Overview of existing robotic platforms

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 relatively short period of time, with new devices being developed constantly. Robotic surgical devices represent a leap in surgical innovation, and robotic surgery addresses several limitations of manual laparoscopy. In fact, recent data suggest a trend moving away from open procedures toward robot-assisted procedures. 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 ). 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. 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.

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. 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 procedures. 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. Each boom-mounted arm is capable of three degrees of freedom (DOF), allowing for manipulation of the proprietary EndoWrist instrument. The EndoWrist technology mimics the movements of a human wrist, providing an additional seven DOF to the platform. 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 user interface, allowing the surgeon tools for precision and dexterity. Additional features include tremor filtration and handle- and pedal-controlled optics. 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. 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. 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 instruments during a procedure. 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. 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. 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.

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 InvendoScope controller is a detachable, lightweight joystick that was designed with surgical ergonomics in mind. This handheld tool has robot-assisted tip control with full retroflection 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.

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 working 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 complementary metal oxide semiconductor (CMOS) imaging chip. Its low startup cost allows for greater potential utilization than other larger and more expensive robotic platforms.

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.