INTRODUCTION:

Robotic surgery, also known as robot-assisted surgery, allows doctors to perform many types of complex procedures with more precision, flexibility and control than is possible with conventional techniques. Robotic surgery is usually associated with minimally invasive surgery procedures performed through small incisions. Robot-assisted surgery uses specialized technology that enhances the capabilities of surgeon’s hands. It allows surgeons to perform procedures in hard-to-reach areas through small incisions. This specialized technology also enables precise movements and enhanced magnification.

Modern surgery is thought to have been started by a surgeon in India named Sushruta, who invented many flap surgery techniques like rhinoplasty, and surgery on nose. Following this, in ancient Asia and South America, archaeologists have found that many tribes used heat and compounds like sulfur to stop bleeding and infections, like surgery using fire. Surgery and medical procedures were really painful back then. A lot of cultures experimented with different substances to numb the pain. The most commonly accepted one method over a long time was alcohol. It wasn't until 1846 that Dr. Norton was the first to use ether gas as an anaesthetic and was successful in pioneering modern anesthesiology¹.

The application of robotic surgery began in the 1970s as a military project, which was accomplished by NASA. Essentially, the idea was to replace the physical presence of surgeons in space or on the battlefield. The first robot was used for image-guided precision tasks, something like taking a biopsy of the brain with the use of imaging techniques. This was done in 1985 when a machine named PUMA was used to get a brain biopsy using a CT scan.

ROBOTIC GENERATIONS:

The very first surgical robots were directly modeled on industrial robots. Manufacturers simply added standard surgical tools and included a few security protocols in order for the robots to be approved for use in the Oracle (OR). Robotic surgical systems were officially introduced in the OR back in 1985. One of the pioneer models, Puma 260 was produced by Unimation Co. and was actually used by National Aeronautics and Space Administration (NASA). It was then followed by the Scara robot, which was the outcome of a cooperative effort between IBM and the University of California. In the early years, surgical robots were mainly used in neurosurgery and orthopedic surgery².

(a) First-Generation Robots:

Medical robots had their beginning in 1985 as industrial robots and computed medical robots were used to insert a probe into the brain for a biopsy specimen. A biopsy specimen is a condition tissues from the body are removed and examined under a microscope to look at what type of disease exists. This procedure was the first robotic surgery that was recorded. Robotic surgery has allowed doctors to perform, many different types of complex procedures with a lot more precision, control and flexibility, which cannot be done with conventional surgical techniques³.

A robotic surgery system has a camera arm and mechanical arms, which have surgical instruments attached to them. The surgeon sits at the computer console, controlling these arms. Some robots could carry out these procedures by themselves without the help of the surgeon and were cleared by the US Food and Drug Administration⁴.

One specific robot that discussed in detail is the Robodoc. It is the first surgical application using humans for total hip arthroplasty, or THA. THA is also known as Total Hip Replacement and is a surgical procedure where the damaged cartilage and bone are removed from the hip and replaced with prosthetic parts. The Robodoc received FDA approval in 1998. It has assisted surgeons in more than 24,000 joint replacement procedures, across many countries such as the United States, Europe, Japan, Korea and India. The advantages of using the robotic system during THA surgery are that it causes less pain and blood loss, quicker recovery, fewer complications like infections and it results in smaller and less appearance of scars.

Similar to Robodoc, a few years later, the Computer-Assisted Surgical Planning And Robotic System, also known as CASPAR, was developed. Using this robotic system which has an industrial robotic arm, called Programmable Universal Manipulation Arm or most commonly referred to as Puma robots, was created for total hip and knee arthroplasty. Knee arthroplasty is a surgical procedure that is used to resurface a damaged knee by arthritis. Although Robodoc is still in operation, Caspar was discontinued in 2004⁴.

(b) Second-Generation Robots:

A robot uses assistive and collaborative approaches. These robots can carry out their procedures, they're not programmed to do so, and instead, they are programmed to follow the surgeon's motions in a master-slave configuration. Many surgical robotic systems use this configuration, where the surgeon uses the joystick controls at the master console, to direct the movements of the robotic instruments. These instruments are known as the slave. These devices are intended to be less invasive during surgery. Essentially this only allows for a small incision or an instrument to be inserted into the body, which can allow for minimal damage to the body tissues.

One specific example of a second-generation robot is called the Da Vinci surgical robot, which is a Master-Slave system that has the patient side part with three or four robotic arms and visualization system and exclusive instruments. This robotic system translates the surgeon's fingers, wrist and hand movements into corresponding movements of the instruments that are positioned inside the patient in real-time, without any tremors. The surgeon operates sitting down at a console while viewing the surgical field. There are many surgical stops assisting and supervising laparoscopic arms and tools being used. The advantages of this robot are intuitive control, range of motion, 3D visualization of open surgery and fine tissue manipulation capabilities, which will allow the surgeon to work through other tasks, like making tiny incisions.

Another example of a second-generation robot is the Sensei Robotic Catheter system, which is a master-slave system used for interventional cardiology. Interventional cardiology specifically deals with catheter-based treatment for heart diseases. A catheter is a thin tube, a medical device, which can be inserted into the body to perform surgical procedures or treat diseases. This robotic system allows for accurate positioning, manipulation and control of catheters during surgery. This robot system received FDA clearance in May 2007. So much like DaVinci, the Sensei system also translates the physician's hand movements as a controller to control the catheter in the patient's heart⁴.

(c) DaVinci Robotic Surgical System:

The da Vinci™ robotic surgical system consists of three parts namely; the surgeon’s console which controlled by surgeon, an electronic tower holding the video equipment (vision system) and the surgical cart (robotic arms), which have three arms to perform the procedures, Fig. 1. This system was developed by Intuitive Surgical (Mountain View, CA). There are around 196 da Vinci™ robotic surgical systems installed worldwide. This system is useful for surgical operations, such as general surgery, urology, cardiothoracic surgery and pediatric surgery. The console system controls the whole procedure that resides in the hands of surgeon. The features of this system includes the surgical instruments which move like human hand motion by artificial articulation and the visualization through a high-quality 3D endoscope is optimal, known as Endo Wrist™. Regarding the treatment of cancer and tumors, surgeons have successfully performed robotic surgery for esophageal tumors, thymoma, retromediastinal tumor, gastric cancer and colon cancer using this system⁴.

Figure 1. Da Vinci robotic system

(d) Next Generation Robots:

The future robots seem to have tools that are smaller, lower-cost considering to how expensive they are currently, and developing disposable robots which are versatile. Currently, robotic systems do have guide positioning devices, which are attached to the patient and eliminate patient immobilization. Robotic exoskeletons are also being used to assist paralyzed people to walk and to correct for any malformations. Small robots may replace traditional endoscopy, which is a procedure that can allow one to examine the interior of an organ or the cavity of a body. Besides, small robots can help to carry out tasks like biopsies or using catheters. Small robots can be used to travel through blood vessels and thus for radiation therapy and can be used to deliver medicine even to a certain body site and also to gather information or patrol⁵. Through the digestive system robotic capsules can be swallowed. Robotic nurses furthermore can be implemented in hospitals to assist or replace overwork of nurses with certain tasks. The idea of surgical robots came because higher speed and accuracy could be achieved during surgery.

PROS AND CONS OF SURGICAL ROBOTS:

Although rapidly developing, robotic surgical technology comes with its advantages such as benefits, usefulness and disadvantages like risks and problems which may occurs. Some of the pros and cons of surgical robots are listed below^{6, 7}.

Pros of Surgical Robots:

(1) Reduces the size of the incision, meaning that less damage is caused to surrounding healthy tissues.

(2) The surgical accuracy increases to high level, which makes it superior for brain surgeries.

(3) Provides faster recovery time.

(4) Provides better assistance in performing delicate surgeries.

(5) These are precise and accurate at surgeries.

Cons of Surgical Robots:

(1) Higher costs related to installing and maintaining the machine.

(2) Delay between the command of the surgeon and the action of the robot.

(3) The hand-eye coordination of the surgeon has decreased.

(4) Only available at hospitals those can afford the technology and have specially trained surgeons.

(5) Robotic malfunction, which is extremely rare.

SUCCESS RATE OF SURGICAL ROBOTS:

The success rate for robotic surgery by various research agencies depends on factors like age of the patient and the medical condition, is around 93%. The comparison of benefits of various types of surgeries, viz. open surgery, MILS surgery and MIRS surgery is given in Table 1.

Table 1: Comparison between benefits of various surgery types^{6, 8}

Benefits	Type of Surgery			Benefits	Type of Surgery
Benefits	Open	MILS	MIRS	Benefits	Open	MILS	MIRS
Shorter operative time	Yes	No	No	Less fatigue (surgeon)	No	No	Yes
Shorter post-operation stay	Yes	No	No	Less expensive equipment	Yes	Yes	No
Shorter recovery time	Yes	No	No	Less specialized training	Yes	Yes	No
Less blood loss	Yes	No	No	Compensate for hand tremors	No	No	Yes
Less post-operation pain	Yes	No	No	Enhanced view	Yes	No	No
Less scarring	Yes	No	No	Small incisions	Yes	No	No
Fewer complications	Yes	No	No	Less anesthesia required	Yes	No	No
Less infection risk	Yes	No	No	Fewer doctors in Operation Room	No	No	Yes
Less transfusion requirement	Yes	No	No

ROBOTIC SURGERY IN INDIA:

The first robotic installation at all over India was for urology at All India Institute of Medical Sciences (AIIMS), New Delhi, in 2006. Thereafter, unprecedented growth has been seen in robotic surgery in India. Currently, there are about 66 centers and 71 robotic installations done as reported on July 2019, with more than 500 trained robotic surgeons in our country. More than 12,800 surgeries have been performed with robotic assistance in previous years.

The charges for robotic surgery in India are significantly cheaper when compared to the US, UK, Singapore, etc. The base cost for a robotic surgery in India starts from INR 1.42 lakh. The mediocre cost of a robotic surgery in India is INR Rs. 4.55 lakh. The highest cost for robotic surgery in India is up to INR 11 lakh. The other aspects that matter to the cost of robotic surgery, but not limited are admission fee, doctor’s fee, type of robotic surgery, the medical condition of the patient, post-surgical complications involved, admission room opted, the laboratory tests such as X-rays and examination tests such as ECG, etc.

While considering these factors, the cost for single robotic surgery in India ranges between INR 1.65 lakh to INR 13 lakh, whereas, the same surgery in the US costs around USD 200,000. The basic and highest cost of robotic surgery for cancer diagnosis is presented in Table 2.

Table 2: Cost of robotic surgery for cancer diagnosis in major cities of India^{9, 10}

City	Base Cost (INR)	Highest Cost (INR)
Bangalore	1,50,000	10,00,000
Delhi	1,57,500	10,50,000
Mumbai	1,65,000	11,00,000
Gurgaon	1,50,000	10,00,000
Chennai	1,42,000	9,50,000
Hyderabad	1,50,000	10,00,000
Pune	1,50,000	10,00,000

APPLICATIONS OF ROBOTIC SURGERY:

Robotic surgeries are mostly useful in certain situations such as laparoscopic surgeries, or surgeries in which a laparoscope is used, the arms of the robot are extremely helpful, Fig. 2. The most common procedures are gastro-jejunostomy, pyloroplasty, Roux-en-Y gastric bypass for obesity, esophageal myotomy for achalasia, nephrectomy for transplantation and bile duct surgery, general adrenalectomy, cholecystectomy, esophagectomy, gastric bypass, heller myotomy, nissen fundoplication, thoracic, esophageal surgery, thymectomy, mediastinal tumor resection, lobectomy, biventricular resynchronization epicardial leads, cardiac, atrial septal defect repair, coronary artery bypass, etc. Other surgeries include removing cancer tissue from sensitive body parts such as blood vessels, nerves, or vital body organs, gallbladder removal, hip replacement, hysterectomy, kidney removal, kidney transplant, mitral valve repair, pyeloplasty (surgery to correct ureteropelvic junction obstruction), pyloroplasty, radical prostatectomy, tubal ligation, etc.

Figure 2. Heart surgery using robot assistance¹¹

(a) Telepresence Surgery:

Telepresence surgery and robotic telementoring are two revolutionary applications achieved by linking a robot to a telecommunication system, such as SOCRATES (computer motion). In telerobotic procedures, the surgeon operates the patient from the surgeon's console, which is miles away from the slave robotic arm mounted on the patient; the surgeon's commands are relayed on the manipulator via fibre-optic cables. The first major telerobotic surgery was performed by surgeons in New York, USA, on a patient in Strasbourg, France, in 2001. Since then, many telerobotic operations have been performed worldwide.

Telepresence surgery technique allows surgeons to operate without being in direct contact with the patient. This technique of virtual surgery has many implications, such as good and bad, one of the potentially beneficial is the delivery of surgical care in medically underserved areas. However, the purchase cost is very high, and a surgical robot is too expensive for places where it is most needed such as, in Africa where the average annual per capita healthcare expenditure is very low. Whereas when finances are not limited, delivering surgical care to patients is very difficult due to no direct access to a surgeon. In telementoring, an expert surgeon helps another surgeon operating a patient miles away; both surgeons “share” the view of the surgical field and control the robotic system and communicate via phones. Telementoring technique is used for teaching surgical skills to junior surgeons all around the world by expert colleagues¹².

(b) Robotic Surgeries in Treatment of Cancer:

There are some types of cancers for which traditional open surgery may not be the best option that can treat the cancers. With the help of robotic surgery, specially trained surgeons use surgical robots, which have small surgical tools and a computer console, to remove a patient's cancer. Robotic surgery, also known as robot-assisted surgery, is usually laparoscopic. During the time of surgery, the surgeon places a thin tool with a light and small camera called a laparoscope through minor cuts in the patient's body. With the help of these laparoscopes, the surgeon can see inside the patient's body, on the video monitor without having to make larger cuts. The robot assistance allows 3-D imaging technology, which permits surgeons to perform complex surgeries more precisely than traditional techniques¹³.

Mainly, surgeons have two important goals when they perform cancer surgery, that includes dealing with the patient's cancer in the most effective way possible and recover the patient as fast and smoothly as possible. Depending on the exact situation of the patient, possible goals for surgery could be curing cancer by completely removing the tumour or reducing the growth of the tumour's size to prepare for chemotherapy or other treatment and relieving symptoms like pain or loss of function. The surgeon will determine whether robotic surgery is possible for a patient's particular cancer. If so, the surgeon may recommend robotic surgery over open surgery. The surgeon will design a surgical treatment plan that's best for the patient¹⁴.

LIMITATIONS OF ROBOTIC SURGERY:

As this rapidly developing robotic surgical technology has not achieved its full potential, it does have a few limitations. As an example, cost-effectiveness is a major issue. Two recent studies comparing robotic procedures with conventional operations showed that the cost for robotic operations was higher; the major part of the increased cost is the initial cost of purchasing the robot which is estimated at $12 million and yearly maintenance of around $1 million. These factors are expected to decrease as robotic systems get more widespread acceptance. However, further technical advances may increase prices even higher. Decreasing operative time and hospital stay will also contribute to the cost of robotic surgery. Another drawback to robotic surgery is the bulkiness of the equipment currently in use. Besides, lack of feedback to the surgeon is another major problem¹⁴.

CONCLUSION:

Robots have come a long way and they're many success stories that are known from surgical robots literature. These are not limited only to cancer surgeries but are the only future of robotics that has much more to offer such as small, inexpensive and disposable robots which can help deliver greater value to the healthcare industry. Before surgical robots mature, there is a lot of work that needs to be done concerning the development of these tools and methods to ensure that there are safer procedures that occur using these robots. We hope that the surgery someday can be done without skin incisions as well and that robots will be helping health care professionals with more accuracy, less cost and with timeliness.

ACKNOWLEDGEMENT:

The authors are thankful for the kind support of the surgeons for providing their valuable insights on the area of study with the authors. The authors also sincerely acknowledge the motivation from their educational institution and peers.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding views expressed in this review.

REFERENCES:

1. Singh V. Sushruta: The father of surgery. National Journal of Maxillofacial Surgery. 2017; 8:1–3.

2. History and evolutions of Robotic surgical system. (Revtrived on November 2022). https://stan-institute.com/en/news/histoire-de-la-chirurgie-robotique/

3. Dwivedi J and Imadeldin M. Robotic Surgery -A Review on Recent advances in Surgical Robotic Systems. Florida Conference on Recent Advances in Robotics. 2012; 1-7.

4. Gomes P. Surgical robotics: Reviewing the past, analysing the present, imagining the future. Robotics and Computer-Integrated Manufacturing. 2021, 27(2);11: 261-266.

5. Gerhardus D, Robot-assisted surgery: the future is here. 2002; 48(4): 242-51.

6. Bora G, Narain TA, Sharma AP and Ravimohan M. Robot-assisted surgery in India: A SWOT analysis. Indian Journal of Urology. 2020; 36(1):1-3.

7. Robot-assisted surgery, advantages and disadvantages. Cleveland Clinic (Revtrived on November 2022) https://my.clevelandclinic.org/health/treatments/22178-robotic-surgery

8. Coelho RF, Rocco B, Patel MB, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a critical review of outcomes reported by high-volume centres. Journal of Endourology. 2010;24:2003- 2015.

9. Robotic surgeries in India (Revtrived on November 2022). https://www.practo.com/health-wiki/robotic-surgery-india/310/article

10. Robotic surgeries in India and its benefits (Revtrived on November 2022) https://www.dheerajbojwani.com/robotic-surgery-India-low-cost-benefits.html

11. Robotic Surgery – Mayo Clinic. Patient care and health information under tests and procedures. (Revtrived on November 2022) . https://www.mayoclinic.org/tests-procedures/robotic-surgery/about/pac-20394974

12. Ballantyne GH. Robotic surgery, telerobotic surgery, telepresence, and telementoring. Surgical Endoscopy. 2002;16(10):1389-1402.

13. Raghunath SK, The advantages and benefits of robotic surgery for cancer. The Economic Times. April 2022. https://health.economictimes.indiatimes.com/news/industry/the-advantages-and-benefits-of-robotic-surgery-for-cancer/91031901

14. Hashizume M and Tsugawa K. Robotic surgery and cancer: the present state, problems and future vision. Japanese Journal of Clinical Oncology. 2004; 34(5): 227–237.

Received on 12.10.2022 Modified on 22.11.2022

Research J. Pharm. and Tech 2023; 16(1):429-434.

DOI: 10.52711/0974-360X.2023.00073