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, ref2, ref3, ref4, da Vinci (Lobontiu A. The da Vinci surgical system performing computer-enhanced surgery. Osp Ital Chir 2001;7:367–72)ref and ZEUSref1, ref2, ref3, ref4 (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, ref2. 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, ref2, ref3. 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, ref2, ref3. In addition, the combination of surgical robots and navigation systems using CTref, MRIref and USref (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).

Comparison between da Vinci and ZEUS 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, ref2. 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 and Technique)

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