Journal of Surgical Protocols and Research Methodologies, 2022, 1–3

https://doi.org/10.1093/jsprm/snac003
Editorial

Editorial
Robotic surgery: an evolution in practice
1,
Elizabeth Z. Goh * and Tariq Ali2
1 Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia

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2 Oral and Maxillofacial Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
*Correspondence address. Faculty of Medicine, University of Queensland, 288 Herston Road, Herston QLD 4006, Australia. E-mail: [email protected]

BACKGROUND Robotic surgery offers advantages over conven-

Robotic surgery is a progression on the minimally inva- tional endoscopic surgery in visualization, dexterity
sive spectrum and represents an evolution in practice and ergonomics, while maintaining the peri-operative
across numerous disciplines. benefits of minimally invasive surgery [1]. The dual-
From its origins in the late 1980s, pioneering technolo- camera system offers 3D views with depth perception,
gies like the ROBODOC for hip replacements and the unlike conventional endoscopic views [1]. Precision
PROBOT for urological procedures were early iterations features include articulated ‘EndoWrist’ instruments
of the idea that mechanical augmentations could at the with increased degrees of freedom, removal of the
very least be useful adjuncts in the complex task that fulcrum effect and motion scaling with tremor filtration
is surgery [1]. In the 1990s, researchers from the United [1, 3]. Accordingly, objective advantages over laparoscopic
States (US) National Aeronautics and Space Adminis- techniques in terms of dexterity and muscle fatigue
tration and Stanford Research Institute investigated the have been demonstrated [4]. The remote console also
potential of robotics for telepresence surgery [1]. Subse- allows an ergonomic operating position while optimizing
quent US Army funding attempted to devise a system to visualization and manoeuvrability [1]. Recent da Vinci
remotely operate on wounded soldiers via robotic equip- iterations have included a reconfigured robotic arm
ment, in hopes of decreasing battlefield mortality [1]. design to improve access; faster docking to reduce oper-
Commercial development introduced Automated Endo- ative time; fluorescence-detection to identify structures
scopic System for Optimal Positioning (AESOP) (Com- and lesions of interest; robotic staplers to overcome
puter Motion, CA), a voice-controlled robotic arm with an difficulties in endoscopic stapler positioning by the
endoscopic camera, to the civilian surgical community assistant and a dual console for training [5, 6].
[1]. This was superseded in the 2000s by two comprehen- Feasibility, efficacy and cost considerations exist.
sive master–slave platforms: the da Vinci system (Intu- Access concerns may be ameliorated with a pre-
itive Surgical, CA), an eponymous nod to Leonardo da operative screening endoscopy, whereas operative time
Vinci’s fifteenth-century ‘mechanical knight’ automaton reduces with experience [3]. Ongoing technological
[2], and the Zeus system (Computer Motion, CA), which advances and global uptake of robotic surgery are
was designed for cardiac surgery [1]. A company merger expected to improve efficacy through optimization
established the former as today’s main platform [1]. of case selection and equipment guided by growing
The da Vinci system consists of a console from longitudinal data [3]. Purchase and maintenance costs
which the surgeon remotely controls arms connected are significant, but will be offset by high volume use as
to a robotic cart beside the patient [3]. A dual-camera well as savings from reduced length of stay and improved
endoscope mounted on one arm transmits images of the clinical outcomes [3].
surgical field to the console, providing the surgeon with
a magnified three-dimensional (3D) view [3]. In response, CARDIOTHORACIC SURGERY
the surgeon manipulates instruments attached to the The benefits of 3D vision and enhanced manoeuvra-
other arms via the console [3]. The assistant is positioned bility provided by robotic surgery are crucial in the
beside the patient to suction and retract at the surgical mediastinum, which contains many vital structures.
field [3]. Myriad applications exist for cardiac surgery, including

Received: January 10, 2022. Accepted: January 17, 2022

Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2022.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/
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2 | E. Z . Goh and T. Ali

cardiac revascularization and mitral valve repair, which knee arthroplasty, which has been found to result
were some of the earliest robotic surgeries performed in decreased iatrogenic trauma to periarticular soft
[7]. Robotic thymectomy for thymomas is aided by tissue and bone, increased accuracy of component
fluorescence-guided detection of the tumour and positioning and improved peri-operative outcomes
adjacent structures [5]. Robotic lobectomy for lung compared to conventional jig-based techniques [26, 27].
cancer is also gaining traction, with Yang et al.’s 10- Cost-effectiveness analysis of robotic arthroplasty is also
year cohort study reporting comparable oncologic and in progress via the Robotic Arthroplasty: a Clinical and
peri-operative outcomes to video-assisted and open cost Effectiveness Randomised controlled (RACER) trial
approaches [8]. [28]. Still under investigation for clinical use are passive
systems, such as the da Vinci platform for hip and shoul-
GENERAL SURGERY der arthroscopy, and active systems, which can indepen-
dently perform procedures without surgeon input [29].

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Robotic surgery is feasible for numerous general surgical
procedures, pending cost and operative time considera-
UROLOGY AND GYNAECOLOGY
tions, which will improve with technological advances. It
has been used for rectal cancer resection, with the 2017 Robotic surgery is particularly suited for surgical access
ROLARR trial finding comparable open conversion rates within the anatomically restrained pelvic space. Robotic-
with laparoscopic techniques [9], and Lee et al.’s large assisted radical prostatectomy is one of the most com-
cohort study finding comparable resection quality with mon robotic procedures. It is a widely-accepted manage-
transanal techniques [10]. Robotic surgery is also a safe ment option for prostate cancer, with Tewari et al.’s land-
and effective clinical alternative for common operations mark meta-analysis reporting comparable oncologic and
such as gastrectomy [11], Roux-en-Y gastric bypass [12] peri-operative outcomes to laparoscopic and open tech-
and thyroidectomy [13]; as well as rare procedures such niques [30]. Robotic partial nephrectomy is an emerg-
as median arcuate ligament (MAL) release in MAL syn- ing indication, with Bravi et al.’s prospective multicentre
drome [14]. Recent da Vinci iterations incorporate a more cohort study reporting better peri-operative outcomes
flexible robotic arm configuration to simplify set-up and than laparoscopic and open approaches for anatomically
facilitate four-quadrant access for complex procedures, low-risk renal tumours [31]. Robotic surgery provides
and specific single-site surgery instruments with sim- improved outcomes for complex benign hysterectomy,
ilar peri-operative benefits to single-port laparoscopic where superior post-operative quality-of-life may offset
surgery [6]. the increased operating time, and endometrial cancer
staging, where obesity and other comorbidities are com-
mon in the population [32]. There is emerging evidence
HEAD AND NECK SURGERY
for its use in cervical and ovarian cancer [33], myomec-
The head and neck area is difficult to access due to its tomy and sacrocolpopexy [32].
complex anatomy and confined space. Transoral robotic
surgery (TORS) is an emerging option for oropharyngeal CONCLUSION
carcinoma, as it enables minimally invasive access to
the oropharynx without large and mutilating open pro- Robotic surgery is an emerging modality across numer-
cedures such as a mandibulotomy and/or pharyngotomy, ous surgical specialties. It offers advantages over conven-
which cause significant functional and aesthetic deficits tional endoscopic surgery in visualization, dexterity and
[15]. It also offers similar oncologic and functional out- ergonomics, while maintaining the benefits of minimally
comes to radiotherapy, pending further comparisons [16, invasive surgery. Feasibility, efficacy and cost concerns
17]. In addition, TORS is being increasingly used for can- may be ameliorated with technological advances and
cers of unknown origin. Systematic reviews by Farooq et increased uptake. Robust longitudinal comparisons with
al. [18] and Fu et al. [19] found that tongue base muco- established treatment modalities are imperative to sup-
sectomies and lingual tonsillectomies performed with port this evolution in practice.
TORS and transoral laser microsurgery (TLM) identified
the primary tumour in over 70% of cases with negative CONFLICT OF INTEREST STATEMENT
conventional diagnostic findings. Other indications for None declared.
TORS include laryngeal tumours [20] and parapharyn-
geal space tumours [21]; salvage surgery [22]; free flap
reconstruction [23] and sleep apnoea surgery [24]. FUNDING
This research received no specific grant from any fund-
ORTHOPAEDIC SURGERY ing agency in the public, commercial or not-for-profit
sectors.
Various robotic systems for orthopaedic procedures
exist. Haptic systems, which provide intra-operative
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