Robotic surgery: Past, Present and Future

Amir R Razavi, Reijo Jämsä

Department of Biomedical Engineering, Linköping universitiet Fokurs - Tekniska System Inom Kirurgin, 2007

Fokurs - Tekniska System Inom Kirurgin, 2007

Contents
Introduction ................................................................................................................................ 3 Definition ............................................................................................................................... 3 Motivation and History .......................................................................................................... 4 Real-life Applications and Considerations................................................................................. 4 Robots in Surgery................................................................................................................... 4 Da Vinci™ robotic system ................................................................................................. 4 Zeus™ robotic system........................................................................................................ 5 Other Systems .................................................................................................................... 6 Surgery Domains.................................................................................................................... 6 General surgery .................................................................................................................. 7 Cardiology.......................................................................................................................... 7 Gynaecology....................................................................................................................... 7 Neurosurgery...................................................................................................................... 7 Urology............................................................................................................................... 8 Orthopaedics....................................................................................................................... 8 Paediatrics .......................................................................................................................... 8 Robot-assisted surgery in Sweden.......................................................................................... 9 Human-robot Interaction ........................................................................................................ 9 Robot-assisted surgery and AI ............................................................................................. 11 Comparison with traditional surgeries, a case study ............................................................ 12 Computer-assisted vs. robot-assisted surgery ...................................................................... 12 Strengths and limitations.......................................................................................................... 13 Strengths............................................................................................................................... 13 Weaknesses .......................................................................................................................... 13 Ethical, Safety and Financial Consideations ............................................................................ 14 Ethics and Legal Aspects ..................................................................................................... 14 Risks and Safety measures ................................................................................................... 14 Evaluation of technical solutions and cost benefits ............................................................. 15 Challenges, Future and Conclusion.......................................................................................... 16 Challenges ............................................................................................................................ 16 Future ................................................................................................................................... 16 Conclusion............................................................................................................................ 17 References ................................................................................................................................ 17

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Introduction
Definition
Scenario 1: a spaceship far far away from earth is cruising in the deep space. One of the crews has a sharp pain in the right lower quadrant of his/her abdomen. The intelligent diagnostic software, after reviewing blood results and analyzing symptoms and signs suggests acute appendicitis. If he/she is not operated in time, there is a risk that the infected appendix ruptures. However, there is no problem for such a simple operation like appendectomy. The patient can be put into sleep by another crew who have had some education regarding anaesthesia and primary medical procedures. However, the operation is entirely done by a surgeon, a robotic surgeon. The patient is placed on the operation bed and is put into sleep. Vital signs are measured continuously and the patient is stable. The robot first identifies the abdomen’s landmarks and locates incision locations. Then the standard operation procedure is started. The skin over abdomen is disinfected and three small incisions are made by the robot, two for inserting instruments and the other one for entering the camera. The operation goes smoothly and the infected appendix is removed. Incisions are repaired and the patient awakes shortly. Without the robot, this operation would have been impossible. The unexpected emergency could have killed one of the crews and the loss would have been immense on the journey. Scenario 2: this scenario starts similar to the previous one but the robot is guided and controlled by a real surgeon from the base station. The real surgeon can see and even virtually feel the organs but the robot performs the actual operation millions of kilometres away. The only task that the robot does is to act as a medium between patient and surgeon. These scenarios may look like a sci-fi story but it is actually an emerging technology called robotic surgery. Three major advances aided by surgical robots have been remote surgery, minimally invasive surgery, and unmanned surgery [1]. It is a combination of medicine and robotics. The production can be a robot, which can autonomously identify tissues and differentiate normal ones from diseased, move the organs and cut them, stop and coagulate bleeding and at the end repair the incisions. In a simpler form, the robot can be controlled by a real surgeon who gives mechanical hands to him/her. The surgeon can be in a distant location or even near the patient. In this case, the robot is used to enhance the performance of the surgeon and overcome his/her limitations or weaknesses and be controlled by remote control and voice. This is called robot-assisted surgery (RAS). Important advantages of this type of robot applications are precision increasing and enabling the surgeons to perform miniature surgeries more easily. Giving surgeons a magnified and a high-quality 3D view to the operation site and also performing difficult articulation manoeuvres are other advantages. It should be noticed that there are differences between robot-assisted surgery and autonomous robotic surgery (ARS). In the RAS form, the robot is like an extension of the surgeon. It enhances him/her and increases the performance and efficiency of the real surgeon. There are some available systems and many operations using RAS have already beed performed. On the other hand, in ARS, an autonomous robot that can do the operation without the presence of a human surgeon. It can plan for the best surgery and performs it without any human intervention. There are no working autonomous robotic surgeons available today but it is a growing research area and a future technology.

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Motivation and History
The origin of robotic surgery starts with the weaknesses and strengths of its predecessor, minimally invasive surgery (MIS). In MIS, tiny cameras in instruments called endoscopes were introduced. These visual and surgical aids could be inserted in the patient's body through small ports. It began in 1987 with the first laparoscopic cholecystectomy and the number of possible laparoscopy operations is increasing. Important strengths of laparoscopies are smaller incisions, shorter stay in the hospitals after operations and reduced risk for infections. Also, they result in a faster return to work, lesser pain and also better cosmetics [2]. However, they have several limitations too. Some important weaknesses are loss of touching feedback, eye-hand coordination and dexterity. It is difficult to move the arms while looking at a 2D video on a TV. Degree of motion for the instruments is limited too and most of them have just 4 degrees of motion in contrast to human wrist with 7 degrees of motion. Decreased sense of touch makes it even more difficult to do the operation because then manipulating the tissues will be dependent on the 2D visualization, which is not convenient. In order to overcome some of the limitations and weaknesses of MIS and also strengthening capabilities of human surgeons, the concept of surgical robots emerged. In 1985, a robot called Puma 560 was used to place a needle for a brain biopsy while it was guided by CT scan [3]. Three years later in 1988, Puma 560 was used to do the transurethral resection of prostate (TURP) operation [4]. PROBOT a robot, which is specifically designed to perform TURP, is the continuation result of Puma 560. In the meantime, precise fittings in the femur for hip replacement surgery was done by The ROBODOC from Integrated Surgical Systems [5]. However, NASA has started to develop telepresence surgery in the 80s. This was the main research force behind the development of surgical robots. The US army then funded a research in order to develop a telepresence surgery system. These researchers then formed a commercial company and introduced automated endoscopic system for optimal positioning (AESOP) for civilian uses. This is a voice-controlled robotic arm to control endoscopic camera. The telepresence surgery system after extensive improvements and changes then resulted in the da Vinci™ surgical system [2]. Another company, shortly after, produced the Zeus system [6].

Real-life Applications and Considerations
Robots in Surgery
Da Vinci™ robotic system It is the first robotics system of its kind to be approved by the Food and Drug Administration (FDA) for use in the US for robotic surgeries. Da Vinci reduces the average 2-3% infection probability to nearly zero. There are four main components to the da Vinci robotic system: the surgeon console, patientside cart, EndoWrist Instruments, and Insite Vision System with high resolution 3D Endoscope and Image Processing Equipment (Figure 1). A brief description of each component follows. Surgeon Console: The surgeon is situated at this console several feet away from the operating table. The surgeon sits viewing a magnified 3-D image of the surgical field with a real-time progression of the instruments as he/she operates.

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Patient-side Cart: This component contains the robotic arms that directly contact the patient. It consists of two or three instrument arms and one endoscope arm. As of 2003, Intuitive launched a fourth arm. It provides the advantages of being able to manipulate another instrument for complex procedures and removes the need for one operating room nurse. Detachable Instruments (Endowrist®): The Endowrist detachable instruments allow the robotic arms to manoeuvre in ways that simulate fine human movements. The device memorizes the position of the robotic arm before the instrument is replaced so that the second one can be placed in the exact same position as the first. The instruments’ abilities to rotate in full circles provide an advantage over non-robotic arms. The seven degrees of freedom offers considerable choice in rotation and pivoting. Moreover, the surgeon is also able to control the amount of force applied. 3D Vision System (Insite®): The camera unit or endoscope arm provides enhanced threedimensional images. This high-resolution real-time magnification showing the inside of the patient allows the surgeon to have a considerable advantage over regular surgery.

Figure 1: Four main components in da Vinci system

Zeus™ robotic system It is another system or robot-assisted surgery system [7]. It has a computer workstation, a video display, and hand controls that are used to move the table-mounted surgical instruments (Figure 2). Zeus also employs the assistance of the Automated Endoscopic System for

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Optimal Positioning (AESOP) Robotic System. It's basically just one mechanical arm, used by the physician to position the endoscope. Foot pedals or voice-activated software allows the surgeon to position the camera, leaving his or her hands free to continue operating on the patient.

Figure 2: A Zeus system in operation

Using the Zeus system, surgeons have achieved some success in France, a series of operations have been performed on infants to repair a condition known as patent ductus arteriosis. Using the Zeus robotic system, a surgeon was able to close an open artery with only 3 incisions of 0.2" diameter each on the patient's body, in contrast to the 4-5" opening and rib cage separation which were previously necessary. In Canada, a surgeon using the Zeus system was able to perform a bypass procedure on a beating heart, again with small incisions only rather than a split chest. The patient was able to return home the day after the operation. Other Systems A list of the working robots in surgery is summarized in Table 1 [8]. Other systems are less common than the previously mentioned systems.
Robot Zeus Da Vinci Inch-Worm Probot Robodoc CASPAR Acrobot Minerva AESOP Fips endoarm Endoassist Classification Master-slave telemanipulator Master-slave telemanipulator Active autonomous Active surgical Active surgical Active surgical Semi-active surgical (synergistic) Active surgical Active camera Active camera Active camera Application General, cardiothoracic, and gynaecological surgery General, cardiothoracic, and gynaecological surgery Colonoscopy Resection of benign prostatic hyperplasia Prosthetic hip implantation Prosthetic knee implantation Prosthetic knee implantation Stereotactic neurosurgery Minimal access surgery camera manipulation (voice controlled) Minimal access surgery camera manipulation (finger ring joystick controlled) MAS camera manipulation (synchronised to surgeon's head movements)

Table 1: A summary of robots in surgery.

Surgery Domains
In some domains robotic surgery is more common than others. Robots are used more in General surgery, Cardiac surgery, Gynaecology, Neurosurgery, Urology, Orthopaedics and Paediatrics.

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General surgery MIS has now been around for about a decade and some simple operations such as cholecystectomies now being performed with laparoscopic instrumentation routinely. Some difficult procedures, such as donor nephrectomy, bowel resection, and even pancreatic surgery have been done by laparoscopy but the number is low and MIS is limited mostly to simple operations. New advancements in technology such as robotics and image processing that allow more complex procedures to be done by laparoscopy broaden this field to almost any operation. This is the main reason for introducing robots in general surgery. Common procedures aided by robots in general surgery are bowel resection, cholecystectomy, antireflux surgery, Heller myotomy, splenectomy, exploratory laparoscopy, adrenalectomy, pyloroplasty and resection of a gastric mass, duodenal and colonic polyps [9]. Cardiology Because the heart is a dynamic organ which moves all the time during operation and also necessary surgical manoeuvres are complex, ordinary NISs are not convenient and very difficult to perform. Therefore robotic heart surgery focuses on making endoscopic heart operations feasible [10]. In this type of operation, a computer is used to control and manoeuvre instruments and a tiny endoscope provides a 3D varies of the operation site. Computer control of the surgical instruments eliminates the hand tremor and facilitates complex manoeuvres. The experience is similar to playing a TV-game by using special gamepads. Robotic heart surgery started with bypass surgery and has so far been limited to single bypass grafts in the left anterior descending coronary artery (the LAD) [11]. Furthermore, robotic procedures have been successfully performed in mitral valve repair, repairing atrial septal defects (ASD) and repairing patent ductus arteriosus (PDA). Most of the heart patients are old and any method to decrease the post-operative complications is appreciated. Because of the tiny incisions, the recovery after the operation is fast and the patient can be discharged from the hospital faster. This is good both for the patient and for the hospitals. Because the technology is new and the expenses to start such systems are very high, they are not still very popular. Nowdays cardiac surgeons are operating without the robots so it needs more time to see more robots in heart surgery. The ultimate goal of the robotic cardiac surgery field is a robot capable of performing closed-chest, beating-heart surgery. Gynaecology Robotic system has been used for benign and malignant female pelvic conditions, such as cancer of the uterus and cervix. It is especially useful in the performance of hysterectomies, removal of fibroids while preserving the uterus, correction of vaginal prolapse, and for the treatment of gynaecologic cancers. Patients undergoing these procedures experience less pain, have fewer instances of infection and recover more quickly than those undergoing open surgery. The robotic operation is more precise than conventional surgery and it allows patients to return to normal activities quicker because of the less tissue trauma [12]. Neurosurgery Programmable Universal Machine for Assembly (PUMA) industrial robot was the first robot ever used for neurosurgery. The surgeon entered the x-y coordinates to a probe based on a preoperative image of an intracranial lesion and then used programs which calculated the stereotactic coordinates, which then guided the drilling of the biopsy. The device lacked safety features, but the potential of this technology excited scientists all over the world.

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However, the first neurorobotic device to be approved by FDA was NeuroMate. Preoperative imaging helped the surgeon plan the procedure, and a passive robotic arm was able to perform limited tasks in over 1000 procedures. However, this technology still relied on preoperative images to position the robot, and was prone to errors when the brain shifted [13]. Minerva was the first system to provide image (CT scan) guidance in real-time, allowing the surgeon to change the trajectory as the brain moved, resulting in frameless stereotaxy [14]. The position of surgical tools in relation to intracranial imaging could now be seen. The system improved safety features, which were lacking on the previous models. However, the system was still limited because it could only perform single dimension incursions, and the patient had to be inside the CT system. Robot-Assisted Microsurgery System (RAMS) was the first robotic system that resembled present day robotic surgical suites [15]. It was the first system that was compatible with magnetic resonance imaging (MRI), as it was able to filter out electromagnetic fields that distorted images. Intraoperative imaging could now be fully integrated into the operating room unlike the Minerva. The system was based on master-slave control with 6 degrees of freedom, allowing 3-D manipulation, and not just limited to stereotactic procedures. The NeuRobot was the first system that performed telecontrolled surgery through an endoscope [16]. The 10-mm endoscope contained twin tissue forceps, a camera, a light source, and a laser. The investigators removed a tumor from a patient, and found the system to be more accurate and less invasive then traditional methods. The SpineAssist Robot was the first FDA approved robotic system for spinal surgery. The device is guided by imaging and is placed directly on the spine for more accurate tool placement and less invasive surgery [17, 18]. Urology Advantages of robotic surgery was the main reason to introduce this type of operation in Urology in the late 80s [19]. The first urological robot, also known as URobot was the PROBOT in 1989 which was used in clinical trials for transurethral resection of the prostate (TURP) [20]. Automated Endoscopic System for Optimal Positioning (AESOP) was one of the first to control laparoscopic tools in urologic surgery with its manipulator arms. In Urology, robots are assisting urologists with TURP, percutaneous renal access, laparoscopy, and bracytherapy. Laparoscopic nephropexy, pyeloplasty, and ileocystoplasty have been done with robots. However, they had a longer operative time than conventional laparoscopy for a particular urologic surgery while other showed a shorter operative time, and reconstruction time. Orthopaedics The main advantages of robotic surgery in Orthopaedics are improved accuracy and precision in the preparation of bone surfaces, more reliable and reproducible outcomes, and greater spatial accuracy. The ability to isolate and rigidly fix bones in known positions allows robotic devices to be securely fixed to the bone. Some of the surgeries in this category are include total hip and knee replacement, tunnel placement for reconstruction of knee ligaments, and trauma and spinal procedures [21]. Paediatrics Until the mid-1990s, MIS had been limited in paediatrics because of the large size of the available laparoscopic equipment as compared to the small size of the patient. Robotic surgery made it possible to many new possibilities for MIS in children. Dissecting, suturing,

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and knot-tying have become simple compared to standard laparoscopic movements. Paediatric surgeons commonly use robots to perform fundoplications, a procedure to tighten the oesophagus in children with reflux disease and ligation of patent ductus arteriosus [22]. With using robots, surgeons began to think about fixing fetal abnormalities such as diaphragmatic hernias or myelomeningoceles in utero. Because no hysterectomy is required, such surgery is not subject to the disastrous complication of preterm labour [23]. So far, Robotic surgery has been used in many types of paediatric surgical procedures including: tracheoesophageal fistula repair, cholecystectomy, congenital diaphragmatic hernia repair, and others.

Robot-assisted surgery in Sweden
Today there are four operation robots in Sweden. The Urology clinic in Karolinska University Hospital has done under 2005 nearly 9000 prostate cancer operations using robotic techniques, which is the highest number of such operations in Europe. There are just a couple of centres in USA with higher number of such operations. In 2005, Lund University hospital and University Hospital in Malmö (UMAS) bought a da Vinci robotic surgery system to each hospital and the first hysterectomy by robotic surgery in Scandinavia took place in the Gynaecology department in Lund. At UMAS a collaboration started between Urology-, Surgery- and Gynaecology departments at the hospital. This year Linköping university hospital plan to purchase a robotic system used for urological surgery (Figure 3).

Figure 3: Linköping University Hospitals planed new robot which is similar to this shown in the picture. Foto: [2007] Intuitive Surgical, Inc.

Human-robot Interaction
What is an appropriate user interface for a medical robot? Is force feedback necessary for a high-definition user interface? The answer surely will differ, depending on the medical mission for the robot. Is a push-button or joystick suitable to the surgeon? Medical robots will initially be more accepted by surgeon if the he/she sense that they are totally in control of the procedure [24]. The interface has an amazing importance for the safety and efficiency of the surgical treatment. The Zeus system includes a voice-controlled arm called AESOP (Automated Endoscopic System for Optimal Positioning). Providing steady image and reliable scope movements the robotic arm automates the monotonous and tiresome job to hold the endoscope and assist in

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minimally invasive heart surgery. The operator carries special glasses to produce a 3D image. This is two of the main differences to the da Vinci system that has a 3D optical lens system, which can increase the visual area up to15 times. Sensors give the surgeon information such as mechanical speed, force, pressure, stress and acceleration. These sensors can be divided into following categories based on their function: sensors replacing the manual palpation, for in situ diagnosis, to control of the movement of the tele-manipulator and the effectors, and for monitoring of the various functions of the telemanipulator [25]. Two topics is the main research area in this field are design and implementation of better instruments, that can supply the surgeon with high standard sensorial feedback, and implementation of more advanced human-robot interfaces. Robotic surgeries need the use of imaging in advance to perform and diagnose the operation. Images are supplied through computed tomography or magnetic resonance imaging in 3-D or through X-ray radiography, ultrasonography, and fluoroscopy in 2-D ones. Even though telesurgery and robotic surgery have many points in common, the robot control methods and human-computer interface can differ considerably, usually a human guides the robot throughout the process. The robot behaviour is not fixed but real-time controlled by the surgeon. In telesurgery it’s almost the opposite, the surgeon have to rely on the sensor data, transmitted from a distant place. Examples of some robot interface have been shown in the following pictures (Figures 4-8).

Figure 4: Hand on Control

Figure 5: InSite® Vision

Figure 6: A prototype glove-like device that senses the positions of the surgeon's fingers and wrist with its index, thumb, and wrist flex sensors and wrist rotation sensor

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Figure 7: Console Masters and EndoWrist

Figure 8: Zeus console

Robot-assisted surgery and AI
AI techniques is usually used to produce a series of operations to perform a semi-automatic surgical task. It must be compatible to the robot system. An interface translate the surgeon’s “command” into the robot language so the robot can execute a pre-programmed sequence. The need of force feedback makes AI less practical and no applications of AI to medical robotics are described in the literature [25].

Microrobots
Very small robots, each one measuring about 1.5 by 3 cm and are designed with different kinds of actuators for gripping, cell manipulation, and so on. Each one would be wireless, with built-in electronics, and an infrared control system. They should be able to cooperate together on a range of tasks. Many new technologies are used in microrobots such as wireless powering system. The individual robots are not that intelligent, and don’t, for example, know where they are, although they know which direction they are moving in. A special positioning system is necessary to know where each robot is. It views them from 40 to 50 cm above and they are controlled by a central robot control system, with several networked computers for planning and commands. There are different scenarios to use these robots. A medical or biological application, in which the robot was handling biological cells, injecting liquid into them and a micro-assembly, in which the robot soldered tiny parts. A more ambitious plan will be to use much more microrobots together in a variety of applications, including micro assembly, biological, and medical or cleaning tasks. The number can reach up to a thousand robot clients. This is a project, which is led by Jörg Seyfried of the Institute for Process Control and Robotics (IPR) at the University of Karlsruhe in Germany.

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The picture below (Figure 9) is an example of cell manipulation, which has typical dimensions in the micrometer range. Here, tasks range from simple cell pick-and-place operations to injection of substances into the cell [26].

Figure 9: Cell manipulation [43]

Comparison with traditional surgeries, a case study
In the first direct comparison of robot-assisted and traditional surgery for children’s heart defects, University of Michigan surgeons report that the robot’s help reduces patients’ recuperation time and surgery-related trauma and scarring, while extending the length of the operation by just over half an hour. This method can give the same surgical result as openchest techniques, with less impact on the young patient’s body. The robot used in this operation has two main components: a robot with three arms for instruments and a small camera, and a visualization and guidance station where the surgeon can manipulate the robot arms using three-dimensional images from the camera inside the patient. The patient had atrial septal defect (ASD) and vascular rings, rare birth defects in which blood vessels surround the esophagus and trachea, reducing ability to breathe. Surgeons by help of the robot divided the vascular ring. Children ranged in age from 1 to 10 years, and the smallest weighed 10 kilograms, since the camera is too large for a smaller child. The robot-assisted group had a median hospital stay of two days, compared with four days for children who had open-chest surgery. One patient in each group experienced a complication called a chylothorax, in which a lymphatic duct was punctured and leaked fluid into the chest cavity. This report is the first to describe the use of the da Vinci surgical system to assist in a thoracoscopic procedure for a paediatric patient and showed that robot assisted surgery for young heart patients reduces hospital stay, pain, scarring and healing time [27].

Computer-assisted vs. robot-assisted surgery
Computer-assisted surgery (CAS), Alternatively referred to as “image-guided surgery,” “surgical navigation,” or “3-D computer surgery,” is the application of advanced computerized technology in the planning, performance and follow-up of invasive surgical procedures. CAS improves visualization as well as improved diagnostic competence, resulting in a significant advantage over conventional techniques. Robot-assisted surgery, on the other hand, requires the use of a surgical robot, with or without the direct role of a surgeon during the procedure. One advantage of robot-assisted surgery over CAS is its accuracy and ability to

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repeat identical motions. Their main distinctions lie in the intraoperative phase of the procedure: robot-assisted surgeries may use a large degree of computer assistance, but computer-assisted surgeries do not use robots [28].

Strengths and limitations
There are some advantages and also some weaknesses in using robot-assisted surgery [29]. In each domain, these should be evaluated first and then the system be implemented.

Strengths
Some of the strengths of this system are: 1- physical separation of the surgeon from the patient by operating at a console rather than at the patient’s side. One of the benefits is to reduce the probability for infections transmitted to the patient. 2- Degree of freedom. Wrist action of the robotic arms providing seven degrees of freedom plus grasp compared with four degrees of freedom plus grasp for standard laparoscopic instruments. Additional degrees of freedom comparing to the laparoscopy instruments, internal pitch and internal yaw, create the sense of actually having the surgeon’s hand within the abdominal cavity during laparoscopic surgery. 3- Tremor elimination: The system eliminates any tremor from a surgeon’s hand. 4- Optional motion scaling up to 5:1. Motion scaling reduces the surgeon’s motion at the console to finer movements within the patient. Thus, when the system is set to 5:1, a 5-cm sweep by surgeon’s hand is a 1-cm sweep within the abdomen or a 5-mm sweep is a 1-mm sweep. This enables the general surgeon to perform microsurgical tasks laparoscopically without the need for loupes or other vision augmentation devices. 5- A three-dimensional stereoscopic image. It is not comparable to the views from laparoscopic surgery. The surgeon can control the visual field and changing the view and angle. 6- Electronic information transfer. In the current systems, all of the information transferred is digital. With the current configuration, wires connect all these elements. There is no reason that in the future, Internet link-up, telephone wires, or satellite links could not connect them. Telesurgery is a concept that has existed, and been controversial, for a number of years. In civilian practice, such systems may provide the ability for super-specialized academic surgeons to help rural surgeons perform operations from the convenience of their own offices.

Weaknesses
Some weaknesses of the system are: 1- sensation. A weakness in the system is reduced sensation. The system has some force feedback, but there is little correlation between the pressure placed on the controller and the amount of pressure placed on tissue by the various instruments. Thus, the surgeon must rely on visual data to know how much pressure is being exerted and it is even less than laparoscopic instruments. 2- Confined operative field. Some extensive operations such as total abdominal colectomy, where multiple areas of the abdomen are approached, are extremely difficult to be operated with this system and would require movements of the cart. 3- Anesthesia complications. If the surgical cart is positioned above the patient, the robotic arms are directly above the patient’s face. This could put the patient’s face and airway at risk during movement of the cart. In addition, during the procedure itself, there is limited access to

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the patient’s airway and nose. 4- Communication. Another surgeon at the operating room table must provide retraction and manipulation beyond the two robotic arms. Constant communication back and forth between the surgeon at the console and the surgeon at the table is essential. The surgeon’s head being buried in the surgical console can hamper this communication. 5- Break down. A complication that can occur with robotic surgery is that the robot can breakdown in the middle of the surgery, which will cause the surgeon to rely on conventional surgery.

Ethical, Safety and Financial Consideations
Ethics and Legal Aspects
The use of robots is in practice based on, cost, safety, usability and performance. To consider the ethical aspect how to provide people in Europe healthcare equally and safe when it’s in the future is possible that people need to pay for services due to economic limitations, and when we speak of Robot surgery with intelligent robots, the cost of use is still higher than conventional surgery due to investment expenses, although the outcome is not substantially improved yet [30]. The patients capability to afford the treatment or its benefits effects also how new healthcare technologies is spread and accepted. Legislation has to follow the technology development to ensure patient and personnel safety, i.e. risk or accident cased by the robot, whose responsibility?, supplier, owner, user or the robot, in the extreme situation once the robot loses control. Today medical equipment follows Medical Devices Directive (MDD) which regulates the selling and usage. This is even a bigger issue when discussing telesurgery where the traditional need of face-toface contact between surgeon and patient is impossible. More than one country or state can be involved and conflicts of jurisdictions may occur. Errors associated to equipment malfunction, transmission delays or when approval is needed for some decisions may cause problems between the involved partners. With the introduction of such a system, complexities have increased exponentially. In order to understand and utilize the new technologies as effective as possible, surgeons need to be familiar to the science of systems integration. Requirement for these systems and their applications demands skills, education, training, assessment needs, and also new responsibilities [31].

Risks and Safety measures
Medical robots present complex safety problems in comparison to other industrial robots due to human presence, fault consequences and non-generic parameters [32]. In the industrial environment using robots, usually a person is present. Safety rules state that the robot must be de-activated in case of unexpected accidents and the person takes control in the meantime. Medical robots are vital to assist and have to be able to work together with the surgeon. Concerning their environment, medical robots need to have rich sensory and logic potential which pushes robot designers to the technology limits in order to guarantee the safety of the patients and users [33]. Industrial robots usually perform a series of actions in a number of pre-defined order but when using medical robots, each patient has their individual anatomy, making a standardized approach unsuitable [32].

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The picture of total safety is a myth. In general, the probability of fault/mistake must always be kept very low. Even more essential than the possibility of a fault is perhaps the skill to detect that a fault has in fact occurred and avoid hazards as a result from it by allowing the robot to "fail safely". This typically means shutting the robot down and continuing operation manually. Unsafe operation of a medical unit may be caused by failure in hardware and/or software components, misunderstandings, wrong or insufficient specification. The task in robot surgery becomes increasingly difficult to carry out which raises the possibility of fault/mistake exponentially. It is noteworthy that software is especially difficult to argue about, while hardware isn’t of prime importance. Robot size can be a consideration to take in concerning safety when a larger robot usually is more powerful than a small one resulting in more damage in case of a fault. In addition, both doctors and patients may feel uneasy working side-by-side with a big and heavy tower [32]. The most common risk factor during standard robotic surgery procedure is obesity (an abnormally high proportion of body fat) which increases the probability of having complications at some stage after robotic surgery. Other complications during the procedure may occur such as: anaesthesia-related problems (a longer time is required to achieve the same outcome), bleeding, damage to neighbouring organs or structures and infection. Sometimes it even becomes necessary during the procedure to abandon the robotic method and perform the surgery using traditional methods. A problem is that haptic (sense of touch) feedback is missing throughout robotic surgery. Robot-assisted surgery gives on the other hand benefits in the surgical care of patients. Computer-assisted robots give exact movement and trajectories. Smaller incisions to access patient can also be done by the use of surgeon-guided robotics. In the area of remote telesurgery the main problem is the need of a fast and secure network connecting hospitals [34, 35]. Remote operations demand both rapid and exact communication for information [36]. To perform surgeries on a ship or in space is not yet possible because currently they are accessible only through satellite communication, which as for now is unsuited for secure surgical operations [37]. Low orbit satellites may bring this to a technical solution.

Evaluation of technical solutions and cost benefits
Robot-assisted surgery can unite intuitive thinking, the human skill and a robots accuracy and speed. Surgery on distance, or distance assisted surgery may increase the skill of the local surgeon as well for the surgeon specialist. The degree of surgeon interaction during the procedure divide robotic surgery into three categories: shared-control, supervisory-controlled and telesurgical [38]. Most surgeon participation is with a shared-control system. A robot offers steady-hand manipulations of the instruments to the surgeon. However, the system can act in two ways. One is a supervisory-controlled system, in which the procedure is executed according to the computer program, and the other is remote surgery, also known as telesurgical system. The robotic arms are manipulated by the surgeon during the procedure. Real-time image feedback with sensor data from the robot helps operating from a remote location. The da Vinvi® Surgical System belongs to this type of robotic surgery. The acceptance of the master-slave robotic platform is prevented by the excessive cost including the initial robot investment, maintenance cost and special pre-programmed laparoscopic instruments. Cost every time the robot is used a special team has to set it up

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involving calibration of the laparoscopes, attachment of instrument holders, application of special drapes and docking the robotic arms and instruments. OR-room time which is expensive and not negligible, is used but may be reduced with experience. Training and knowledge with the docking procedure is necessary to reduce start up time [39]. The complete robotic system occupies a lot of a regular operating room and some hospitals have developed explicit rooms to hold robotic surgery which adds to the cost of the system use. Although the total cost is quite high the system have limitations which reduce its use as the size of the robotic arms and instruments is big for small body and paediatric patients. Endoscopic manipulators can be a substitute to robots with the advantages of lower cost, easy set-up and need of less space compared to master–slave robotic systems [39]. Once RAS becomes cost-effective, there is little reason why we should not use robotic system wherever possible. Most studies reported that gastrointestinal surgery with robot compared to conventional laparoscopic surgery is sufficient and safe, reduced tiredness, improved handiness, gives better images and higher levels of precision [40]. Main drawbacks for robots are the lack of force feedback and enormously high costs. The outlook of telesurgery is limited by the availability of high bandwidth communication lines and lag time, cost of technology, ethical and liability issues and possible conflicts of jurisdictions between countries involved [41]. Use of the high-speed terrestrial network, rather than satellite connections, would significantly reduce the time lag for transmission of data [42].

Challenges, Future and Conclusion
Challenges
Developing new technologies in the field of robotic-assisted surgery has contributed to increased operation safety, easier and faster sterilization, increased compatibility with other devices and improved ergonomics. Haptic feedback is one of the future development areas to focus on and to refine better improved reality, miniaturization and telesurgical capabilities is other developing goals [41]. Future goal is to make a safe, slow, sterilizable, small, accurate and compact robot and on multimodal images based planning system. To achieve safe and secure remote surgery, a secure and fast network must be available to hospitals and solutions on legal responsibility and ethical issues need to be solved to avoid potential conflicts between involved countries.

Future
Using robots in surgery is in its first stages. There are some more challenges in front of researchers and also surgeons who are using this system. Increasing the safety of the system and make it easier to sterile parts specially fixed part like arms and the base robot unit should be focused. Reducing the size of the components and operating room requirements can make their application more convenient. Compatibility with available medical equipment and standardizing the equipments for each operation and considering the ergonomics and reducing the cost of the system are required for the development of new technology in the field of robotic surgery. These advances can lead to a more common use of robots in surgery. Of course, there is a necessity to compare robot-assisted surgery with

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traditional ones and calculate the benefits, which are gain. These benefits are both economically and also qualitatively based on the outcome for the patients. Another field for the future development is integration of intelligent systems. Autonomous surgeons, which can start an operation and end are still in the sci-fi stories. However, all the necessity technologies are present and just integrating them in one place and for one aim is necessary. Make these intelligent system safer and economically reasonable should always be in mind.

Conclusion
The scenarios that were told in the beginning of the report are still far from the hand but they are the paths for robot-assisted surgery. Both of scenarios, assisting the surgeons and autonomous robots are two fields that many researchers with high motivation are working on. The technology is in hand and their integration and also making them cost-effective is the focus for researchers. We are sure that the medical community will hear more breaking news from researchers in this field in the future. It is a bright future whose aim is to increase the level man kind quality of life.

References
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