Robotic surgery: an evolution in practice

Robotic surgery is a progression on the minimally invasive spectrum and represents an evolution in practice across numerous disciplines. From its origins in the late 1980s, pioneering technologies like the ROBODOC for hip replacements and the PROBOT for urological procedures were early iterations of the idea that mechanical augmentations could at the very least be useful adjuncts in the complex task that is surgery [1]. In the 1990s, researchers from the United States (US) National Aeronautics and Space Administration and Stanford Research Institute investigated the potential of robotics for telepresence surgery [1]. Subsequent US Army funding attempted to devise a system to remotely operate on wounded soldiers via robotic equipment, in hopes of decreasing battlefield mortality [1]. Commercial development introduced Automated Endoscopic System for Optimal Positioning (AESOP) (Computer Motion, CA), a voice-controlled robotic arm with an endoscopic camera, to the civilian surgical community [1]. This was superseded in the 2000s by two comprehensive master–slave platforms: the da Vinci system (Intuitive Surgical, CA), an eponymous nod to Leonardo da Vinci’s fifteenth-century ‘mechanical knight’ automaton [2], and the Zeus system (Computer Motion, CA), which was designed for cardiac surgery [1]. A company merger established the former as today’s main platform [1]. The da Vinci system consists of a console from which the surgeon remotely controls arms connected to a robotic cart beside the patient [3]. A dual-camera endoscope mounted on one arm transmits images of the surgical field to the console, providing the surgeon with a magnified three-dimensional (3D) view [3]. In response, the surgeon manipulates instruments attached to the other arms via the console [3]. The assistant is positioned beside the patient to suction and retract at the surgical field [3]. Robotic surgery offers advantages over conventional endoscopic surgery in visualization, dexterity and ergonomics, while maintaining the peri-operative benefits of minimally invasive surgery [1]. The dual-camera system offers 3D views with depth perception, unlike conventional endoscopic views [1]. Precision features include articulated ‘EndoWrist’ instruments with increased degrees of freedom, removal of the fulcrum effect and motion scaling with tremor filtration [1, 3]. Accordingly, objective advantages over laparoscopic techniques in terms of dexterity and muscle fatigue have been demonstrated [4]. The remote console also allows an ergonomic operating position while optimizing visualization and manoeuvrability [1]. Recent da Vinci iterations have included a reconfigured robotic arm design to improve access; faster docking to reduce operative time; fluorescence-detection to identify structures and lesions of interest; robotic staplers to overcome difficulties in endoscopic stapler positioning by the assistant and a dual console for training [5, 6]. Feasibility, efficacy and cost considerations exist. Access concerns may be ameliorated with a pre-operative screening endoscopy, whereas operative time reduces with experience [3]. Ongoing technological advances and global uptake of robotic surgery are expected to improve efficacy through optimization of case selection and equipment guided by growing longitudinal data [3]. Purchase and maintenance costs are significant, but will be offset by high volume use as well as savings from reduced length of stay and improved clinical outcomes [3]. The benefits of 3D vision and enhanced manoeuvrability provided by robotic surgery are crucial in the mediastinum, which contains many vital structures. Myriad applications exist for cardiac surgery, including cardiac revascularization and mitral valve repair, which were some of the earliest robotic surgeries performed [7]. Robotic thymectomy for thymomas is aided by fluorescence-guided detection of the tumour and adjacent structures [5]. Robotic lobectomy for lung cancer is also gaining traction, with Yang et al.’s 10-year cohort study reporting comparable oncologic and peri-operative outcomes to video-assisted and open approaches [8]. Robotic surgery is feasible for numerous general surgical procedures, pending cost and operative time considerations, which will improve with technological advances. It has been used for rectal cancer resection, with the 2017 ROLARR trial finding comparable open conversion rates with laparoscopic techniques [9], and Lee et al.’s large cohort study finding comparable resection quality with transanal techniques [10]. Robotic surgery is also a safe and effective clinical alternative for common operations such as gastrectomy [11], Roux-en-Y gastric bypass [12] and thyroidectomy [13]; as well as rare procedures such as median arcuate ligament (MAL) release in MAL syndrome [14]. Recent da Vinci iterations incorporate a more flexible robotic arm configuration to simplify set-up and facilitate four-quadrant access for complex procedures, and specific single-site surgery instruments with similar peri-operative benefits to single-port laparoscopic surgery [6]. The head and neck area is difficult to access due to its complex anatomy and confined space. Transoral robotic surgery (TORS) is an emerging option for oropharyngeal carcinoma, as it enables minimally invasive access to the oropharynx without large and mutilating open procedures such as a mandibulotomy and/or pharyngotomy, which cause significant functional and aesthetic deficits [15]. It also offers similar oncologic and functional outcomes to radiotherapy, pending further comparisons [16, 17]. In addition, TORS is being increasingly used for cancers of unknown origin. Systematic reviews by Farooq et al. [18] and Fu et al. [19] found that tongue base mucosectomies and lingual tonsillectomies performed with TORS and transoral laser microsurgery (TLM) identified the primary tumour in over 70% of cases with negative conventional diagnostic findings. Other indications for TORS include laryngeal tumours [20] and parapharyngeal space tumours [21]; salvage surgery [22]; free flap reconstruction [23] and sleep apnoea surgery [24]. Various robotic systems for orthopaedic procedures exist. Haptic systems, which provide intra-operative feedback based on pre-operative data for accurate resection and reconstruction, are commonly used [25]. A common application is robotic-arm-assisted total knee arthroplasty, which has been found to result in decreased iatrogenic trauma to periarticular soft tissue and bone, increased accuracy of component positioning and improved peri-operative outcomes compared to conventional jig-based techniques [26, 27]. Cost-effectiveness analysis of robotic arthroplasty is also in progress via the Robotic Arthroplasty: a Clinical and cost Effectiveness Randomised controlled (RACER) trial [28]. Still under investigation for clinical use are passive systems, such as the da Vinci platform for hip and shoulder arthroscopy, and active systems, which can independently perform procedures without surgeon input [29]. Robotic surgery is particularly suited for surgical access within the anatomically restrained pelvic space. Robotic-assisted radical prostatectomy is one of the most common robotic procedures. It is a widely-accepted management option for prostate cancer, with Tewari et al.’s landmark meta-analysis reporting comparable oncologic and peri-operative outcomes to laparoscopic and open techniques [30]. Robotic partial nephrectomy is an emerging indication, with Bravi et al.’s prospective multicentre cohort study reporting better peri-operative outcomes than laparoscopic and open approaches for anatomically low-risk renal tumours [31]. Robotic surgery provides improved outcomes for complex benign hysterectomy, where superior post-operative quality-of-life may offset the increased operating time, and endometrial cancer staging, where obesity and other comorbidities are common in the population [32]. There is emerging evidence for its use in cervical and ovarian cancer [33], myomectomy and sacrocolpopexy [32]. Robotic surgery is an emerging modality across numerous surgical specialties. It offers advantages over conventional endoscopic surgery in visualization, dexterity and ergonomics, while maintaining the benefits of minimally invasive surgery. Feasibility, efficacy and cost concerns may be ameliorated with technological advances and increased uptake. Robust longitudinal comparisons with established treatment modalities are imperative to support this evolution in practice. None declared. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.