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Hellenic Journal of Surgery (2014) 86:3, 117-121

A Short History of the Invasion of Robots in Surgery M.L. Lorentziadis

Abstract The term ‘robot’ comes from the Czech word ‘robota’ which means forced labour, and it was first introduced by the Czech play writer Karel Capek in his fiction play “Rossum’s Universal Robots”. Initially, robots were used in the industry for hazardous tasks. Since 1985, they have invaded surgical practice, helping surgeons to perform delicate operations with precision. The passage from industrial robots to surgical robots was long. In this paper, the author makes a brief reference to the steps that were followed by the pioneers of the robotics in surgery up to the present day where the Da Vinci and Zeus are used in many fields of surgery such as general surgery, urology, ophthalmology, thoracic surgery etc. Key words: Robots; robotic surgery; Da Vinci, Zeus

Science fiction is strongly linked with robots. The first robots were primitive, dumb machines that could replace monotonous industrial work while the latest models can perform very fine and complex activities. The term ‘robot’ was coined by the Czech playwright Karel Capek who borrowed the term from the Czech word ‘robota’, which means forced labour, and used it in 1921 for his classic science fiction play “Rossum’s Universal Robots” [1]. In the play, the entire human race is destroyed after a war with robots, which were used for cheap industrial labour cost once they became intelligent and able to make decisions. Gradually, the robots were used in the industry for hazardous tasks or where dexterity and precision was needed. Although these machines can exceed human performance, they cannot develop superior critical thinking and, in point of fact, they have the mentality of a baby. Against this background, the concept of using robotic technology in surgical practice was first explored by NASA Arms Research Center in 1985. The researchers, Michael McGreevy and Steve Ellis, who were later joined by Scott Fischer and Joe Rosen, improved the programme of virtual reality by contributing to the Data Glove (Figure 1) and Object Oriented Programming which led to the three-dimensional (3-D) virtual scenes. The results were all included in a concept called Telepresence Surgery (Telesurgery) i.e. a system that permits the surgeon to operate on a patient across distances by way of controlling the remote hand [2]. It was in 1985, at the Memorial Hospital of Los Angeles,

that Kwoh and his team first introduced the industrial Unimetis PUMA 200 robot (Figure 2) which manipulated a laser system for neurological biopsies and cranial stimulus [3]. The NASA team brought its experience on virtual reality to Phil Green at Stanford Research Institute (S.R.I.) and worked with the clinical contribution of Joe Rosen, a biomechanic who was working on Robotics. They developed a dexterous telemanipulator that could assist the surgeon in performing vascular and nerve anastomosis for hand surgery while the patient was physically located at the other side of the room (Green Telepresence Surgery Systems) [4]. Towards the end of the 80’s, Jacques Perrisat of Bordeaux, France, presented a video of a new technique for a cholecystectomy, namely the laparoscopic approach, at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeon (SAGES), heralding a new era in surgery [5]. Laparoscopic cholecystectomy became a gold standard in the excision of the gallbladder but presented certain technical problems such as the loss of 3-D visualization, the lack of sense of touch and dexterous use of instruments. Richard Satava,

Michael L. Lorentziadis MD, PhD, FISS Department of Surgery, Athens Medical Centre, Athens, Greece Correspondent Author: Michael L. Lorentziadis MD, PhD, FISS Department of Surgery, Athens Medical Centre, Athens, Greece Tel: +30 210 8661465 E-mail: [email protected] Received 9 Feb 2014; Accepted 9 April 2014 Hellenic Journal of Surgery 86

Figure 1. The data glove

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Figure 2. Puma 200 Robot

a general surgeon and surgical endoscopist who joined the SRI telepresence team, introduced telepresence and suggested that it could improve laparoscopic surgery [6]. A videotape illustrating telesurgery drew the attention of the US Army to the project and Dr.Satava was transferred to the Pentagon’s Advanced Research Projects Agency (ARPA) with instructions to include telepresence surgery in Advanced Biomedical Technology. The military interest in the robotic system was focused on decreasing wartime mortality by bringing surgery from the Mobile Advanced Surgical Hospital to the wounded soldier in the battlefield [7]. In the early 1990’s, at the TJ Watson Research Center, Dr. Hop Paul, William Barger (an orthopaedic surgeon) and Russell Taylor of IBM conducted a research which resulted in the first robot in surgery named “RoboDoc” (Figure 3) that was used for hip replacement surgery. RoboDoc was constructed by Integrated Surgical Supplies of Sacramento, CA and was the first robot to be approved by the FDA. More specifically, it was a modification of the IBM PUMA arm and was used in matching the prosthesis exactly with the femur that would receive the prosthesis. After animal experimentation, the device was taken to clinical human trials since the precise core out of the femur with the RoboDoc was 96% while standard hand accuracy was only 70% [8]. Another robotic system called HipNave was developed by Dr. Antony DiGioia which was used in the knee and hip joint replacement [9]. During the same period of time, Sir John Whickham and Bryan Dan at Guys Hospital in London produced an early prototype similar to RoboDoc [10]. Sir John Whickham, a consultant urologist, applied the precise coring of the RoboDoc for transurethral prostate resection with safety and accuracy. In Germany, Herman Rinnsland and Gerhard Buess, having the experience of telemanipulation robotics for handling nuclear waste, developed a system called Advanced Robot and Telemanipulator System for Minimal Invasive Surgery called “ARTEMIS” (Figure 4). With this Hellenic Journal of Surgery 86

Figure 3. RoboDoc Surgical System

system, the surgeon’s console had the hand input device over the shoulder for extra manipulation ability. Rick Satava and Don Genking developed the “DEFENSE ADVANCED RESEARCH” (DARPA) an advanced biomedical technology (ABMT Programme) which aimed to save wounded soldiers in the battlefield. In the Vietnam war, approximately 30% of battlefield casualties lost their lives although they were survivable based on today’s technology. Thus, Scott Fischer and Joe Rosen began working on the programme of the Green Telepresence Surgery System in order to bring the surgeon to the wounded soldier by means of telemedicine. Medical Forward Area Surgical Telepresence (MedFast) involved robotic manipulator arms mounted on a Bradley fighting vehicle – 577A (Figure 5) which was placed in the rare echelon Mobile Advanced Surgical Hospital (MASH). The idea was that a paramedic could place the wounded

Figure 4 ARTEMIS (Advance Robot and Telemanipulator System for Minimal Invasive Surgery)

A short history of the invasion of robots in surgery 119

soldier on the MedFast and proceed to operate with the help of the surgeon by means of telesurgery in order to stop the haemorrhage (damage control surgery), thereby giving enough time for the transport of the wounded to the MASH alive to undergo a curative operation [7]. The system, a slave-master type, was successfully demonstrated in animal models but was never used in the battlefield. The changing pattern of battle from conventional open battlefields to closed quarters in urban territories did not allow the use of a MedFast vehicle in the 1990’s battlefield. A significant number of practical problems on application in robotic surgery were solved by Thomas Sheridan Ph.D. of Massachusetts Institute of Technology (MIT) and Alberto Rovetta Ph.D. of Milan Italy. In 1993, the latter performed a liver biopsy on a pig model, where the surgeon was operating at the NASA Jet Propulsion Lab (JPL) in Pasadena, California and the arm manipulation and the pig was in Milan [11]. Another group, Kenneth Salisbury Ph.D., Marc Ribent Ph.D. and Robert Plater Ph.D., worked on the sense of touch and developed a commercial product called “The Phantom” which became the industrial standard provider of haptics in a virtual environment [12]. The commercial use of robots among the medical community began in 1992 with the RoboDoc system, although it needed to undergo a prolonged approval process by the F.D.A. (Food and Drug Administration). The first application of the robot was to orally control the manipulation of the camera in laparoscopic operations in response to the surgeon’s commands. Yulun Wahg developed AESOP (Automatic Endoscopic System for Optimal Positioning) (Figure 6) which received F.D.A approval and was accepted by the surgical community [14]. In so doing, the robot reduced the number of surgical assistants by one and offered a steadier endoscopic view. The first robot in general surgery had become a reality. The surgical robotic system included three types: active, semi-active or master-slave type. The active system performs its tasks autonomously

Figure 5. Bradley Fighting Vehicle Hellenic Journal of Surgery 86

Figure 6. AESOP (Automatic Endoscopic System for Optimal Positioning)

under the supervision of the surgeon. The master-slave system is telemanipulated by the surgeon from a remote command control. The semi-active system has components from both aforementioned systems, i.e. it has an autonomic and a surgeon-influenced component. At this time, commercialization spread to the guided surgery system which was used in Eurosurgery (the Neuronet Richard Bucholz’s stealth system). Frederick Moll M.D. acquired the licensed rights to S.R.I.Green Telepresence Surgery and founded the Intuitive Surgical INC. In April 1997, this corporation presented the Da Vinci Robotic Surgical System (Figure 7) which was the evolution of the MONA robot. Jacques Himers M.D. and Guy Cordiere M.D. performed the first robotic surgical procedure, namely a cholecystectomy, on a patient in Brussels [15]. In 1998, Computer Motion presented another robotic system called ZEUS. This system consisted of an AESOP robotic camera holder combined with two additional robotic arms. The first generation of ZEUS only allowed 2-D vision while the second generation system offered 3-D glasses. These two commercial systems, Da Vinci and ZEUS, were manipulated by a remote surgical control station. They are

Figure 7. Da Vinci Robotic System

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classed as master-slave robotic systems. The stereoscopic image in the Da Vinci system is displayed in the console above the hand handles, requiring the surgeon to lean in front, over the goggles of the console, while in the ZEUS system, the sequence is surgeon-instrument handles-console, which is more ergonomically designed. Both systems allowed an additional degree of freedom and mimicked wrist movement. In July 2000, the Da Vinci system was approved by FDA for general laparoscopic surgery, and in November 2002 for mitral valve repair surgery. The robotic system Zeus was used to perform the first fully endoscopic robotic surgery and the initial beating heart, totally endoscopic coronary bypass procedure. Originally, the Green Telepresence Surgery System was designed for application in the battlefield for military trauma surgery. However, it was thought that the development of commercial telepresence systems which enhanced dexterity could be applied to delicate coronary artery bypass grafting. The idea, which is still under development, is to allow minimal access to the heart and achieve anastomosis of the graft by “virtual stillness” of the beating heart, to block and then overpace the heart and gauge the motion of the robotic arms to the heart rate. Another field in which the robot has gained recognition is ophthalmologic surgery. In retina laser surgery, the distance between the blood vessels of the retina is 25microns while human accuracy performance is limited to 200microns. The robotic system RAMS (Robot Assisted Micro Surgery) which emerged from the collaboration of Steven Charles M.D., Micro Dextery System INC and NASA Jet Propulsion Laboratory (JPL) [16] had the advantage of 10microns accuracy through 100:1 scaling, tremor reduction and a perfectly still video image. Nowadays, the accuracy of this device enables any surgeon to perform laser surgery with 10microns accuracy in the human retina. A limitation to performing remote long distance surgery is the delay time, i.e. the time from the hand motion of the surgeon to the motion of the robotic arms, which cannot exceed 200m second. Longer delay time renders the system unstable and dangerous since the tissue can move and the surgeon catches the wrong tissue instead of that intended. In 2001, using an Asynchronous Transfer Mode (ATM) fiber optic cable, Jacques Marescaux and Michel Gagner [17] were able to perform a transatlantic remote robotic cholecystectomy with the ZEUS system combined with a Socrates telecommunication system. The surgeon was in New York and the patient in Strasburg. The operation was named Lindbergh operation for its transatlantic character. With the advent of next generation internet, such remote robotic surgery will be feasible for patients in many places around the world. The era of robotic surgery has just begun. With the evolution and assistance of technology, the future will witness the development of improved instruments and Hellenic Journal of Surgery 86

an enhanced sense of touch. Systems will become smaller and less expensive, providing a field for research with the specific aim of improving the quality of operative surgery and patient care.

Conflict of Interest The author declare that he have no conflict of interest. He has full control of all primary data and he agrees to allow the journal to review their data if requested.

References 1. Klima I. Karel Čapek: Life and work. New Haven CT: Catbird Press, 2001; pp. 191-200 2. Fisher SS, McGreevy M, Humphries J, Robinett W: Virtual Environment Display System. Proceedings of the Workshop on Interactive 3-D Graphics, 1986; 1:1-12 3. Kwoh YS, Ha J, Jonckheere EA. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Brain Biomed Eng 1988; 35:153-60 4. Green PS, Hill JH, Satava RM. Telepresence: Dexterous proceeding in virtual operating field. Surg Endosc 1991; 57:192-9 5. Perissat J. Laparoscopic cholecystectomy: The European experience. Am J Surg 1993; 165:444-9 6. Satava RM. Robotics telepresence and virtual reality: a critical analysis of the future of surgery. Min Inv Therapy 1992; 1:357-63 7. Satava RM. Virtual reality and telepresence for military medicine. Comput Biol Med 1995; 25:229-36 8. Paul HA, Bargar WL, Mittlestadt B, et al. Development of a Surgical Robot for Cementless Total Hip Arthroplasty. Clin Orthop 1993; 285:57-66 9. DiGioia AM, Jaramaz B, Colgan BD. Computer Assisted Orthopaedic Surgery: Image Guided and Robotic Assistive Technologies. Clin Orthop 1998; 354:8-16 10. Wickham JEA. Future Developments of Minimal Invasive Therapy. Brit Med J 1995; 308:193-6 11. Schurr MO, Buess G, Neisius B, Voges U. Robotics and telemanipulation technologies for endoscopic surgery. Surg Endosc 2000; 14: 375-81 12. Rovetta A, Sala R, Cosmi F, Wen X, Sabbadini D, et al. Telerobotics surgery in a transatlantic experiment: application in laparoscopy. Proceed telemanipulator Technology and Space Telerobotics, Boston, 1993; 13. Massie TH, Salisbury JK. The PHANTOM Haptic Interface: A Device for Probing Virtual Objects. Proceedings of the ASME Winter Annual Meeting, Symposium on Haptic Interfaces for Virtual Environment and Teleoperator Systems, Chicago, IL, 1994; 14. Wang Y, Sackier J. Robotically Enhanced Surgery: from concept to development. Surg Endosc 1994; 8:63-4 15. Himpens J, Leman G, Cadiere GB. Telesurgical Laparoscopic Cholecystectomy. Surg Endosc 1998; 12:1091-3 16. Charles S, Das H, Ohm T, et al. Dexterity-enhanced Telerobotic Microsurgery. Proc IEEE Int Conf adv Robot 1997; 17. Marescaux J, Leroy J, Gagner M, et al. Transatlantic robotassisted telesurgery. Nature 2001; 413:379-80

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Hellenic Journal of Surgery (2014) 86:3, 117-121

Η Ιστορία της Eισόδου των Ρομποτικών Συστημάτων στη Χειρουργική Μ.Λ. Λορεντζιάδης

Περίληψη Ο όρος ρομπότ, προέρχεται από την Τσέχικη λέξη robota, η οποία σημαίνει καταναγκαστική εργασία και προτάθηκε για πρώτη φορά από τον Τσέχο συγγραφέα Karel Capek στο επιστημονικής φαντασίας έργο του “Rossum’s Universal Robots”. Αρχικά χρησιμοποιήθηκαν στη βιομηχανία για εκτέλεση επικίνδυνων εργασιών. Από το 1985, τα ρομπότ έχουν εισβάλλει στην καθημερινή χειρουργική πράξη, βοηθώντας τους χειρουργούς να εκτελέσουν λεπτές χειρουργικές επεμβάσεις με ακρίβεια. Το πέρασμα από τα βιομηχανικής χρήσης ρομπότ, στα ρομπότ της χειρουργικής πράξης είναι μακρύ. Ο συγγραφέας του άρθρου κάνει μία συνοπτική αναφορά στα βήματα που ακολούθησαν οι πρωτοπόροι της ρομποτικής χειρουργικής μέχρι τις μέρες μας όπου τα ρομποτικά συστήματα DaVinci και Zeus χρησιμοποιούνται σε πολλούς τομείς της χειρουργικής όπως στη γενική χειρουργική, ουρολογία, οφθαλμολογία, θωρακοχειρουργική και αλλού. Λέξεις κλειδιά: Ρομπότ, χειρουργική, Da Vinci, Zeus

Μ.Λ. Λορεντζιάδης MD, PhD, FISS Τμήμα Χειρουργικής Ιατρικό Κέντρο Αθηνών

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