Surgical robots: Inevitable tech or niche helper?

Not much happened in the field of robotics between the years 1495 and 1970.

From Leonardo da Vinci’s “Automaton Knight,” which could raise its visor and maneuver its arms thanks to a series of pulleys, to WABOT-1, the world’s first full-scale humanoid robot, the world of robotics was constrained to sketches in notebooks and movie screens.

Most advances in robotics were focused on military, space, or academic applications, according to a recent article by George Garas, MD, Department of Otorhinolaryngology and Head and Neck Surgery, St. Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK, and Asit Arora, MBBS, MS, MCh (GI Surgery), Department of Otorhinolaryngology and Head and Neck Surgery, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK, published in ORL, a journal focusing on otorhinolaryngology and head and neck surgery.

In 1985, the PUMA 560 robot, which the defined trajectory for a stereotactic brain biopsy, became the first robotic technology to be applied in a surgical setting. In 1988, PROBOT performed the first robotic-assisted transurethral resection of the prostate at Imperial College in London, UK.

As is typical in such situations, innovation gave way to more innovation. ROBODOC kicked off the 1990s as the first robotic system approved by the US Food and Drug Administration (FDA) for milling precise cavities in the femur for hip replacement surgery, and ZEUS enabled the first telerobotic operation in 2001. For the first time, a surgeon in New York was able to perform a laparoscopic cholecystectomy on a patient in Strasbourg, France.

The da Vinci system became the first FDA-approved robotic-assisted surgical system for general laparoscopic surgery in 2000. Since then, the system has been used in more than 3 million procedures, including urologic, gynecologic, colorectal, thoracic, and cardiac surgeries.

The da Vinci system began to be used in head and neck surgery in 2005, and the term TransOral Robotic Surgery (TORS) was coined. By using the oral cavity, the system could gain access to the pharynx, parapharyngeal space, and larynx without cervical incisions.

“Currently, TORS constitutes a valuable treatment modality for tumors of the oropharynx (including advanced oropharyngeal carcinoma), hypopharynx, parapharyngeal space, and supraglottic larynx,” the authors wrote. “More recently, it has been deployed in the management of carcinoma of unknown primary tumors as well as for transoral robotic total laryngectomy.”

While TORS has grown from an experimental concept to standard-of-care in robotic surgery centers, data on its effectiveness are limited to case or retrospective studies. Currently, there are three multicenter randomized controlled trials in the recruitment phase to define further the system’s usefulness.

The future

As successes mount, so does funding. According to Drs. Garas and Arora, the market for robotic surgery will increase in value from $3 billion in 2014 to an estimated $20 billion or more in 2021.  

The next wave includes the i-Snake, a miniature, flexible robot developed at Imperial College, and the Flex system from Medrobotics, Raynham, MA. Large medical device companies are also partnering with Silicon Valley to introduce new, cutting edge devices and expanded indications for existing technologies.

“In terms of future directions, the introduction of augmented reality (AR) will facilitate image-guided TORS by providing the surgeon with real-time navigational cues and representations of key anatomical structures overlaid on the operative field,” the authors wrote. “Other developments likely to follow include miniaturization (nanorobots) and the development of autonomous surgical robots.”

Even though it took almost 500 years to go from a robot that raised an arm via a pulley to one that could remove a prostate from across the ocean, the medical robotics field is set to increase dramatically in the near future.