Surgical robots and robot surgeons
Dr Paula Gomes, Cambridge Consultants
04 April 2013
Robots have established a
foothold in surgery but what role will they play 20 years from now?
Two decades ago, autonomous surgical robots were perceived as
potential replacements for surgeons, raising the question of who is
in control of the procedure — surgeon or device.
surgical robots are teleoperated by surgeons from a console. The purpose of these master/slave robots is to provide superior
ergonomics to the surgeon, expected to result in superior clinical
outcomes for the patient. But new research points to very different
robotic surgical devices in the future — micro and nano devices. How
will surgeons interact with them? Can we expect to see surgical
robots-on-a-chip and surgery taking place outside operating rooms
and clinical environments without surgeon’s interaction?
Autonomous surgical robots
The motivation behind earlier surgical robots was their
industrial counterparts. The premise was to use robotics to speed up
and standardise procedures, and to carry out repetitive tasks with
no or minimal intervention from the surgeon.
In 1991, the Probot (Imperial College London, UK), a
special-purpose device designed to have a small cone-shaped working
volume and hence to be inherently safe, was used to autonomously
remove tissue from a patient’s prostate for the first time. Soon
after, in 1992, ROBODOC (Curexo Technology Corporation, Fremont,
CA, USA), which is still in use today, became the first autonomous
robot to be used on humans in the USA, in total hip arthroplasty.
ROBODOC (Figure on right) used a customised version of an industrial 5
degree of freedom SCARA robot as its core.
During these procedures, the surgeon, after setting up the
parameters for the robot’s operation, stood back, with a finger
hovering over the emergency button, whilst the robot carried out
Surgeons and public have not universally
embraced the paradigm of robots that replace surgeons, even if some
systems have found widespread acceptance, eg CyberKnife (Accuray,
Sunnyvale, CA, USA), and others, eg ARTAS (Restoration Robotics,
San Jose, CA, USA), using this principle are still being developed
and entering the market.
The CyberKnife radiosurgery system relies on a KUKA industrial
robot to target radiation to treat tumours, meeting demanding
requirements for accuracy (Figure below). ARTAS exemplifies the potential
benefits brought about by industrial robots’ speed and repeatability
characteristics. This device harvests hair follicles for hair
transplants and was used in the UK for the first time in February
Despite autonomous devices posing a question of who is in
control of the surgery - surgeon or device - perceived advantages of
accuracy, repeatability and speed translate into clinical benefits
in some niche applications.
Teleoperated surgical robots
The surgical robotics sector of today is dominated by Intuitive
Surgical’s da Vinci teleoperated device for
laparoscopic procedures, cleared by the FDA in 1997 (Figure below). Intuitive Surgical is
the market leader and has been the sole player in this space for
nearly two decades.
The intention behind teleoperated robotic devices
is to improve surgeon comfort and capabilities through better
ergonomics and superior visualisation; this enables surgeons to
convert open procedures into laparoscopic minimally-invasive
operations, deemed better for the patient.
In current teleoperated systems, the surgeon
operates from a console located a few metres from the patient, using
joysticks, buttons and foot pedals to control the robot arms which
move the instrumentation to perform surgery on the patient. da Vinci
has a ‘closed console’ where the surgeon is immersed (Figure above).
Infrared sensors are provided as a safety feature. The robot arms do
not move, even if the surgeon moves the joysticks, unless the
presence of the surgeon’s head in the console is detected. This
prevents involuntary movement of the surgical instruments when the
surgeon is not looking at the endoscopic view displayed on the
Inspired by Intuitive Surgical’s commercial
success, other companies are entering this space with products
embracing the same principles but incorporating additional features
to improve the surgeon-robot interface. Examples include DLR’s
(German Aerospace Centre, Munich, Germany) MiroSurge research system
which favours an open console to better integrate the surgeon with
all the activity in the operating room, and haptics to return touch
feedback to the surgeon (Figure below); and SOFAR’s (Milan, Italy) Telelap ALF-X for endoscopic interventions, CE-marked in 2011, which
uses eye tracking to enable the surgeon to activate the various
instruments by merely looking at their respective icons on the
MiroSurge command devices for the surgeon.
In current systems, the surgeon operates away from the
patient in a non-sterile environment. A potentially interesting
development is to have a sterile console which would allow the
surgeon to move between console and patient without compromising the
sterile field. Eye-tracking and touchless technologies are features
that may contribute to this.
A variant of teleoperated master/slave systems is
that where the surgeon physically holds on to the robot and moves
it, with the position of the end effector being constrained to
programmable volumes in space. Examples in use include Stanmore’s
(UK) Sculptor RGA (Figure right) and MAKO Surgical’s (Fort Lauderdale,
FL, USA) RIO, both for orthopaedic joint replacement. This hands-on
approach means the surgeon continues to be fully immersed in the
sterile field rather than operating from a console away from the
patient. Draping procedures and techniques, and mechanical buffers
to preserve sterilisation, are of paramount importance.
Surgical robots as surgical assistants
When the FDA cleared Computer Motion’s ZEUS
Robotic Surgical System in 1994, a robotic device for cardiovascular
interventions and a precursor of the da Vinci of today, ZEUS
incorporated three robotic arms, which were controlled remotely by
Two robotic arms acted like extensions of the surgeon’s
arms, following the surgeon’s movements whilst allowing for more
precise executions by scaling down movements and eliminating tremors
resulting from fatigue. The third arm was a voice-activated
endoscope named AESOP (Automated Endoscopic System for Optimal
AESOP's function was to manipulate a video camera
inside the patient according to voice controls provided by the surgeon. AESOP
eliminated the need for a member of the surgical team to hold the
endoscope and allowed the surgeon to directly and precisely control
their operative field of view, providing a steady picture during
minimally invasive surgeries.
NASA-funded research determined that voice-controlled commands
are preferred in the operating room as opposed to alternatives such
as eye-tracking and head-tracking. However, patents on
voice-controlled robotic devices forced competitors to develop other
means for a surgeon to control endoscopic equipment. For instance,
with the FreeHand device (Freehand 2010 Ltd, UK), the surgeon has
hands-free control of the endoscope position through a head-band
attached to a surgical cap, and an activation pedal.
Now that restricting patents are reaching the end of their life,
will we see a surge of voice-controlled devices in the operating
room? EndoControl (Grenoble, France) already has one: ViKY EP
system is a motorised endoscope positioner for laparoscopic and
thoracic surgeries. The system holds and moves the endoscope under
direct surgeon control in one of two modes: voice-activated or with
a foot control.
If voice is the best means of interacting with surgical
equipment, when will we see virtual assistants in ORs who can
interpret higher-level instructions than a simple “up” or “down”
command? With medical devices adopting technologies developed for
the consumer market, we can expect to see the medical industry
develop interfaces similar to Siri on iPhone to allow surgeons to
control equipment in a less prescriptive way by talking in free
speech and also to allow the equipment to talk back, providing
warnings and information relative to the patient and the procedure
20 years from now: robots-on-a-chip
A new wave of surgical robots, inspired by biological systems, is
currently the focus of many research initiatives — with some devices
being close to entering the market. One motivation has been the
development of flexible robots as alternatives to the essentially
rigid instruments currently in use.
Another, the development of endoluminal devices of a much smaller
scale to operate internally to the body. At a miniature scale,
research systems, such as those from the ARAKNES programme,
University of Nebraska (USA) and Scuola Superiore Sant’Anna (Italy)
are indications of what the future may hold. Wireless endoscopic
diagnostics capsules have been in use for over 10 years and robotic
capsules capable of delivering therapeutic action are in
Characteristics of biological systems, such as diversity,
adaptability and autonomy, are influencing the development of very
different surgical robots: micro and nano devices. These devices
allow intervention at local — even cell — level, resulting in
completely new procedures well beyond human capabilities.
In two decades from now, we can expect to see special-purpose
robots entering and acting on the body, self-assembling inside the
body, collaborating with other robots and dismantling once the
therapeutic action has been carried out. These robots will harvest
the body’s own systems for power and propulsion, and to promote
healing and tissue regeneration.
How will the relation between surgeons and robots develop?
seems feasible that surgery will one day be performed without
surgeon intervention using natural orifices or minimal incisions as
entry points and robotic micro and nano devices for the delivery of
therapeutic action. This robotic surgery-on-a-chip will enable
entirely new procedures and allow surgery to take place in a totally
different environment from the current operating room or
A likely scenario for the future is that a multitude of robotic
embodiments will co-exist, to be deployed depending on the context
and specific circumstances. This will be a combination of external
autonomous devices inspired by industrial robots, teleoperated
systems inspired by aviation, and endoluminal untethered micro and
nano devices inspired by biological systems. The way surgeons
interact with them, and the environment where they will be deployed,
will vary hugely (see below).
The surgical robot environment: from the OR to
©2013 Cambridge Consultants
Whatever shape surgical robots take, they will need to have
proven track records for indisputable patient outcomes and cost
efficiencies in order to gain market traction, as well as strike the
right balance of human and robot interaction.
Dr Paula Gomes, Cambridge Consultants
Dr Gomes leads developments of surgical and interventional
medical devices at Cambridge Consultants.