ROBOTIC SURGERY – PAST, PRESENT AND FUTURE
Authors: Hibner Michael 
Published: September 2024

In the quest for progress, humanity has always aimed for ‘faster, higher, stronger’. The modern surgical journey owes much to pioneers like William Halsted and Howard Kelly from Johns Hopkins University. Despite their invasive procedures, they saved countless lives. The next leap in surgery came thanks to German gynecologist Kurt Semm. In September 1980, he performed the first laparoscopic appendectomy. Initially viewed as a charlatan by his colleagues, Semm’s groundbreaking work revolutionized surgical techniques. In the third surgery revolution, a remarkable transformation occurred as minimally invasive endo- scopic procedures became commonplace. A significant breakthrough occurred in 1985 with the introduction of the PUMA 560, the first surgical robot used for brain biopsies. This marked a turning point in the history of surgery, opening up new possibilities and saving countless lives. Before this, surgical robots had been in development for about a decade, thanks to pioneering efforts by NASA and the United States Defense Research Advanced Project Agency (DARPA). These agencies recognized the need for remote-controlled surgery, especially for astronauts and wounded soldiers in combat zones. By the late 1990s, three distinct surgical systems emerged, combining laparoscopic technology with robotic assistance: da Vinci Surgical System, AESOM, and ZEUS Surgical System. The first-ever robotic surgery was a tubal reanastomosis procedure performed in 1996. These advancements marked a paradigm shift, allowing for greater precision, reduced tissue trauma, and improved patient outcomes. Between 2000 and 2003, the author of this presentation had hands-on experience with three different surgical robots. Among them, the da Vinci robot, developed by Intuitive Surgical, stood out. Initially designed for coronary artery bypass procedures, the da Vinci system faced technological challenges in synchronizing the beating heart with visual feedback and surgeon hand movements. However, it found an unexpected niche: prostatectomies. Early Intuitive executives humorously quipped,“We aimed for the heart, but we hit the prostate.”Robotic surgeries are most common in gynecology, where they enhance comfort during longer and more complex procedures. Interestingly, despite its cardiac origins, the da Vinci robot now performs approximately 75% of all prostatectomies worldwide. The global market for surgical robots grew from $800 million in 2015 to a staggering $3.5 billion a decade later. In the United States, a remarkable 78% of surgeons across various specialties express interest in using robotic assistance. Robotic surgery provides several advantages over straight-stick laparoscopy. Surgeons benefit from 7 degrees of freedom and 520° of rotation, along with three-dimensional vision through a high-definition camera. While theoretical improvements in precision exist, studies have not yet fully demonstrated this. Additionally, robotic surgery enables less experienced laparoscopic surgeons to perform complex procedures due to enhanced range of motion and three-dimensional vision. Tremor reduction further allows for precise dissection and suturing. Undoubtedly, the robotic platform significantly enhances surgeon comfort, especially during lengthy and intricate procedures. As artificial intelligence rapidly evolves, so does robotic surgery. While fully autonomous surgery remains a distant goal, certain advancements are imminent. For instance, augmented reality systems – already in use on some platforms – overlay patient images with radiological scans, enhancing safety and precision. Additionally, these systems can be combined with fluorescent imaging. By injecting dyes into the patient, surgeons gain visualization of specific structures such as vessels, ureters, malignant lesions, and sometimes endometriosis. The development of flexible, snake-like robotic arms surpasses the capabilities of current 7-degree-of-freedom instruments. These arms provide enhanced dexterity, allowing precise maneuvers during surgery. The next frontier involves robots performing semi-automated tasks like coagulation or suturing. These capabilities enhance surgical precision and reduce human error. A significant advancement we eagerly anticipate is miniaturization and micro-robotics. Ideally, surgical robots could operate from within the abdominal cavity, eliminating the need for external devices. However, challenges related to signal latency persist. The initial goal of robotic surgery – to enable ground-based surgeons to operate remotely – may remain limited by the time it takes for signals to travel between the surgeon and the robot. Despite the remarkable technological advancements in robotic surgery, the surgeon remains at the helm, overseeing the entire procedure. Surgical robots serve as valuable tools, enhancing precision and capabilities, but the human touch and expertise remain irreplaceable.