OCTOBER 202319AN OVERVIEW OF ROBOTIC SURGICAL SYSTEMS IN 2023open and laparoscopic surgery begins by considering robotic surgery as an integrated tool and data platform rather than an individual surgical tool. The robotic surgical platforms currently being used are capable of recording cases, analyzing instrument and surgeon movement, detecting economy of motion, case annotation, detecting trend over time, and many other functions for use in education and for quality improvement purposes. The difference between robotic surgery versus other surgical approaches begins upon access to a surgical site. After making minimally invasive incisions, ports are placed to allow robot docking, instrument placement and exchange. The torque generated by use of robotic instruments is generally lower than that of laparoscopic tools. Even this small difference leads to less patient pain and vastly improved intraoperative ergonomics. Further, the location of port sites can be better standardized across patients for improved reproducibility as robotic arms allow for greater degrees of motion and overall maneuverability of camera and surgical instruments. This maneuverability, including articulation of instruments, allows for improved access to regions such as the foregut, leading to improved visualization, surgical dissection, performance of fine tasks such as suturing, safety, and both short- and long-term patient outcomes, notable in complex colorectal, foregut, and bariatric surgery. In stark contrast to open or laparoscopic surgery, a surgeon is capable of controlling all instruments and camera throughout the duration of a case, which may result in less dependence on a surgical assistant. Despite these benefits, it is important to note that robotic surgery is not appropriate in all cases and is best used under appropriate surgeon discretion. While robotic surgical systems have been FDA-approved and on the US market for decades, robotic surgery rates range widely from 15 percent for common general surgical procedures to over 85 percent for some procedures such as prostatectomies. Robotic-assisted surgery is now commonly performed in general, bariatric, colorectal, cardiothoracic, gynecologic, orthopedic, neurosurgery and even trauma surgery, with rising rates across surgical fields. Barriers to entry in using robotic surgical systems include up-front cost, surgeon and staff training, existing operating room facilities and lack of familiarity with these technologies as well as their advantages and disadvantages. The robotic surgical market is primarily dominated by Intuitive Surgical, Inc., maker of the Da Vinci surgical system, which now accounts for approximately 80 percent of robotic surgical systems in use globally (BIS Research). Other robotic surgical systems with FDA approval include Asensus Surgical's Senhance® Surgical System, Hominis® Surgical System, Intuitive's IonTM endoluminal system, Johnson & Johnson's MONARCHTM robotic flexible endoscopy platform, and Stryker's Mako SmartRoboticsTM. There are many robotic surgery systems undergoing further development and FDA evaluation, including some that are already in use outside of the US including Medtronic's HugoTM Robotic-Assisted Surgery device and the CMR VersiusTM Surgical Robot. Johnson & Johnson has also recently announced their anticipated Surgical Robotics OTTAVATM system, which demonstrates unique interaction with existing OR infrastructure. As more robotic surgical systems enter the field, adoption of these different systems will largely depend on access and training. With the widespread use of the Intuitive Surgical Da Vinci robot, the vast majority of surgeons and residents in general surgery and its subspecialties are trained on this platform. The training of both physicians and surgical staff in varied robotic surgical systems will impact patient access to robotic surgery and hospital acquisition of these technologies and has yet to be standardized. It is anticipated that as robotic surgical system adoption increases, their data features to assist in quality improvement such as artificial intelligence are on the horizon. It is anticipated that as robotic surgical system adoption increases, their data features to assist in quality improvement such as artificial intelligence are on the horizonIan Soriano,MD, FACS, FASMBS
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