A short history of robotic surgery

A short history of
robotic surgery
A concise review of the use of robotic
technology to enhance surgery

Tim Lane Consultant Urologist and he extent to which ro- – artificial intelligence. In the play the
Robotic Surgeon, Lister Hospital,
Stevenage

DOI: 10.1308/rcsbull.2018.5
T botic surgery has been
embraced by the surgical
fraternity has been unpar-
alleled. It has been driven in part by
rapid developments in technology
robots that once undertook mundane
tasks for their human masters later
attempt to throw off their subservi-
ent roles and take control of their
own destinies. Although the current
and in part by the ease with which use of robots – machines that can
adaptations have been made to undertake ultra-precise, repetitive
existing laparoscopic procedures and and pre-programmed procedures – is
techniques. Robotic procedures are commonplace in industry, they have
rapidly becoming the new standard only relatively recently been adopted
of care. As with a number of other by the medical sector to enhance the
technological advances in medicine delivery of care.
and surgery, these developments have
seldom been introduced as a result of There are three main types of robotic
randomised prospective studies. systems currently in use in the sur-
gical arena. Active, semi-active and
There is not a review of the history master–slave systems. Active systems
of robotic surgery that does not start essentially work autonomously (while
with a literary foray into the world of remaining under the control of the
the author Karel Capek and this brief operative surgeon) and undertake
introduction to the history of robotic pre-programmed tasks. The PROBOT
surgery will not disappoint. Capek and ROBODOC platforms described
was a Czech playwright. His play later are good examples of this.
Rossum’s Universal Robots defined Semi-active systems allow for a sur-
the term ‘robot’ for the first time. geon-driven element to complement
Derived from the Czech word robota, the pre-programmed element of these
which describes a forced labour or robot systems. Formal master–slave
activity, the term has rapidly become systems (of which the da Vinci® and
corrupted to reflect a machine-orien- ZEUS platforms were the forerunners)
tated repetitive task with little – if any lack any of the pre-programmed or

5
Robotics: Annals of the Royal College of Surgeons of England

autonomous elements of other sys- Although the early active robotic sys- operating surgeon. At about that time,
tems. They are entirely dependent on tems clearly demonstrated the poten- the forerunner to what was eventually
surgeon activity. Surgeon hand move- tial of mechanical devices to enhance to become Intuitive Surgical released
ments are transmitted to laparoscopic surgical interventions, the driving force the SRI Green Telepresence system,
surgical instruments, which faithfully for developments that were ultimately which was later to undergo a radical
reproduce surgeon hand activity – to enhance laparoscopic procedures overhaul before morphing into an early
but intracorporeally. were based on the concept of telep- version of the current da Vinci® system.
resence, which in turn was derived
Authors often differ in their definition from a collaboration between the These two rival systems, ZEUS and da
of the first robotic procedure of the Ames Research Centre at NASA and Vinci, went on to dominate the field of
modern era. For most, the honours researchers from Stanford. The US mil- robotic surgery for a decade – trading
are awarded to Kwoh et al1 , who used itary, recognising the potential signifi- world-firsts and pushing back the
the PUMA 560 robotic system to cance of linking surgeons (distant from frontiers of minimally invasive surgery.
undertake neurosurgical biopsies with the battlefield) to patients via a robotic The three-armed ZEUS platform con-
greater accuracy – in effect, stereo- platform, saw a potential to reduce the tinued to make use of the voice-ac-
tactic brain surgery. The same system mortality and morbidity from service tivated AESOP camera system. One
was subsequently used by Davies personnel serving in fields of conflict. of its three arms held the camera
et al2 to undertake a transurethral Researchers (many of whom were orig- and a further two arms were used
resection of the prostate (TURP) – a inally involved with this military interest to hold surgical instruments. The da
precursor of what would ultimately be group) went on to develop their ideas Vinci® platform represented a three-
termed the PROBOT. It was designed commercially in the public and com- to-four-armed system, with a central
specifically to undertake a TURP and mercial sectors.3,4 Direct funding was arm holding a binocular lens (for 3D
was developed by Integrated Surgical
Supplies Ltd. In essence, the PROBOT
represented a framework to direct a These two rival systems, ZEUS and da
rotating blade to complete the process
of prostatic resection. Although the
Vinci, went on to dominate the field of
PROBOT failed to gain wider clinical robotic surgery for a decade – trading
appeal, a similar concept was simul- world-firsts and pushing back the
taneously being explored elsewhere.
In this respect, parallel developments
frontiers of minimally invasive surgery
were being undertaken to develop the
ROBODOC system (the first of the
active robotic systems to achieve a provided to Computer Motion to devel- vision). Perhaps more significant,
formal FDA approval) and a machine op the Automated Endoscopic System however, was the fact that the surgical
designed to improve the precision of for Optimal Positioning (AESOP) ro- instruments used via the remaining
hip replacement surgery. It was adopt- botic platform. This system essentially arms on the cart were articulated at
ed almost immediately in Europe (and enabled surgeons to voice control the the wrist to seven degrees of freedom.
subsequently in the US), with the first positioning of a laparoscopic camera It represented a unique selling point
procedures being undertaken in 1992. system. Later modifications resulted in and an innovation that ultimately
A further system (PAKY) employed the system being re-launched as the proved crucial in the subsequent
a similar percutaneous approach to ZEUS operating system. An alternative dominance of the da Vinci® platform.
access the kidney for stone surgery. option was the EndoAssist (a slightly
None of these systems, however, were bulkier but considerably cheaper alter- The da Vinci® platform was the first to
designed to embrace or augment a native), which relied on infrared signals be used to undertake a cholecystec-
laparoscopic procedure. directed from a headset worn by the tomy (Belgium 1997). The following

6
 A short history of robotic surgery

year Carpentier et al (also using the using the ZEUS system (the operative The reviews presented here in this
da Vinci® platform) undertook a mitral surgeon undertaking the procedure in supplement to the Annals of the
valve replacement – significantly taking New York while the patient was physi- Royal College of Surgeons explore
advantage of the innovative ‘wristed’ cally in Strasbourg, France). The ZEUS the current extent to which robotic
instruments for the first time. Subse- and da Vinci® systems were effectively surgery is now enhancing surgical
quently, a re-anastomosis of a Fallopian unified when Computer Motion and practice and consider future develop-
tube was performed using the ZEUS Intuitive Surgical merged in 2003. As a ments in the field as a new genera-
system in 1998. The following year the result, further innovations and improve- tion of companies enter this rapidly
first closed-chest beating-heart cardiac ments were centred on the da Vinci® changing arena.
bypass procedure was undertaken platform, which has subsequently
by Douglas Boyd and colleagues at dominated the world of robotic surgery
the London Health Sciences Centre for almost a decade.5–8 It has only References
in Ontario. The same team later went been in the past few years that newer The reference list for this article is
on to undertake a cardiac revascu- technology companies have emerged available online at
larisation procedure, also using the and introduced a significant element of publishing.rcseng.ac.uk/journal/ann
ZEUS platform. In 2001 a transatlantic competition and choice to this rapidly
cholecystectomy was undertaken evolving field.

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