Surgical Robotics

Robotic surgery has become an established part of clinical surgery. The advantages of using a robot have been enumerated by many clinicians, however the true potential has yet to be realized. In addition, the systems available today are extraordinarily simple and cumbersome relative to the more sophisticated robotic systems used in other industries. However more important is the fact that the fundamental principles underlying robotics have yet to be exploited, such as systems integration, feedback control, automatic performance, simulation and rehearsal and integration into healthcare enterprise. By looking at robotic implementation in other industries, and exploring the new robotic technologies in the laboratories, it is possible to speculate on the future directions which would be possible in surgical robotics.

Buddy treatment, first responder combat casualty care, and patient evacuation under hostile fire have compounded combat losses throughout history. Force protection of military first responders is complicated by current international and coalition troop deployments for peacekeeping operations, counter terrorism, and humanitarian assistance missions that involve highly visible, politically sensitive, low intensity combat in urban terrain. The United States Department of Defense (DoD) has significantly invested in autonomous vehicles, and other robots to support its Future Force. The US Army Telemedicine and Advanced Technology Research Center (TATRC) has leveraged this DoD investment with augmented funding to broadly focus on implementing technology in each phase of combat casualty care. This ranges from casualty extraction, physiologic real-time monitoring, and life saving interventions during the “golden hour” while greatly reducing the risk to first responders.

The TATRC portfolio of projects aims to develop, integrate, and adapt robotic technology for unmanned ground and air battlefield casualty extraction systems that operate in hostile environments that include enemy fire. Work continues on multiple ground extraction systems including a prototype dynamically balanced bipedal Battlefield Extraction Assist Robot (BEAR) capable of extracting a 300–500 pound casualty from a variety of rugged terrains that include urban areas and traversing stairs. The TATRC and the Defense Advanced Research Projects Agency (DARPA) are collaborating to investigate the use of Unmanned Aircraft Systems (UAS) to conduct casualty evacuation (CASEVAC) missions. TATRC has also sponsored research in robotic implementation of Raman and Laser-Induced Breakdown Spectroscopy (LIBS) to detect and identify potential chemical and biological warfare agents and explosive hazards to casualties and first responders during the extraction process, and patient monitoring equipment with sophisticated telemedicine and patient monitoring equipment such as “smart stretchers” that allow for real-time physiologic monitoring throughout the combat casualty care process, from extraction to definitive care. Other projects are intended to build upon these monitoring systems and incorporate telerobotic and near autonomous casualty assessment and life saving treatment to the battlefield. These have included the DARPA Trauma Pod and several TATRC efforts to integrate robotic arms with the Life Support for Trauma and Transport (LSTAT) litter for robotic implementation of non-invasive technologies such as acoustic cauterization of hemorrhage via High Intensity Focused Ultrasound (HIFU). Several projects have explored the essential telecommunication link needed to implement telesurgery and telemedicine in extreme environments. UAS were leveraged to establish a telecommunication network link for telemedicine and telesurgery applications in extreme situations. Another collaborative telesurgery research project at the NASA Extreme Environment Mission Operations (NEEMO) included performing telesurgery in an undersea location.

Research into identification and solutions of the limitations of telecommunication and robotics that prevent robust casualty interventions will allow future medical robots to provide robust casualty extraction and care that will save the lives and limbs of our deployed warfighters.

Providing medical care in the field is very challenging because of the limited availability of medical resources. The current practice in military operations is to stabilize patients far forward and evacuate them to better equipped medical facilities, such as combat field hospitals. This strategy has proven very successful in recent conflicts. However, it is possible to save more lives and ameliorate the consequences of long term injuries by providing an accurate diagnosis earlier, specialized surgical care faster and more sophisticated intensive care during transport. This chapter focuses on technologies that allow augmenting the diagnostics and treatment capabilities of medical teams in the field.

Advances in technology yield many benefits to our daily lives. Our ability to integrate robotics, telecommunications, information systems and surgical tools into a common platform has created new approaches in utilizing less invasive means to treat both common and more complex disease states. A significant amount of investment has been made both from government funding and private sector or commercial funding in the research and development of systems in the area of robotic surgery and the application of telesurgery; and this has led to the development of clinically-relevant distribution of surgical expertise using a surgical robot and telecommunication link. This has predominately been in support of government-funded activities. While early work by Jacques Marescaux in Operation Lindberg and the extensive research performed using Intuitive Surgical’s da Vinci, SRI’s M7 and the University of Washington’s Raven has shown tremendous promise in surgical care, there remains a variety of barriers to wider adoption of telerobotic surgery. These barriers are multidisciplinary and often interdisciplinary. Widespread application of telesurgery as a medical force multiplier depends upon resolution of these barriers, which include bandwidth, latency, quality of service (QoS), research, and reimbursement. The following summarizes how telesurgery has developed, what the challenges are and how they are being ameliorated for wider adoption.

Heart failure resulting from myocardial infarct, oxygen-deprived tissue death, is a serious disease that affects over 20 million patients in the world. The precise injection of tissue-engineered materials into the infarct site is emerging as a treatment strategy to improve cardiac function for patients with heart failure. We have developed a novel miniature robotic device (HeartLander) that can act as a manipulator for precise and stable interaction with the epicardial surface of the beating heart by mounting directly to the organ. The robot can be delivered to and operate within the intrapericardial space with the chest closed, through a single small incision below the sternum. The tethered crawling device uses vacuum pressure to maintain prehension of the epicardium, and a drive wire transmission motors for actuation. An onboard electromagnetic tracking sensor enables the display of the robot location on the heart surface to the surgeon, and closed-loop control of the robot positioning to targets. In a closed-chest animal study with the pericardium intact, HeartLander demonstrated the ability to acquire a pattern of targets located on the posterior surface of the beating heart within an average of 1.7 ± 1.0 mm. Dye injections were performed following the target acquisitions to simulate injection therapy for heart failure. HeartLander may prove useful in the delivery of intrapericardial treatments, like myocardial injection therapy, in a precise and stable manner, which could be performed on an outpatient basis.

Eliminating all external incisions would be a significant step in reducing the invasiveness of surgical procedures. Accessing the peritoneal cavity through a natural orifice, as in Natural Orifice Translumenal Endoscopic Surgery (NOTES), promises distinct patient advantages, but is surgically challenging. Performing laparoscopic surgeries through a single transumbilical incision is also gaining renewed interest as a potential bridge to enabling NOTES. Both of these types of surgical procedures are inherently limited by working with multiple instruments through a constrained insertion point. New technologies are necessary to overcome these limitations and provide the surgeon with adequate visual feedback and triangulation. Miniature in vivo robots provide a unique approach by providing a platform that is completely inserted into the peritoneal cavity to enable minimally invasive surgery. This chapter describes the design and feasibility testing of miniature in vivo robots that can provide stable visualization and manipulation platforms for NOTES and single incision surgery.

The utility of current commercial teleoperated robotic surgery systems is limited by their high cost, large size, and time-consuming setup procedures. We have developed a prototype system which aims to overcome these obstacles by being much smaller, simpler, and easier to set up and operate, while providing equivalent functionality and performance for executing surgical procedures. The prototype system is modular and each component manipulator is approximately 2.5 kg or less, so that they system is easily portable and each manipulator can be individually positioned and fixed in place by hand to a rigid frame above the operating table. All system components and materials are autoclaveable and immersible in fluids, so that each manipulator can be sterilized and stored by the standard operating procedures used for any other surgical instrument, and no sterile draping is required. The system is described and results of untrained user trials performing standard laparoscopic surgery skill tasks are given.

For decades surgery and robotics were progressing along two parallel paths. In surgery, minimally invasivesurgery (MIS) revolutionized the way a significant number of surgical interventions were performed. Minimally invasive surgery allows the surgeon to make a few small incisions in the patient, rather than making one large incision for access. This technique allows for significantly faster recovery times, less trauma, and decreased pain medication requirements for the patient.

In this chapter we describe the evolution of the

da Vinci

surgical system from the very early days of Intuitive Surgical, through to 2009. In order to provide context, we begin with a short summary of the origins of telerobotic surgery itself. This involves a unique convergence of technologies and clinical needs, as well as several groups of individuals who independently recognized the role that robotics and telepresence technologies could play in medicine. The regulatory landscape has played – and continues to play – an important role in the development and use of surgical devices such as

da Vinci

. In this chapter, we describe some of the important aspects of device regulation and how they affect the deployment of medical devices such as ours. It should be noted that this story is told from the Intuitive Surgical perspective and is not intended to be exhaustive. Nevertheless, we hope that it provides some insight into the unique process of invention and development that has resulted in a marriage of technology and medicine that benefits hundreds of patients each day.

The dream of robots, automatons that can think, move, and act like humans, has been with us for centuries, dating back to Leonardo daVinci, the ancient Greeks, and possibly even earlier. The word robot was introduced by Czech writer Karel Capek in his play R.U.R. (Rossum’s Universal Robots), published in 1920. Capek’s play describes robots that are very close to the androids of films like

Star Wars

– mechanical, intelligent servants with a purpose to serve their human masters.

Since its emergence, modern robotics has empowered mankind to reach goals ranging from the hazardous to unfeasible. In the medical field, robots have ushered in an era of minimized invasiveness, improved accuracy, lessened patient trauma and shortened recovery periods. This chapter offers an overview of currently available medical robots and especially evaluates their technology-enabling capacities. Combination of significantly higher accuracy than conventional free-hand techniques with minimally invasive capability renders robotics an enabling technology. Obviously, dramatic dimensional changes in robots, to levels allowing for their introduction to the body for diagnostic and therapeutic purposes, also designates them to an enabling technology. The few currently available surgical robots are categorized in this chapter according to their enabling potential, along with a presentation of a future micro-robot for in-body treatment.

Minimally invasive cardiac surgery (MICS) is an evolving strategy aimed at delivering the desired form of cardiovascular therapy with the least change in homeostasis, ideally matching the same degree of invasiveness of percutaneous cardiac interventions. Cardiac surgery is different from other surgical procedures because the large sternotomy incision required to access the heart requires general endotracheal anesthesia (GETA) and the heart–lung machine that is required for open-heart surgery (e.g. valve repair) adds further morbidity. We have developed a novel, highly articulated robotic surgical system (CardioARM) to enable minimally invasive intrapericardial therapeutic delivery through a subxiphoid approach. The CardioARM is a robotic surgical system consisting of serially connected rigid cylindrical links housing flexible working ports through which catheter-based tools for therapy and imaging can be advanced. The CardioARM is controlled via a computer-driven user interface which is operated outside of the operative field. We believe single port access to be key to the success of the CardioARM. We have performed preliminary proof of concept studies in a porcine preparation by performing epicardial ablation.

Many current and proposed retinal procedures are at the limits of human performance and perception. Microrobots that can navigate the fluid in the interior of the eye have the potential to revolutionize the way the most difficult retinal procedures are conducted. Microrobots are typically envisioned as miniature mechatronic systems that utilize MEMS technology to incorporate sensing and actuation onboard. This chapter presents a simpler alternative approach for the development of intraocular microrobots consisting of magnetic platforms and functional coatings. Luminescence dyes immobilized in coatings can be excited and read wirelessly to detect analytes or physical properties. Drug coatings can be used for diffusion-based delivery, and may provide more efficient therapy than microsystems containing pumps, as diffusion dominates over advection at the microscale. Oxygen sensing for diagnosis and drug therapy for retinal vein occlusions are presented as example applications. Accurate sensing and therapy requires precise control to guide the microrobot in the interior of the human eye. We require an understanding of the possibilities and limitations in wireless magnetic control. We also require the ability to visually track and localize the microrobot inside the eye, while obtaining clinically useful retinal images. Each of these topics is discussed.

The present chapter illustrates robotic approaches to endolomuninal diagnosis and therapy of hollow organs of the human body, with a specific reference to the gastrointestinal (GI) tract. It gives an overview of the main technological and medical problems to be approached when dealing with miniaturized robots having a pill-like size, which are intended to explore the GI tract teleoperated by clinicians with high precision, flexibility, effectiveness and reliability. Considerations on different specifications for diagnostic and surgical swallowable devices are presented, by highlighting problems of power supply, dynamics, kinematics and working space. Two possible solutions are presented with details about design issues, fabrication and testing: the first solution consists of the development of active capsules, 2–3 cm

3

in volume, for teleoperated diagnosis in the GI tract; the second solution illustrates a multiple capsule approach allowing to overcome power supply and working space problems, that are typical in single capsule solutions.

In microsurgery, a surgeon often deals with anatomical structures of sizes that are close to the limit of the human hand accuracy. Robotic assistants can help to push beyond the current state of practice by integrating imaging and robot-assisted tools. This paper demonstrates control of a handheld tremor reduction micromanipulator with visual servo techniques, aiding the operator by providing three behaviors: “snap-to”, motion scaling, and standoff regulation. A stereo camera setup viewing the workspace under high magnification tracks the tip of the micromanipulator and the object being manipulated. Individual behaviors are activated in task-specific situations when the micromanipulator tip is in the vicinity of the target. We show that the snap-to behavior can reach and maintain a position at a target with Root Mean Squared Error (RMSE) of 17.5 ± 0.4 µm between the tip and target. Scaling the operator’s motions and preventing unwanted contact with non-target objects also provides a larger margin of safety.

We review micro-systems with robotic aspects that are used in medical diagnosis and intervention. We describe the necessary components for a micro-robot and present the state of the art and gaps of knowledge. One of the great challenges in micro robots is the propulsion. Different propulsive strategies and specifically flagellar propulsion is evaluated in this chapter. We analyze the influence of the miniaturization on the micro-robot and try to estimate the future developments in the field.

Enhancing targeting in the smallest blood vessels found in the human microvasculature will most likely require the use of various types of microdevices and nanorobots. As such, biology may play an important role where medical bio-nanorobots including nanorobots propelled in the microvasculature by flagellated bacteria to target deep regions in the human body will become important candidates for such applications. In this chapter, we introduce the concept and show the advantages of integrating biological components and more specifically Magnetotactic Bacteria (MTB) for the development of hybrid nanorobots, i.e., nanorobots made of synthetic and biological nanoscale components, designed to operate efficiently in the human microvascular network. Similarly, the chapter shows the advantage of using Magnetic Resonance Imaging (MRI) as an imaging modality to control and track such medical nanorobots when operating inside the complex human vascular network. The chapter also presents preliminary experimental results suggesting the feasibility of guiding and controlling these nanorobots directly towards specific locations deep inside the human body.

It is hypothesized that the lack of haptic (force and tactile) feedback presented to the surgeon is a limiting factor in the performance of teleoperated robot-assisted minimally invasive surgery. This chapter reviews the technical challenges of creating

force

feedback in robot-assisted surgical systems and describes recent results in creating and evaluating the effectiveness of this feedback in mock surgical tasks. In the design of a force-feedback teleoperator, the importance of hardware design choices and their relationship to controller design are emphasized. In addition, the practicality and necessity of force feedback in all degrees of freedom of the teleoperator are considered in the context of surgical tasks and the operating room environment. An alternative to direct force feedback to the surgeon’s hands is sensory substitution/augmented reality, in which graphical displays are used to convey information about the forces between the surgical instrument and the patient, or about the mechanical properties of the patient’s tissue. Experimental results demonstrate that the effectiveness of direct and graphical force feedback depend on the nature of the surgical task and the experience level of the surgeon.

While commercial surgical robotic systems have provided improvements to minimally invasive surgery, such as 3D stereoscopic visualization, improved range of motion, and increased precision, they have been designed with only limited haptic feedback. A number of robotic surgery systems are currently under development with integrated kinesthetic feedback systems, providing a sense of resistance to the hands or arms of the user. However, the application of tactile feedback systems has been limited to date. The challenges and potential benefits associated with the development of tactile feedback systems to surgical robotics are discussed. A tactile feedback system, featuring piezoresistive force sensors and pneumatic silicone-based balloon actuators, is presented. Initial tests with the system mounted on a commercial robotic surgical system have indicated that tactile feedback may potentially reduce grip forces applied to tissues and sutures during robotic surgery, while also providing high spatial and tactile resolution.

The challenges imposed by Minimally Invasive Surgery (MIS) have been the subject of significant research in the last decade. In the case of cancer surgery, a significant limitation is the inability to effectively palpate the target tissue to localize tumor nodules for treatment or removal. Current clinical technologies are still limited and tumor localization efforts often result in the need to increase the size of the incision to allow finger access for direct palpation. New methods of MIS tumor localization under investigation involve restoring the sense of touch, or haptic feedback. The two most commonly investigated modes of haptic perception include kinesthetic and tactile sensing, each with its own advantages and disadvantages. Work in this area includes the development of customized instruments with embedded sensors that aim to solve the problem of limited haptic feedback in MIS. This chapter provides a review of the work to date in the use of kinesthetic and tactile sensing information in MIS for tissue palpation, with the goal of highlighting the benefits and limitations of each mode when used to locate hidden tumors during MIS.

The past decades have seen the notable development of minimally invasive surgery (MIS), in which the surgical gesture is performed through small incisions in the patient’s body. The benefits of this modality of surgery for patients are numerous, shortening convalescence, reducing trauma and surgery costs. However, several difficulties are imposed to the surgeon, such as decreased mobility, reduced visibility, uncomfortable working posture and the loss of tactile feedback. In this context, robotic assistance aims to aid surgeons to overcome such difficulties, making the surgical act more intuitive and safer. Consequently, commercially available surgical platforms such as the daVinci

TM

(Intuitive Surgical) quickly became popular.

The use of intelligent robotic tools promises an alternative and superior way of performing off-pump coronary artery bypass graft (CABG) surgery. In the robotic-assisted surgical paradigm proposed, the conventional surgical tools are replaced with robotic instruments, which are under direct control of the surgeon through teleoperation. The robotic tools actively cancel the relative motion between the surgical instruments and the point-of-interest on the beating heart, in contrast to traditional off-pump CABG where the heart is passively constrained to dampen the beating motion. As a result, the surgeon operates on the heart as if it were stationary. We call the proposed algorithm “Active Relative Motion Cancelling” (ARMC) to emphasize the active cancellation. This chapter will provide a review of our research towards developing robotic tools for off-pump CABG surgery. First, we will explain the algorithm we have developed to achieve effective motion cancellation. Second, we will explain the necessary sensory system for the beating heart surgery and the developed whisker sensors to detect three-dimensional heart motion. Third, we will explain the millirobotic gripper developed for minimal invasive surgery. Finally, we will outlay the overall system design for robotic-assisted beating heart surgery.

This chapter describes how advances in needle design, modeling, planning, and image guidance make it possible to steer flexible needles from outside the body to reach specified anatomical targets not accessible using traditional needle insertion methods. Steering can be achieved using a variety of mechanisms, including tip-based steering, lateral manipulation, and applying forces to the tissue as the needle is inserted. Models of these steering mechanisms can predict needle trajectory based on steering commands, motivating new preoperative path planning algorithms. These planning algorithms can be integrated with emerging needle imaging technology to achieve intraoperative closed-loop guidance and control of steerable needles.

Accurate knowledge of biomechanical characteristics of tissues is essential for developing realistic computer-based surgical simulators incorporating haptic feedback, as well as for the design of surgical robots and tools. Most past and current biomechanical research is focused on soft and hard anatomical structures that are subject to physiological loading while testing the organs in situ. Internal organs are different in that respect since they are not subject to extensive loads as part of their regular physiological function. However, during surgery, a different set of loading conditions are imposed on these organs as a result of the interaction with the surgical tools. The focus of the current study was to obtain the structural biomechanical properties (engineering stress-strain and stress relaxation) of seven abdominal organs, including bladder, gallbladder, large and small intestines, liver, spleen, and stomach, using a porcine animal model. The organs were tested in vivo, in situ, and ex corpus (the latter two conditions being postmortem) under cyclical and step strain compressions using a motorized endoscopic grasper and a universal-testing machine. The tissues were tested with the same loading conditions commonly applied by surgeons during minimally invasive surgical procedures. Phenomenological models were developed for the various organs, testing conditions, and experimental devices. A property database—unique to the literature—has been created that contains the average elastic and relaxation model parameters measured for these tissues in vivo and postmortem. The results quantitatively indicate the significant differences between tissue properties measured in vivo and postmortem. A quantitative understanding of how the unconditioned tissue properties and model parameters are influenced by time postmortem and loading condition has been obtained. The results provide the material property foundations for developing science-based haptic surgical simulators, as well as surgical tools for manual and robotic systems.

Minimally invasive surgery (MIS) involves a multi-dimensional series of tasks requiring a synthesis between visual information and the kinematics and dynamics of the surgical tools. Analysis of these sources of information is a key step in mastering MIS but may also be used to define objective criteria for characterizing surgical performance. The BlueDRAGON is a new system for acquiring the kinematics and the dynamics of two endoscopic tools synchronized with the visual view of the surgical scene. It includes passive mechanisms equipped with position and force torque sensors for measuring the position and the orientation (P/O) of two endoscopic tools along with the force and torque (F/T) applied on them by the surgeon’s hands. The analogy between Minimally Invasive Surgery (MIS) and human language inspires the decomposition of a surgical task into its primary elements in which tool/tissue interactions are considered as “words” that have versions pronunciations defined by the F/T signatures applied on the tissues and P/O of the surgical tools. The frequency of different elements or “words” and their sequential associations or “grammar” both hold critical information about the process of the procedure. Modeling these sequential element expressions using a multi finite states model (Markov model – MM) reveals the structure of the surgical task and is utilized as one of the key steps in objectively assessing surgical performance. The surgical task is modeled by a fully connected, 30 state Markov model representing the two surgical tools where each state corresponds to a fundamental tool/tissue interaction based on the tool kinematics and associated with unique F/T signatures. In addition to the MM objective analysis, a scoring protocol was used by an expert surgeon to subjectively assess the subjects’ technical performance. The experimental protocol includes seven MIS tasks performed on an animal model (pig) by 30 surgeons at different levels of training including expert surgeons. Analysis of these data shows that the major differences between trainees at different skill levels were: (a) the types of tool/tissue interactions being used, (b) the transitions between tool/tissue interactions being applied by each hand, (c) time spent while performing each tool/tissue interaction, (d) the overall completion time, and (e) the variable F/T magnitudes being applied by the subjects through the endoscopic tools. An objective learning curve was defined based on measuring quantitative statistical distance (similarity) between MM of experts and MM of residents at different levels of training. The objective learning curve (e.g. statistical distance between MM) was similar to that of the subjective performance analysis. The MM proved to be a powerful and compact mathematical model for decomposing a complex task such as laparoscopic suturing. Systems like surgical robots or virtual reality simulators in which the kinematics and the dynamics of the surgical tool are inherently measured may benefit from incorporation of the proposed methodology for analysis of efficacy and objective evaluation of surgical skills during training.

The ability to extend the physical reach of a surgeon to treat a patient surgically in another locality was one of the many promises which came with the introduction of Robotic and Computer Assisted Technology into the field of surgery in the late 1970s and early 1980s. In fact, it was the possibility of using a robot as surgeons’ hands and eyes at a distance which led to some of the major grants from DARPA, NASA and NIH for the development of the prototypes of the da Vinci and the Zeus Systems which revolutionized the practice of Robotic and Computer Assisted Surgery in the late 1990s.

The primary incentive of these agencies for making such investments was to develop a system to allow them to provide emergency surgical care to the remote operatives. Others saw parallel uses in enhancing quality of surgical care which can be provided to settlements in remote parts of the world or at times of major disasters. And yet another use of telesurgery was an application for practical knowledge translation and a means for an expert surgeon to effectively achieve tele-presence during telementoring of another surgeon with acquisition of new surgical skills. The ability for two surgeons to collaborate across distances during a surgical act was seen as the ultimate achievement in knowledge translation in surgery.

It was these promises which sparked the efforts of many surgeons, engineers, and inventors who dedicated a significant portion of their lives into enhancing the field of Robotic Telesurgery.

The concept of machines performing tasks normally done by humans was first introduced in 1921 by Czechoslovakian playwright Karel Capek. His play “Rossum’s Universal Robots” was a satirical piece intended to protest the growth of technology in Western civilization. However, much to his dismay the play had the opposite effect. Public fascination with robots increased and to this day is still a fascination of modern society. The word robot is derived from the Czechoslovakian word “robata” which is defined as forced labor or servitude. According to Merriam-Webster’s Dictionary its simplest definition is “a device that automatically performs complicated often repetitive tasks” [1]. The term robotics was first introduced by Isaac Asimov in 1938 in his short story “Runaround” for

Super Science Stories

Magazine. This was followed by a series of short stories that were later collected and published as “I Robot” in 1942. He used the term robotics to describe three laws governing robot behavior which later became the inspiration for the 2004 movie “I Robot”. In society today robots are used to perform highly specific and precise tasks that are impossible to perform or difficult to perform reproducibly by humans. They are utilized in manufacturing, exploration of space and the deep sea, and work in hazardous environments to name a few examples [2].

The clinical use of robotic-assisted laparoscopic surgery has been most prevalent in urologic care. The robotic prostatectomy is

the

procedure that has highlighted the potential of robotics. Because this procedure has become so rapidly embraced, urologists have readily adapted the robotic platform to other procedures such as radical cystectomy, partial nephrectomy, pediatric reconstructive procedures, and now female urologic and fertility procedures. Data on comparative effectiveness between the robotic, laparoscopic, and open versions of urologic procedures is still sparse, yet public pressure has forced a demand for access to robotic urologic care. It remains to be seen if adequate robotic training can keep up with the exploding need to provide robotic surgery options, but simulation training is ideally situated to offer a solution to novice trainees and experienced surgeons who wish to embark on robotic urologic surgery.

Minimally invasive surgery has revolutionized many fields of surgery over the last two decades. Robotic assisted surgery is the latest iteration towards less invasive techniques. Cardiac surgeons have slowly adapted minimally invasive and robotic techniques into their armamentarium. In particular, minimally invasive mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centers worldwide because of excellent results. We have developed a robotic mitral valve surgery program which utilizes the da Vinci

®

telemanipulation system allowing the surgeon to perform complex mitral valve repairs through 5 mm port sites rather than a traditional median sternotomy. In this rapidly evolving field, we review the evolution and clinical results of robotically-assisted mitral valve surgery and review other cardiac surgical procedures for which da Vinci

®

is currently being used.

Use of robots in surgery, especially in neurosurgery, has been a fascinating idea since the development of industrial robots. Using the advantages of a robot to complement human limitations could potentially enhance surgical possibilities, other than making it easier and safer. Over the last few decades, much progress has been made in this direction across various disciplines of neurosurgery such as cranial surgery, spinal surgery and radiation therapy. This chapter details the necessity, principles and the future directions of robotics in neurosurgery. Also, the concept of curvilinear robotic surgery and associated instrumentation is discussed.

Robotic technology poses some distinct challenges in pediatric general surgery. The biggest problem is simply a matter of size. The current robot is huge when compared to a neonate and the instruments were not designed with small patients in mind. In this chapter, we will present the areas where robotic surgery can excel while also discussing the issues and problems with the current technology as it pertains to the huge variety of congenital anomalies and patient sizes that a pediatric general surgeon encounters.

Surgeons strive to minimize surgical complications and new procedures are developed with this goal in mind. It is critical when evaluating new innovations that their be no compromise in overall surgical technique and treatment goals. The emergence of minimal invasive surgery (MIS) has led to a significant reduction in perioperative morbidity, mortality and length of hospital stay as compared to traditional laparotomy. However, current conventional laparoscopy has seen limited application in many complex pelvic procedures due to the pelvis’s limited space and complex anatomy. The introduction of robotic assisted MIS has overcome many of these limitations by providing superior dexterity, intuitive movement, 3-D vision, ergonomics and autonomy. The use of the da Vinci surgical system has now become an integral surgical tool in gynecologic surgeries. This chapter will review the current robotic platform’s development and use in the field of gynecology and gynecologic oncology since 2005 demonstrating its feasibility and safety.

From the first laparoscopic cholecystectomy performed in 1985 to the introduction of robotic surgical telemanipulators in general surgery in the early 2000s, the field of general surgery has changed tremendously, to the point that isn’t general anymore; indeed this concept barely exists as a surgical discipline outside rural areas. It has however evolved into the last subspecialty of what was once known as general surgery, and it called Gastrointestinal or Alimentary Tract surgery. The factor the influenced the most on this change was the adoption of Minimally Invasive Surgery in the late 1980s, which selected the General Surgeons that were interested on the abdominal cavity and the gastrointestinal tract. Furthermore, the success and wide spread acceptance of the Laparoscopic Cholecystectomy, brought this field to the spotlight. Nowadays laparoscopic anti-reflux surgical procedures, esophagectomies, colectomies and bariatric surgery are done routinely in major centers across the United States, Europe and many parts of the world.