavity, with the number of devices
not limited by the small diameter of the natural orifice. Such robots equip-
ped with stereoscopic imaging could provide much needed depth perception
for the surgeon and could allow triangulation between the image plane and
the motion of the tools.
Mobile miniature robots provide a remotely controlled platform for vision
and surgical task assistance. The basic design of a mobile robot consists of two
independently driven wheels with a helical profile allowing for forward,
reverse, and turning motions. A tail is used to prevent counterrotation. The
capabilities of robots with a mobile platform have been demonstrated in
multiple porcine model procedures as shown in Fig. 3. A mobile robot with
an adjustable-focus camera has provided the sole visual feedback for a laparo-
scopic gallbladder removal without damage to peritoneal structures [16]. The
ability of a robot with a mobile platform to provide task assistance has also
been demonstrated through the successful biopsy of three samples of hepatic
tissue [17]. The onboard camera provided visualization for locating an ade-
quate biopsy site, and the mobile platform enabled the robot to traverse the
peritoneal cavity to the chosen site. The feasibility of using in vivo mobile ro-
bots for NOTES procedures has been successfully demonstrated in a porcine
model [18]. A mobile robot was introduced through the esophageal opening
and was inserted into the stomach through a sterile overtube using a standard
upper endoscope. It was able to explore the gastric cavity before advancement
into the peritoneal cavity through a transgastric incision. Once fully inserted,
an endoscope was advanced to view the mobile robot as it maneuvered within
the peritoneal cavity. The robot was then retracted into the gastric cavity, and
the transgastric incision was closed. The ability to navigate the peritoneal cav-
ity while not restrained from the outside was very advantageous and led to the
next set of experiments in which multiple robots could be used.
The insertion of multiple tools is limited by the size of the natural orifice,
and the tools must be entirely flexible for insertion through the complex
1126 OLEYNIKOV

Fig. 3. The mobile camera robot viewed from (A) benchtop and (B) laparoscope during porcine
cholecystectomy. A mobile robot demonstrates (C) liver biopsy and (D) translumenal peritoneal
exploration.

geometry of the natural lumen. In a nonsurvivable in vivo procedure in

a porcine model, the feasibility of using multiple miniature robots for im-
proving spatial orientation and providing task assistance was demonstrated
[19]. This cooperative procedure used three miniature in vivo robots, shown
in Fig. 4, including a peritoneum-mounted imaging robot, a lighting robot,
and a retraction robot in cooperation with a standard upper endoscope to
demonstrate various capabilities for NOTES procedures.

Fig. 4. Retraction, imaging, and lighting robots used in cooperative NOTES procedure.
 ROBOTIC SURGERY 1127

The peritoneum-mounted imaging robot provides a stable, reposition-

able, adjustable focus imaging platform for minimally invasive surgery.
The basic design of the robot consists of an inner housing containing the
lens and focusing mechanism, two LEDs for lighting, and a permanent mag-
net direct current motor for rotating the inner housing within the clear outer
housing. Each end of the imaging robot is fitted with a magnetic cap. The
robot is held to the upper abdominal wall using the interaction of magnets
housed in the robot and those contained in an external magnetic handle. The
handle can be moved along the exterior surface of the abdomen for gross
positioning and panning of the robot. The video feedback from the imaging
robot is displayed on a standard monitor in the operating room.
The external housing for the lighting consists of a clear outer tube that
contains six white LEDs and is fitted on each end with a magnetic cap. Sim-
ilar to the imaging robot, the lighting robot is held to the interior abdominal
wall using the interaction of the magnetic end caps with magnets housed in
an external handle. The retraction robot is designed to enable tissue retrac-
tion for natural orifice procedures. The basic design of the retraction robot
consists of an external housing with two embedded magnets for fixation and
a tethered grasping device. A permanent magnet direct current motor
coupled with a drum is contained within the external housing. As the motor
rotates, the tether is wound and unwound about the drum to raise and lower
the grasping device. Endoscopic or laparoscopic tools are currently used to
actuate the grasper device. In the near future, this task will be accomplished
using a cooperative robot.
A nonsurvivable NOTES procedure in a porcine model was performed us-
ing the imaging robot, lighting robot, and a retraction robot in cooperation
with a standard upper endoscope. The endoscope was used via a gastrotomy
into the peritoneal cavity. Once inserted, each robot was independently se-
cured to and positioned along the upper abdominal wall using the external
magnetic handles. The video feedback from the imaging robot guided
the exploration of the peritoneal cavity and provided visualization for
endoscopic manipulation of the bowel and gallbladder. The retraction robot
provided access for the endoscope to the surgical target.
This procedure demonstrated the feasibility of providing a stable, reposi-
tionable platform for NOTES procedures through using multiple miniature
in vivo robots with appropriate capabilities. The stable image and additional
lighting were key to the surgeon’s ability to visualize and manipulate within
the peritoneal cavity for this NOTES procedure. A multi-armed dexterous
miniature in vivo robot with stereovision capabilities has been developed
to provide the surgeon with a stable, repositionable platform for visualiza-
tion and tissue manipulation for performing NOTES procedures in the
peritoneal cavity [20]. The basic design of the robot, shown in Fig. 5,
consists of two ‘‘arms,’’ with each connected to a central ‘‘body’’ by a rota-
tional ‘‘shoulder’’ joint. Each arm consists of an upper arm and a lower arm
fitted with either a forceps or cautery end effector.
1128 OLEYNIKOV

Fig. 5. University of Nebraska mini robot.

The body of the robot is held to the upper abdominal wall using magnets
housed in the body of the robot and an external magnetic handle which can
be moved along the outer surface of the abdomen throughout a procedure
to reposition the robot internally. This handle enables the surgeon to posi-
tion the robot to obtain alternative views and workspaces within each quad-
rant of the peritoneal cavity without requiring an additional incision or
a retroflexed configuration. The NOTES robot successfully demonstrated

Fig. 6. View from robot camera of tissue grasping (A), cautery arm positioning (B), and cautery
(C, D).
 ROBOTIC SURGERY 1129

various capabilities in a nonsurvivable procedure in a porcine model.

Through a standard endoscopically created gastrotomy, the robot was in-
serted into the peritoneal cavity and magnetically attached to the anterior
abdominal wall. Using the video feedback from the on-board cameras,
the surgeon explored the peritoneal cavity, identified the target for tissue
manipulation, and positioned the robot to provide a suitable workspace
for visualization and tissue manipulation. A small bowel dissection was
then performed, as shown in Fig. 6. The forceps arm was extended toward
the small bowel and was used to grasp the tissue. The arm was then retracted
to provide access to the tissue for the cautery arm. The shoulder of the
cautery arm was then rotated and the lower arm was extended to cauterize
the small bowel. The visualization and dexterity are very similar to that in
routine laparoscopy but without abdominal wall incisions.

Summary
The dVSS remains the only commercially available therapeutic robotic
system currently available. It has allowed surgeons to perform procedures
that previously were thought to be either too complicated or too risky to
be performed in a laparoscopic fashion. New technology has since
improved, allowing one to reach areas that could not be reached before
and to perform operations without scars, such as natural orifice surgery.
With the development of new types of devices that are smaller, cheaper,
and based on more modular components, each device will be tailored to
a given operation. New technologies are sure to follow along, and this field
will not look the same in 10 to 15 years. It can be expected that we will con-
tinue to move toward more automation, more computer interface, and more
mechanical assist and further away from the open surgical techniques that
were pioneered in the years before.

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