Intuitive Surgical, Inc. (Sunnyvale, CA), which manufactures the daVinci Surgical Robot, had been given seed money by the U.S. Government to develop a robot to assist in the surgical care of our soldiers. It was originally intended to provide these surgical services remotely from behind enemy lines. This technology has, in fact, been used demonstratively across the Atlantic Ocean, with surgeon on one side and patient (and the rest of the surgical team) on the other side. The focus of the company evolved, however, to improve the qualitative experience of surgeons engaged in laparoscopic surgery. The company, and surgeons with interest in this technology, was more concerned with enhancing control of events during laparoscopic surgery. We want a system that makes laparoscopic surgery easier, safer, and expands the possibilities of what can be done using closed techniques.
In the time since the first prototype of the daVinci was launched, the daVinci has evolved into a more compact machine, with more arms (4 now), longer reach within the body, and a wider range of motion. The latest iteration, the Xi model, can now access all aspects of the abdomen and pelvis (whereas previous models were essentially locked into one quadrant). Software upgrades have been made (eg, better filtration of the manipulators in order to read the surgeon’s intention to move). High definition TV technology has been adopted, and picture-in-picture technology has been incorporated as well. This allows for the surgeon to view radiographic images concurrent with surgery.
Near-InfraRed fluorescence imaging (Firefly technology, similar to use of night vision goggles) has been adopted to assist in the differentiation of tissue characteristics. It can help determine whether or not there is good blood supply to an organ; to ascertain good vascular control of a kidney during tumor resection; to delineate between normal kidney and its tumor; and to sort out biliary anatomy, to name a few applications.
Single-site surgery is another technology in evolution. Currently there is a module that adapts to the Si platform so that a camera and two working arms may be manipulated through one port at the belly button. Freedom of motion and reconstructive abilities are currently limited with this platform. However, there will soon be a free-standing robot for this purpose with the freedoms of motion currently enjoyed with the multi-port robots.
One of the criticisms of the technology, as it exists, is that tactile feedback is lost. As it stands, the surgeon loses manual feel of the tissues and depends entirely on visual cues. Future robots are likely to restore this information in some capacity.
There will be a day when preoperative 3D radiographic imaging will be synchronized with intra-operative findings. The computer will calculate distances between structures during surgery, track tissues and predict the emergence of important structures. In essence, future robots will likely help the surgeon sort through the anatomy.
There are multiple factors which promote surgical infections. Reducing incision size is a great leap forward in their prevention. Reducing traffic of people in the operating room, and minimizing human contact would be another. Future operating rooms will be more automated to dispense surgical materials, and surgical robots are likely to be incorporated into this greater system.
The future of robotics is a matter of human imagination. It has made an indelible impact upon laparoscopic surgery, and in the world of urology, it has upended standards of care in procedures such as prostatectomy, pyeloplasty, cystectomy and partial nephrectomy. Ultimately, the methods that bring the best cure rates with the least side effects mark progress in medicine. Robotic surgery has already proven its need for many years to come.