At the dawn of the 20th century, robots weren’t yet a part of the sci-fi. In 1917, when ‘Joseph Capek’ wrote the short story “Opilec” describing Automats and in 1921 when his brother Karel Capek wrote the play Rossum’s Universal Robots (RUR) that the concept of robotics entered the consciousness of the human world. The term Robot is derived from the Czech word, ‘Robota,’ meaning labourer or serf. Karl Capek for his play, RUR, to protest the rapid development of modern technology described the evolution of robots with increasing capabilities and the eventual revolt of these robots against their human counterparts. Inadvertently, the Capek brothers introduced the term robot into the modern language and sparked public fascination with their innovations.

Isaac Asimov is credited with the popularisation of robotics in a collection of short stories published between 1938 – 1942. Asimov is best known for his fundamental three laws governing the robot’s behaviour.

A robot may not injure a human being or through inaction allow a human to come to harm.

A robot must obey the command given by humans except when doing so conflicts with the first law.

A robot must protect its existence as long as this does not conflict with the first or second law.

Asimov conceived his laws of robotics to impose order on the free will of his fictional robots. Since then, robots have been widely depicted in literary and cinematic fiction, sometimes as a man’s friend like in StarWars, but often as a man’s enemy like in the Terminator. Over the last half-century, robots similar to first envisioned by Capek have become a reality and are used to perform mechanical labour in factories, to minimise the human error and injury while increasing the efficiency of the production.

The transition from Sci-Fi to reality happened in 1958 when General Motors (GM) introduced the Unimate to assist in its automobile production. Since Unimate’s first use in the assembly line in 1961, the application of robotics to the industry has exploded. Since then, Robots are being used in a variety of applications including Space exploration, military use, deep sea, and for search and rescue missions. In all the cases, robotics has the aim of either improving or duplicating human function or serving in jobs that are too hazardous for humans to be directly involved.

A variety of classifications for different types of robots help to describe these heterogeneous devices. Robots can be characterised as mobile devices, mills, automated arms or telerobotic devices. Besides, they can be active, passive or semi-active. Active devices are entirely programmable and carry out tasks independently. One can imagine a physician entering a 3D (three-dimensional) computed tomography data into a computer and then programming the computer to direct a mill to remove a particular area of bone. Passive and Semiactive robotic devices translate movements from an operator’s or surgeon’s hands into unpowered or powered movements of the robot end-effector arms. Surgical robots in research or use include today both active mills and semiactive telerobotic devices.

Active Surgical Robots:

Active surgical robotic devices, in which pre-programmed data and computer generated algorithms function without a real-time operator’s inputs. They were the first robots to be used in a live surgical application. In 1985, the first surgical application of industrial robotic technology was described when an industrial robotic arm was modified to perform a stereotactic brain biopsy with 0.05mm accuracy. This served as the prototype for Neuromate (Integrated Surgical Systems, Sacramento, USA) which received the approval from the FDA (Food and Drug Administration) in 1999. The Robodoc (Integrated Surgical Systems) was introduced for use in replacement surgery (Fig below). The Robodoc is a computer-guided mill used to core the femoral head to receive a hip replacement prosthesis. Clinical trials demonstrated greater accuracy comparing the well drilled by Robodoc to conventional techniques or procedures. However, the Robodoc has been used in thousands of patients in Europe, yet it has not received the FDA’s approval in the USA because of concerns regarding complication rates. Similar devices have also been designed for use in knee replacement and temporal surgery, notably the Acrobot based in London, UK and the RX-130 robot (Staubli Unimation Inc in France). Neither devices as yet completed the clinical testing nor received the FDA approval.

Telerobotics:

The concept of remote robotic surgery or operation has long been recognised to have several benefits in various fields. Defusing bombs, surveying the deep sea and space, and treating patients in the battlefields, etc. Telepresence, or the insertion of the robot operator, into a virtual-reality (VR) displays emerged from envisioning these potential benefits. In 1980 the National Aeronautics and Space Administration (NASA) joined with the Ames Research Center to begin the development of a head-mounted VR display to enable users to immerse themselves in the vast data-sets that were transmitted from the Aerospace missions. By coupling 3D stereoscopic vision with the DataGlove, users were able to see their interactions with the virtual world.

Scott Fisher recognised the potential benefits that telepresence could provide surgeons, a PhD scientist at NASA and Joe Rosen, MD of Stanford University, a plastic surgeon, together envisioned the telepresence surgery to include the virtual insertion of the surgeon into the operative field with the manipulation of remote robotic arms. Rosen and Fisher collaborated with Phil Green, of Standford Research Insititute (SRI International) to develop the robotic arm. The next decade saw the field of telerobotic surgery to grow, and the concept of integrating this technology into the burgeoning field of laparoscopic surgery was realised fully. The idea was introduced to the Pentagon’s DARPA (Defense Advanced Research Projects Agency) to let the surgeon treat the wounded soldier in the battlefield from a remote haven with the surgeon’s hands controlling the robotic arms on the battlefield.

In 2003, Intuitive Surgical acquired Computer Motion funded by DARPA, developed the AESOP (Automated Endoscopic System for Optimal Positioning), a robotic arm for endoscopic camera control. AESOP was designed to replace the surgical assistant in laparoscopic surgery which was coupled with Hermes voice activation system to let endoscope control by voice command. The FDA approved the devices in 1994, while the AESOP/Hermes platform was the first actively marketed telerobotic system. The devices’ key functionality was serving as the groundwork for the surgical robotic instruments which is currently integrated into clinical practice.

In 1995, Fedrick Moll MD of Robert Younge and John Freund MD acquired the licensing rights for the original SRI telepresence surgical system, and Intuitive Surgical Inc. was formed. The potential widespread clinical application of the newly developed telerobotic devices was commercially recognised. In 1997, Intuitive Surgical’s “Da Vinci” surgical system was used to perform a laparoscopic cholecystectomy in Belgium. The original Da Vinci surgical system consisted of a remote surgeons’ console and a three-armed robotically controlled device drive system. In the surgeon’s console, there are two viewers, one for each eye, which provides a 3D view of the operating area. The surgeon sits at the console resting his hands in control grips which allow for the wrist, arm, and pincer movement. The surgeons’ hands, that rest in line with the visual axis, controls the seven degrees tower with three multiply jointed arms, two of which controls a variety of 8mm surgical instruments while the third drives a binocular video endoscope. The video system provides 15x magnification and true 3D vision. The wristed device tracks the surgeons’ hand movements 1300 times per sec and provides for tremor filtration and scaled motion translating larger movements of the surgeon’s hand into finer movements of the wristed instrumentation.

In 1999, Computer Motion introduced the surgical system called Zeus which was different from Da Vinci primarily in the configuration of the surgeon’s workstation. To operate the Zeus, the surgeon has to sit at a console and wears a polarised glasses to view the operating area in 3D. After the acquisition of Computer Motion by Intuitive Surgical in 2003 the Zeus system was no longer available commercially.

In 2001, the Zeus surgical system was used for the telepresence surgical procedure. The military’s vision for telepresence surgery was realised when the first transatlantic surgical procedure – a laparoscopic cholecystectomy was performed on a patient in Strasbourg, France by the surgeon seated at the console 3800 miles away in New York, US. He utilised a 155 ms bandwidth, the time delay between the operating surgeons’ movements and the remote device’s movement was minimised.

Since the original introduction of the “da Vinci” surgical system, there have been several modifications and variations. A fourth robotic arm has been added which lets the surgeon toggle between three devices. An increasing number of both 5mm and 8mm surgical instruments are available and the new da Vinci S (Intuitive Surgical) adds an interactive video displays with streamlined setup.

Therefore, the FDA has approved the da Vinci surgical system for a wide range of general, gynecologic, cardiac, and urologic procedures. Clinical data measures document equal or enhanced surgical outcomes with improved postoperative functions such as shorter hospital stay, decreased blood loss, and a favourable learning curve for newly trained robotic surgeons. More than 500 da Vinci surgical systems have been installed globally, and the instruments use continues to grow. Procedure development in the thoracic and abdominal-pelvic surgery continues as the clinical research into applications in the upper aerodigestive tract, soft tissues of the neck, and skull base.

The surgical robots available at present, in both clinical trials and use offer potential advantages, to recognise the concept of minimally invasive surgery vs laparoscopic procedure. Robotic devices with more streamlined platforms, remote telemonitoring, and smaller instrumentation will be a reality in the foreseeable future, and we can already see the breakthrough happening. Following the tenets of ancient medicine and modern including clinical outcomes research and “doing no harm,” robotic surgery, both with active surgical robotic mills and telerobotic manipulators, has the potentials to provide patients with the choice to optimise minimally invasive surgery.

To summarise, The concept and technology of robotics that began as a Science Fiction play a critical role in the modern era. In the healthcare industry, “Surgical Robotics” promise to play an integral role in years to come, although the disruption has begun and it is only a matter of time for the healthcare industry to adapt and implement robots in every aspect of the hospital management system. In my next article, I will discuss in detail more about the different types of medical robots that are transforming the world of healthcare.

Image Credit: Surgical Products Mag

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