Robotic Surgery: Current StatusCHAPTER 1

The term “robot” was introduced by the Czech playwright Karel Capek in 1923. The Czech word robata means drudgery. In the play RUR, robots—mechanical objects designed for drudgery—take over the human race. During the 20th century, the notion of robots was a popular science fiction theme. In films, “Humanoid” (looking) robots have ranged from friendly companions to vicious predators manipulated by villains to autonomously functioning machines endangering humanity. In reality and in practical daily life, robots have revolutionized industrial production and are used to accomplish repetitive tasks precisely and without fatigue. Unlike robots of science fiction, these robots are driven by computers that are, in turn, programmed for specific tasks. Consequently, to the lay public robots are either “humanoid” looking science-fiction curiosities, or mechanical machines that are driven by digital systems without human intervention.

Surgical robotic systems grew out of the concept of telesurgery and minimally invasive surgery. The concept of telesurgery—that the surgeon did not need to be at the patient's side to conduct the operation was explored by the US military 2and National Aeronautic and Space Administration (NASA) in the 1970s and 1980s. Following the successful testing of this one-armed system, the Advanced Biomedical Technologies Program at the Defense Advanced Research Project Agency funded the development of a prototype surgical robotic system. The system provided an eye-hand axis similar to that of conventional open surgery and enabled a surgeon seated at a workstation across the room to move the surgical instruments. The initial thrust of this program was to develop systems that could be used to treat injured soldiers on a battlefield in remote locations around the world. This particular military application has not been realized until now. However, the concepts of three-dimensional (3D) visualization, heightened dexterity, and fine instrument manipulation were incorporated into surgical robotic systems, which moved out of the hands of the military and NASA, into commercial civil applications in the early 1990s. The first computer-enhanced surgical instrument was the RoboDoc (Integrated Surgical Systems, Sacramento, CA) in 1992. RoboDoc enabled precise drilling of the shaft of the femur by orthopedic surgeons. AESOP (automated endoscopic system for operative positioning) (Computer Motion Inc, Santa Barbara, CA) was introduced in 1994. AESOP gave the surgeon control of the video-endoscope. It provided a stable field of vision and was directed by voice commands by the surgeon. In the late 1990s, two commercial robotic surgical systems were introduced. The da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced in 1997. In March 1997, the first clinical robotic procedure, a cholecystectomy, was performed by Cadiere and Himpens in Brussels, Belgium, using a da Vinci robot. The first robot-assisted cardiac procedure was performed with the da Vinci system in May 1998 and the first closed-chest coronary artery bypass graft was performed in June 1998. The da Vinci system was approved by FDA for General Surgery applications in July 2000. The Zeus robotic surgical system (Computer Motion, Santa Barbara, CA) was introduced in 1998. However, the two companies merged soon after and da Vinci system is the only Surgical Robotic System in the market since 2000 till date. Since its approval in 2000, 1933 da Vinci systems have been installed in 1560 hospitals worldwide (status June, 2011), majority in the US hospitals.

The da Vinci Si-surgical system (Figure 1.1) works on the Master-Slave concept and is made up of three components:

This telescope has dual viewing channels (each connected to a camera) and twin light channels providing two independent optical systems representing the right and left eye of the surgeon. The two independent optical systems project to the binocular viewer at the surgeon console, providing the 3-D stereoscopic vision to the surgeon. The surgeon controls the level of magnification by adjusting the depth of camera insertion in the operating field. 3-D image, reconstructed from the input from the two cameras is displayed on a binocular screen on the surgeon's console. The vision cart (Figure 1.10) is composed of several components:

The Master console is connected to the main power supply and the system is switched on by pressing on the SYSTEM on the user switch panel. The system 9start up sequence includes an initial self-test sequence. The surgical arm homing maneuvers are initiated, during which the system will move the arms to calibrate the neutral position for each arm. Then the system initiates a mechanical integrity test for the wire rope cables in each arm. Once this is completed, each of the four arms is draped with the sterile drapes. The sterile drapes for the instrument arms are provided with an instrument adapter reinforcement, to which a sterile instrument adapter is attached. After draping, the four rotating heads on the instruments should synchronize with the rotating discs provides on the adapter. The cannula mount through which the arm is connected to the port, is then attached to the instrument arm. In the same way, camera arm is also draped and the camera mounts is attached. The draped patient cart is then covered with a sterile sheet to prevent it being contaminated. The camera and endoscopic vision systems are calibrated, white and black balancing done before every use to ensure excellent image quality. The endoscope is then attached to a sterile camera adapter, which is then passed through a sterile drape and connected to the camera head. The endoscope alignment target is attached to the end of the endoscope and the stereo viewer on the console. A 30-degree endoscope will need to be calibrated both in the up-viewing and down-viewing positions. Once all this is done the system is put in the standby mode.

When the surgery is completed or when conversion is needed, the surgeon presses the stand by button on the control panels provided in the Master console. This causes the robotic arms to disengage from the master controls. The instruments placed within the ports are removed and the arms are separated from the ports at the cannula mounts and the patient cart is moved aside. The patient can be repositioned if necessary and the surgery can be continued in the desired way. The whole procedure of undocking takes not more than 2-3 minutes in the hands of a trained team.

The last two decades experienced a revolution in the surgical technique namely Minimal access surgery (MAS), aimed at reducing patients’ pain and recovery time from surgical procedures by minimizing the trauma of the large incisions required in conventional open surgery. However, on the flip side, the MAS has made the otherwise simple procedures into technically complex ones due to reasons mentioned below:

Vision in MAS is limited to two dimensions, losing the depth dimension of binocular vision. Though few stereoscopic endoscopes do exist, their performance is limited in resolution and contrast both at the endoscope level and at the display level.

With the introduction of MAS, the surgeon operates seeing at a display unit rather than at his own arms. The camera control is in the hands of the assistant who may not always and rapidly follow the Surgeon's maneuvers leading to the desired field of vision being lost by the surgeon at critical moments. This becomes extremely important in bleeding and other emergency situations.

Laparoscopic instruments are long, rigid and cumbersome and operate on a fixed fulcrum at the point of entry of the trocars. These results in limited range of motion, diminished tactile feel, and exaggeration of the surgeon's natural tremor. As the direct result of pivoting far away from the operative site, the conventional endoscopic instruments have restricted access to non-contiguous structures, and reverse or counter intuitive response at the instrument tip in relation to the movements of the surgeon's hand. (i.e. to move the Instrument tip to right,you have to move the handle outside to left). They also lack the wrist like human hand. All these with loss of the few degrees of freedom from 116 degrees to 2 degrees of freedom further compromise on the dexterity during the laparoscopic procedure. Suturing and knot-tying are difficult. Appropriate tension is difficult to achieve when intracorporeal knots are tied by instruments that have a fulcrum point at the trocars site rather than the target tissue. Furthermore, the long length of the instruments compromises ergonomics and thereby contributes significantly to surgeon fatigue and longer learning curves.

The da Vinci robot system uses a two-channel endoscope which sends both a left and right eye image back to the surgeon, essentially functioning as an extension of the surgeon's eyes. Moreover, the robotic camera is controlled by the surgeon, and held in a steady position without fatigue or delay in movement. The magnification provided by the system actually delivers to him an image even better than open surgery.

The alignment of the surgeon's hand motions to the motion of the surgical tool tips is both visual and spatial. For visual alignment, the system projects the image of the surgical site atop the surgeon's hands and to achieve spatial alignment, the system software aligns the motion of the tools with the camera frame of reference. Put together, the visual and spatial alignment make the surgeon feel as though his hands are inside the patient's body while performing the surgery.

The da Vinci robot system restores the degrees of freedom lost in conventional laparoscopy by use of Endo Wrist® technology, placing a wrist with three degrees of freedom inside the patient and controlling it naturally, bringing a total of seven degrees of freedom to the control of the tool tip (3 of orientation, 3 of translation, and 1 of grip). Motion scaling, another novel feature of the system is the ability of the system to scale down large movements made by the surgeon on the master console to smaller movements made by the “slave” arm and instrument tip (Figure 1.11) For example, a 5:1 scale factor maps 5 cm of movement on the masters into 1 cm of movement at the slaves. The robot uses software that electronically allows for large, coarse motions of the surgeon's hand to be translated into fine movements by the instruments. This enables extremely fine dissection, precise suturing, and maneuvering in awkward and narrow anatomic locations. There is no fatigue factor in the robotic arms and 12Surgeon can operate and perform most complex tasks even in awkward anatomic locations without getting tired.

The ergonomic sitting position for the surgeon at the master console further reduces the fatigue factor, which is VITAL in complex Surgeries.

The robots were initially used by the cardiothoracic surgeons. It was later on used on experimental basis, in prostate surgery initially. With the FDA approving the use of robot in the field of urology, it is clinical applications and installations expanded exponentially over the next few years. At present robot is used for minimal access surgery in a wide range of specialties, from general surgery, urology, gynecology, cardiac, thoracic and vascular surgery, oral and maxillofacial surgery, endocrine surgery to head and neck surgery, with almost all procedures which were performed by conventional minimal access surgery being successfully carried out with robotic-assistance. Robotic surgery has been proved to be feasible and safe for all operations across various surgical disciplines, though its advantages over conventional minimal access surgery still need to be established in most of these procedures.

The maximal use of robot has been in the field of urology. The first reported use of robot in urological procedure dates back to 1989, when Davies et al used an “industrial robot” to perform transurethral resection of the prostate (TURP).¹ Experience with the da Vinci system started with prostate cancer surgery. Slowly and progressively, robot has found its application in all procedures in urology like prostatectomy, radical cystectomy with lymph node dissection, renal resections–partial/total, pelviuretric junction reconstructions and many more.13

The first report of da Vinci robotic radical prostatectomy (RRP) was by Binder and Kramer (Frankfurt) who reported their experience with 10 cases in 2001.² Thereafter, due to the pioneering efforts of Dr Mani Menon and his team at Vattikuti Institute of Urology at Henri Ford Hospital, Detroit, USA, the use of robot in radical prostatectomy for prostate cancer spread like wild fire. Today, it is the most common robotic procedure performed worldwide and is the standard of care for resectable prostate cancer. In 2010, over 300,000 robotic procedures were performed worldwide out of which, nearly 98,000 were robotic radical prostatectomies.³ Over 1100 articles dealing with this topic are already published in the 10 years of existence of this procedure. The largest reported series is from The Vattikuti Institute, USA, by Menon, Badani et al, with an experience of more than 3317 cases of RRP.⁴ Many other major series of RRP, are also available in the literature.^5-10

The first report of robotic-assisted laparoscopic nephrectomy was by Guillonneau et al from France in 2001 for a nonfunctioning kidney.¹³ Since then, numerous series have reported experience with nephrectomy as well as partial nephrectomy, both for benign as well as malignant diseases. Experience with robotic donor nephrectomy has also been reported with an advantage of increased vessel length.¹⁴ A perusal of the literature reveals that while nephrectomy offers no advantages when performed robotically, in case of partial nephrectomy, there are distinct advantages due to the ease of suturing in robotic surgery. In fact, robotics has been a big impetus for partial nephrectomy and nephron sparing surgery being performed by minimal access techniques at an increasing number 14of centers. These two robotic techniques were found to be comparable to laparoscopic surgery in various aspects like duration of surgery, warm ischemia time, amount of blood loss, positive surgical margins (oncological clearance) and postoperative patient recovery time. The robotic approach scores over the conventional laparoscopic approach in the fact that the learning curve for complex dissection and intracorporeal suturing is shorter.¹⁵ With robotic- assistance, the tumors could be excised with greater ease and better precision providing adequate oncological clearance and one could also do fine suturing used to repair the collecting system and for renorrhaphy. Scoll BJ et al and Abreu AL et al have reported amongst the largest series of robotic partial nephrectomy (more than 100 cases each) with results which were comparable to conventional laparoscopic partial nephrectomy.^16,17 Haber GP et al and Benway BM et al in their studies comparing robotic and conventional laparoscopic partial nephrectomy (> 75 cases of each ) have also shown that the robotic-assisted surgery offers the advantage of significantly less intraoperative blood loss and shorter warm ischemia time-providing maximal preservation of renal reserve.^18,19

Though open radical cystectomy (ORC) is the gold standard for muscle invasive bladder cancers, robotic radical cystectomy (RRC) has been gaining more recognition and has been increasingly practiced in high volume centers. Initial experience of RRC came from Menon et al, who performed the RRC with extracorporeal neobladder reconstruction and the anastomosis between the neobladder and the ureter with in the abdomen using the robot for intracorporeal suturing.²⁰ Beecken et al were the first to perform robotic intracorporeal neobladder reconstruction in literature.²¹ Till now, there are about 224 articles published quoting robotic cystectomies, with experience ranging from 35 to 164 cases.^22-25 In all these reports, the outcome has been comparable to that of open procedure in almost all aspects, with the RRC being superior in the field of intraoperative blood loss, better yield of lymph nodes, lesser requirement of analgesics, early recovery of bowel movement and shorter hospital stay.^22-24 The long-term outcomes of RRC are still to be evaluated, although short-term results show comparable results with open radical cystectomy.²⁵ Two series by Kauffman EC et al and Richards et al, comparing the open with robotic radical cystectomy in cases of bladder neoplasm show that the RRC is in fact better than the open procedure with low positive margins and lesser hospital stay.^26,27

The robotic-assisted gastrointestinal (GI) surgery had its beginning with the simplest procedure i.e. cholecystectomy and diversified into complex ones pancreatic and colorectal surgeries.³⁰

Nissen's fundoplication is the most common type of fundoplication performed. The advent of robotic surgery with the use of articulated arms has shown to have clear benefit while dissecting behind and around the esophagus and for suturing.³¹ Chapman et al found no statistical difference in the duration of surgery between robotic and conventional laparoscopic fundoplication.³²

The first robot-assisted gastrectomy (RAG) was reported by Hashizume et al in 2003.³⁶ Robotic gastrectomies for malignancy have become popular since then. Much of the reported work on robotic gastrectomy is from Korea and Japan, with Song et al reporting the largest series with 100 cases.^37-41 The literature indicates a relatively good short-term results with robotic procedures, comparable to those obtained with laparoscopic or conventional open surgery,⁴⁰ with shorter hospital stay, low morbidity rates and lesser blood loss.^42-44 Song et al in their single largest series of robotic gastrectomies for malignancy, showed that RAG with lymph node dissection for gastric cancer is safe as well as feasible.⁴⁵ “Endo-wrist” technology enables precise and fine movements and easier and more complete lymph node dissection especially around the vessels.⁴⁶

The first robotic-assisted procedure was done by Weber et al in 2001 for diverticulitis.⁴⁷ Robotic surgeries in colorectal cancers were initially restricted mainly to colectomy, with lesser cases of abdominoperineal resection (APR) 16and low anterior resection (LAR). The greatest advantage with robotic colorectal surgeries is better approach and maneuverability in the depth of pelvis, where traditional laparoscopic instrumentation may be particularly difficult. Jeong-Heum Baek et al and Huettner et al have separately their experience in more than 100 robotic-assisted colorectal surgeries, with Huettner et al reporting favorable duration of surgery in robotic colorectal surgeries in comparison with that reported in the literature.^48,49 AL Rawlings et al found it was possible to do intracorporeal suturing using robot in cases of colectomies, though it was associated with longer operating time.⁵⁰ D Annibale et al comparing robotic and laparoscopic colectomies reported no difference in operating time and length of hospital stay between the two groups.⁵¹

Minimally invasive colorectal cancer surgery has proven advantages over open procedures. Jeong-Heum Baek et al compared laparoscopic and robotic colorectal surgery (total mesorectal excision) and found a shorter mean operating time and lesser conversion rates with robotic colorectal surgery (7.3% vs 22%), with identical postoperative course in both techniques.⁵² deSouza AL et al in their experience with robot-assisted total mesorectal excision (TME) for rectal cancer found it to be safe and feasible, with comparable perioperative and pathological outcomes as with open surgery.⁵³

The first robotic surgery ever to be performed on human was robotic-assisted cholecystectomy in March 1997, performed by Cadiere and Himpens in Brussels, Belgium, using a da Vinci robot.⁵⁴ It was noted that the robotic cholecystectomy is comparable to conventional laparoscopic cholecystectomy.⁵⁵ Since, the procedure requires no major dissection or suturing, and the robotic procedure involves higher costs, the conventional laparoscopic cholecystectomy is still the preferred approach.

Pancreatic resections for tumor have conventionally been performed by open approach across the world, with minimal access surgery being increasingly used in recent times. To date, the role of minimally invasive surgery for radical resection of locally advanced pancreatic tumors remains unreported. The procedure requires an extensive dissection, with complex vascular and digestive reconstruction, which is difficult to perform laparoscopically. The robotic surgery with its clear advantages like fine intuitive movements, its magnification and tremor stabilization, the use of EndoWrist^® technology and the 3D binocular vision helps in performing fine dissection and anastomosis especially of the 17vessels and bowel.^56,57 Kang et al comparing 20 cases of robotic-assisted spleen preserving pancreatectomy with conventional laparoscopic approach found that spleen preservation rates were higher in robot-assisted procedure, though it involved longer operative time.⁵⁸ Buchs et al comparing the robot-assisted pancreaticoduodenectomy (n-44) with open procedure found that the robot- assisted surgery was less time consuming and was associated with lesser blood loss, and was comparable to the open procedure in terms of complication rates.⁵⁹ Giulianotti PC et al reported their experience in robot assisted extended pancreatectomies with vascular resections in 5 cases of locally advanced pancreatic tumors found that the robot-assisted procedure was feasible and safe, with no perioperative mortality.⁶⁰ Apart from the above stated experiences, robotic pancreatic surgery has also been reported to be safe and feasible in distal pancreatectomies for distal pancreatic tumors.⁶¹

The deep anatomic location of the liver, its abundant vascularity, and its volume, make it technically difficult to safely reproduce the basic maneuvers of open liver surgery in conventional laparoscopy. The robotic assistance has been able to overcome many of these problems. Giulianotti PC et al, reported their experience of robotic hepatic resections and noted that the dissection at the hilum and hepatocaval dissection and billiary reconstruction were far superior in robotic surgery. The many advantages of robotic surgery mentioned above along with a more stable retraction provided by the use of the fourth arm make robotic hepatic resections much easier and safer than the laparoscopic surgery.^62,63 Even donor hepatectomy has recently been reported with robotic-assistance.⁶⁴

The increasing awareness of complications associated with obesity has lead to an increasing acceptance of surgical management of obesity. Of the many procedures described, the gastric bypass has been the preferred procedure in US, while gastric bypass surgery along with gastric sleeve resections have been gaining popularity in the rest of the world. A review of literature in 2010 by Gill et al revealed 22 studies with 1253 patients having been operated for obesity by robotic-assisted approach.⁶⁵ They found the anastomotic leak, bleeding and stenosis rates to be acceptable with no reported operative mortality, though no definite advantage was detected in this study.

The laparoscopic Roux-en-Y gastric bypass is arguably one of the most challenging minimally invasive procedure in general surgery requiring advanced laparoscopic skills such as suturing, intracorporeal knot tying, stapling, two-handed tissue manipulation, and the ability to operate in multiple quadrants of the abdomen. The robotic approach has provided a great advantage especially in suturing, 18but the need to operate in various quadrants of the abdomen, limits its use for the complete procedure. The robot is thus used for the difficult aspect—the intracorporeal anastomosis. Snyder BE et al found a significantly lesser leak rate, lower morbidity and mortality rates in robot-assisted procedure than in laparoscopic procedure.⁶⁶ Robot-assisted procedure was also found to have a lesser operating time than complete laparoscopic procedure.⁶⁷

Ayloo et al in their study comparing the robotic and conventional laparoscopic sleeve gastrectomy found that the procedure can be safely and successfully performed by robotic approach, although with no added benefits.⁶⁸

Edelson et al comparing robotic and conventional techniques for laparoscopic adjustable gastric banding (LAGB), found robotic procedure to have a statistically significant shorter duration of surgery in patients with BMI > 50, and similar duration of postoperative stay, pain and postoperative complication rates as with the conventional technique.⁶⁹

Though robot was first approved by FDA for use in the field of cardiothoracic and vascular surgery, there was initial skepticism on it is widespread acceptance. However, recently, increasing applications have been reported.⁷⁰ The commonly performed procedures are discussed below:

Robotic mitral valve surgery has evolved to become the preferred method of mitral valve repair and replacement. Folliguet et al in their study compared robotic-assisted mitral valve replacement with traditional open sternotomy approach and found that the robotic approach was as efficient and safe as the open approach with similar short time postoperative echocardiographic findings.⁷¹

Robotic total endoscopic, single-vessel and double-vessel coronary artery bypass grafting procedures have been standardized on both the beating and arrested heart. Poston RS et al in their study comparing mini CABG and conventional open CABG found mini CABG to be safe with shorter recovery time, but with increased duration and cost of surgery.⁷² In spite of the shorter hospital stay, lesser transfusion needs, and earlier return to activity found with robotic-assisted surgeries, more comparative data are needed to determine long-term effectiveness.⁷³19

Robot-assisted repair of abdominal aorta and splenic artery aneurysms have also been described. Almost 17 articles have been published till date in the medical literature stating the use of robot in various vascular procedures.⁷⁴ Kolvenbach R et al in their series, found robotic approach to be equally successful as the conventional laparoscopic procedure.⁷⁵

Application of robot in general thoracic surgery ranges from robotic thymectomy, to lobectomy for malignancies, esophageal surgeries and for mediastinal tumors. A systematic review of literature for robot-assisted mediastinal procedures, show almost 24 publications with 257 procedures performed till 2010. Among these robotic thymectomy was the most commonly performed (69%), followed by esophageal resections (21%). The biggest advantage with robotic thymectomy is that the whole surgery can be done from a single sided approach. Ruckert JC et al in the largest series of robot-assisted thymectomy in 106 cases found that robot-assisted surgery was superior for mediastinal dissection than conventional thoracoscopic surgery.⁷⁶ Few other series have reported robot-assisted thymectomies.^77-80 In India, robot-assisted thymectomy is being performed by the authors at the All India Institute of Medical Sciences (AIIMS) since 2008 with 60 cases being done entirely by robot-assisted approach.

Robot has been found to be increasingly used in the surgeries of head and neck region. There has been more than 22 publications of transoral robotic surgery (TORS), with the largest having almost 148 subjects.⁸³ Moore EJ et al and Weinstein GS et al in their studies found that TORS was equally effective as conventional surgery in treatment of oropharyngeal carcinoma with similar short-term follow-up and also in terms of oncological clearance.^84,85

Robots have also been used for thyroid malignancies to perform robot-assisted thyroidectomy (RAT) along with lymph node clearance.⁸⁶ Much of this work has been reported from Korean Centers. Two different approaches have been used: a gasless transaxillary approach (TAA) with incisions in both the axillary 20folds and a bilateral axillary breast approach (BABA), with incisions in the peri-areolar as well as bilateral axillary folds. Kang et al and Lee et al reported their experience with over 1000 gasless TAA-RAT, with comparable results in terms of oncological clearance and complication rates, while having longer operating time.^87,88 Lee et al reported their experience with BABA-RAT with almost 700 cases, having final outcome comparable to conventional surgeries.⁸⁹ Although, some other approaches have also been tried in cadavers, presently these are the two approaches in clinical use.⁹⁰

Literature search for robotic radical hysterectomy (RRH) with pelvic lymphadenectomy for endometrial cancer reveals 22 studies till 2010, with 590 case report.⁹¹ Various comparative studies have shown RRH to be comparable to laparoscopic radical hysterectomy in various aspects like duration of surgery, blood loss, oncological clearance and length of hospital stay with slightly higher complication rates.⁹²

Robotic surgeries for cervical cancer are also becoming popular, with 21 publications addressing radical hysterectomy, trachelectomy, parametrectomy with pelvic and aortic lymphadenectomy been published till date.⁹³ Robot has also been used for benign conditions like myomectomy, fallopian tube anastomosis and sacrocolpoplexy.^94-96

Robotic surgery has been proven to be doable and safe in almost all the surgical branches. The biggest short coming today is the costs involved. Robotic surgery involves significantly higher costs in terms of acquisition, maintenance, and recurring instrument costs in comparison to conventional laparoscopy and opens surgical techniques.⁹⁷ Costs involved include initial investment in the robot acquisition, large operating rooms required to house the robot, recurring cost of instruments and custom made arm drapes and variable costs involving operating room costs which is directly proportional to the length of the surgery and routine maintenance charges.^98,99 The initial cost of the robot today in India ranges from rupees 7 to 9 crores (depending on the model, i.e. single master control da Vinci S or double master control da Vinci Si model). Each instrument costs about 1,35,000 rupees and is programmed to last for maximum 10 uses (roughly Rs 15,000 per use). Average surgery uses three types of instruments (Rs 45,000 per case). The drapes for the arms (4 drapes per case) cost about Rs 10,000 per case. Thus, average per case recurring expenditure on the instruments and 21drapes alone is about Rs 50,000 to 60,000. Over and above this is the cost of maintenance and repairs, which are proportional to the original cost of the machine. The Docking of the robot takes lot of time initially, though it comes down as the experience of the whole team increases. Thus, initially, the surgery takes much longer, with increase in the OT time cost, etc. Due to these cost factors, the use of robot has not become as popular as the conventional laparoscopic surgery. Moreover, it has also been seen that costs associated with learning robotic surgery is substantial, due to longer operating time initially. However, in high volume centers with trained manpower, the learning curve and the associated higher costs can be rapidly traversed.¹⁰⁰

Much work is currently underway in developing solutions to the problem of haptic feedback and solutions can be expected in near future. Lack of wide range of instruments and various other adjunct technologies used in laparoscopic surgery today (like vessel sealing system, ultrasound, laser, etc.) is also a drawback today. In near future, solutions to these are expected. The development of newer instruments that can incorporate all these technologies at the press of a button is an area of research.

The application of robotic technology in the field of surgery marks a paradigm shift in the way surgery is done. We are presently at the beginning of this precision surgery revolution with the available instrumentation being expensive, large in size and needs time to setup. At present, we are using it only as an electromechanical device without using much of the “brain” of the system. Lack of tactile feedback and limited range of instrumentation is also a handicap. However, this technology is here to stay and will become an integral part of every operation theater. The numerous technological innovations on the horizon and the inevitable reduction in initial and recurring costs (which will occur with time), will make it happen sooner than later.