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 ATLAS OF

Robotic
General
Surgery
 ATLAS OF

Robotic
General
Surgery
YURI W. NOVITSKY MD
Professor of Surgery
Surgery
Columbia University Medical Center
New York, NY
USA

ASSOCIATE EDITORS

CONRAD BALLECER MD, MS

Clinical Assistant Professor
Department of Surgery
Creighton University School of Medicine
Phoenix, AZ, USA

IGOR BELYANSKY MD
Chief of General Surgery,
Director, Abdominal Wall Reconstruction Program,
Anne Arundel Medical Center
Annapolis, MD, USA

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 CHAPTER 1 Functional Anatomy of the Respiratory Tract v

Contents

Foreword vii 11 Robotic Transabdominal Preperitoneal

Dedication viii (rTAPP) Ventral Hernia Repair 99
Preface ix Kelly Tunder, Emily Helmick, Conrad Ballecer
List of Contributors x
Disclosures xv 12 Robotic Transabdominal Retrorectus Repair 107
Video Table of Contents xvi Filip Muysoms

Section I: General Issues in Robotic Surgery 13 Robotic Totally Extraperitoneal

Retrorectus Repair 117
1 Overview of Existing Robotic Platforms 1 Igor Belyansky, Richard Lu
Laura Flores, Priscila Rodrigues Armijo, Salim Hosein,
Dmitry Oleynikov 14 Robotic Transversus Abdominis
Release (r-TAR) Procedure 127
2 Teaching Robotic Surgery 11 Dina Podolsky, Vahagn C. Nikolian, Yuri W. Novitsky
Vahagn C. Nikolian, Jake G. Prigoff, Dina Podolsky
15 Robotic Anterior Component Separation 141
3 Achieving Proficiency: Flavio Malcher, Leandro Totti Cavazzola,
Mastering the Learning Curve 17 Eduardo Parra-Davila
Andrea Pakula
16 Robotic Parastomal Hernia Repair 147
Section II: Robotic Hernia Surgery Vedra Augenstein, Samuel Yelverton,
William Charles Sherrill III
4 Clinical Anatomy and Physiology
of the Abdominal Wall 23 Section III: Robotic Bariatric and Foregut
Luis A. Martin-Del-Campo
Surgery
5 Preoperative Imaging in Hernia Surgery 31 17 Robotic Gastrectomy 157
David J. Morrell, Eric M. Pauli
Alexander S. Rosemurgy, Sharona B. Ross,
Timothy J. Bourdeau, Iswanto Sucandy
6 Perioperative Optimization
of a Hernia Patient 45 18 Robotic Sleeve Gastrectomy 167
Samuel Torres-Landa, Sean B. Orenstein
Francesca Dimou, Cheguevara Afaneh

7 Robotic Inguinal Hernia Repair with Mesh 55 19 Robotic Gastric Bypass 175
Allegra Saving
Abraham Krikhely

8 Robotic Inguinal Hernia Repair 20 Robotic Hiatal Hernia Repair

without Mesh 69 and Antireflux Surgery 185
Desmond Huynh, Shirin Towfigh
Colin Dunn, Aleeson Eka, Caitlin Houghton

9 Anatomy of the Groin and Robotic 21 Robotic Paraesophageal Hernia Repair 193
Neurectomies 75 Mohanad R. Youssef, Eric Rachlin, Carlos A. Galvani
Ian T. MacQueen, Sean M. O’Neill, David C. Chen
22 Robotic Heller Myotomy 203
10 Robotic Intraperitoneal Hernia Repair 91 Marcia Alayon-Rosario, Alfredo M. Carbonell
Hemasat Alkhatib, Ajita S. Prabhu

v
vi Contents

23 Robotic Transhiatal Esophagectomy 211 29 Robotic Hepatectomy 275

Sharona B. Ross, Andres Giovannetti, Iswanto Sucandy, Sarah Corn, Ali Ahmad
Trenton Lippert, Alexander S. Rosemurgy
30 Robotic Distal Pancreatectomy 287
Section IV: Intestinal and Colorectal Surgery Kazuki N. Sugahara, John A. Chabot

24 Robotic Right Colectomy 223 31 Robotic Whipple Procedure 297

Jerald D. Wishner Jesse Sulzer, Dioneses Vrochides, John B. Martinie

25 Robotic Left Hemicolectomy 32 Robotic Pylorus-preserving

and Low-anterior Resection 231 Pancreaticoduodenectomy
Sandeep S. Vijan and Cholecystectomy 309
Sharona B. Ross, Alexander S. Rosemurgy, Jack Wecowski,
Section V: Robotic Hepato-Biliary and Solid Timothy J. Bourdeau, Iswanto Sucandy

Organ Surgery 33 Robotic Adrenalectomy – Transabdominal

26 Robotic Multiport Cholecystectomy 241 Approach 323
Clark Gerhart Maureen M. Tedesco, Micaela M. Esquivel

27 Robotic Single-Site Cholecystectomy 255 Index 333

Anthony Gonzalez

28 Robotic Splenectomy 265

Hany Takla

Foreword
Over the last 100 years the role of the general surgeon has evolved
as other specialties have come into their own. Not only have the
procedures performed changed, but the techniques used have
become less invasive while offering patients a less morbid recov-
ery. Abdominal operations in particular have benefited from the
transition from large laparotomies to a minimally invasive ap-
proach. The first step was the development of the laparoscopic
approach to standard abdominal procedures. However, as sur-
geons became more skilled performing complex procedures using
the MIS approach, it became apparent that conventional laparos-
copy had some inherent limitations and its adoption was often
limited.
Early adopters of a robotic MIS approach found that they could
equal the results of conventional MIS procedures but extend their
application beyond what had been achieved with “straight-stick”
laparoscopy. The learning curve appeared shortened and utilization
of the approach markedly increased. In addition, there has been
a rapid progression of the complexity of procedures this new
platform has allowed general surgeons to perform across general
surgery and its subspecialties.
In the past there have been excellent textbooks to guide
surgeons through open and more recently through laparoscopic
CHAPTER 1 Functional Anatomy of the Respiratory Tract vii
procedures. Until now, however, there has not been a text which
accomplishes the same goals for this new robotic platform. It is
essential that surgeons in training as well as accomplished sur-
geons learning a new technique have a text that gives them such a
step-by-step guide. The Atlas of Robotic General Surgery is just such
a text. From the introduction which covers the basics of robotics
to its five major sections which include robotic inguinal and
abdominal hernia repair, bariatric and forget surgery, intestinal
and colorectal surgery, and hepatic and solid organ surgery, this
book gives the reader an in-depth guide of how to safely and effi-
ciently accomplish simple, as well as complex, procedures utilizing
the robotic platform. The editors have engaged the true experts in
each discipline who are not only experienced robotic surgeons but
are accomplished teachers and mentors. I am confident that this
text will set the standard for robotic education and is only the first
of many editions to come as this field continues to grow and
evolve. It is a must for any surgeon planning to begin robotic
general surgery, for surgeons wanting to adopt new robotic proce-
dures, and especially for those mentoring or teaching surgeons to
incorporate this platform into their repertoire.
Edward Felix, MD
vii
viii PART I This is an Example of Part Title

Dedication
To surgical innovators before me who paved the way, to my present
colleagues who support and inspire me, to future generations
of surgeons who will make it all much better, and to my
girls Maya, Ella, Lily, Phoebe and Chloe who
make it all worth my while.
Yuri W. Novitsky

I would like to offer my deepest gratitude to my brother Dan,

my mom Amelita, and my doctor “hero” father Conrado,
to my wife Michelle, and my two daughters,
Madison and Emma, I love you more
than you could ever imagine.
Conrad Ballecer

To all my mentors who believed in me when

I needed them most.
Igor Belyansky
Preface
Surgical science is uniquely dynamic. Introduction of new tech-
niques and technologies is a frequent occurrence. What seems one
day like the ‘standard of care’ practice can rapidly become an ‘old-
fashioned’ obsolete technique. Something that is viewed as revo-
lutionary may become evolutionary in a short span. Incorporation
of the robotic technology into general surgery and related fields
had become that catalyst of the recent past. Robotics has fueled
profound advances in surgical techniques, especially those in my
field of abdominal wall and hernia surgery. The speed of surgical
progress, that has occurred in the past 7–8 years largely due to
development and implementation of robotic techniques, has been
nothing but astounding.
My personal foray into robotics was stunted early on by several
unfounded biases and preconceived hesitations. As an expert lapa-
roscopist I felt little need for another expensive ‘toy’ to help me
to deliver, what I thought, were already cutting edge minimally-
invasive operations. However, once I committed to understanding
and learning the robotic platform, it became abundantly clear that
I was venturing into the next era of surgery. The robotic ‘train’ was
picking up steam and I had little hesitation about jumping aboard
and helping drive it. I joined those surgeons, many of them con-
tributing chapters in this textbook, who were dedicating their en-
ergy and time to integrating robotics, perfecting or pioneering
techniques, developing pathways to responsible skill acquisition
and implementation, and finally gathering data to demonstrate
the unquestionable benefits of robotic surgery in many surgical
procedures.
This textbook will hopefully become an invaluable resource to
both bread-and-butter general surgeons, as well as tertiary care
subspecialists. While our surgical field is advancing rapidly, the
information in this textbook remains to be state of the art. We
have assembled a uniquely comprehensive list of topics encom-
passing a wide variety of abdominal surgeries, from the most basic
to the most complex robotic procedures performed today. Each
chapter is authored by some of the top robotic surgeons and
should provide a unique insight into their preoperative decision
making, patient preparation, operative setup, and technical de-
tails. Along with vivid intraoperative photographs, the narrated
video collection of this Atlas should propel it to become a ‘go-to’
resource for both trainees and practicing surgeons embarking on
robotics. I am confident this textbook will help the readers to be-
come better at their craft and that their patients will be the greatest
beneficiaries.
Yuri Novitsky, MD
Even with all the attendant benefits of improved 3D visualization,
precision, and dexterity, the da Vinci robotic platform struggled
to penetrate the market of general surgery. In existence since the
early 21st century, and initially designed for introducing mini-
mally invasive surgery (MIS) to the field of cardiac surgery, Intui-
tive Surgical, “Aimed for the heart, and hit the prostate.” This
innovative surgical instrument clearly advanced MIS in the fields
of urology and gynecology, and attained some purchase in the
field of colorectal surgery; yet its use in general surgery was gener-
ally met with contentious resistance. Many surgeons claimed that
the robot had no application in the field of general surgery, and
was reserved only for the few that were untrained in conventional
laparoscopic surgery.
My first true exposure at the potential of robotic surgery in my
general surgical practice was from watching a podium presenta-
tion by Dr. Ricardo Abdalla, showcasing his modified robotic
Rives-Stoppa Repair. I was amazed at the dexterity of the instru-
ment which allowed for dissecting layers of the anterior abdomi-
nal wall and suturing these layers back together. Immediately after
the presentation I came to two conclusions: one, although I was
an MIS-trained fellow, I could not readily reproduce his extra-
peritoneal repair with the conventional ‘straight-sticks’, and two,
the robotic platform represented an advanced iteration of laparos-
copy going forward.
Coincident with this time, I virtually abandoned laparoscopic
ventral hernia repair, preferring open techniques where I could
readily hide mesh from the visceral content, as well as reconstitute
linea alba while addressing the divarication of the rectus muscle
complex. As an ‘all-in’ MIS advocate, this MIS to open transfor-
mation was all too discouraging. I adopted the robotic platform to
re-engage my abdominal wall practice back to MIS. With all its
attendant benefits and vast improvement in ergonomics, this
adoption was transformative. Essentially everything I used to do
with the straight-sticks I converted to the articulating robotic plat-
form. At the time there were no educational resources guiding my
initial pursuits; pursuits that were widely rejected in private and
public forums. Yet, myself and others forged on, confident we
would end up on the ‘correct’ side of history.
Personally, I am very proud of how the culture of adoption of
robotic surgery has evolved over the last few years and I am even
more proud to serve a role, albeit a small one, in educational dis-
semination regarding its use. The Atlas of Robotic General Surgery
serves as a culmination of all the hard work that many of the pio-
neering authors detail. I, and many others, will forever enjoy this
Atlas as a premier educational resource in our daily practice.
Conrad Ballacer, MD
ix
List of Contributors
Cheguevara Afaneh MD Alfredo M. Carbonell D.O.
Assistant Professor of Surgery Vice Chairman of Academic Affairs
Department of Surgery Professor of Surgery
New York-Presbyterian Hospital/Weill Cornell Medical College Department of Surgery
New York, NY Prisma Health-Upstate
USA University of South Carolina School of Medicine
Greenville, SC
Ali Ahmad MD USA
Clinical Assistant Professor of Surgery
Division of Surgical Oncology Leandro Totti Cavazzola MD, MSc, PhD
University of Kansas School of Medicine Associate Professor of Surgery
Wichita, KS Universidade Federal do Rio Grande do Sul
USA Department of Surgery
Hospital de Clínicas de Porto Alegre
Marcia Alayón-Rosario MD Porto Alegre, Rio Grande do Sul
Department of Surgery Brazil
Division of Minimal Access and Bariatric Surgery
Prisma Health-Upstate John A. Chabot MD
Greenville, SC David V. Habif Professor of Surgery
USA Columbia University Vagelos College of Physicians and
Surgeons
Hemasat Alkhatib MD
Associate Director, Herbert Irving Comprehensive Cancer
Resident
Director, The Pancreas Center
Department of Surgery
Chief, GI and Endocrine Surgery
Cleveland Clinic
Department of Surgery
Cleveland, OH
Columbia University Irving Medical Center
USA
New York, NY
Vedra Augenstein MD USA
Associate Professor of Surgery
Department of Surgery David C. Chen MD
Carolinas Medical Center Professor of Clinical Surgery
Charlotte, NC Department of Surgery
USA David Geffen School of Medicine at UCLA
Los Angeles, CA
Conrad Ballecer MD, MS USA
Clinical Assistant Professor
Department of Surgery Sarah Corn MD
Creighton University School of Medicine Clinical Assistant Professor
Phoenix. AZ Division of Surgical Oncology
USA Department of Surgery
University of Kansas School of Medicine-Wichita
Igor Belyansky MD Wichita, KS
Chief of General Surgery USA
Director, Abdominal Wall Reconstruction Program
Department of Surgery Francesca Dimou MD, MS
Anne Arundel Medical Center Fellow
Annapolis, MD Department of Surgery
USA New York-Presbyterian Hospital/Weill Cornell Medical
College
Timothy J. Bourdeau II BSc New York, NY
Surgical Research Technician USA
AdventHealth Tampa
Tampa, FL
USA

x
 List of Contributors xi

Colin Dunn MD Salim Hosein MD

Research Fellow General and Bariatric Surgeon
Department of Surgery Department of Surgery
Keck School of Medicine of University of Southern California Southern Illinois Healthcare
Los Angeles, CA Herrin, IL
USA USA

Aleeson Eka Caitlin Houghton MD

MD-MPH Candidate Assistant Professor of Surgery
Keck School of Medicine of University of Southern California Division of Upper GI and General Surgery
Los Angeles, CA Keck School of Medicine of University of Southern California
USA Los Angeles, CA
USA
Micaela M. Esquivel MD
Clinical Assistant Professor of Surgery Desmond Tuan-Khai Huynh MD
Division of MIS/Bariatric Surgery Resident
Stanford University Department of Surgery
Stanford, CA Cedars-Sinai Medical Center
USA Los Angeles, CA
USA
Laura E. Flores
MD-PhD Scholar Abraham Krikhely MD
University of Nebraska Medical Center Assistant Professor of Surgery
Omaha, NE Department of Surgery
USA Columbia University Irving Medical Center
New York, NY
Carlos A. Galvani MD USA
Professor and Chief
Division of Minimally Invasive and Bariatric Surgery Trenton Lippert
Tulane University School of Medicine Research Coordinator
New Orleans, LA Surgery
USA AdventHealth Tampa
Tampa, FL
Clark Gerhart MD USA
Director of Minimally Invasive Surgery and Robotics
General and Bariatric Surgery Richard Lu MD, DABS
Wilkes-Barre General Hospital Assistant Professor of Surgery
Wilkes-Barre, PA Department of Surgery
USA The University of Texas Medical Branch
Galveston, TX
Andres Giovannetti MD USA
General and Minimally Invasive Surgery
Robotic Hepatopancreaticobiliary Surgery Ian T. Macqueen MD
Chicago Institute for Advanced Surgery Assistant Professor of Clinical Surgery
Chicago, IL David Geffen School of Medicine at UCLA
USA Department of Surgery
UCLA Health - Santa Monica Medical Center
Anthony Gonzalez MD Santa Monica, CA
Chief of Surgery USA
Baptist Hospital of Miami
Associate Professor of Surgery Flavio Malcher MD, MSc
Florida International University Assistant Professor of Surgery
General and Bariatric Surgery Albert Einstein College of Medicine
Miami, FL Director, Abdominal Wall Program
USA Department of Surgery
Montefiore Medical Center
Emily Helmick DO Bronx, NY
Resident USA
Department of Surgery
Creighton University School of Medicine
Phoenix, AZ
USA
xii List of Contributors

Luis A. Martin-del-Campo MD Sean B. Orenstein MD

Centro de Cirugía Robótica Associate Professor of Surgery
Departamento de Cirugía Department of Surgery
Hospital Ángeles del Carmen Oregon Health and Science University
Guadalajara, Jalisco Portland, OR
Mexico USA

John B. Martinie MD Eduardo Parra-Davila MD

Professor of Surgery Director, Minimally Invasive and Colorectal Surgery
Division of Hepatobiliary and Pancreas Surgery Director, Hernia and Abdominal Wall Reconstruction
Director, Robotic HPB Fellowship Robotic Surgery Institute
Carolinas Medical Center, Atrium Health Good Samaritan Medical Center
Charlotte, NC West Palm Beach, FL
USA USA

David J. Morrell MD Andrea Pakula MD, MPH

Resident Medical Director of Robotic Surgery
Department of Surgery Department of Surgery
Penn State Hershey Medical Center Adventist Health Simi Valley Hospital
Hershey, PA Simi Valley, CA
USA USA

Filip Muysoms MD, PhD Eric M. Pauli MD

Head of Department of Surgery Professor of Surgery
Maria Middelares Gent Director of Endoscopic Surgery
Ghent Chief, Division of MIS/Bariatric Surgery
Belgium Penn State Hershey Medical Center
Hershey, PA
Vahagn C. Nikolian MD USA
Assistant Professor of Surgery
Department of Surgery Dina Podolsky MD
Oregon Health and Science University Assistant Professor of Surgery
Portland, OR Columbia University Vagelos College of Physicians and Surgeons
USA Department of Surgery
Columbia University Irving Medical Center
Yuri W. Novitsky MD New York, NY
Professor of Surgery USA
Columbia University Vagelos College of Physicians and
Surgeons Ajita Prabhu MD
Director, Columbia Hernia Center Associate Professor of Surgery
Department of Surgery Department of Surgery
Columbia University Irving Medical Center Cleveland Clinic
New York, NY Cleveland, OH
USA USA

Dmitry Oleynikov MD Jake G. Prigoff MD

Chairman, Department of Surgery Resident
Monmouth Medical Center Department of Surgery
Robert Wood Johnson Barnabas Health Columbia University Irving Medical Center
Monmouth, NJ New York, NY
USA USA

Sean M. O’Neill MD Eric Rachlin PhD

Resident MIS Fellow
Department of Surgery Department of Surgery
David Geffen School of Medicine at UCLA Memorial Hermann Health System
Los Angeles, CA Houston, TX
USA USA
 List of Contributors xiii

Priscila Rodrigues Armijo MD Hany Takla MD

Assistant Professor of Surgery General and Bariatric Surgeon
Department of Surgery Department of General Surgery
University of Nebraska Medical Center Beth Israel Lahey Health
Omaha, NE Winchester Hospital
USA Winchester, MA
Clinical Instructor
Alexander S. Rosemurgy MD Tufts Medical School
Director, Hepatopancreaticobiliary Surgery Boston, MA
Department of Surgery USA
AdventHealth Tampa
Tampa, FL Maureen Tedesco MD
USA Chief of Surgery
Robotic and Minimally Invasive General Surgery
Sharona B. Ross MD, BS The Permanente Medical Group, Inc.
Hepatopancreaticobiliary Surgeon Kaiser Permanente Santa Clara Medical Center
Department of Surgery Santa Clara, CA
AdventHealth Tampa Clinical Assistant Professor (Affiliated)
Tampa, FL Department of Surgery
USA Stanford University School of Medicine
Stanford, CA
Allegra Saving MD USA
General Surgeon
Department of Surgery Samuel Torres-Landa MD
Norton Healthcare Resident Surgeon
Louisville, KY Department of Surgery
USA Oregon Health and Science University
Portland, OR
William C. Sherrill III MD USA
Resident
Department of Surgery Shirin Towfigh MD
Carolinas Medical Center, Atrium Health President, Founder
Charlotte, NC Beverly Hills Hernia Center
USA Beverly Hills, CA
USA
Iswanto Sucandy MD
Clinical Instructor Kelly H. Tunder DO
Department of Surgery Assistant in Clinical Surgery
University of Pittsburgh School of Medicine Fellow, Advanced Abdominal Wall Surgery
Pittsburgh, PA Department of Surgery
USA Columbia University Irving Medical Center
New York, NY
Kazuki N. Sugahara MD, PhD USA
Instructor in Surgery
Department of Surgery Sandeep S. Vijan MD
Columbia University Irving Medical Center Vice President of Medical Affairs & Quality
New York, NY Chief of Surgery
USA Director of Robotic Surgery
Parkview Medical Center
Jesse Sulzer MD, PhD General and Gastrointestinal Surgeon
Fellow Sangre de Cristo Surgical Associates
Division of Hepatobiliary and Pancreas Surgery Pueblo, CO
Department of Surgery USA
Carolinas Medical Center, Atrium Health
Charlotte, NC Dionisios Vrochides MD, PhD
USA Professor of Surgery
Vice Chairman, Quality of Outcomes
Department of Surgery
Division of Hepatobiliary and Pancreas Surgery
Carolinas Medical Center, Atrium Health
Charlotte, NC
USA
xiv List of Contributors

Jack Wecowski MD Samuel R. Yelverton MD

Ocala Health Surgical Oncology Resident
Ocala Health, Department of Surgery
Ocala, FL Carolinas Medical Center, Atrium Health
USA Charlotte NC
USA
Jerald D. Wishner MD
Co-Director, Minimally Invasive and Robotic Surgery Mohanad R. Youssef, MD
Director, Colon and Rectal Surgery Research Scientist
Northern Westchester Hospital Division of Minimally Invasive and Bariatric Surgery
Mount Kisco, NY Tulane University School of Medicine
USA New Orleans, LA
USA
Disclosures
Cheguevara Afaneh MD Consultant: Intuitive Surgical
Vedra Augenstein MD Consultant: Intuitive Surgical, Allergan, Acelity, BD Interventional, Medtronic,
Vicarious surgical
Conrad Ballecer MD, MS Consultant: Intuitive Surgical, BD Interventional, Medtronic; Equity - IHC, Inc
Igor Belyansky MD Consultant: Intuitive Surgical, WL Gore, Medtronic, BD Interventional; Equity - IHC, Inc
Alfredo M. Carbonell D.O. Consultant: Intuitive Surgical, WL Gore, Ethicon
Carlos A. Galvani MD Consultant: Intuitive Surgical, BD Interventional, Medtronic
Clark Gerhart MD Consultant: Intuitive Surgical
Eduardo Parra-Davilla Consultant: Intuitive Surgical, Medtronic, BD Interventional, Johnson and Johnson,
Auris, Storz, Titan Medical, CMR Surgical
Anthony Gonzalez MD Consultant: Intuitive Surgical, Verb Surgical, Medtronic; Advisory board: LapDome
Caitlin Houghton MD Consultant: Intuitive Surgical, Ethicon, Allergan
Abraham Krikhely MD, FASMBS Consultant: Intuitive Surgical, Medtronic, CSATs, Johnson and Johnson
Flavio Malcher MD, MSc Consultant: Intuitive Surgical, BD Interventional, Medtronic, Acell, Allergan
John Martinie MD Consultant: Intuitive Surgical; Grant support: Intuitive Surgical
Filip Muysoms MD, PhD Consultant: Intuitive Surgical, BD Interventional, Medtronic, CMR Surgical, FEG
Textiltechnik
Yuri W. Novitsky MD Consultant: Intuitive Surgical, BD Interventional; Grant support: Intuitive Surgical;
Equity: Anchora Medical
Dmitry Oleynikov MD Consultant: Intuitive Surgical; Equity: Virtual Incisions
Sean B. Orenstein MD Consultant: Allergan, Intuitive Surgical, BD Interventional, PolyNovo
Andrea Pakula MD, MPH Consultant: Intuitive Surgical; BD Interventional
Eric M. Pauli MD Consultant: BD Interventional, Medtronic, Ovesco, Boston Scientific, Cook Medical,
CMR Surgical, Actuated Biomedical, Surgimatrix, Wells Fargo
Dina Podolsky MD Consultant: Intuitive Surgical
Ajita Prabhu MD Consultant: Intuitive Surgical, CMR Surgical, Verb Surgical; Grant support: Intuitive
Surgical
Sharona B. Ross MD, BS Consultant: Intuitive Surgical
Kazuki N. Sugahara MD, PhD Equity: Cend Therapeutics
Hany Takla MD Consultant: Intuitive Surgical, Medtronic
Sandeep S. Vijan MBBS, CPE Consultant: Intuitive Surgical
Jerald Wishner MD Consultant: Intuitive Surgical

The rest of the authors report no financial disclosures.

xv
Video Table of Contents

1 Overview of Existing Robotics Platforms 15 Robotic-assisted Sleeve Gastrectomy

2 Achieving Proficiency: Mastering the Learning 16 Robotic Gastric Bypass Using Da Vinci Xi
Curve 17 Robotic Transversus Abdominis Release (rTAR)
3 Preoperative Imaging in Hernia Surgery (1 of 2) 18 Robotic Paraesophageal Hernia Repair
4 Preoperative Imaging in Hernia Surgery (2 of 2) 19 Robotic Heller Myotomy
5 Robotic Inguinal Hernia Repair 20 Robotic Transhiatal Esophagectomy
6 Robotic Iliopubic Tract Repair of Indirect Inguinal 21 Robotic Right Hemicolectomy
Hernia 22 Robotic Low-Anterior Resection with Intracorporeal
7 Robotic Inguinal Mesh Removal and Anastomosis
Neurectomy 23 Robotic Multiport Cholecystectomy
8 Robotic Intraperitoneal Hernia Repair 24 Robotic Single-site Cholecystectomy
9 Robotic TAPP (rTAPP) Ventral Hernia Repair 25 Robotic Splenectomy
10 Robotic Transabdominal Retrorectus Repair 26 Robotic Right Hepatectomy
11 Robotic (eTEP) Ventral Hernia Repair (upper dock) 27 Robotic Distal Pancreatectomy
12 Robotic Transversus Abdominis Release (rTAR) 28 Robotic Pylorus Preserving Pancreaticoduodenectomy
13 Robotic Anterior Component Separation (RACS) with Antrectomy
14 Robotic Total Gastrectomy with Roux-en-Y 29 Robotic Left Adrenalectomy
Esophagojejunostomy

xvi
 SECTION I General Issues in Robotic Surgery

1
Overview of Existing Robotic Platforms
LAURA FLORES, PRISCILA RODRIGUES ARMIJO, SALIM HOSEIN,
DMITRY OLEYNIKOV

Introduction
Healthcare technology is advancing rapidly and transforming procedures for surgeons and
patients alike. Tremendous progress has been made in minimally invasive surgery over a rela-
tively short period of time, with new devices being developed constantly. Robotic surgical
devices represent a leap in surgical innovation, and robotic surgery addresses several limita-
tions of manual laparoscopy. In fact, recent data suggest a trend moving away from open
procedures toward robot-assisted procedures.1 This shift is particularly prominent in general
surgical procedures such as colectomies, cholecystectomies, hernia repairs, and bariatrics.
One of the many benefits of robot-assisted surgery is the ability to assist in complex tasks
in confined body cavities. Traditional robotic platforms consist of a console or device
control center, a bedside cart with arms and a camera, and a cart for software and
other supporting instruments. The recent advances in robotics stray from the traditional
setup, allowing for new technology, such as microinstruments, to emerge. This chapter will
serve as a comprehensive resource describing the medical and surgical robotic platforms
currently being used (Video 1). The devices discussed here represent a review of current and
emerging surgical robotic technology and a platform for new technology to grow upon.

da Vinci Surgical System

The da Vinci Surgical System, developed by the US-based company Intuitive Surgical Inc.,
serves as a leader in the surgical robotics market, with surgical applications ranging from
use in cardiac, colorectal, general, gynecologic, head and neck, thoracic, and urologic
surgery (Fig. 1.1).2 Over 1 million procedures were completed using the da Vinci in the
United States in 2018, just 7 years after its initial FDA clearance in 2011.3 Intuitive
Surgical Inc. holds over 1500 patents; however, as the first-generation patents are set to
expire in 2019, it is expected that new technology will arise.4
Four current models of the da Vinci are available and used in hospitals in the United
States, namely, the da Vinci Si, X, Xi, and SP.5 In 2014 Intuitive Surgical Inc. released the
da Vinci’s latest model, the Xi, which is composed of a closed master console, a mobile
platform, and a four-armed operational cart. The master console, also referred to as the
“surgeon console,” provides a magnified high-definition, three-dimensional (HD-3D) view
of the surgical field. The benefit of a closed console such as that used by da Vinci is the
immersion of the surgeon in the operating field. The 8-mm camera is capable of “camera-
hopping,” or use in all four ports, allowing for a more varied repertoire of surgical proce-
dures.4 The console’s features include adjustable finger loops on the telemanipulators,
an adjustable intraocular distance, and padded headrest and arm bars to accommodate
each surgeon’s ergonomic needs.4 Each boom-mounted arm is capable of three degrees
of freedom (DOF), allowing for manipulation of the proprietary EndoWrist instru-
ment. The EndoWrist technology mimics the movements of a human wrist, providing
an additional seven DOF to the platform.6 The instrument motion functions through
cable-driven joints at the distal end of the instrument. The system achieves its precision
and accuracy through high-resolution 3D visualization, motion scaling, and a comfortable

1
2 SECTION I General Issues in Robotic Surgery

• Fig. 1.1 ​The da Vinci Surgical System, featuring a closed master console system and four boom-mounted arms. (From Intuitive Surgical, Inc.,
Sunnyvale, CA.)

user interface, allowing the surgeon tools for precision and dexterity. Additional fea-
tures include tremor filtration and handle- and pedal-controlled optics.5 The slave is
controlled via master-slave finger-cuff telemanipulators, which were designed to allow
rapid user training.
One of the drawbacks of robotic surgery that has likely limited the advancement of this
technology is the cost of the robot and instruments. Each da Vinci surgical system costs an
estimated $1.5 to $2 million, with additional annual maintenance fees to consider.7 The
large size of the system is also a burden for hospitals, and the closed console design may lead
to less bedside contact with the surgical team.8 Surgeons often describe the lack of haptic
feedback, which gives the user a sense of touch, as a potential limitation of the da Vinci
platform. Additionally, surgeons may feel limited by the inability to rapidly switch instru-
ments during a procedure.4 Despite these drawbacks, the superior visual capabilities and
dexterity provided by the platform have allowed for a sharp increase in the utilization of
robotic surgery across many specialties. Technical reviews of the da Vinci platform cite its
ease of use and excellent functionality.9 In terms of practical use, it has been shown to be
more cost-effective than open surgery due to its reduced length of stay; however, the same
benefit over conventional laparoscopy has not been proven.10 The high technical standards
set by the da Vinci platform make it the current gold standard in robotic surgical platforms,
and new robotic technology is likely to be developed based on this platform’s design and
implementation.4

Invendoscopy E210
The Invendoscopy E210, developed by Invendo Medical, is commercially available for use
in colonoscopy. It obtained FDA approval in 2001. This robot-assisted platform is
composed of a reusable, handheld controller (InvendoScope controller) and a single-use
sterile colonoscope with individual packaging for aseptic setup (Fig. 1.2). The Invendo-
Scope controller is a detachable, lightweight joystick that was designed with surgical
ergonomics in mind. This handheld tool has robot-assisted tip control with full retroflec-
tion capabilities, allowing for enhanced ergonomics while performing procedures. Working
in conjunction with the SC210 colonoscope (the newest version of the colonoscope),
this platform is able to perform conventional colonoscopy functions such as insufflation,
suction, and image capturing.11
The additional features of this platform include a 170-cm working length colonoscope, an
optical system capable of 180-degree rotation, a 35-mm bending radius, and a 3.2-mm work-
ing channel, allowing for interventions using standard instruments. The combined features
allow for broad visualization of the colon. The Invendoscopy E210 system offers state-of-the-
art visualization through an HD camera, complete with three white-light LEDs, and a com-
plementary metal oxide semiconductor (CMOS) imaging chip. Its low startup cost allows for
greater potential utilization than other larger and more expensive robotic platforms.4
In a feasibility study designed to test safety and efficacy, paid healthy volunteers between
50 and 70 years old were recruited for a screening colonoscopy using the SC210 computer-
assisted endoscope. Sixty-one volunteers were recruited and screened using the SC210, and
no device-related complications were found. Further, the cecal intubation rate was very
high, at 98.4%, and the procedure was extremely well tolerated, with 95.1% of patients
having a sedation-free procedure.12
 CHAPTER 1 Overview of Existing Robotic Platforms 3

A D

• Fig. 1.2​The SC210 colonoscope and Invendoscopy E210 system, featuring (A) the complete system, (B) the tip in driving mode, (C) the tip in its fully
flexed position, and (D) the ability to utilize tools (biopsy forceps shown) through the working channels. (From Invendo Medical GmbH.)

Flex Robotic System

The Flex Robotic System was developed by the Medrobotics Corporation for transoral use
and allows for visualization and access to otherwise difficult-to-reach head and neck sites.13
This platform gained FDA approval in 2015. The operator-controlled platform is com-
posed of a tower console, a joystick controller, a flexible endoscope, and two flexible guide
tubes, capable of use in oropharyngeal, hypopharyngeal, and laryngeal minimally invasive
surgery (Fig. 1.3). Through articulated segments the Flex System is able to rotate, move
laterally, and maintain its position without external support. Placement of the surgeon at
the head of the patient allows even greater visualization and access to the larynx.13 Its
additional features include endoscopic technology that can be used in a semi-rigid or
flexible state, simply by adjusting the cable systems running internally through the
segments. The design of this platform allows the surgeon to navigate an outer robotic
mechanism through which an inner mechanism follows, which is similar to existing steer-
able catheter and endoscopic technology. In 2017, Medrobotics also received FDA
approval to use the Flex System in colorectal procedures. According to Medrobotics the
Flex Robotic System is the only minimally invasive, steerable, and shapeable robotic
platform produced for colorectal surgery.14
As the Flex Robotic System contains two working channels to accommodate a wide
variety of instruments, Medrobotics offers a full suite of 3.5-mm Flex surgical instruments
for use in this platform, including the Flex Monopolar Scissors, Flex Monopolar Spatula,
Flex Needle Diver, and Flex Fenestrated Grasper.15 The two external accessory channels,
4 SECTION I General Issues in Robotic Surgery

Flex Base

Flex Drive

Flex Console

Flex Cart

Flex TO Instrument
Support & Assembly

• Fig. 1.3 ​The Flex Robotic System illustrating the capacity for easy repositioning around the operating room and unique positioning at the head of the
bed. (From Flex Robotic System, Medrobotics Corp., Raynham, MA.)

combined with the above accessories, allow the surgeon to perform two-handed procedures,
in addition to the single-hand manipulation that is also possible with the Flex System.
As the Flex System was designed and adapted for otolaryngologists, much of the litera-
ture on its use is in head and neck surgery. One case series, designed to test the safety and
efficacy of the Flex System, was conducted in human subjects in 2014. Each patient had a
unique diagnosis (obstructive sleep apnea, vocal fold polyp, and carcinoma of the lateral
edge of the tongue) and underwent surgery using the Flex System. The investigators found
the platform to have good visualization, and there were no reported complications.13 A
larger clinical study with 40 patients in need of head and neck surgery echoed the feasibil-
ity, safety, and efficacy of the Flex System. The system could safely resect lesions in 95% of
the patients, with zero adverse events reported.16

Senhance
The Senhance console-type robotic platform, designed by TransEnterix, gained FDA
approval in 2017. It has proven successful in gynecologic and laparoscopic colorectal pro-
cedures.8 This platform consists of a remote-control station called the cockpit that allows
for an unobstructed view of the operating room, a connection node, and four individual
manipulator arms, each mounted on its own cart (Fig. 1.4). This is in contrast to the single-
cart operation of the da Vinci system.
An additional feature of the Senhance system is the capability for haptic feedback.
Compared to the da Vinci platforms that do not offer haptic feedback, this system boasts
1:1 force feedback, which allows the surgeon to perceive the stress exerted by the instru-
ments on the tissue. This sensation is directly relayed to the hand of the surgeon through
the controller.8 Visualization is made possible by an HD-3D technology display with eye-
tracking software and an eyeglass-based 3D system. The infrared eye-tracking system allows
the surgeon to control the endoscopic arms using gaze and head movements. As the surgeon
moves their head toward the screen, the camera zooms in. This visualization system mini-
mizes image distortion and is maintained in the system software for each surgeon.8 It is
worth noting, however, that eye-tracking, an indirect form of console control, runs the risk
of inadvertent movements, leading to potential damage or malfunction during surgery.8
Additional benefits of the Senhance platform include its compatibility with reusable
laparoscopic instruments, which offer a cost benefit.5
 CHAPTER 1 Overview of Existing Robotic Platforms 5

• Fig. 1.4 ​Senhance, by TransEnterix, featuring an open console and four

individually mounted robotic arms. (From TransEnterix, Inc.)
• Fig. 1.5​Versius by CMR Surgical offers an open console and robotic arms
that bio-mimic the human arm. (From CMR Surgical Ltd, Cambridge, UK.)

The Senhance platform is FDA-approved for colorectal and gynecological surgery;

thus the majority of literature describing the use of the Senhance Surgical Robot is in these
areas.5 However, additional research is being conducted in porcine models, exploring the
use of Senhance in prostate surgery.17 Although a limited number of wrist-articulated in-
struments, such as a needle-driver, are available in Europe, the instruments available in the
United States are similar to those used in laparoscopy, a major drawback of this platform.

Versius Surgical Robot

The Versius Surgical Robot is a modular system designed for use in upper gastrointestinal, gyne-
cologic, colorectal, and renal surgeries.4 The unique design of Versius features multiple wristed
robotic arms, an open operator console, joystick controllers, and an HD-3D camera system
(Fig. 1.5).18 The robotic arms are equipped with connecting instruments, including those as small
as 5 mm to allow for reduced incision size. The arms are each mounted individually, allowing for
more versatility in the operating room. Versius allows haptic feedback to inform the controller of
the force exerted while using the platform. Cadaveric trials have demonstrated the platform’s abil-
ity to perform surgical tasks such as needle driving, suturing, and tissue manipulation.18

MiroSurge
MiroSurge, a developing telemanipulated, minimally invasive surgical robot, is under the
broad umbrella of the DLR Institute of Robotics and Mechatronics.19 This platform consists
of a height-adjustable 3D display, three to five individual minimally invasive robot-assisted
(MIRO) arms, and an autostereoscopic display (Fig. 1.6). The DLR MIRO is a low-weight,
fully torque-controlled robotic arm, also developed by DLR. The three to five MIRO arms
can be used in various combinations, allowing for at least two arms dedicated to left and right

A B

• Fig. 1.6
​The MiroSurge platform, featuring an open, autostereoscopic console (A) and three individual robotic-assisted arms (B). (From DLR, German
Aerospace Center.)
6 SECTION I General Issues in Robotic Surgery

movement and one arm for guidance of the endoscopic camera. Alone, each MIRO has seven
DOF, but many more can be accomplished via the addition of actuated surgical instruments.
The minimally invasive robotic instruments are equipped with haptic feedback, and the
system has the ability to be mounted to table rails in the operating suite.20
The MiroSurge platform serves primarily as a teleoperated master-slave system; however,
it also comes equipped with a unique feature that enables the surgeon to manually position
the robot arm.21 The joints of the MIRO arms, which contain torque and position sensors,
allow manual positioning by the surgeon. If the surgeon wants to operate the robot in
impedance-controlled mode, the points of insertion are planned prior to surgery with
algorithmic assistance that accounts for the kinematics of the robot.4

Miniature In Vivo Robots

The Virtual Incision Corporation, a company based out of the University of Nebraska,
has developed a series of miniature in vivo robots designed to perform surgery via a
single incision the size of a traditional colectomy extraction site.2 In collaboration with
the Center for Advanced Surgical Technology (CAST), miniature in vivo robots are cur-
rently being tested for use in a variety of laparoscopic procedures, with a primary focus
on colorectal surgery. Virtual Incision offers over 50 robotic prototypes, 140 patents and
applications, and 80 comparative medical studies.22 The most current robotic platform
has been described as small, dexterous, and self-contained, with the capability to utilize
machine learning and artificial intelligence (Fig. 1.7).23 Miniaturized robotic platforms
boast an increased range of motion and better access to difficult-to-reach abdominal

• Fig. 1.7
​The Virtual Incision surgical robot, featuring two arms equipped with interchangeable end effectors and unique compartmentalization of all drive
technology into the arms themselves. (From Virtual Incision, Omaha, NE, USA.)
 CHAPTER 1 Overview of Existing Robotic Platforms 7

spaces compared to traditional robotic platforms. The miniature robots have been tested
in human colectomy cases outside the United States, as well as in porcine models.24,25
The initial feasibility and safety human trials of the miniature in vivo robots were per-
formed in Paraguay, South America. These trials demonstrated the robot’s ability to
perform tasks such as ligation, dissection, and suturing, as well as both right and left
colectomies.25 There was no harm to the subjects in these trials, showing the capability
these robots possess in performing colectomies. Additional trials have been performed in
porcine models, wherein the miniature robot successfully performed a colectomy.26
The research and development of the miniature robotic platforms has continued to
optimize and shrink the technology while maintaining its unique capabilities. The signifi-
cantly reduced size and ability to traverse smaller spaces compared to traditional robotic
platforms is of great benefit to minimally invasive surgeons. Smaller robots can be maneu-
vered completely inside the peritoneal cavity through a single 3.5-cm abdominal incision,
and thus have the capability to overcome many of the limitations of laparoscopic surgery.
Reducing the size of the robots increases their ease of use in the operating room, not only
due to a smaller footprint but also because of their predicted reduced cost compared to
traditional robotic platforms.26
The miniature in vivo robot is composed of two miniaturized triple-jointed arms, with
the capability to incorporate interchangeable end effectors. The end effectors are capable of
four DOF and can be replaced for tasks such as cautery or ligation. The small size of the
platform allows insertion of multiple tools into the peritoneum, a feature distinct from
traditional robotic platforms.4 Another key technological advancement of the robots
developed by the Virtual Incision team is the miniaturization of the motors driving the
robotic arms. Unlike traditional platforms where the arms are driven by cumbersome mo-
tors and pulleys, this platform uses novel technology to compartmentalize all of the drive
technology into the arms themselves.26
Currently, there are additional models of the robot under development, as are new platforms
for gallbladder removal and hernia repair.4

MASTER
The Master and Slave Transluminal Endoscopic Robot (MASTER), developed by the Nan-
yang Technological University, is composed of two arms, an externally attached endoscope,
and a master console with a cable-driven flexible robotic slave. The flexible endoscope uses
a tendon-sheath mechanism, allowing for nine DOF. The unique design of the telechirs
(robotic arms under human control) allows for up/down and left/right dexterity, as well as
translation. The platform is also equipped with a navigation system that allows for 3D re-
construction, haptic feedback capability, two end effectors, a monopolar electrocautery
hook, and a grasper (Fig. 1.8).
The use of this platform requires careful cooperation between two surgeons. One
surgeon is responsible for operating the telechirs through the master control device and is

Endoscope

Sheaths

Slave manipulators
Attachment
to endoscope

A B

• Fig. 1.8 ​The Master and Slave Transluminal Endoscopic Robot (MASTER), featuring (A) two cable-actuated robotic arms with fixed end effectors
and (B) an externally attached conventional endoscope. (From Phee SJ, Low SC, Sun ZL, Ho KY, Huang WM, Thant ZM. Robotic system for no-scar
gastrointestinal surgery. Int J Med Robotics Comput Assist Surg. 2008;4:15-22.)
8 SECTION I General Issues in Robotic Surgery

ultimately responsible for executing the surgical treatment. The second surgeon is respon-
sible for directing the endoscope and performing suction and inflation. MASTER has been
used in endoscopic submucosal dissection, a technique designed to target intraluminal
conditions without iatrogenic damage to the visceral wall.27
The limitations of the MASTER system include movement delays and hysteresis
associated with the tendon-sheath mechanism and prolonged operating time due to the
complex and cumbersome setup of the platform. However, Nanyang Technological Univer-
sity is developing an interventional navigational system that would be capable of using
preoperative and intraoperative imaging to help guide procedures.28 The intrinsic draw-
backs of the tendon-sheath mechanism are balanced by the mechanism’s ability to provide
larger forces with a smaller size than can alternative technologies.4

Medical Microinstruments
Medical Microinstruments is a start-up company based out of Italy with the goal to provide
the first miniaturized wristed robotic instrument.29 A device of this kind lends itself to fill-
ing gaps in microsurgery or in operations requiring optical magnification, particularly in
micro-anastomosis. As of 2018, Medical Microinstruments announced the completion of
$24.5 million of Series A funding intended for continued development on their surgical
robotics platform. Medical Microinstruments’ microrobotic platform is not yet commer-
cially available.30

Discussion
The robot-assisted platforms covered in this chapter are the culmination of collaboration
between computer scientists, engineers, designers, and physicians working together to
implement new technology in the medical sphere. Robot-assisted surgery has emerged
from the groundwork laid by Intuitive Surgical and the da Vinci platform and has grown
into a multi-billion-dollar industry.3 Advancements in the field have allowed for a transi-
tion from open procedures to minimally invasive procedures, with promise for improved
patient outcomes in a variety of operations.1
Public perception of robotics and artificial intelligence is shifting as new technology is ad-
opted, and it is projected that big data, robotics, and artificial intelligence will revolutionize the
future of healthcare.4 Robotic surgery platforms capable of independent functions, such as
identification of tissue types, suturing, and even performing surgery completely autonomously,
are anticipated as technology continues to evolve. With each emerging platform a broader
foundation for robotic surgery is built from which both surgeons and patients can benefit in
the future. Patients are expected to benefit from decreased recovery times, particularly with the
use of single-incision platforms, and potentially better outcomes.1 Surgeons are expected to
benefit from improved ergonomics, leading to decreased work-related disability.28
As new technology is developed and implemented, however, standardized training
among robotic surgeons and a clear expectation for the safe introduction of new technology
will be imperative.31 There are safeguards in place, such as the FDA approval process, which
requires transparent reporting of adverse events and/or death as a result of technology;
however, public education of the risks and benefits of new technology will remain a
necessary venture to ensure adequate transparency.4 It will also be necessary to address cost
reduction, ease of implementation, and clinical and surgical outcomes of new technology as
it emerges in order to maintain high-quality and ethical surgical care.
In conclusion, this chapter serves as a growing platform on which to build knowledge of
robot-assisted surgery. It is anticipated that new devices and companies will continue to
emerge as the conversion from open to minimally invasive surgery continues to increase.1
Likewise, it is necessary to evaluate the strengths and weaknesses of current and future ro-
bot-assisted platforms in the operating room, as we face growing reliance on technology
throughout healthcare.

References
1. Armijo PR, Pagkratis S, Boilesen E, Tanner T, Oleynikov D. Growth in robotic-assisted proce-
dures is from conversion of laparoscopic procedures and not from open surgeons’ conversion:
a study of trends and costs. Surg Endosc. 2018;32(4):2106-2113.
2. Oleynikov D. Robotic surgery. Surg Clin North Am. 2008;88(5):1121-1130.
 CHAPTER 1 Overview of Existing Robotic Platforms 9

3. Tindera M. Robot wars: $60B intuitive surgical dominated its market for 20 years. Now rivals
like alphabet are moving in. Forbes Innovation. Available at: https://www.forbes.com/sites/
michelatindera/2019/02/14/intuitive-surgical-stock-robot-surgery-da-vinci-alphabet-jnj-ceo-
gary-guthart/?sh=2d40d8d6a37b
4. Peters BS, Armijo PR, Krause C, Choudhury SA, Oleynikov D. Review of emerging surgical
robotic technology. Surg Endosc. 2018;32(4):1636-1655.
5. Rao PP. Robotic surgery: new robots and finally some real competition! World J Urol.
2018;36(4):537-541.
6. van den Bedem LJM. Realization of a demonstrator slave for robotic minimally invasive surgery
[doctoral thesis]. Eindhoven, The Netherlands: Department of Mechanical Engineering,
Eindhoven University of Technology; 2010.
7. Leung T, Vyas D. Robotic surgery: Applications. Am J Robot Surg. 2014;1(1):1-64.
8. Rassweiler JJ, Autorino R, Klein J, et al. Future of robotic surgery in urology. BJU Int.
2017;120(6):822-841.
9. Freschi C, Ferrari V, Melfi F, Ferrari M, Mosca F, Cuschieri A. Technical review of the da Vinci
surgical telemanipulator. Int J Med Robot. 2013;9(4):396-406.
10. Leal Ghezzi T, Campos Corleta O. 30 years of robotic surgery. World J Surg. 2016;40(10):
2550-2557.
11. Ambu. The sterile, single-use colonoscope. 2019. Available at: https://www.ambu.co.uk/?gclid=
CjwKCAiA8Jf-BRB-EiwAWDtEGgh-WAOgOkPxfXHf_PSzjTBaiIbqr7cFUjoRx6wGxrXl0
DhjlpXS9xoC3A4QAvD_BwE
12. Groth S, Rex DK, Rosch T, Hoepffner N. High cecal intubation rates with a new computer-
assisted colonoscope: a feasibility study. Am J Gastroenterol Suppl. 2011;106(6):1075-1080.
13. Remacle M, Prasad VMN, Lawson G, Plisson L, Bachy V, Van der Vorst S. Transoral robotic
surgery (TORS) with the Medrobotics Flex System: first surgical application on humans. Eur
Arch Otorhinolaryngol. 2015;272(6):1451-1455.
14. Frangou C. An Eye on Surgical Robots. 2018. Available at: https://www.generalsurgerynews.
com/In-the-News/Article/07-18/An-Eye-on-Surgical-Robots/50133. Accessed May 23, 2019.
15. Medrobotics. Flex: Expanding the reach of surgery. In: Corporation M, ed. Raynham, MA, USA:
Medrobotics Corporation; 2016. https://medrobotics.com/gateway/flex-robotic-system-us/
16. Mattheis S, Hasskamp P, Holtmann L, et al. Flex Robotic System in transoral robotic surgery:
the first 40 patients. Head Neck. 2017;39(3):471-475.
17. Navaratnam A, Abdul-Muhsin H, Humphreys M. Updates in urologic robot assisted surgery.
F1000Res. 2018;7:F1000 Faculty Rev-1948.
18. Surgical C. Next-generation robot revealed to the world for the first time. 2018. Available at:
https://www.generalsurgerynews.com/In-the-News/Article/07-18/An-Eye-on-Surgical-Robots/
50133?sub=573632B879914E7B6D35ECD181843FD42B8598E599337EDB7DC98F2D
57495379&enl=true
19. Hagn U, Nickl M, Jörg S, et al. The DLR MIRO: a versatile lightweight robot for surgical
applications. Ind Rob. 2008;35(4):324-336.
20. Beasley RA. Medical robots: current systems and research directions. J Robot. 2012;2012:14.
21. Konietschke R, Hagn U, Nickl M, et al. The DLR MiroSurge - A robotic system for surgery.
Paper presented at: 2009 IEEE International Conference on Robotics and Automation; 12–17
May 2009, 2009.
22. Corporation VI. About us. 2019. Available at: https://www.virtualincision.com/. Accessed May
30, 2019.
23. Pedersen A. Why a two-pound robot is getting love from investors. 2017. Available at: https://
www.mddionline.com/why-two-pound-robot-getting-love-investors. Accessed May 30, 2019.
24. Rentschler ME, Oleynikov D. Recent in vivo surgical robot and mechanism developments. Surg
Endosc. 2007;21(9):1477-1481.
25. Virtual incision announces world’s first use of its miniaturized robot in human surgery [press release].
March 1, 2016.
26. Wortman TD. Design, Analysis, and Testing of in Vivo Surgical Robots. Department of Mechanical
Engineering, University of Nebraska Lincoln. 2011:1-109.
27. Ono H, Kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric
cancer. Gut. 2001;48(2):225-229.
28. Yeung BP, Gourlay T. A technical review of flexible endoscopic multitasking platforms. Int J
Surg. 2012;10(7):345-354.
29. Teichmann DH. Medical microinstruments – Advancing microsurgery. 2018. Available at:
http://www.roboticsurgerytoday.com/medical-microinstruments-advancing-microsurgery/. Accessed
May 23, 2019.
30. Medical Microinstruments S.p.A. Announces €20M in Series A Funding to Advance Its Robotic
Platform for Microsurgery [press release]. CALCI, Italy: MMI; 2018.
31. Chen R, Rodrigues Armijo P, Krause C, Siu KC, Oleynikov D. A comprehensive review of
robotic surgery curriculum and training for residents, fellows, and postgraduate surgical educa-
tion. Surg Endosc. 2020;34(1):361-367.
 e1

Abstract: An increasing demand for minimally invasive surgery has led to the development
of various robotic surgery platforms. This chapter serves as a comprehensive resource
describing a variety of platforms for robotic surgery, including both FDA-approved devices
and those under development. Platforms described include the da Vinci surgical system,
Invendoscopy E200, Flex Robotic System, Senhance, Versius, MiroSurge, Master and
Slave Transluminal Endoscopic Robot (MASTER), Miniature In Vivo Robot, Medical
Microinstruments, and the Einstein Surgical Robot.

Keywords: Robotic Surgery, Surgical Robots, Laparoscopy, Endoscopy, Robot-Assisted

Surgery, Robotic Platforms
Another random document with
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paint it again.” Later Greville wrote: “Emma’s picture shall be sent by
the first ship. I wish Romney yet to mend the dog.” The picture is
said to have been lost at sea, on its way back from Naples, but at
Greville’s sale in 1810, the Bacchante—in that case a replica of the
lost canvas—was catalogued as “Diana, original of the well-known
engraved picture,” and bought by Mr. Chamberlayne for 130
guineas.—Mrs. Jordan in the character of “The Country Girl”
(Plate VII.). It was as Peggy in Garrick’s comedy “The Country Girl,”
adapted from Wycherly’s “Country Wife,” that Dorothy Jordan first
appeared at Drury Lane in 1785, and immediately bewitched the
public with the natural, irresistible joyousness of her acting and the
lovable charm of her personality. In the following year she gave
Romney thirteen sittings for this picture. At the first he could not
satisfy himself as to the best pose for her. After many tries she
pretended to be tired of the business, and, jumping up from her
chair, in the hoydenish manner and tone of Peggy, she said, “Well,
I’m a-going.” “Stay!” cried Romney; “that’s just what I want.” And at
once he began to sketch her for this picture. It was bought in 1791
for 70 guineas by the Duke of Clarence, afterwards King William IV.,
and thereby, of course, hangs the well-known tale of a twenty years’
love, ten children, and unhappy separation. The print, first published
as The Romp at 5s., may now fetch, if fine in colour, like Major
Coates’s copy, as much as £200.— Hobbinol and Ganderetta
(Plate VIII.). William Somerville’s “Hobbinol” was a mock-heroic
poem on rural games, which Mr. Gosse describes as “ridiculous.”—
Countess of Oxford (Plate IX.). This is in the National Gallery; but
Hoppner exhibited an earlier portrait in 1797. Jane Scott, daughter of
a Hampshire vicar, married, in her twentieth year, the fifth Earl of
Oxford, whom Byron described as “equally contemptible in mind and
body”; but then, she and the poet were lovers when she was forty
and he about twenty-five. “The autumn of a beauty like hers is
preferable to the spring in others,” he said in after years. “I never felt
a stronger passion, which,” he did not forget to add, “she returned
with equal ardour.” It was on Lady Oxford’s notepaper that Byron
wrote his final letter to Lady Caroline Lamb, and this in the very year
in which, it now appears, he revived his boyish passion for Mary
Chaworth.—Viscountess Andover (Plate X.). Eldest daughter of
William Coke, of Holkham, the famous agriculturist, so long M.P. for
Norfolk, and later Earl of Leicester.
St. James’s Park (Plate XIV.). M. Grosley, a Frenchman, describes
this scene in his “Tour of London,” 1772: “Agreeably to this rural
simplicity, most of these cows are driven about noon and evening to
the gate which leads from the park to the quarter of Whitehall. Tied
to posts at the extremity of the grass plots, they swill passengers
with their milk, which, being drawn from their udders upon the spot,
is served, with all the cleanliness peculiar to the English, in little
mugs at the rate of a penny a mug.”—A Tea Garden (Plate XV.).
Bagnigge House had been the country residence of Nell Gwyn, and
in 1757 the then tenant accidentally discovered a chalybeate spring
in his grounds, which two years later he turned to profit. Bagnigge
Wells then developed a tea garden, with arbours, ponds with
fountains and gold-fish, a bun-house, music, and a reputation for the
amorous rendezvous. The place was very popular, and much
favoured, especially on Sundays, by the would-be fashionable wives
of well-to-do city-folk. In the character of “Madam Fussock” Colman
took this off in his prologue to Garrick’s Drury Lane farce, “Bon Ton;
or High Life above Stairs,” 1776.—The Lass of Livingstone (Plate
XVI.). A popular old Scotch song, words by Allan Ramsay. There is
also an older version, “The Bonnie Lass o’ Liviston,” associated with
an actual person who kept a public-house in the parish of
Livingstone.
Lady Cockerell as a Gipsy Woman (Plate XIX.). One of the
beautiful daughters of Sir John and Lady Rushout, whose miniatures
are, perhaps, Plimer’s masterpieces.—Lady Duncannon (Plate
XX.). One of the “Portraits of Four Ladies of Quality,” exhibited by
Downman at the Royal Academy in 1788. There are also colour-
prints of Viscountess Duncannon after Lavinia, Countess Spencer
and Cosway, and, with her more famous sister, Georgiana, Duchess
of Devonshire, after Angelica Kauffman; while they both figure, with
other fashionable beauties, in J. K. Sherwin’s picture “The Finding of
Moses,” also in Rowlandson’s “Vauxhall,” and two prints in which the
same artist celebrated their triumphant share in the Westminster
election of 1784, when it was said that “two such lovely portraits had
never before appeared on a canvass.” The Countess of
Bessborough, as she became, was the mother of Lady Caroline
Lamb. Her distinguished grandson, Sir Spencer Ponsonby-Fane,
kindly lent the print reproduced here.
Rinaldo and Armida (Plate XXII.). The enchantment of Rinaldo, the
Christian Knight, by Armida, the beautiful Oriental sorceress, in
Tasso’s “Gerusalemme Liberata.” Love and Beauty: Marchioness
of Townshend (Plate XXIV.). One of the three beautiful daughters
of Sir William Montgomery immortalised by Reynolds on the large
canvas now in the National Gallery, called “The Graces decorating a
terminal figure of Hymen.” She married the distinguished general
who finished the battle of Quebec when Wolfe had fallen.
Two Bunches a Penny, Primroses (Plate XXV.). Knives,
Scissors and Razors to Grind (Plate XXVI.). Numbers 1 and 6 of
the Cries of London. The other plates are: 2, Milk below, Maids. 3,
Sweet China Oranges. 4, Do you want any Matches? 5, New
Mackerel. 7, Fresh Gathered Peas. 8, Duke Cherries. 9,
Strawberries. 10, Old Chairs to Mend. 11, A new Love-song. 12,
Hotspice Gingerbread, two plates. 13, Turnips and Carrots. There
are still in existence two or three paintings of similar character by
Wheatley—one depicting a man selling copper kettles—which would
suggest, besides the belated publication of the thirteenth plate, that it
was originally intended to issue a larger number of the “Cries” than
those we know, had the public encouragement warranted it. The
colour-printing of the earliest impressions was superlatively fine, and
in the original pink board-wrappers these are, of course, extremely
rare, and would realize to-day as much as a thousand pounds.
Mrs. Crewe (Plate XXVII.). The famous beauty, Fulke Greville’s
daughter. It was to her house in Lower Grosvenor Street that the
triumphant “true blues”—the Prince of Wales among them—crowded
in the evening to toast Fox’s victory at Westminster. Reynolds has
perpetuated Mrs. Crewe’s rare beauty on three canvasses, and
Sheridan in dedicating to her “The School for Scandal” did reverence
to her mind as well as her features. Fox poetised in her praise, and
Fanny Burney said “She is certainly the most completely a beauty of
any woman I ever saw! She uglifies everything near her.”—The
Dance (Plate XXVIII.). The tradition, lately repeated in book and
periodical, which gives the figures in this print as those of the
Gunning sisters, is obviously absurd. When Bunbury was an infant in
arms the beauty of the Gunnings first took the town by storm; next
year Maria became a countess, Elizabeth a duchess, and, when this
print was done the one had been dead twenty-two years, the other
already widowed and “double duchessed,” as Horace Walpole put it.
—Morning Employments (Plate XXIX.). The name on the
harpsichord should obviously be Jacobus Kirkman; there was no
Thomas. The instrument with the double keyboard is exactly like that
in my own possession, which Dr. Burney selected from Jacob
Kirkman’s shop in 1768. When a fashionable craze for the guitar was
sending the makers of harpsichords and spinets very near to
bankruptcy, Kirkman bought up all his own fine instruments, which
the ladies were practically “giving away” for guitars; then he
purchased a lot of cheap guitars and presented them to milliner’s
girls and street-singers, so that they were twanged everywhere and
became vulgar, the ladies bought harpsichords again, and he made
a large fortune.
Mademoiselle Parisot (Plate XXXVII.). A noted dancer in the
opera ballets at the King’s Theatre in the Haymarket. There is a
beautiful mezzotint of her, dated 1797, by J. R. Smith after A. W.
Devis. This is very rare, and in colours extremely so. Mdlle. Parisot
also figures as one of the three dancers in Gillray’s caricature
“Operatical Reform, or La Danse à l’Evêque,” published in 1798 to
ridicule the Bishop of Durham’s protest against the scanty attire of
the ballet-dancers.—Maria (Plate XXXVIII.). Maria of Moulines, in
Sterne’s “Sentimental Journey.”
MALCOLM C. SALAMAN.
 Plate I.
“Jane, Countess of Harrington,
Lord Viscount Petersham and the
Hon. Lincoln Stanhope.”
Stipple-Engraving by F. Bartolozzi, R.A., after
Sir Joshua Reynolds, P.R.A.
(Published 1789. Size 8¾″ × 11⅛″.)
From the collection of Major E. F. Coates, M.P.
 Plate II.
“Robinetta.”
Stipple-Engraving by John Jones, after Sir Joshua
Reynolds, P.R.A.
(Published 1787. Size 8⅞″ × 10½″.)
From the collection of Major E. F. Coates, M.P.
 Plate III.
“Master Henry Hoare.”
Stipple-Engraving by C. Wilkin, after Sir Joshua
Reynolds, P.R.A.
(Published 1789. Size 7⅝″ × 9⅝″.)
From the collection of Major E. F. Coates, M.P.
 Plate IV.
“The Duchess of Devonshire and Lady Georgiana Cavendish.”
Mezzotint-Engraving by Geo. Keating, after Sir Joshua
Reynolds, P.R.A.
(Published 1787. Size 15⅞″ × 12¼″.)
From the collection of Frederick Behrens, Esq.
 Plate V.
“The Mask.”
Stipple-Engraving by L. Schiavonetti, after Sir Joshua
Reynolds, P.R.A.
(Published 1790. Size 9¼″ × 7⅜″.)
From the collection of Major E. F. Coates, M.P.
 Plate VI.
“Bacchante” (Lady Hamilton).
Stipple-Engraving by C. Knight, after George Romney.
(Published 1797. Size 10½″ × 12⅝″.)
From the collection of Frederick Behrens, Esq.
 Plate VII.
“Mrs. Jordan in the character of
‘The Country Girl’” (“The Romp”).
Stipple-Engraving by John Ogborne, after George Romney.
(Published 1788. Size 9⅝″ × 12⅛″.)
From the collection of Major E. F. Coates, M.P.
 Plate VIII.
“Hobbinol and Ganderetta.”
Stipple-Engraving by P. W. Tomkins, after
Thos. Gainsborough, R.A.
(Published 1790. Size 14⅛″ × 18¼″.)
From the collection of Basil Dighton, Esq.
 Plate IX.
“Countess of Oxford.”
Mezzotint-Engraving by S. W. Reynolds, after J. Hoppner, R.A.
(Published 1799. Size 8-1/ ″ × 10⅛″.)
From the collection of Frederick Behrens, Esq.
 Plate X.
“Viscountess Andover.”
Stipple-Engraving by C. Wilkin, after J. Hoppner, R.A.
(Published 1797. Size 6⅝″ × 8⅛″.)
From the collection of Major E. F. Coates, M.P.
 Plate XI.
“The Squire’s Door.”
Stipple-Engraving by B. Duterreau, after George Morland.
(Published 1790. Size 12-/4″ × 15⅛″.)
From the collection of Basil Dighton, Esq.
 Plate XII.
“The Farmer’s Door.”
Stipple-Engraving by B. Duterreau, after George Morland.
(Published 1790. Size 12¾″ × 15⅛″.)
From the collection of Basil Dighton, Esq.
 Plate XIII.
“A Visit to the Boarding School.”
Mezzotint-Engraving by W. Ward, A.R.A., after George Morland.
(Published 1789. Size 21¾″ × 17⅜″.)
From the collection of Basil Dighton, Esq.
 Plate XIV.
“St. James’s Park.”
Stipple-Engraving by F. D. Soiron, after George Morland.
(Published 1790. Size 19¾″ × 16″.)
From the collection of Basil Dighton, Esq.
 Plate XV.
“A Tea Garden.”
Stipple-Engraving by F. D. Soiron, after George Morland.
(Published 1790. Size 19¾″ × 16″.)
From the collection of Basil Dighton, Esq.
 Plate XVI.
“The Lass of Livingstone.”
Stipple-Engraving by T. Gaugain, after George Morland.
(Published 1785. Size 11¾″ × 9¾″.)
From the collection of Major E. F. Coates, M.P.