Surgical Robotics: Past, Present and Future

Fig. 1.1

Humanoid automaton, designed by Leonardo da Vinci, it is believed to be able to perform several human-like motions

In the eighteenth century, miniature automatons became popular as toys that can move like humans or small animals. John Brainerd created the Steam Man used to pull wheeled carts in 1865 and its electric vision the “Electric Man” was built by Frank Reade Jr in 1885. The Industrial Revolution of the late eighteenth century led to the development of complex mechanics and electricity that paved the way for robotic advancement and its application in surgery.

1.3 Evolution of Surgical Robot

The term “robot” was first used in a play called “R.U.R.” or “Rossum’s Universal Robots” (from Czech robota meaning “forced work”) by the Czech writer Karel Capek in 1921 [3]. The term robotics was first adopted by Isaac Asimov, a scientist and writer in 1941 and refers to the study and use of robots. However robot is scientifically defined as ‘a re–programmable, computer controlled mechanical device equipped with sensors and actuators’. An important early concept in robotic surgery was ‘telepresence’. Telepresence robotic arms were developed in 1951 by Raymond Goertz, while working for the Atomic Energy Commission (USA) and this was used to handle hazardous radioactive material. This marked a major milestone in force feedback (haptic) technology. In 1961 George Devol and Joseph Engelberger developed the first industrial robot called Unimate for General Motors [4]. As a result, Engelberger has been called the ‘father of robotics’. These successful experiments were determining factors for the introduction of robotics in all other industrial areas around the world. Hence, the labor intensive or dangerous tasks, especially those that required high precision were performed by the industrial robot.

1.3.1 Pre-programmable Robot

In 1978 Victor Scheinman developed the Programmable Universal Manipulation Arm (PUMA – Fig. 1.2), and this became widely used in industrial operations. In 1985 Kwoh used PUMA to perform neurosurgical biopsies [5]. Its accuracy and success led to its application in urology surgeries at the Imperial College in London, in 1988. This robot was substituted in prostate surgery by the surgeon-assistant robot for prostatectomy (SARP) and the prostate robot (PROBOT – Fig. 1.3), and in urological procedures by UROBOT. These robots had to be preprogrammed based on the fixed anatomic landmarks of each patient.

Fig. 1.2

Unimate PUMA 200 first robot used in a surgical intervention during a stereotactic brain biopsy

Fig. 1.3

The PROBOT was able to performed precise and repetitive cone shaped cuts of the prostate following an pre-establish plan

1.3.2 Robotic Telesurgery

The United States mission to put man on Mars led NASA’s Ames Research Center to develop research projects to perform long-distance surgeries in astronauts. Michael McGreevey, Stephen Ellis, and Scott Fischer developed a head-mounted display (HMD) that consisted of tiny television monitors attached to a helmet immersed in a three-dimensional (3D) environment. HMD combined with data gloves, created by Jaron Lanier, allowed the user to interact with the virtual world. The computer scientist, Scott Fischer, and the plastic surgeon, Joseph Rosen, produced the first idea of telepresence surgery to perform remote surgeries in space. They achieved it by combining SRI telemanipulator with the HMD and data glove. The telepresence surgery was not technically feasible. The HMD was replaced with monitors and the data gloves with handles for controllers at the surgeon’s console.

The US military assigned Richard Satava to be program manager for Advanced Biomedical Technologies of the government-run Defense Advanced Research Projects Agency (DARPA). Philip Green, at the Stanford Research Institute (SRI), and the military surgeon Richard Satava joined and developed an operating system for instrument telemanipulation, the “Satava and Green Telepresence system” with the goal of improving surgical capabilities on the battlefield. DARPA provided grant for the development of a robotic system the ‘Bradley 557A’ that could “virtually” take the surgeon to the front lines to provide medical assistance to wounded soldiers in the battlefield. A pivotal point for the Green Telepresence Surgery System came in 1994 when Jon Bowersox, the medical scientist for the program, performed an intestinal anastomosis on ex-vivo porcine intestine using a wireless microwave connection [6].

1.3.3 Robodoc

ROBODOC (Fig. 1.4) robot was designed to mill bone to precisely fit a prosthesis in hip replacement surgery, which improves the bonding of the bone to the prosthesis [7]. This first generation of surgical robots was notable for performing image-guided precision tasks, which preoperatively requires the surgeon to view CT images and select the appropriate implant and its placement. The surgeon must participate in the registration of the pre-operative images by locating anatomical landmarks to synchronize the CT images with the physical patient. In August 2008, ROBODOC obtained FDA approval for total hip arthroplasty and is currently the only FDA-approved robot for orthopedic surgery.

Fig. 1.4

ROBODOC used for the first time in 1988, during a total hip replacement

1.3.4 Automated Endoscopic System for Optimal Positioning (AESOP)

The evolution of surgical robots has led to a current generation of real-time telemanipulators. Yulun Wang received funding from DARPA and designed a robotic arm to hold a laparoscopic camera. His company, Computer Motion, commercialized the AESOP (the robotic laparoscopic camera holder – Fig. 1.5), which was later used in the ZEUS robot. The system was designed to assist the surgeon by taking control of the laparoscopic camera and responding to voice commands [8]. The Food and Drug Administration (FDA) approved AESOP in 1994 as an endoscopic camera manipulator, eliminating the need of an assistant to perform this task. It became the first robot to assist surgeons in operating room [9].

Fig. 1.5

AESOP® (Automated Endoscope System for Optimal Positioning), is a voice-activated robot used to hold the endoscope

1.3.5 Zeus

Wang obtained funding from DARPA to develop a robot capable of reproducing the movements of the arms of the surgeon. As a result, the Zeus system was created with arms and surgical instruments controlled by the surgeon. The FDA cleared ZEUS in October 2001 to assist in the control of blunt dissectors, retractors, graspers, and stabilizers during laparoscopic and thoracoscopic surgeries.

ZEUS (Fig. 1.6) has three robotic arms that are mounted on the operating table, one of which is AESOP. The other two arms of ZEUS are the extension of the left and right arms of the surgeon. Surgeons sit at a console and wear special glasses that create a three-dimensional image. The ZEUS robotic surgical system was first used in a fallopian tube anastomosis at the Cleveland Clinic, Ohio, USA, in July 1998 [10]. On September 3, 2001, ZEUS was used for the first-ever transatlantic telesurgery (“Operation Lindbergh”). Using a fiber-optic cable running from a ZEUS console in New York, USA, to the robot operating on the patient in Strasbourg, France, Marescaux successfully performed a telerobotic cholecystectomy [11]. This was a major landmark for surgery. In 2003, the Computer Motion, Inc., merged with Intuitive Surgical Inc. and discontinued the development of the ZEUS.

Fig. 1.6

The ZEUS Robotic Surgical System (ZRSS) was a medical robot designed to assist in surgery, originally produced by the American robotics company Computer Motion

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