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The future of robotic surgery

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Approved by USFDA in 2000, over five million robotic surgeries have been performed using Intuitive Surgical’s da Vinci platform, informs Dr Vivek Venkat, Consultant – Uro-oncologist and Robotic Urologist at Nanavati Super Specialty Hospital

Initially developed with a view to perform surgery on the battlefield, robotic surgery has grown by leaps and bounds in the last two decades. Today, it has become one of the most sophisticated tools a surgeon has, allowing for precise, tremor-free surgery with the added benefits of a minimally-invasive approach.

Dr Vivek Venkatesh

Robotic surgery involves the surgeon sitting at a console and operating on two joysticks. The surgeons’ wrist movements are replicated within the patients’ body by the robotic instruments allowing the surgery to be performed. Ultimately, the instruments are in direct control of the surgeon.
The surgery was approved by the United States Food and Drug Administration (US FDA) in the year 2000 and since then over five million procedures have been performed using Intuitive Surgical’s da Vinci platform. The fourth generation Xi system has seen significant advances and the future of robotic surgery is more exciting than ever.

One of the drawbacks of robotic surgery remains the added costs associated with the procedure. The monopoly of Intuitive Surgicals, which has generated over 1,500 patents, has contributed to this. In 2019, a number of patents are due to expire, opening up the space for significant competition with a potential for cost reduction. The Telelap Alf-X (TransEnterix Corporation) was approved by the US FDA for gynaecological and certain general surgery procedures last year and systems have been installed in the US, Italy and Japan. This system also tracks the surgeons’ eye movements in order to move the instruments which is a unique feature and something other companies will seek to emulate. The Revo-I system, developed in South Korea, is a traditional master-slave platform with four arms. It has an open console design allowing the surgeon more peripheral vision. It has begun human trials and the first successful feasibility study for prostate cancer surgery was published last year. There are other companies in advanced stages of development and the Medtronic MiroSure device is expected to be launched in India (before any other country) in the next year or two. All these developments are expected to spur increased competition and a resulting reduction in cost, leading to more widespread adoption of robotic surgery.

One limitation for any minimally-invasive surgical approach is the loss of the ability to touch the tissue with the fingers (haptic feedback) which is useful to the surgeon, especially in more difficult cases with large, advanced tumours or in repeat surgeries. With robotic surgery, the surgeon relies only on vision to operate, and the addition of haptic feedback to robotic instruments will be a significant advancement. Research using pressure or tactile sensors and other components such as ‘haptic gloves’ to simulate touch is ongoing. All robotic companies are trying to figure out how to make this work, and this will be a race worth looking out for.

Another avenue of research is further miniaturisation of instruments, while still maintaining their incredible dexterity. This will be specially useful in paediatric surgery where current instruments can be too large. Robotic systems are also trying to advance to single-port access which allows all the instruments to be placed through a single, albeit slightly larger, port, thereby minimising incisions. The da Vinci SP (single-port) system was approved for surgery in 2018. Perhaps, some years down the line, there will be nanorobots coursing through patient’s blood vessels and reaching the diseased tissue to operate – no incisions, no pain!

Training in robotic surgery remains a roadblock for many surgeons and improvements in simulation and training modules would make a significant impact. The integration of machine learning with large databases could give surgeons guidance by allowing a step-by-step guide or short video to pop up. Such integration between robotic systems, operating rooms and databases of trainers or videos would help overcome a surgeons’ initial learning period.

Twenty years ago, robotic surgery was conceptualised for long-distance surgery. However, due to technical difficulties, this couldn’t be realised. There were isolated reports of transatlantic surgery but it never became a practical occurrence. With more advanced and faster communication networks, it is possible that tele-surgery will be a reality in the future. The surgeon could literally operate from anywhere in the world, as long as the infrastructure needed was available in the patient’s town. This could potentially allow delivery of the best possible care to anyone in the world, irrespective of geographic location.

Artificial intelligence is a buzzword on everyone’s lips today. Johnson & Johnson has partnered with Google to form Verb Surgical, which is developing a ‘digital surgery programme.’ While it is still quite early in development, it is expected to include advancements in data analytics, machine learning, and connectivity. A recent study from this device reported on completely autonomous suturing using the robot in an animal model. Artificial intelligence could also potentially play a significant role in pre-surgical planning, intra-operative 3-D imaging and navigation allowing for even more precise and subtle operations. People expect that ultimately robots will replace surgeons and actually perform the surgery. Nevertheless, I believe that this still remains well in the future. However, given the speed at which artificial intelligence research is progressing, you never know when surgeons’ jobs could be under threat.

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