The SurgiBot™, by TransEnterix, is currently under development, and is preparing for FDA approval [12]. This robotic platform offers a bedside robotic cart and a vision cart, which employs a 3D high-definition monitor (Fig. 21.3). This allows the surgeon to remain at the patient’s side in a sterile field and also provides a portable 3D experience for everyone in the operating room wearing 3D glasses. The footprint is therefore smaller than the da Vinci system and offers more mobilization in smaller rooms. The SurgiBot™ is designed with a focus on single-port surgeries, which utilizes a midline camera and two articulating robotic channels, in which flexible instruments can be robotically controlled (Fig. 21.4). Flexible and catheter-based instruments can also be passed through a third channel for additional assistance. Laparoscopic handles are used to control the instruments, giving a familiar experience to laparoscopic surgeons, but lack the wristed motion of the da Vinci platform. However, this platform does provide tactile feedback providing added instrument control. Additionally, the SurgiBot™ allows for multiquadrant movement without having to undock and dock the robotic cart from the patient. Advanced energy devices including Flex Ligating Shears and a monopolar hook have recently been developed. Other instruments currently available for this platform include a wavy grasper, Maryland dissector, Flex shears, suction irrigator, fenestrated grasper, clip applier, and a needle driver. For this platform, stapling will need to be performed extracorporeally or a stapling device will have to be inserted through a separate trocar site. Currently, preclinical studies have shown success with this platform in single incision cholecystectomies and nephrectomies in porcine models. Although no specific colorectal use has been marketed, the single-site platform and ability to work in multiple abdominal quadrants make the SurgiBot™ a plausible option for colorectal and likely transanal surgeries.

Titan Medical Inc. was known to be working on a multiport robotic platform but appears to have shifted resources to a single-port platform in order to appeal more to general surgery and other specialties underserviced by current robotic devices [13]. The SPORT™ (Single Port Orifice Robotic Technology) surgical system consists of a surgeon workstation and a single-port patient cart. This platform has a high-definition 3D camera and two flexible robotic arms, which can fit through a 25 mm port. The SPORT™ surgical system will have disposable instruments, which currently include a curved dissector, hook cautery, needle grasper, and an atraumatic grasper. The benefit of the SPORT™ surgical system will be a smaller footprint and lower cost (<$1.0 million) compared to the da Vinci platform. However, the disadvantages will be the need for additional ports for separate laparoscopic vessel sealers, stapling devices, and clip appliers. Furthermore, there have been no reports about the incorporation of haptic feedback. Titan Medical Inc. has estimated a release date in Europe in 2016, and a United States release date in mid-2017 pending FDA approval. Similarly to the SurgiBot™, the SPORT™ surgical system may have a role in single-port colorectal and transanal procedures at a reduced cost to other platforms.

The Telelap ALF-X is a new advanced platform for minimally invasive surgery developed in Italy by the pharmaceutical company SOFAR S.p.A [14]. It also provides a high-definition 3D camera, which can be used in any robotic arm, as well as an ergonomic surgeon console with a 3D monitor. The surgeon console, or “surgical cockpit,” also employs laparoscopic instrument handles, providing familiar instrument handling to laparoscopic surgeons (Fig. 21.5). The platform is unique in that individual bedside carts control one robotic arm each, and 3–4 arms can be connected to 1–2 surgeon consoles through a connection node cart (Fig. 21.6). Subsequently, this requires a larger footprint in the operating room but offers other benefits. This includes quicker docking (which takes seconds), fewer arm collisions, more accurate movement of surgical instruments, and the ability to operate in multiple abdominal quadrants without undocking and redocking. Each arm provides 6 degrees of freedom in movement and instruments attach to the arms with magnets, allowing for quick and uncomplicated instrument exchanges. It is also more assistant friendly for the attachment and replacement of surgical instruments and provides an uninhibited view of and easy access to the surgical field. Another potential advantage of the Telelap ALF-X is the haptic feedback features, which enable the perception of the consistency of tissues and the forces exerted. An eye movement tracking system allows the surgeon to control the camera by moving any point looked at to the center of the screen. The eye-tracking system also enables the activation of the various available instruments by just looking at their respective icons on the screen. In addition, standard laparoscopic trocars can be used, and a fulcrum search application adjusts the most appropriate insertion instruments to minimize local stress and trauma on the surrounding tissue. Telelap ALF-X also offers a wide range of reusable instruments and adapters, which can be sterilized by autoclave (Fig. 21.7). Monopolar and bipolar energy devices are currently offered, but vessel-sealing devices are now under development and will be available in the near future. SOFAR S.p.A also suggests the cost of the platform to be two-thirds that of the da Vinci platform. With a less expensive platform and reusable instruments, costs are close to standard laparoscopic surgery. The Telelap ALF-X platform provides many benefits of other robotic platforms for colorectal surgery, including easier multiquadrant operations, but also offers more advanced technological features such as haptic feedback and an eye-tracking system. However, the individual arm carts may inhibit the use of this platform for transanal surgeries and might require a larger operating room spatial footprint, limiting the areas of its use. Furthermore, laparoscopic stapling devices are needed, but may be easier for assistants to use with increased access to the surgical field. Currently, the Telelap ALF-X platform is only marketed in the European Union, but there are plans to apply for FDA clearance and market in the United States in the near future. SOFAR S.p.A may integrate with TransEnterix to accomplish this goal.

The technological advancements in robotic surgery have made the idea of telesurgery a reality. With telesurgery, patients can acquire unique surgical expertise despite being great distances from highly specialized surgeons. The military has envisioned the use of telesurgery in forward operating bases near combat zones with limited medical staff. If telesurgery could be employed in civilian life, it could allow advanced surgical care in any region with limited resources including rural communities, third world countries, and even the international space station. However, implementation of telesurgery has been limited due to data transmission latency. Once cables are no longer used to connect the surgical console to the robot, the data must be compressed, transmitted, and then uncompressed at the receiving location. This creates a latency period, which can degrade surgical performance. Studies have revealed that basic tasks can be satisfactorily performed with up to a 600-ms time delay, but complex procedures have a significant increase in errors with delays greater than 300 ms [15–17]. Despite the issue with latency, Jacques Marescaux of Strasbourg, France performed the first transatlantic cholecystectomy on a patient in Strasbourg while sitting on a surgical console in New York City in 2001 [18]. Currently, telementoring is being employed allowing for colorectal surgeons to provide real-time intraoperative feedback during complex cases, but latency times and medical–legal factors have dissuaded telesurgery use in the United States. Although still limited, telesurgery continues to be explored.

Stanford Research International (SRI) , who has helped pioneer robotic surgery platforms from the 1980s under contract to the U.S. Army and funding from the NIH, developed the M7 surgical robot in 1998 [19]. The current version has two anthropomorphic robotic arms, which move through 7 degrees of freedom, and in which conventional surgical tools can be swapped rapidly by a technician. The advantage of the M7 not offered by other platforms is the incorporation of auditory, visual, and tactile sensations, as well as haptic feedback. Additionally, the robotic platform software compensates for jarring or turbulence on a moving platforms (such as in vehicles, aircraft, or in space) virtually eliminating tremor. In 2006, the M7 successfully completed a real-time abdominal surgery on a patient simulator remotely in the Aquarius Underwater Laboratory 60 ft underwater off the coast of Key Largo, Florida as part of the ninth NASA Extreme Environment Mission Operations [20]. Similarly, in 2007, the M7 was used to complete basic exercises aboard a NASA C-9 aircraft simulating the microgravity of space [21]. The M7 was also used to perform the first automated ultrasound-guided tumor biopsy [20].

Another robotic platform focusing on telesurgery is the Raven, developed by physicians and scientists at the BioRobotics Laboratory affiliated with the University of Washington in 2005, and is sponsored by the Department of Defense [22]. The current version of the robot (Raven II) weighs 22 kg, and has two articulated, tendon-driven arms in which different surgical instruments can be easily exchanged. It can be easily disassembled/assembled for transport by nonengineers, and the communication links have been designed for long-distance remote control. The unique feature of this platform is that the Robot Operating System software contains a popular open-source robotics code, allowing other labs and researchers to connect the Raven II to other devices and share ideas. Other robotic labs including Harvard, Johns Hopkins University, the University of Nebraska-Lincoln, UCLA, and UC Berkeley have also received Raven II robots to further research and problem-solve the current limitations of robotic surgery. The Raven II has also been tested in underwater NASA training habitats, remote desert locations, unmanned aerial vehicles, as well as zero-gravity astronaut training drills [23–26].