In the 1990s, laparoscopic surgery entirely changed the traditional
style of surgical operations. Laparoscopic cholecystectomy has spread rapidly
and is now established as the standard treatment. However, besides cholecystectomy,
endoscopic procedures are still not applied so widely to a variety of surgical
operations. This is because laparoscopic techniques, such as suturing or
ligation, make it difficult for surgeons to perform other kinds of operations
and thus greatly increase their mental and physical stress. It is necessary
to introduce various advanced technologies such as: surgical robots, three
dimensional (3D) images, computer graphics (CG), computer simulation technology
and others. Surgical robots, including the AESOP, da Vinci and ZEUS systems,
provide surgeons with technologically advanced vision and hand skills.
As a result, such systems are expected to revolutionize the field of surgery.
However, there have so far been few studies which discuss the indications
of robotic surgery for tumors/cancer. Therefore, herein we review various
studies published in English to focus on the application of robotic surgery
to tumors/cancer. There are several problems to be solved for robot surgery:
i) price of surgical robots, ii) training systems for surgeon, iii) coverage
by medical insurance, iv) downsizing and v) navigation system. In conclusion,
we believe that, in the near future as robotic technology continues to
develop, almost all kinds of endoscopic surgery will be performed by this
technology. It will replace traditional surgery not only in the treatment
of benign diseases but also in malignant illnesses. In the 1990s, laparoscopic
surgery entirely changed the style of surgical operations. The popularity
of the laparoscopic cholecystectomy has spread rapidly and it has now become
the standard treatment for cholelithiasis. However, the technique has not
spread much beyond cholecystectomy, because laparoscopic techniques, such
as suturing or ligation, make it difficult for surgeons to perform other
kinds of operations, thereby greatly increasing their mental and physical
stress. Basically, surgical operations have been developed over the years
based on the surgeon’s skillful hands and trained eyes. However, to develop
new surgical therapies in the 21st century, it is now necessary to adopt
various advanced computer-enhanced technologies; such as surgical robots,
three dimensional (3D) images, computer graphics (CG), computer simulation
technology and others. 3D images for surgical operations provide surgeons
with advanced vision. Surgical robots, such as AESOPref1,
da Vinci (Lobontiu A. The da Vinci surgical system performing computer-enhanced
surgery. Osp Ital Chir 2001;7:367–72)ref
(Isgro F, Kiessling A-H, Blome M, Lehman A, Kumle B, Saggau W. Robotic
surgery using Zeus microwrist technology: the next generation. Osp Ital
Chir 2001;7:373–8), provide surgeons with technologically advanced vision
and hand techniques, which have revolutionized surgery in various fields.
The advanced vision and hand techniques now available to surgeons are leading
to the development of new surgical fields such as minimally
invasive surgery (MIS),
non-invasive surgery, virtual reality micro-surgery, tele-surgery,
fetal surgery, neuro-informatic surgery and othersref1,
However, so far there have been few reports which have discussed indications
of robotic surgery in the treatment of tumors and cancers. In many surgical
fields, including craniomaxillofacial surgery, computer-aided surgery
(CAS) based on computed tomography (CT) data is becoming increasingly
important. Navigation systems, which allow precise intraoperative orientation
of surgical instruments, can be used for greater accuracy in determining
the resection margins of target lesions. These techniques also greatly
support ablative procedures. However, more complex procedures, such as
reconstruction, still remain a problem. Therefore, a computer-aided
design (CAD) and computer-aided manufacturing (CAM) system has
been developed which allows the construction and fabrication of individual
templates for resections based on coherent numerical 3D modelsref1,
Iseki and co-workers developed an overlaid three-dimensional image-guided
navigation system in neurosurgery, which is able to navigate surgeons accurately
during operative proceduresref1,
In addition, the combination of surgical robots and navigation systems
(Sakuma I, Takai Y, Kobayashi E, Inada H, Fujimoto K, Asano T. Navigation
of high intensity focused ultrasound applicator with an integrated three-dimensional
ultrasound imaging system. Lect Notes Comput Sci 2002;2489:133–9) will
allow us to perform more precise and more minimally invasive gene therapy
(e.g. local injection).
the Master–Slave manipulator : in general, robotic systems consist
of 3 parts: a surgical cart, a vision cart and the surgeon’s console. The
surgeon sits at a control console equipped with a display that presents
images obtained with an endoscopic camera inside the patient’s body. The
surgeon’s console also provides master manipulators, which the surgeon
can use to control the movements of the corresponding surgical or patient-side
manipulators (slave manipulator) that hold the surgical instruments and
the endoscopic manipulator used for the procedure. The surgeon looks down
into the viewer as if looking into the surgical field and at his hands.
He holds on to the control handles with his left and right hands. He then
carefully guides the tool tips inside the patient’s body. As the surgeon
moves the manipulators on the surgeon’s console, the patient-side manipulators
closely follow the input motions. This master–slave manipulator allows
surgeons to perform more precise surgical procedures than those available
in conventional endoscopic surgery. A previous study showed that remote-access
endoscopic telemanipulation can successfully achieve complex 3D manipulations
and the intuitive orientation of the surgeon’s workstation may also make
such tasks easier to completeref.
automated endoscope system for optimal positioning (AESOP®)
(Computer Motion, Goleta, CA) : the first robot approved by the US Food
and Drug Administration (FDA) for clinical use in the abdomen. At the time
it was first introduced, the surgeon controlled the robotic arm either
manually or remotely with a foot switch or hand control (1,2), but the
most recent generation of AESOP is voice controlledref1,
da VinciTM Surgical System was developed by Intuitive
Surgical (Mountain View, CA). So far, 196 da Vinci systems have been installed
worldwide. Many kinds of surgical operations, such as general surgery,
urology, cardiothoracic surgery and pediatric surgery, have already been
performed using the da Vinci system. This system consists of 3 main parts:
(i) The Surgeon Console, which is controlled by the surgeon: (ii) the Surgical
Cart, of which 3 arms directly perform the procedures; and (iii) the Vision
System. The computer system which controls the whole system resides in
the Surgeon Consoleref
(Lobontiu A. The da Vinci surgical system performing computer-enhanced
surgery. Osp Ital Chir 2001;7:367–72). The notable features of the da Vinci
Surgical System are as follows: the surgical instruments with the Endo
WristTM move like human hand motion by artificial articulation and the
visualization through a high-quality 3D endoscope is optimal. This system
provides surgeons with (i) an intuitive translation of the instrument handle
to the tip movement, thus eliminating the mirror-image effect, (ii) scaling,
(iii) tremor filtering, (iv) coaxial alignment of the eyes, hand and tooltip
image and (v) an internal articulated endoscopic wrist providing an additional
three degrees of freedom. Regarding the treatment of tumors and cancer,
we have successfully performed robotic surgery for esophageal tumors, thymoma,
retromediastinal tumor, gastric cancer and colon cancer using the da Vinciref.
ZEUS® telerobot (Computer Motion) (7) (Fig. 2). It
used AESOP as the foundation for the development of a robot capable of
telerobotic surgery. In this system, the voice-controlled robot, AESOP,
continues to hold the camera. Two additional AESOP-like units have been
modified to hold surgical instruments. The ZEUS system provides almost
the same function as the da Vinci, except for the internal articulated
endoscopic wrist. Furthermore, ZEUS enables surgeons to perform long-distance
remote control surgery using SOCRATESTM (Computer Motion). SOCRATESTM is
a surgical telecollaboration system that links remote surgeons directly
with colleagues in the operating room. HERMES® (Computer
Motion) is the leading-edge operating room’s central nervous system. HERMES®
enables the surgeon and staff to control a wide variety of networks consisting
of AESOP®, ZEUS® and SOCRATESTM.
The ZEUS robotic surgical system consists of two parts: (i) the video monitor
projects a 3D image that can be viewed through glasses mounted with a polarizing
filter and (ii) a surgeon sitting comfortably in a chair at the ZEUS console.
NaviotTM : a new system has also been developed recently
in Japan called the laparoscope manipulator, NaviotTM (Hitachi,
(Tomikawa M, Hashizume M, Kobayashi E, Yamaguchi S, Sakuma I, Fujie M,
et al. Merits of a newly developed laparoscope manipulator: experiences
with 4 cases. In: Lemke HU, Vannier MH, Imamura K, Farman AG, Doi K, Reiber
JHC, editors. CARS/Springer 2002;320–3). This system is recognized as the
first surgical robot ever developed in Japan. This manipulator is based
on a five-bar linkage mechanism that has two independent motors on the
bottom. In addition, the zoom-up mechanism of the laparoscope was applied
to this manipulation system. The moving range was about 25° in both
the vertical and horizontal directions. As of March 2004, we had performed
laparoscopic surgery on 100 patients using this Naviot.
Comparison between da Vinci and ZEUS
At present, according to 2 evaluation studiesref1,
the da Vinci system is considered to have some advantages over the ZEUS
system. In an animal study by Sung and Gillref,
during a laparoscopic nephrectomy, the da Vinci system had a significantly
shorter total operating room time (51.3 versus 71.6 min; P = 0.02) and
actual surgical time (42.1 versus 61.4 min; P = 0.03) compared with the
ZEUS system. For a laparoscopic adrenalectomy, the da Vinci system (n =
5) had a shorter actual surgical time (12.2 versus 26.0 min; P = 0.006)
than did the ZEUS system. For laparoscopic pyeloplasty, the da Vinci system
had a shorter total operating room time (61.4 versus 83.4 min; P = 0.10)
and anastomotic time (44.7 versus 66.4 min; P = 0.11). During pyeloplasty
anastomosis, the total number of suture bites per ureter was 13.0 for the
da Vinci system and 10.8 for the ZEUS system. In a study by Dakin and Gagnerref,
18 surgeons performed tasks in a training box using three different instrument
systems: standard laparoscopic instruments, the ZEUS Robotic Surgical System
and the da Vinci Surgical System. The basic tasks included running a 100
cm rope, placing beads on pins and dropping cotton peanuts into cylinders;
fine tasks included intracorporeal knot tying and running stitches with
4–0, 6–0 and 7–0 sutures. The time (in seconds) required and precision
(number of errors) in performing each task were recorded. Standard instruments
performed significantly faster than either robotic system on the rope and
bead tasks (P < 0.05), whereas da Vinci performed significantly faster
than ZEUS in all three basic tasks (P < 0.05). No significant difference
in precision was found between the standard instruments and the robotic
systems regarding any of the basic tasks. Knot tying and the running suture
time were similar between the standard instruments and da Vinci, which
were significantly faster than ZEUS (P < 0.05) for all suture sizes.
The robotic systems showed a similar precision for fine suturing tasks
and they were also significantly more precise in knot tying (ZEUS and da
Vinci) and running sutures (da Vinci) than standard instruments (P <
neurosurgery is the pioneer and the most active field in robotic
surgery. Lunsford reported for the first time the introduction of the gamma
knife for brain surgery without making an incision. According to this study,
the gamma knife was approved for marketing by the FDA in 1982 and the device
received approval of the Nuclear Regulatory Commission (NRC) in 1986. Finally,
this gamma knife device was first used for patient treatment in 1987 in
Pittsburgh, PA (Lunsford LD. The Presbyterian University Hospital, Pittsburgh.
The gamma knife: brain surgery without an incision. Hosp Physician 1998;24:28)
and due to this first step, the concept ‘brain surgery without an incision’
is now a reality. Drake et al. performed a computer- and robot-assisted
resection of thalamic astrocytomas in childrenref.
6 children ranging in age from 2 to 10 years who had deep benign astrocytomas
were operated on using a robot-assisted system and a radical excision was
achieved. This system consists of an interactive 3D display of CT image
contours and digitized cerebral angiograms which were taken using the Brown–Roberts–Wells
(BRW) stereotactic frame. The surgical retractor is held and manipulated
using a Programmable Universal Manipulation Arm (PUMA) 200 robot (Westinghouse
Electric, Pittsburgh, PA) and the position and orientation of the surgical
retractor are shown in the 3D display. Both preoperative planning and simulation
are important features of this system. The movement of the brain after
removal of the tumor and cerebrospinal fluid is substantial, therefore
the tumor removal is based on visually defined marginsref.
Carney et al. confirmed that intraoperative image guidance is available
The ISG viewing wand (ISG Technologies, Missasauga, ON, Canada) is an intraoperative
guidance system with a proprioceptive robotic-like jointed arm. It provides
surgeons with almost instantaneously reconstructed computer-generated CT
or MRI images in 2D or 3D which can correlate any points within the operative
field to its corresponding locus on the reformatted scan images. In this
report, 14 patients with skull-base, cerebello-pontine angle or temporal
bone lesions also underwent wand-guided resections. Zamorano et al. reported
the application of interactive image-guided resections for cerebral cavernous
In their report, 15 patients with cavernous malformations underwent an
interactive image-guided resection of their lesions. Diagnoses were made
using MRI and digital subtraction angiography (DSA). In addition, an infrared
system was used intraoperatively to confirm the location and the extent
of the resection in real time. Levesque and Parker confirmed the usefulness
of Mehrkoordinaten Manipulator (MKM)-guided resection for diffuse
2 patients with extensive brainstem tumors underwent a frameless stereotactic
craniotomy using an MKM robotic microscope (Carl Zeiss, Oberkochen, Germany)
and intraoperative neurophysiological monitoring. Their result shows that
image-guided surgery with an MKM microscope allows surgical outlines to
be injected in the microscope viewer, thereby facilitating a resection
of extensive brainstem tumors that were previously considered inoperable.
Hongo et al. developed NeuRobot, a telecontrolled micromanipulator system
for minimally invasive microneurosurgery, at Shinshu Universityref.
Using this system, surgical simulations were performed with a human cadaveric
head. The system consists of four main parts: (i) a micromanipulator (slave
manipulator), (ii) a manipulator-supporting device, (iii) an operation-input
device (master manipulator) and (iv) a three-dimensional display monitor.
3 1 mm forceps and a three-dimensional endoscope, which could be remotely
controlled with three degrees of freedom (rotation, neck swinging and forward/backward
motion), were installed in the slave manipulator. All surgical procedures
were accurately performed using this system. Furthermore, the same group
showed the usefulness of a potassium titanyl phosphate (KTP) laser with
micromanipulators in neurosurgery based on an animal study (Goto T, Hongo
K, Koyama J, Kobayashi S. Feasibility of using the potassium titanyl phosphate
laser with micromanipulators in robotic neurosurgery: a preliminary study
in the rat. J Neurosurg 2003;98:131–5). This system was shown to be capable
of performing various surgical procedures including cutting, coagulation
and bleeding control compared with conventional systems.
cardiology : the da Vinci was specifically designed to perform closed-chest
coronary artery bypass graftingref.
As a result, cardiac surgeons have accumulated substantial experimental
experience using the da Vinci prototyperef1,
In 1999, Carpentier et al. reported the first successful use of da Vinci
for closed-chest coronary bypass graftingref.
Kappert et al. used da Vinci to harvest both the left and right internal
mammary arteries for coronary artery bypass grafting in 27 patientsref.
Mohr et al. performed coronary artery bypass surgery using da Vinci for
In brief, they used da Vinci to harvest 81 left internal
(LIMA) and then used it to sew 15 LIMA to left anterior descending (LAD)
coronary artery bypass grafts through a median sternotomy incision. Following
these patients, they constructed 27 LIMA-to-LAD bypass grafts on an arrested
heart with a closed chest. More recently, they succeeded in using the da
Vinci to anastomose the LIMA to the LAD on a beating heart with a closed
chest. Autschbach et al. established a mitral valve repair for 13 patients
using the same systemref.
Regarding ZEUS, in 1999 Reichenspurner et al. reported its first successful
clinical use for coronary artery bypass graft for two patientsref.
They harvested LIMA using endoscopic techniques and then sutured LIMA to
LAD through three thoracic trocars. The heart was arrested using an endovascular
cardiopulmonary bypass system. Later that year, Boehm used ZEUS to successfully
perform closed-chest, off-pump coronary artery bypass grafting (LIMA to
LAD) in 3 patientsref.
By 2000, the same group had performed coronary artery bypass grafting on
beating hearts in 10 patientsref.
The total operating time ranged from 4 to 8 h (median, 5.5 h) and ZEUS-assisted
anastomoses required 14–50 min (median, 25). ZEUS is also used for a pericardiectomyref
or mitral valve surgeryref.
However, due to the unique characteristics of heart disease, there have
so far been no reports on robotic surgery in the treatment of tumors or
coronary artery disease : IMA harvest
beating heart : totally
(TECAB) (single vessel). A right-sided thoracic approach was used to
access both ITAs and the target vessels. The patient was placed on the
operating table with the right chest elevated about 40°. 3 ports were
placed around the breast to introduce the stereo endoscope and the robot
arms of the daVinci™ surgical system. The ports for the 2 robot arms were
inserted under endoscopic control in the 3rd and 7th intercostal space
(ICS) on the anterior axillary line after placement of a midaxillary camera
port in the 5th ICS and insufflation of the chest with CO2.
Using a 30° stereo videoscope looking upward, the anterior mediastinum
was first dissected and the remotely located left ITA was mobilized without
opening the left pleural cavity. Then the right ITA was dissected. Given
the flexibility of the daVinci™ surgical system it was possible to dissect
the total length of both ITAs from the subclavian origin down to the bifurcation.
The end of the ITAs and a neighbouring segment were skeletonized for transient
occlusion with bulldog clamps (Scanlan Int, Saint Paul, Minnesota). After
heparinization, both arteries and internal thoracic veins were clipped
distally and taken down. Cardiopulmonary bypass was instituted under TEE
guidance via cannulation of the left femoral vessels using the Port Access
EndoCPB™ system (Heartport Inc, Redwood City, CA). After CPB was started
with suction on the PA vent catheter, the heart was decompressed and endoscopic
pericardiotomy was performed about 2 cm left from the mid line. The LAD
and the RCA were identified on the surface of the epicardium and marked
with clips. A transthoracic stay suture was placed, elevating the left
pericardium to expose the LAD. Cardioplegic arrest was achieved by antegrade
St. Thomas cardioplegia delivered to the aortic root via the Port Access
aortic endoclamp. After a 7 mm arteriotomy of the LAD, the left ITA was
anastomosed end to side with a 7.0 running polypropylene suture (7.5 cm
length, Fumalene, Fumedica Medizintechnik, Herne, Germany). An epicardial
stay suture (4.0 prolene) was placed to expose the anastomotic site of
the RCA and facilitate access with the instruments. Then the right ITA
graft was anastomosed end to side to the RCA. After deflation of the aortic
endoclamp, the patient was weaned from CPB. 2 chest tubes were inserted
through the camera and right arm incisionref1,
arrested heart : TECAB (single and multiple vessel)
multi-vessel small thoracotomy bypass
mitral valve disease :
mitral valve repair
mitral valve replacement
pericardial fluid : pericardial window
dilated cardiomyopathy (DCM) : epicardial lead placement for Bi-V pacing
respiratory system : Okada et al. performed a thoracoscopic major
lung resection for primary lung cancer by a single surgeon with AESOP and
an instrument retraction system (UNITRAC; Aesculap, Tuttlingen, Germany)ref.
For a 72-year-old woman with lung cancer, a thoracoscopic middle lobectomy
of the right lung with dissection of the mediastinal lymph nodes was successfully
performed without human assistance and no complications were observed.
Melfi et al. carried out thoracoscopic surgery using the da Vinci system
in 12 cases: 5 lobectomies, 3 tumor enucleations, 3 excisions and one bulla
stitching completed with fibrin glue for spontaneous pneumothoraxref.
lung cancer :
mediastinum : Yoshino et al. successfully performed a thoracoscopic
thymomectomy using da Vinci in a 74-year-old male patient who demonstrated
Ruurda et al. reported a thoracoscopic resection of a schwannoma using
da Vinci in a 46-year-old female who presented with a left paravertebral
mass in the thoraxref.
thymoma : thymectomy
upper limb hyperhidrosis : sympathectomy
breast : in 2000, Kaiser et al. suggested a strong possibility regarding
the application of a robotic system for a biopsy and therapy of breast
lesions in a high-field whole-body magnetic resonance tomography unit called
system for biopsy and interventional therapy of mammary lesions (ROBITOM;
Institute for Medical Engineering and Biophysics (IMB), Karlsruhe, Germany)
consists of a trocar, coaxial sleeve, biopsy needle, laser applicator and
a control and drive unit. In this study, in vitro experiments on a pig
liver including eight targets (vitamin E capsules, 4 mm in diameter) were
performed as a model of breast cancer and all eight capsules were hit precisely
by this robotic biopsy system. The procedure was performed directly in
the isocenter of a 1.5 T whole-body scanner. According to these results,
such a robotic system may allow the coordinates of the lesion in the breast
to be approached in a high magnetic field. Veronesi et al. showed the usefulness
of intraoperative radiotherapy (IORT) in limited-stage breast cancers in
Because local recurrences after breast conserving surgery occur mostly
in the quadrant harboring the primary carcinoma, the main objective of
postoperative radiotherapy should be sterilization of residual cancer cells
in the operative area, while irradiation of the whole breast may be avoided.
They developed a new technique of performing IORT on a breast quadrant
after removing the primary carcinoma. A mobile linear accelerator (linac)
with a robot arm is utilized delivering electron beams capable of producing
an amount of energy ranging from 3 to 9 MeV. 17 patients received a dose
of IORT ranging from 10 to 15 Gy as an anticipated boost to external radiotherapy,
while 86 patients received a dose of 17–19–21 Gy intraoperatively as their
whole treatment. This IORT treatment allowed the whole treatment course
to be shortened. Recently, MR imaging-guided focused ultrasound US (MR-FUS)
ablation has rapidly developed as a non-invasive treatment for breast cancerref1,
Gianfelice et al. showed the effectiveness of non-invasive MR-FUS ablation
in 12 patients with breast carcinomasref.
In brief, before undergoing a tumor resection, patients were treated with
MR-FUS ablation consisting of multiple sonications of targeted points that
were monitored with temperature-sensitive MRI (SignaTM; GE Medical
Systems, Milwaukee, WI, USA). The effectiveness of the treatment was determined
by a histopathological analysis of the resected mass which was performed
to determine the volumes of necrosed and residual tumors. Complications
resulting from the procedure were assessed by means of questionnaires,
medical examinations and an MR image analysis. US ablation (ExAblateTM
2000; In-Sightec-TxSonics, Haifa, Israel) was well tolerated by the patients
and, except for minor skin burns in two patients, no complications occurred.
A histopathological analysis of resected tumor sections allowed the quantification
of the amount of necrosed and residual tumor and the visualization of the
surrounding hemorrhage. In three patients treated with one of the US systems,
a mean of 46.7% of the tumor was within the targeted zone and a mean of
43.3% of the cancer tissue was necrosed. In nine patients treated with
the other US system, a mean of 95.6% of the tumor was within the targeted
zone and a mean of 88.3% of the cancer tissue was necrosed. Residual tumors
were identified predominantly at the periphery of the tumor mass, thus
indicating the need to increase the total targeted arearef.
Huber et al. also revealed the usefulness of MR-FUS ablation in a 56-year-old
female who presented with breast cancer (invasive ductal carcinoma)ref.
Hynynen et al. also showed the usefulness of MR-FUS ablation for fibroadenomaref.
11 fibroadenomas in nine patients under local anesthesia were treated with
MR-FUS. 8 of the 11 lesions treated demonstrated a complete or partial
lack of contrast material uptake on post-therapy T1-weighted images. 3
lesions showed no marked decrease in the contrast material uptake. This
lack of effective treatment was most likely due to a lower acoustic power
and/or patient movement that caused misregistration. No adverse effects
were detected, except for one case of transient edema in the pectoralis
muscle 2 days after therapyref.
These papers suggested that (i) invasive ductal carcinoma, (ii) adenocarcinoma,
(iii) invasive lobular carcinoma and (iv) fibroadenomaref1,
were all indications for robotic surgery.
abdomen : Himpens et al. reported the first successful clinical
implementation of telerobotics in March 1997, when they performed a laparoscopic
cholecyctectomy using a prototype of the da Vinciref.
The same group also reported a successful use of this system for telerobotic
laparoscopic gastric bypassref,
(Cadiere GB, Himpens J. Nissen fundoplication by robot. Osp Ital Chir 2001;7:385–92)
and Fallopian tube reanastomosisref.
Other studies showed many kinds of robotic surgery in the abdomenref1,
(Ballantyne GH, Merola P, Weber A, Wasielewski A. Robotic solutions to
the pitfalls of laparoscopic colectomy. Osp Ital Chir 2001;7:405–12; Chapman
WHH, Albrecht RJ, Kim VB, Young JA, Nifong LW, Chitwood WR Jr. Computer
enhanced robotically assisted telemanipulative cholecystectomy [abstract].
Surg Endosc 2001;15:S114; Young JA, Chapman WHH, Albrecht RJ, Kim VB, Nifong
LW, Chitwood WR Jr. Initial patient series with robotic assisted Nissen
fundoplication [abstract]. Surg Endosc 2001;15:S175; Melvin WS, Needleman
BJ, Krause KR, Scheider C, Wolf RK, Michler RE, et al. Computer enhanced
‘robotic’ telesurgery: initial experience in foregut surgery [abstract].
Surg Endosc 2001;15:S148; Ozawa S, Furukawa T, Ohgami M, Wakabayashi G,
Kitajima M. Robot-assisted laparoscopic anti-reflux surgery [abstract].
Surg Endosc 2001;15:S152; Talamini MA, Campbell K, Stanfield C, Are C.
Robotic laparoscopic surgery: early lessons learned [abstract]. Surg Endosc
2001;15:S165). Ballantyne and co-workers performed a sigmoid colectomy
for diverticulum and right hemicolectomy for cecal diverticulum using da
(Ballantyne GH, Merola P, Weber A, Wasielewski A. Robotic solutions to
the pitfalls of laparoscopic colectomy. Osp Ital Chir 2001;7:405–12) and
the operative time for a sigmoid colectomy was 340 min whereas for a right
hemicolectomy it was 228 min. The same group also performed the first two
cases of ventral hernia repair with meshref.
Hashizume and co-workers reported the first completely intraabdominal laparoscopic
distal gastrectomy for early gastric cancer using da Vinciref1,
The same group also performed the first gastric devascularization and splenectomy
for portal hypertensionref.
This report indicates that telepresence technology facilitates these proceduresref1,
Melvin et al. reported a robotic assisted Heller myotomyref.
The same group also performed a pancreatic resection with da Vinciref.
A 46-year old woman presented with back pain and a complex cystic mass
in the tail of the pancreas. The da Vinci was used to remove the lesion
en bloc with the tail of the pancreas and spleen. Marescaux et al. reported
a large clinical trial with ZEUS and 25 selected patients underwent ZEUS-assisted
Regarding the robotic abdominal surgery for cancerref1,
an extraction of esophageal tumor, a distal gastrectomy for gastric cancer,
an ileocecal resection for cecal cancer, a left hemicolectomy for descending
colon cancer, a sigmoidectomy for sigmoid colon cancer, a thymectomy for
thymoma and an extraction for retromediastinal tumor have all been performed
successfully. As a result, almost all types of tumors or cancers may therefore
be indicated for robotic surgery
urology : Abbou et al. reported on a radical prostatectomy using
The patient was a 63-year-old man presenting with a T1c tumor discovered
on one positive sextant biopsy with a 3 + 3 Gleason score and 7 ng/ml.
preoperative serum prostate specific antigen. The da Vinci provided an
ergonomic surgical environment and a remarkable dexterity enhancement.
The operating time was 420 min and the hospital stay lasted 4 days. The
bladder catheter was removed 3 days postoperatively and 1 week later the
patient was fully continent. A pathological examination showed a pT3a tumor
with negative marginsref.
Young et al. reported an adrenalectomy for adrenal incidentaloma using
In this report, an incidental left adrenal mass was found in a patient
during an evaluation for mediastinal widening. The patient had no symptoms
attributable to adrenal excess. Preoperative biochemical screening was
negative for a functioning medullary or cortical adrenal tumor. A surgical
resection was successfully completed with the assistance of the da Vinci
robotic system. Pathology demonstrated a rare adrenal oncocytomaref.
Recently, in kidney transplantation, a donor nephrectomy has also been
performed using the da Vinciref1,
Guillonneau et al. reported ZEUS-assisted laparoscopic pelvic lymph node
dissection in humansref.
Robotic-assisted laparoscopic pelvic lymph node dissection was performed
in 10 consecutive patients with mainly T3 M0 prostatic carcinoma (robotic
group). All operations were performed according to the established protocol
with no specific intraoperative or postoperative complications. No conversion
was required and no technical incidents were observed. The indications
of robotic surgery for cancer/tumor are renal cancer and prostate cancer
gynecology : Mettler et al. tried the use of AESOP in 50 patients
undergoing routine gynecological endoscopic surgical procedures and AESOP
allowed 2 doctors to perform complex laparoscopic surgery faster than without
the robotic armref.
Diaz-Arrastia et al. reported robotic hysterectomy and salpingo-oophorectomy
for 11 patientsref.
Molpus et al. reported the first clinical case of robotically assisted
endoscopic ovarian transposition using da Vinciref.
Ovarian transposition is the anatomical relocation of the ovaries from
the pelvis to the abdomen. Transposition is beneficial in women who are
scheduled to undergo pelvic radiation, because it allows the maintenance
of ovarian function and preservation of assisted reproductive capacity.
In such cases, it is possible to perform ovarian transposition using the
da Vinci systemref.
Regarding robotic surgery, Margossian and co-workers explored the applications
of ZEUS in gynecology, using experimental modelsref1,
They demonstrated that uterine horn anastomoses in six pigs sutured using
ZEUS were all patent 4 weeks after surgeryref.
This study highlighted the potential role of robotics for microsurgery.
The same group also used ZEUS to perform five hysterectomies in pigsref,
where the mean surgical operating time was 200 min. Regarding the AESOP
system, a laparoscopic robot-assisted ovariectomy was performed for ovarian
Falcone et al. used ZEUS to perform tubal reanastomosis for 10 patients
with previous tubal ligations who underwent a laparoscopic tubal ligation.
The procedure was completed successfully in all 10 patients, none of whom
required conversion to an open procedure. A postoperative hysterosalpingogram
demonstrated patency in 17 of the 19 (89%) tubes anastomosed and there
have been 5 pregnancies so farref.
In gynecology also, the MR-FUS has been used to perform operations for
and fibroid tumorsref.
According to Tempany et al., the eligibility criteria for enrollment were
as follows: adult women (age >18 years), premenopausal status with a uterine
size of <20 weeks and no dominant leiomyoma >10 cm in diameterref.
MR-FUS was performed successfully in 9 women (age range, 39–51 years; mean,
43.4 years) with symptomatic leiomyomas and a hysterectomy was done 3–30
days after MR-FUS as evaluation of its effect.
pediatric surgery : the use of robotic surgery has also become widespread
in pediatric surgeryref1,
Gutt et al. performed Thal and Nissen fundoplication for GERD, a cholecyctectomy
for cholecystolithiasis and bilateral salpingo-oophorectomy for gonadoblastoma
using da Vinci for 11 children with a mean age of 12 years (range, 7–16
The mean operating time for fundoplication was 146 min, whereas for a cholecystectomy
it was 128 min and for a salpingo-oophorectomy it was 95 min and no complications
Bentas et al. performed an adrenalectomy for benign adrenal tumors using
The same group reported pyeloplasty for ureteropelvic junction obstruction
(UPJO) using da Vinciref.
In experienced hands, a laparoscopic pyeloplasty is an effective alternative
treatment for symptomatic UPJO. Although laparoscopic surgery can clearly
benefit patients, laparoscopic pyeloplasty using conventional instrumentation
is complex. Eleven pyeloplasties for UPJO were performed via a laparoscopic
transperitoneal approach exclusively with the da Vinci. The mean procedure
time was 197 min (range, 110–310 min). All operations were completed laparoscopically
with no intraoperative complications and negligible blood loss. All patients
recovered rapidly after surgery with excellent functional results at the
1 year follow-up. Their initial experience suggests that robot-assisted
Anderson–Hynes pyeloplasty is a safe and effective alternative to conventional
Le Bret et al. reported the possibility of robotic surgery for pediatric
56 children weighing from 2.3 to 57 kg (mean, 12 kg) underwent a surgical
closure of a patent ductus arteriosus. They were divided into 2 groups,
one consisting of 28 patients (group 1) who underwent videothoracoscopic
techniques and the other of 28 patients (group 2) who underwent a ZEUS-assisted
approach. The operating time was significantly longer in the robotically
assisted group. One conversion in videothoracoscopy was necessary, but
no thoracotomy was required. 3 persistent shunts were detected at postoperative
echocardiography and were treated by applying a new clip with videothoracoscopy
(1 in group 1 and 2 in group 2). No permanent laryngeal nerve injury and
no hemorrhage were noted. The mean hospital stay was 3 days in both groups.
dermatology : in 1988, Rotteleur et al. reported a robotized scanning
laser handpiece for the treatment of port wine stains and other angiodysplasiasref.
This system is made of a handpiece with a scanning mechanism and a control
box with a microprocessor. The system is independent of the laser (no electrical
connection) and has its own power meter. The deposit of energy was optimized
for effective heat diffusion in the skin. A total of 123 patients were
treated with the robotized handpiece and no hypertrophic scars were reported.
McDaniel reviewed laser treatment for benign cutaneous vascular disorder
and showed that automated robotic laser scanning devices allow faster,
less painful and more cost-effective treatment. Handels et al. showed an
approach to computer-supported recognition of melanoma based on high-resolution
skin surface profilesref1,
In brief, profiles are generated by sampling an area measuring 4 x 4 mm2
at a resolution of 125 sample points per mm with a laser profilometer at
a vertical resolution of 0.1 µm. This new image analysis and pattern
recognition method make it easier and more accurate to treat skin tumorsref1,
There are several basic problems that remain to be resolved in order for
robotic surgery to spread more widely: (i) the price of surgical robots,
(ii) training systems for surgeons, (iii) medical insurance cover, (iv)
downsizing and (v) navigation systems. Regarding the price of robotic systems
and medical insurance cover, the success of laparoscopic surgery over the
past 10 years would endorse further use of robotic surgeryref1,
Regarding the training systems for surgeons, an excellent report on the
significance of training has been publishedref.
Furthermore, our group at the Center for
Integration of Advanced Medicine, Life Science and Innovative Technology
(CAMIT) of Kyushu University started a training course called ‘Hands-on
Training for Robotic Surgery at Kyushu University’ in July 2003. There
are two training courses for robotic surgery. One is a 1-day inanimate
laboratory course and the other is a 2-day course with animate laboratory.
Both courses are open not only for medical doctors, but also for wider
ranges of researchers in engineering in both academia and industry. Regarding
clinical applications, we envisage that almost all surgery can and will
be performed by robotic surgery in the future. For that to happen, the
following systems should be developed further: (i) an image-guided surgical
assistant system, (ii) smaller sized forceps for robots, (iii) capsule
endoscopic surgery and (iv) a surgical robotic system. In education and
training, training centers for robotic surgery, such as CAMIT, should be
established around the world. In the very near future, thanks to the rapid
and continuing development of robotic technology, almost all kinds of endoscopic
surgery and thoracoscopic/laparoscopic surgery will become performed by
robotic surgery, not only for benign disease but also for malignant illnesses
In an effort to combine sophisticated laser and Internet technologies,
scientists in Australia have successfully performed laser surgery and “optical
trapping” in a Southern California laboratory via the Internet. The scientists
used a new Internet-based laser scissor-and-tweezers technology called
RoboLase, demonstrating the potential of using the technology for
real-time research activities between laboratories and for physicians to
perform medical procedures from distant locations. In a proof-of-principle
series of experiments, the scientists from UC Irvine, UC San Diego and
the University of Queensland employed RoboLase to produce surgical holes
in a distinct pattern of < 1 mm in diameter
in single cells. Utilizing a control panel projected onto a computer screen,
Queensland researchers were able to remotely perform the cell surgery on
a laser microscope system in the Southern California laboratory. The speed
and precision of the sub-cellular surgery was equal to what it would be
like if we were doing the same surgery in our labs here in California,”
said Michael Berns, professor of biomedical engineering at UCI and adjunct
professor of bioengineering at UCSD, who led the development of the RoboLase
technology. In addition, the scientists were able to grab onto – or “optically
trap” – swimming sperm in the California lab by operating optical-laser
tweezers remotely from Australia. This was a particularly noteworthy accomplishment,
because it demonstrated the amount of computer bandwidth (1 gigabyte/second)
needed by the Australia and California research groups to observe and grab
a fast-moving sperm with virtually no detectible delay in image transmission
between the 2 laboratories. “If there was a detectible delay in either
the transmission or reception of the video images, our colleagues in Australia
would not have been able to identify and trap a targeted sperm under the
laser microscope in the California laboratory. The general significance
of this work is that researchers can now collaborate on experiments with
scientists around the world using this expensive and sophisticated instrumentation
without having to travel to a single laboratory site. It also serves to
demonstrate that the Internet will become increasingly more useful and
important for the actual conduct of scientific research and possibly for
the delivery of selective medical procedures. This technology is now accessible
to other scientists who may not have easy access to it. And the instrumentation
can be used over the Internet as a learning tool by students just about
anywhere in the world (September issue of the journal Microscopy Research