As a child, I was fascinated with robots, reading about robots, watching robot cartoons like the Jetsons, and collecting toy robots. The only problem was I loved to take the robots apart to see what made them work, but I wasn’t ever very successful reassembling them. Maybe that’s why I eventually became a surgeon instead of an engineer. Today, after a 50-year career as a surgeon, I am once again intrigued by robots—this time wondering how and why they have invaded my operating room, which I thought was the surgeon’s domain. It turns out they are not here to harm us as I once thought, but rather to assist us in our endeavor to deliver better health care.
As most of you are probably aware, the number of the robot invaders is increasing daily in our hospitals and an ever-increasing number of surgeons are combining forces with this relentless army of mechanical surgical assistants. Like the evolution of our favorite bands, the robot invasion didn’t happen overnight. It has taken more than 20 years. As one who witnessed the laparoscopic revolution in surgery, I recently became intrigued by how the robotic one was mirroring it in many ways. The pathway by which robots became surgical assistants in today’s operating theater was sometimes tortuous and arduous. It is worth reviewing to understand how we as surgeons may continue to develop and change the future.
We should not be the specialists of Gropius, the founder of Bauhaus Architecture, who said “specialists are people who always repeat the same mistakes.” As you follow the tale of robotics, it should remind you of how in the past surgeons at first ridiculed, then fought and finally accepted changes in surgery (e.g., laparoscopy, lumpectomy for breast cancer, mesh for hernia repair and other paradigm shifts). Instead, we should listen to Quavo, an American rapper: “History repeats itself. So, you may want to pay attention.”
Origins of the Robot
If we look at the original meaning and origin of the robot, it makes sense why a robot would be a perfect surgical assistant. In 1921, Karl Capek, a Czech playwright, coined the term “robot” to refer to mechanical men who were built to work on an assembly line; in his play, they rebelled against their masters. Isaac Asimov, a science fiction writer, in 1942 took a more positive attitude toward his fictional robots, making them helpful rather than evil. He proposed three “laws of robots,” of which two surely apply to our modern concept of medical robots:
- Law 1—A robot may not injure a human being or, through inaction, allow a human being to come to harm.
- Law 2—A robot must obey the orders given it by human beings except where such orders would conflict with the first law.
The first advanced modern robot appeared in 1958, at the Stanford Research Institute. Although it was named Shakey because of its wobbly clattering movements, it might be considered the great-grandparent of today’s steady-handed medical robots. Three robot systems have been developed:
- active, which work autonomously;
- semi-active, which are preprogramed but allow the operator to complement the actions; and
- master–slave systems, which lack preprogramming and depend on the operator. This type of system is the contemporary model for today’s surgical robots, but this may change in the future.
The Robot’s Journey to the OR
To begin the robot’s trip into today’s OR, we need to go back to the collision of two research groups, one originally from our government and the other at the Stanford Research Institute. Their initial aim was to build a system that could aid the wounded on the battlefield. In 1987, Richard Satava, MD, a surgeon and colonel in the U.S. Army, joined with the Stanford team to begin development of a “telepresence surgery system” that at first was meant for open surgery. After viewing a video of Dr. Jacques Perrisat performing a laparoscopic cholecystectomy in 1989, Dr. Satava suggested the Stanford group switch their research to use the laparoscopic platform instead of conventional open surgery. He felt the telepresence system was ideally suited for the laparoscopic platform because it solved the fulcrum effect of conventional laparoscopic instruments and could improve surgeon performance with its stereoscopic vision, improved dexterity and tremor reduction. Unfortunately, as you will see, it took some time before Dr. Satava’s predictions became reality.
It took two groups that, at first, worked independently, then competitively, and eventually as one company. In 1990, Yulun Wang, MD, from the University of California, Santa Barbara, founded the company Computer Motion. His first endeavor was a robotic endoscope holder that responded to the surgeon’s commands, and eliminated assistant tremor and the need for a human assistant. As an ego-building bonus, if asked, the system would even verbally compliment the surgeon. Aesop, as the system was called, was the first FDA-approved surgical robot and the first voice-controlled equipment to be used in the OR.
Important to the development of robotics in the OR was that Computer Motion used the FDA’s 510(k) process, which allowed robotics to reach the OR and surgeons years sooner, and it set the precedent for the robotic invasion to come. In 1996, Computer Motion introduced Zeus, a robotic system that combined the camera holder with laparoscopic instrumentation. Its first target specialty was cardiothoracic surgery, and although revascularization of a heart had been achieved by Douglas Boyd in Ontario in 1999, difficulties in this arena were encountered because of the enclosed space. In 2001, a transatlantic cholecystectomy was performed using Zeus, proving that telesurgery employing a robot system was, in fact, possible.
Almost simultaneously, Fred Moll, MD, one of the pioneers of laparoscopic instrumentation—including trocars and laparoscopic hernia balloons and staplers—became interested in robotic applications for laparoscopy. In early 1990, however, there were two major hurdles to overcome before the robots could begin their march into our ORs: raising money and FDA approval. Although there was government funding because the military had a keen interest in treating casualties remotely, private or venture capital investment was initially lacking. Dr. Moll, recognizing that a robotic platform might reduce some of the drawbacks of conventional laparoscopy, tried to convince Guidant, a leader in endoscopic instrumentation, to invest, but he was unsuccessful. Not discouraged by industry’s failure to see the benefits of a robotic platform, he approached the venture capital firm Mayfield Fund, which had been a backer of Origin, his previous endoscopic company. Again, the promise of robotics was not evident to investors, but, confident in his predictions, he continued to build a team. In 1995, Fred Moll, John Freund and an engineer named Robert Younge acquired the intellectual property from the Stanford Research Institute, received venture capital funding and founded Intuitive Surgical.
Surgical Robotic ‘Firsts’
On March 3, 1997, in Belgium, Dr. Jaques Himpens performed the first robotic-assisted operation in a living patient, a cholecystectomy using Intuitive Surgical’s robot, called Mona. A human assistant held the endoscope since this system did not have a camera holder. Unfortunately, the paper documenting this event was rejected by two prestigious journals, The New England Journal of Medicine and Lancet. The robot did not receive its first publication until 1998, when the placement of a gastric band robotically was published in Obesity Surgery by Cadiere and Himpens (1999;9[2]:206-209). The system did have several shortcomings, which included fragile instrument coupling, less than adequate visualization, and a difficult and prolonged setup. These problems would be addressed in the next modification of the system, da Vinci, which began human trials in 1998 in Mexico, Germany and France. By 2001, there were 146 procedures—including antireflux, gynecologic, inguinal hernia and cardiac surgery—performed using the Intuitive robotic platforms.
In the United States, FDA approval for a true robotic assistant was not immediate. In 1997, the da Vinci by Intuitive was approved, but only for visualization and extraction, severely limiting its usefulness. It was not until 2000 that the FDA approved the da Vinci system for general surgery—including cholecystectomy and fundoplication—fully utilizing the benefits of the robotic platform. The approval was granted through the 510(k) pathway by claiming equivalence to previous technology, allowing Intuitive to begin to expand from the international market into the United States.
At this point, there were two robotic armies, Computer Motion and Intuitive Surgical, competing for the same battleground with different software and different hardware. The war that ensued, however, was in the courts and not the OR. It dragged on for three years, with each company suing the other over patent infringements. In 2003, the companies merged—Zeus, the Computer Motion robot, was phased out and some of its unique elements were incorporated into future da Vinci robots.
Although the first cases that were part of a trial in Mexico and Europe were performed by general and cardiac surgeons, the first procedures to gain serious credibility in the United States were performed by urologists. Only isolated cholecystectomies, inguinal hernia repairs and fundoplications were attempted in early 2000 in the United States, while robotic radical prostatectomy was gaining rapid acceptance by the urologic community. After the first robotic prostatectomy was performed by Dr. J. Binder in Germany, Mani Menon, MD, at the Vattikuti Institute in Detroit, reported a series of cases in 2002, and, more importantly, a way to successfully teach the robotic approach to surgeons who had previously only performed open radical prostatectomy. The first studies demonstrated that the robotic procedure was safe and effective but initially took longer than conventional open prostatectomy. As data from randomized studies accumulated, the robotic-assisted approach seems to decrease hospital stay and blood loss—important parameters—but whether it decreases long-term morbidities or has oncologic benefit is still debated. After 20 years, however, the preference of surgeons and patients has resulted in more than 85% of radical prostatectomies being performed using the robotic platform.
The next group of surgeons to widely adopt a robotic-assisted approach were gynecologists. Unlike the urologic surgeons who were laparoscopic-naive, this group had extensive experience with laparoscopic procedures, but most had not mastered certain advanced laparoscopic skills, such as suturing. Because the robotic platform simplified learning this skill, thus facilitating an MIS approach to hysterectomy, many were eager to adopt the robotic approach. In 2001, Arnold Advincula, MD, while at the University of Michigan, in Ann Arbor, performed one of the first robotic-assisted hysterectomies in the United States and would later publish the first series. Despite the initial denial of its value by the American College of Obstetricians and Gynecologists, its adoption has grown rapidly to more than 30% for benign and more than 65% for oncologic disease by 2020, a pattern that seems to repeat itself in other surgical disciplines.
Not all the robotic invasion has been in a forward direction. To capture laparoscopic biliary surgery, Intuitive Surgical and robotic surgeons experimented with single-site, robotic-assisted cholecystectomy. There was early adoption by some, but without articulation—one of the major advantages of robotics over conventional laparoscopy—and with an increase in trocar site hernias due to the larger port site, most abandoned this robotic platform for use in biliary surgery. Surgeons learned that the robotic platform must be equal to, or have advantages over, the laparoscopic platform, and be cost-effective, if it is to have value and sustain or increase its use by the surgical community.
Robotic-Assisted Surgery in Subspecialties
The rest of the robotic invasion is fragmented and should be broken down by surgical subspecialties. Although many of the first cases other than cardiac were general surgical in nature—cholecystectomy, inguinal hernia repair, antireflux surgery and even bariatric surgery—surgeon adoption was slow compared with urology and gynecology. The added value of a robotic assistant was not apparent to the majority of academic and private practice general surgeons. However, there were a few pioneers in each discipline who attempted to demonstrate the platform’s value, and influenced not only robotic history but helped determine its direction and ultimately increased its value.
Colorectal surgery is one example where a few surgeons led the way. The first colon resection on record, a sigmoid resection, was performed by Guillermo Gomez, MD, in Texas in 2000, and within a few months was followed by Mark Talamini, MD, at Johns Hopkins University and Pier Giulianotti, MD, in Italy in 2001. The cases were performed with the original da Vinci robot from Intuitive, but adoption was slow because of docking logistics and the need to use conventional laparoscopic staplers and energy sources. This prompted the industry to develop the next generation of robots with improved docking, thereby decreasing operative time and including instruments that would make the procedures completely robotic-assisted. Both professors moved—Dr. Talamini to UC San Diego Medical Center and Dr. Giulianotti to the University of Illinois at Chicago, to become the respective chairman of surgery, where they would continue to advance robotic investigation and establish research and training centers.
What is evident through the different surgical disciplines is that a concerted effort to develop new and improved methods of teaching became an integral part of the robotic invasion and increased the rate of adoption, especially by nonlaparoscopic surgeons.
Initial Resistance to the Surgical Robot
Many of us, including myself, initially resisted the robotic platform because an assistant at the table had to perform some of the essential and important tasks that were traditionally performed by the surgeon of record. Although the robot answered what many of us in the early days of laparoscopy said would be a perfect laparoscopic surgeon, “one with three arms,” it failed to allow the surgeon to have complete control of the operating field. In 2014, the da Vinci Xi robotic platform was introduced largely for general surgery to overcome many of the problems uncovered by the first adopters of the robotic assistant and to answer the questions of the nonbelievers. The Xi not only allowed the surgeon to have a third arm as did earlier robots, but equipped the arm with the essential tools necessary to be a complete assistant, eliminating the need for a surgeon assistant. The surgeon was now in total control of the operating field from retraction to visualization to stapling and energy for hemostasis.
In addition to the added control, because the boom of the Xi robot could rotate, the need for redocking was no longer necessary when the field of dissection was changed—for example, going from the pelvis to the upper abdomen as in mobilization of the splenic flexure. Early growth in robotic-assisted colectomy has been slow, just as it was with laparoscopic colectomy, but it has reached a level of approximately 18% use since the introduction of the Xi platform. Some surgeons have even adopted extraction techniques first promoted by laparoscopic pioneer Morris Franklin, MD, of Texas, to further advance its minimally invasive value.
Foregut procedures, including antireflux and bariatric, were some of the first robotic-assisted procedures performed, but their value was seriously questioned because of the limitations of the original robotic platform. In 2000, Santiago Horgan, MD, at the University of Illinois at Chicago, performed the first robotic-assisted gastric bypass and, in 2001, the first Heller myotomy in the United States. At The Ohio State University, from 2000 to 2002, Scott Melvin, MD, performed the first robotic-assisted pancreatectomy, Whipple procedure and esophagectomy, while Dr. Giulianotti in Italy was the first in Europe to accomplish it during the same period.
I remember well the videos of these feats and others being presented at national meetings like the American College of Surgeons, but other than amazement, most of the audience did not seem impressed. This reaction was similar to what early adopters of laparoscopy experienced from the academic community in the early days of laparoscopy. The value was not appreciated, and many thought it was a novelty not worth pursuing. As with robotic-assisted colon resection, it took improvements in the robotic platform and a second wave of pioneers to demonstrate the value of robotics in foregut and hepatobiliary and pancreatic surgery.
Robot’s Effectiveness in Complex Cases
Just as important as numerous studies showing safety and data were in establishing the value of the robotic assistant, was the benefit it demonstrated for surgeons already skilled in advanced laparoscopy. Skilled laparoscopic surgeons like Steve Scott, MD, Eric Wilson, MD, Carlos Galvani, MD, and others have stated that the robotic assistant stands out especially when performing the most challenging cases—operations on superobese patients or those requiring complex procedures. At first, these robotic surgeons felt limited by available robotic instrumentation just like the colorectal surgeons, and had to combine robotic and laparoscopic approaches. The development of new robotic instruments, especially staplers and energy sources, permitted them to fully utilize the possible benefits of robotics. Now there is an increasing number of procedures including bariatric sleeve gastrectomy, bypass and revisions, as well as foregut procedures including Heller myotomy, antireflux and paraesophageal hernia repair being done with robotic assistance.
In the past, the most difficult thing for even these expert laparoscopic surgeons was passing on their skills to the next generation of surgeons. By using robotic simulators and dual consoles, they have demonstrated that they can pass on their skills to their trainees safely and efficiently just as urologists have done. They have shown that an added advantage of the robotic platform is its ability to facilitate teaching and shorten the learning curve for trainees, which will indirectly improve access to care by increasing the number of experts available.
General Surgery: Recent Growth
The specialty in general surgery that has shown the most recent growth in robotics is repair of abdominal wall hernias—inguinal, ventral and incisional. The first surgeon in the Americas to employ the robotic assistant to repair inguinal and abdominal wall hernias was Barry Gardiner, MD, in 2000, as part of a pilot study. It was not until approximately 2008 that the first significant accounts of a robotic approach to inguinal hernia repair were reported. The repairs were done in conjunction with robotic prostatectomy. Multiple studies appeared in the peer-reviewed literature describing the safety and efficacy of combining these two robotic procedures.
Although several surgeons in private practice began performing robotic-assisted transabdominal preperitoneal (TAPP) inguinal hernia repair as a stand-alone procedure, its value was seriously debated by hernia surgeons, including myself. As the robotic approach became standardized and mimicked closely the TAPP laparoscopic approach, however, it has gained acceptance as an alternative minimally invasive approach. Because of video teaching and mentoring by surgeons such as Conrad Ballecer, MD, and laparoscopic experts like Jorge Daes, MD, David Chen, MD, David Lourie, MD, and others on the International Hernia Collaboration—a social media platform for surgeons started by Brian Jacob, MD, in 2012—there has been widespread acceptance of robotic-assisted inguinal hernia repair. For the first time in more than 20 years, the adoption of a minimally invasive approach began to grow, due to the growth of the robotic approach. Today the minimally invasive approach has grown to approximately 50%, with the majority of those procedures being robotic.
Simultaneously with revitalized interest in MIS inguinal hernia repair using the robotic platform, was the ongoing study of new approaches to abdominal wall hernias. Closure of hernia defects laparoscopically as part of an intraperitoneal onlay mesh (or IPOM) technique, first popularized by Morris Franklin, came back into favor and the use of open retrorectus placement of mesh as well as the transabdominal release (TAR) procedure, proposed by Yuri Novitsky, MD, grew. Robotic surgeons like Dr. Ballecer saw the advantage of the wristed action of the robot in suturing defects and ease of dissecting off the peritoneum to keep the mesh outside the peritoneal cavity. He introduced a robotic TAPP repair of abdominal hernias including umbilical, small incisional and Spigelian. For the larger incisional hernias, Alfredo Carbonell, MD, introduced the robotic TAR using the Si robot (Intuitive Surgical) and a double-docking technique. During the same period Igor Belyansky, MD, was developing a modification of Dr. Daes’ extended totally extraperitoneal (eTEP) repair first introduced for inguinal hernias to accomplish the TAR laparoscopically. He began to train on the robot, and in 2017, developed the eTEP TAR. These procedures were uploaded to social media platforms and YouTube, quickly influencing the growth of robotic hernia repair. The simultaneous appearance of new surgical techniques, a robotic platform that could facilitate their application, a social media platform to spread the word, surgeons willing to mentor other surgeons, and industry support were a perfect storm for the robotic invasion, which resulted in the rapid growth of robotics for general surgeons.
Only the Beginning
It should be understood that we have only seen the beginning of the robotic invasion. An ever-increasing number of robotic platforms are in development or have already been released outside of the United States. In the United Kingdom, Cambridge Medical Robotics (CMR) has launched a robotic system and has already trained surgeons and has approximately 30 units installed across Europe. In 2017, Meere, a South Korean company, released a four-armed robot similar to Intuitive’s da Vinci Si. Five years ago, Verb Surgical was founded as a joint venture between Google and Johnson & Johnson to develop a robotic surgical system. Although Verb Surgical has yet to release a general surgery robot, it has made several acquisitions to further its advance into the robot wars, including Auris Health, a developer of robotic technologies with its founder and CEO Fred Moll. Dr. Moll, you will remember, was the founder of Intuitive Surgical. TransEnterix entered the robot competition in 2016, with a robot called Surgibot, but initially failed because it was denied FDA approval. TransEnterix soon introduced a new robot system called Senhance Surgical Robot System, which was approved by the FDA in 2017. Still another company, Titan Medical, in Canada, has developed a single-port robotic system with no external moving parts, but it is still in the testing phase.
As more competitors come to the market and the original robotic platform evolves, it is obvious we are only at the beginning of a new era in surgery. What will future robotic systems bring to the OR? How will it harness the power of computers, artificial intelligence and internet communication to enhance the surgical experience for the patient and surgeon? Can robotic systems maintain value by decreasing overall cost while increasing benefit? These are all questions that patients, surgeons, hospitals and payors continue to ask. I have therefore asked some of the leaders of the robotic invasion—past and present—to predict the future. Here is what they had to say:
Yulun Wang, MD: “Robotic surgery is really the computerization of surgery, where the power of the computer is placed between the surgeon’s intent and the surgical manipulators. The robotic surgical system will become more and more of an information and communication hub for the surgical procedure. The surgeon’s role will likely become more and more strategic, as opposed to focusing on the precise manipulations, which will be handled more and more by the robot.”
Gary Guthart, PhD [CEO of Intuitive Surgical]: “As robotic-assisted surgery continues its growth and acceptance, the focus moves to not only advancing core robotic capability but also integrating tools, data and services around robotic systems that drive toward better, more predictable patient outcomes, better experiences for patients, better experiences for their care teams, and ultimately, a lower total cost of care.”
Mark Talamini, MD: “I believe we will migrate to more cost-efficient robots designed for specific types of procedures in specific anatomic regions as opposed to one general machine assisting with all types of surgery. Surgery will also be enhanced by more powerful and real-time imaging modalities and artificial intelligence–driven automation, but this will come in stages.”
Steve Scott, MD: “The robot will be ideal for bariatrics because it removes the constraints of the thick abdominal wall, improving the precision of every movement. I see the ever-increasing information feedback with instrumentation and visualization giving a surgeon the ability to decrease complications, improve outcomes and change the way they approach patients.”
Conrad Ballecer, MD: “Robotic surgery will completely change the game for residents and postgraduate trainees, enabling them to become proficient in MIS procedures ranging from the most basic to the most complex procedures.”
Edward Felix, MD: “The future will be based on lessons we learn from the past, so let history be your mentor.”
Dr. Felix is a general surgeon in Pismo Beach, Calif., and an editorial advisory board member of General Surgery News.
Dr. Felix is a lecturer for Intuitive Surgical and Medtronic.
Editor’s note: Opinions in General Surgery News belong to the author(s) and do not necessarily reflect those of the publication.
This article is from the September 2021 print issue.
Please log in to post a comment