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The history of robotic surgery
A full anthology of the development of surgical robotics would require a complete textbook. Perhaps we could start the story with Leonardo da Vinci and his genius with a 16th century drawing of a mechanical knight ( Fig. 1.1 ). The Intuitive Surgical Company recognized the genius of Leonardo by naming their robotic systems in his honor, including the current and most well-known surgical robot, the “da Vinci.” For the purposes of this discussion, we will start our history in the 20th century. We direct readers who are interested in earlier developments to explore the scholarly manuscript by American Urologist Michael Moran, which documents a thorough history of robotic development from antiquity to the present 21st century surgical robotics systems.
Leonardo’s Mechanical Knight.
The word robot was coined by the 20th century by Czech playwright Karel Cacek and used in his play named Rossums Universal Robots , written in 1920. The term robot was used by Cacek to describe unpleasant manual labor. In a further literary association, Isaac Asimov in his novel Runaround (1941) described the three laws of robots: “One: A robot may not injure a human being or, through inaction, allow a human being to come to harm. Two: A robot must obey the orders given it by human beings except where such orders would conflict with the First Law. Three: A robot must protect its own existence as long as such protection does not conflict with the First or Second Laws.” 1a Wonderfully, the conception of the robot has devolved from art, literature, and science.
More recently in 1979, The Robot Institute of America defines a robot as a reprogrammable, multifunctional device, designated to manipulate and/or transport material through variable program motions for the performance of a variety of tasks. Various classification systems exist to categorize robots according to their functionality.
The development of a functioning surgical robot was made possible by the development of industrial robotics. Goertz invented the first real working industrial robot in 1949. He described and developed an operator-robot system, which was used to handle radioactive substances. There were further major developments and improvements in industrial robot design over the next 40 years. Use of the industrial robot has permeated manufacturing processes in many industries, particularly the automotive industry.
Success has many parents, and the development of the contemporary surgical system of robotics is no exception. It seems reasonable to suggest that the development of safe open surgery occurred after introduction of antisepsis, anesthesia, and transfusion to surgery from the late 19th to the early 20th century. Leonard Murphy published his volume The History of Urology in 1972. He includes a history he translated from the French written by Desnos, describing urologic surgery from ancient times to the 19th century. In reading this marvelous book, it becomes clear to the reader that there is nothing new under the sun. Many of the procedures performed after safe surgery was introduced had been tried previously by our surgical forebears in the 19th and early 20th centuries but failed because of lack of intravenous transfusion, antisepsis, antibiotics, and appropriate anesthesia. The practice of surgery via open technique was maintained exclusively until the 1940s, when the practices of endoscopic surgery in urology (transurethral resection of the prostate [TURP]) and laparoscopic minimal access surgery primarily in gynecology were introduced. Celioscopy described by internists for peritoneoscopy or laparoscopy described by gynecologists was first introduced in the 1940s. Laparoscopy was first used for the visual diagnosis of pathologic conditions of female reproductive organs. Contributions to the improvements in gynecologic laparoscopy were reported by Cohen in the late 1950s which popularized gynecologic laparoscopy. Laparoscopic development paved the way for robotic adaptation, with improvement in lenses, light sources, and the ability to raise and maintain intra-abdominal pressure with a pneumoperitoneum by insufflation of the abdomen with carbon dioxide. The ability to achieve hemostasis using diathermy was also vastly improved.
Early surgical robotics
My first acquaintance with robotics in surgery occurred when I read the description by London urologist, John Wickham, of a new surgical machine (Probot) that could perform TURP. TURP is a difficult operation both to teach and to learn. To enable this to be performed hands-free using a robot was an interesting concept. The system made by Wickham and his engineers combined the PUMA robot with a Wickham Endoscope Liquidizer and Aspirator to perform a hands-free robotic transurethral resection for benign prostatic enlargement ( Fig. 1.2 ). The tissue to be removed was mapped by using transrectal ultrasound coordinates. Problems with hemostasis precluded its further success. Robotic technology using a water jet for cutting with ultrasound-mapped coordinates (Aquablation) has been recently described.
Laparoscopic surgery was embraced enthusiastically in the 1990s. Previously this surgery was mainly in the remit of the gynecologist. Laparoscopic techniques were applied in general surgery with cholecystectomy and appendicectomy and in urology with pelvic lymph node dissection. In 1991, Clayman described a single case of successful laparoscopic nephrectomy. This was ground breaking, enabling further expansion of the urologic laparoscopic surgery repertoire into more major procedures than simple pelvic lymph node dissection for staging in bladder and prostate cancer.
A key step toward using robotics in laparoscopic surgery was Computer Motion’s invention of the Automated Endoscopic System for Optimal Positioning (AESOP). AESOP controlled laparoscopic camera positioning rather than requiring a human bedside assistant for this task. Its first model was controlled using foot pedals, but this was later upgraded to a voice control system.
Birth of the contemporary surgical robot
Rival entities, Intuitive Surgical and Computer Motion, raced to develop the contemporary surgical robot. Intuitive finally won when the first robotic operation (cholecystectomy) was performed with their robot “Mona” in 1997 in Belgium.
Much of the driving force behind the development of robotic surgery came from the US Army’s desire to create a technology that would allow surgery to be performed on soldiers in the battlefield, by surgeons remote from the battlefield using telerobotics. The US Defense Advanced Research Projects Agency (DARPA) provided grants to stimulate development of robotic surgery. Similarly, a role for telemanipulation was also imagined in space, and NASA’s Ames Research Center provided funding for proposals toward projects for remote surgical intervention on astronauts.
Intuitive Surgical Company was established in 1995, after it licensed patents from Stanford Research Institute (SRI) (Palo Alto, CA), International Business Machines, and the Massachusetts Institute of Technology. Frederick Moll and his colleagues wanted to build a system of telerobotic surgery, which included three key elements:
- 1.
An operator-robot, software driven system that provided intuitive control of a suite of seven-degree-of-freedom laparoscopic instruments.
- 2.
Stereoscopic vision system displayed in an immersive format.
- 3.
An elaborate system of sensors to eliminate the possibility of erroneous movement and maximize safety during operation.
Intuitive Surgical, building on the original telemanipulation work by Phil Green of SRI, launched their first prototype, Lenny (after the young Leonardo da Vinci). Lenny, used only in animal trials (1996), comprised three separate robotic arms to be attached to the operating table: two working arms and one camera arm. Shortly thereafter came Mona (after Mona Lisa ), Intuitive’s second-generation model that enabled exchange of instruments while maintaining sterility of the surgical field ( Figs. 1.3 and 1.4 ). At a similar time, competitor Computer Motion developed the ZEUS system, which incorporated AESOP’s robotic arm with two arms for laparoscopic instrumentation. ZEUS was used in 1998 for uterine tubal reanastomosis and cardiac bypass surgery.
The Intuitive Surgical robot was further improved and enhanced, and I was fortunate to see it in 1999 as a prototype at the American Urological Association meeting. The first da Vinci which gained US Food and Drug Administration (FDA) approval for use in surgery (in 2000) was a three-part system with a patient cart, surgeon console, and image system. All three robotic arms emanated from the patient cart rather than mounted on the operating table as the previous systems had. The viewing and operating console delivered a three-dimensional (3D) view provided by a novel binocular telescope. Containing two video camera control boxes with two light sources for the cameras, a synchronizer keeps the video frames of the video cameras in phase. The vision system afforded by the original da Vinci was truly outstanding when compared with the two-dimensional view of standard laparoscopic cameras . Another key innovation that led to the success of da Vinci was the design of EndoWrist surgical instruments that afforded seven degrees of freedom, enhancing dexterity and operative precision.
After much legal friction, Computer Motion and Intuitive Surgical merged (2003). Soon afterward, ZEUS was discontinued in favor of da Vinci.
There have been multiple generations of da Vinci systems engineered by Intuitive along the journey to the present Xi model. Vision was further improved with a high-definition 3D camera in the 2006 da Vinci S model, and the introduction of a dual console greatly enhanced training. More recently, Intuitive has also built and marketed a single-port system with flexible instruments and a rigid telescope inserted through one central port. Thus far, this new system has failed to generate the enthusiasm required for widespread use.
After many years of Intuitive Surgical dominating the field of robotics, we are beginning to see an increasing number of new vendors appearing. Cambridge Medical Robotics (CMR) has developed an open console program where the surgeon looks at a flat screen television and uses 3D glasses for depth perception. The system designed by the Cambridge group has no foot controls and is hand controlled only. This allows the surgeon to stand for the surgery. The open system may also allow easier communication between the operating room team at the bedside and the console surgeon. Additional vendors are due to launch their own platforms in the very near future, discussed in brief later in this chapter, as well as in further detail in Chapter 2 .
A frequent criticism of the technology has been the lack of haptic feedback provided to the surgeon in the console. Interestingly, unlike the currently available systems, SRI’s research prototype included haptic feedback. Unfortunately, this aspect was rudimentary, taking into account only force feedback (pressure), not other important sensations such as vibration, friction, and stress. Ultimately the high-definition images delivered by later robots provided visual cues that replaced tactile feedback, and the lack of traditional haptics did not pose a significant barrier to adoption of an excellent surgical dissection technique. Mastery of the learning curve includes developing muscle memory for force required for different instrument use in performance of tasks such as the force applied in suturing to avoid suture breakage.
Adoption of robotic surgery
After the first surgery was performed robotically in 1997 in Belgium, how did robotic surgery become a viable alternative to laparoscopic and open surgery? Although the laparoscopic method had become popular through the 1990s in general surgery, gynecology, and urology, performance of many laparoscopic surgical procedures remained technically challenging. Robotic introduction of 3D vision, 10 times magnified surgical field, and intuitive wristed hand movements with increased dexterity and elimination of tremor heralded the demise of the laparoscopic method. Many of even the most ardent proponents of laparoscopic surgery have modified their enthusiasm and taken up robotics.
Menon, with great foresight, after observing the cardiothoracic surgeons in Detroit using an early da Vinci model, believed this technology could be applied to deep pelvic surgery. Claude Abbou, a very skillful French laparoscopic surgeon, was also instrumental in early robotic prostate surgery, publishing his experience of a case of radical prostatectomy he performed robotically in 2000. Radical prostatectomy is one of the more difficult operations for a urologist to learn. It requires extirpative and reconstructive skill for the surgeon. The siting of the prostate deep in the pelvis anterior to the rectum and under the pubic symphysis makes access and reconstruction very difficult, thus lending itself well to robotic application thanks to the benefits of the seven degrees of freedom with the da Vinci instruments, as well as improved visualization of the relevant anatomy. The operation of open retropubic prostatectomy was made safe only in the 1980s by Walsh, who was first to describe the essential step of suture ligation of the dorsal vein of the penis. Before that, the operation was extremely hazardous for the patient due to major blood loss from this vein located under the pubic arch. He also discovered and reported the neuroanatomy involved in male erectile function and published this in 1982. Until then, surgeons simply cut the neurovascular bundles, destroying erectile function in 100% of surgeries. Contemporary key metrics used to assess technical expertise in this operation are related to preservation of these neurovascular bundles for erectile function, maintaining urinary continence by superbly visualized dissection of the external sphincter, while achieving negative cancer margins. Menon described how to perform the operation robotically using Walsh’s method, preserving the erectile nerve bundles and urinary sphincter. He was able to demonstrate equivalence of the robotic method to the open method in what remains a technically challenging operation. He appreciated that using a robot with its minimally invasive approach, the surgeon could visualize the key anatomic structures in three dimensions and drive the robot to places where the human hand could not easily reach. A clear example of this was the ability to perform a running sutured watertight anastomosis robotically. In the open method surgery, the vesicourethral anastomosis was created by use of four to six interrupted sutures put in blindly by the surgeon. The stricture or bladder neck stenosis rate of the interrupted suture in the open method was historically as high as 17% in some series. Van Velthoven 20 described the running watertight robotic suturing method, the stricture rate reduced to less than 1%. By 2008 surgeons could report robotic-assisted radical prostatectomy outcomes with equivalence in oncologic and quality-of-life parameters. The operation became one that could be performed safely robotically as day case compared with what was previously a 3- to 5-day hospital stay for open surgery. A very positive by-product of introduction of robotic radical retropubic prostatectomy was that many more patients who had previously been denied surgery for their cancer could be offered radical prostatectomy, due to the reduced morbidity associated with the procedure. The minimally invasive robotic approach is associated with significantly less blood loss compared with a mean 1300-mL loss in open prostatectomy. This has allowed urologists to offer surgery to men who warranted radical therapy but were not suited to external beam radiation and previously would not have been eligible for open surgery due to body habitus or comorbidities such as prior mesh hernia repair or previous extensive pelvic surgery.
This new benchmark for radical prostatectomy heralded introduction of the robotic method of surgery in urology. We now have seen similar revolutions in cardiothoracic surgery, gynecology, general and colorectal surgery, and ear, nose, and throat surgery. The robotic approach is also used in some centers of excellence to perform pediatric surgery. The widespread dissemination of robotic method into so many surgical specialties formed the basis for the design of this textbook to be a multidisciplinary one, not exclusively urologic. This book covers both the foundations of robotic surgery for all surgeons and then embraces robotic surgery for the individual surgical craft groups.
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