Robotic surgery uses robotic systems to assist surgeons with complex procedures. A robotic system typically includes a surgeon console for control of robotic arms with surgical instruments, an endoscope for vision, and a surgical cart. Robotic systems allow 7 degrees of freedom of instrument movement compared to 4 for laparoscopy, improving dexterity. The da Vinci system is most commonly used and has been applied to procedures in general surgery, urology, gynecology and others. Robotic surgery provides benefits like 3D high-definition vision, tremor filtering and motion scaling but lacks haptic feedback. It has longer procedure times but may improve precision and surgical outcomes for some procedures like prostatectomy compared to open or laparoscopic approaches.

1. ROBOTIC SURGERY

2.  A surgical robot is a computer controlled
device that can be programmed to aid the
positioning and manipulation of surgical
instruments
 Were developed to overcome the limitations
of laparoscopy
 Surgical robots serve several functions:
 Passive:
 Autonomous e.g Probot (robot performs a sequence of
events which are programmed preoperatively)
 Supervisory e.g Minerva (robot serves as a
navigational aid or a precise positioning system to direct
the surgeon to a lesion or surgical target)
 Active : robot directed by the surgeon
intraoperatively to move surgical instruments.
E.g AESOP, da Vinci system.

3. Features of active robots
 Immersive system- robot is a tool used by the surgeon
while he continues to remain deeply engaged in the
operative feild. Possible by high quality imaging,
magnification of a 3D laparoscope etc.
 Master/slave manipulation
 Lack of haptic feedback – resistance of tissue not felt
Active robots used in a variety of ways:
1. Teleoperated/Telerobotic: robot manipulated by input
devices under the surgeons control, remote from the
operating table.
2. Telepresence surgery: Surgeon located outside the
operating room
3. Telementoring: A-V transmission from a robotic setup to
a remote site allowing guidance from an expert.
4. Dual console system: use of 2 consoles with the option
of swapping control of instruments between 2 surgeons.

4. History of surgical robots
 PUMA 560 (1985) to orient a needle for a brain
biopsy under CT guidance.
 Extension of robotic surgery to
 Urology (PROBOT, 1988)
 Orthopedics (ROBODOC, 1992)
 Gynecology (ZEUS, 1998)
 Robotic laparoscopic camera holder –AESOP
(automated endoscopic system for optimal
positioning)- 1st US-FDA approved system for intra
abdominal surgeries
 Robotic telepresence surgery commercially available
in 2000- da Vinci system developed by Stanford
Research Institue and NASA- to cater to battle feild
injuries from a remote surgical station.

5. Da Vinci system
 Developed by Intuitive Surgical, Inc, Sunnyvale
California
 FDA approval in September 2001
 3 main components:
 Surgeon’s console- consists of a 3D immersive video
screen, hand and foot controls and a seat. Equipped
with a master/slave software system whereby surgeon
directs movement of the robotic arms.
Located within OR, at a distance (10m) from the
operating table.
 Surgical Cart: three or four robotic arms and seven
degree laparoscopic instruments
 Equipment cart –camera (2D images), light and energy
devices (electrocautery)

7. Surgical Cart
 The robot tower with robotic arms
is traditionally placed either
between patient’s legs or centrally
docked. Some models can be side
docked allowing free access to
lower abdominal quadrant and
pelvic structures.
 The da Vinci XI system has an
overhead arm architecture that
provides anatomical access from
virtually any position simplifying
multi quadrant surgeries.
 Arms are connected to surgical
instruments through an instrument
adapter.
 A 12 mm telescope is connected
to central robotic arm and contains
two 5 mm telescopes, producing
3D vision

8. EndoWrist instruments
 designed to provide
surgeons with natural
dexterity while operating
through small incisions.
Most EndoWrist
instruments are modeled
after the human wrist,
offering a greater range of
motion than the human
hand.
 EndoWrist Instruments
feature:
* 7 degrees of freedom
* 90 degrees of
articulation
* Motion scaling (ratio of
motion of surgeons hand
to that of robotic arms)
can also adjust speed of

9. Surgeon’s Console
 Seated at a console,
surgeon views operative feild
via a binocular device.
 Places hands in the
‘masters’ hand controls that
translates movement of
surgeons hand into an
electric signal that activates
robotic arms
 Supinates or pronates
hands while stepping on a
camera foot pedal to focus
picture.
 Buttons on the hand
controls clutch the arms and
hence instruments to
improve instrument
precision.

10.  Initial positioning and preparation of patient is
similar to conventional laparoscopy.
 Laparoscopy can be used intially to explore the
abdomen, free adhesions, mobilise bowel etc
 Port placement varies with the surgical feild
needed

11. Advantages of robotic surgery
 Superior visualisation – affords 3D vision while
allowing rapid zooming and panning of the camera.
 Use of endowrist instruments- conventional rigid
laparoscopic instruments have only four degrees of
freedom, endowrist instruments allow 7 degrees of
freedom. Increases dexterity.
Smaller, thinner robotic arms coupled with longer
instrument shafts also permit greater range of motion and
more flexibility.
 Stablisation of instruments within the surgical feild :
conventional laparoscopy amplifies small movements by
the surgeon(tremors, errors)- minimised by robotic
surgery. Permits motion scaling.
 Better hand eye coordination as opposed to

12. Disadvantages of robotic surgery
 Lack of haptics (tactile feedback)
 Very expensive
 Longer procedure times
 Risk of mechanical failure
 Not designed for abdominal surgery involving
more than 2 quadrants (requires, re-docking and
repositioning)
 Requires extra staff
 Needs additional training

13. Current applications of robotic
surgery
 General Surgery:
 Cholecystectomy
 Nissen Fundoplication
 Heller myotomy
 Gastric bypass
 Adrenalectomy
 Bowel Resection
 Esophagectomy
 Urology
 Radical prostatectomy
 Ureter repair
 Nephrectomy
 Cardiothoracic
surgery:
 IMA harvesting
 CABG
 Mitral valve repair
 Gynaecological
Surgery:
 Tubal reanastomosis
 Hysterectomy
 Oopherectomy/ Ovarian
cystectomy

14. Robotics in foregut surgery
 Robotic Nissen fundoplication results in similar clinical
outcomes when compared to laparoscopy but OR times
are longer and costs higher.
 Robotic Heller myotomy appears to result in fewer
perforations and higher post operative quality of life when
compared to laparoscopy.
 Robotic application for early gastric cancer is safe and
feasible with similar perioperative outcomes. Despite
prolonged OR times, there is an advantage with regards
to length of stay and estimated blood loss. Also enables
easier D2 lymphadenectomy-improved oncological
outcomes.
1. Maeso S, Reza M, Mayol JA, Blasco JA, Guerra M, Andradas E et al (2010) Efficacy of the Da Vinci
surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-
analysis. Ann Surg 252(2):254–262.
2. Wang Z, Zheng Q, Jin Z (2012) Meta-analysis of robot-assisted versus conventional laparoscopic
Nissen fundoplication for gastro-oesophageal reflux disease. ANZ J Surg 82(3):112–117.
with that of laparoscopy: a systematic review and meta-analysis. Ann Surg 252(2):254–262.
3. Marano A, Choi YY, Hyung WJ, Kim YM, Kim J, Noh SH (2013) Robotic versus laparoscopic versus
open gastrectomy: a meta-analysis. J Gastric Cancer 13(3):136–148
5. D'Annibale A, Pende V, Pernazza G, Monsellato I, Mazzocchi P, Lucandri G et al (2011) Full robotic
gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary

15. Robotics in bariatric surgery
 Helps in overcoming difficulties faced by laparoscopy
due to thick abdominal wall, hepatomegaly, increased
intra abdominal fat-improves dexterity in limited
working space.
 Roux en Y gastric bypass- initially considered
challenging due to lack of tactile feedback resulting in
increased bowel surgeries. Later studies showed lower
rates of gastrojejunal strictures with robotic approach –
possibility of hand sewn anatomoses (comapred to
stapler,in laparoscopy)
 Less, non compelling evidence for other bariatric
procedures-sleeve resection, banding.
1.Gallo T, Kashani S, Patel DA, Elsahwi K, Silasi DA, Azodi M (2012) Robotic-
assisted laparoscopic hysterectomy: outcomes in obese and morbidly obese
patients. JSLS 16(3):421–427.
2. Markar SR, Karthikesalingam AP, Venkat-Ramen V, Kinross J, Ziprin P (2011)
Robotic vs. laparoscopic Roux-en-Y gastric bypass in morbidly obese patients:

16. ROBOTICS IN HEPATOBILIARY
SURGERY
 Robotic liver resection(wedge
resection,segmentectomy) is safe and feasible for
experienced surgeons with advanced laparoscopic
skills. Long-term oncologic outcomes are unclear, but
short-term perioperative results seem comparable to
those of conventional laparoscopic liver resection
 Requires a team approach that should include a
highly skilled laparoscopic surgeon at the patient’s
side to manage complex instruments and techniques,
such as the harmonic scalpel, clipping, stapling, the
use of LigaSure or CUSA.
Robotic-assisted laparoscopic anatomic hepatectomy in China: initial
experience.Ji WB, Wang HG, Zhao ZM, Duan WD, Lu F, Dong JH. Ann Surg.
2011 Feb; 253(2):342-8.
Robotic versus laparoscopic resection of liver tumours.Berber E, Akyildiz
HY, Aucejo F, Gunasekaran G, Chalikonda S, Fung J HPB (Oxford). 2010

17.  Robot-assisted pancreatic surgery seems to be safe
and feasible in selected patients and, in left-sided
resections, may increase the rate of spleen
preservation.
 Despite longer operating times, decreased pain and
blood loss, fewer complications, faster recovery and a
shorter hospital stay have been reported.
 Morbidity and mortality rates in robot-assisted
pancreatic surgery are comparable with those in
laparoscopic and open surgery.
 The most common complication in the current study
was pancreatic fistula, which occurred at a rate of
19.9(12-36% open and laparoscopic surgery)
1. Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have
clinical advantages?Kang CM, Kim DH, Lee WJ, Chi HS. Surg Endosc. 2011 Jun; 25(6):2004-9.
2. Robotic distal pancreatectomy: cost effective?Waters JA, Canal DF, Wiebke EA, Dumas RP, Beane JD,
Aguilar-Saavedra JR, Ball CG, House MG, Zyromski NJ, Nakeeb A, Pitt HA, Lillemoe KD, Schmidt CM
Surgery. 2010 Oct; 148(4):814-23.
3. Strijker M, van Santvoort HC, Besselink MG, et al. Robot-assisted pancreatic surgery: a systematic review
of the literature. HPB : The Official Journal of the International Hepato Pancreato Biliary Association.
2013;15(1):1-10.

18. Robotics in colorectal surgery
 Generally feasible for colonic surgery. Technical
advantages of robotics could play a role in more complex
manouvres-extended lymphadenectomy, formation of intra
corporeal anastomoses. More substantial clinical evidence
needed.
Currently, found to have longer OR times, higher costs.
 Rectal surgery: compared to open surgery, found to have
greater distal margins and significant lower blood loss.
Conventional laparoscopy has been described as an
effective alternative- but has higher rates of conversion and
circumferential margin positivity. ROLARR trial underway.
1.Buchs NC, Pugin F, Bucher P, Morel P (2011) Totally robotic right colectomy: a preliminary case
series and an overview of the literature. Int J Med Robot.
2. Trastulli S, Desiderio J, Farinacci F, Ricci F, Listorti C, Cirocchi R et al (2013) Robotic right
colectomy for cancer with intracorporeal anastomosis: short-term outcomes from a single
institution. Int J Colorectal Dis 28(6):807–814
3. Park JS, Choi GS, Park SY, Kim HJ, Ryuk JP (2012) Randomized clinical trial of robot-assisted
versus standard laparoscopic right colectomy. Br J Surg 99(9):1219–1226
4. Jung, M., Morel, P., Buehler, L. et al. Langenbecks Arch Surg (2015) 400: 283.

19. minimally invasive surgery) allows better intraluminal views
(360° versus 220°) and wider instrument freedom than
TEM- larger studies still underway, follow up periods for
recurrence awaited.
 Transanal total mesorectal excision (taTME): colon is
mobilized laparoscopically, but the mesorectal excision is
performed from the bottom using a TAMIS platform. The
specimen is then extracted through the anus, and a hand-
sewn coloanal anastomosis is performed.
 Appealing in patients with low tumors and a narrow pelvis,
as it has the potential to improve visibility while dissecting
in the difficult pelvis.
 Studies show wider resection margins, higher rates of
sphincter saving procedures. Larger cohorts needed to
evaluate long-term functional and oncological results.
1. Hompes, R., Rauh, S. M., Ris, F., Tuynman, J. B. and Mortensen, N. J. (2014), Robotic transanal
minimally invasive surgery for local excision of rectal neoplasms. Br J Surg, 101: 578–581.
doi:10.1002/bjs.9454
2.Muratore A, Mellano A, Marsanic P, De Simone M. Transanal total mesorectal excision (taTME) for cancer
located in the lower rectum: short- and mid-term results. Eur J Surg Oncol. 2015;41(4):478–483.
2. Rai V, Mishra N. Transanal Approach to Rectal Polyps and Cancer. Clinics in Colon and Rectal Surgery.
2016;29(1):65-70. doi:10.1055/s-0035-1570395.

20. Robotics in urology
 Robot assisted prostatectomy -shorter operating room
times, lower estimated blood loss, lower complication rates,
earlier urethral catheter removals, and a shorter hospital
length of stay.
 Functional outcomes in terms of continence and potency
were also improved.
 These benefits were attributed to the surgical robot's 3-
dimensional vision, high quality and intuitive controls, and
high degree of freedom in instrument movements.
 Although oncological outcomes and positive surgical
margin (PSM) rates are equivalent between robot-assisted
radical prostatectomy (RARP) and radical retropubic
prostatectomy (RRP), RARP may have a benefit in a long-
term cancer-recurrence free survival rate
1. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and
preliminary analysis of outcomes.Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO,
Vallancien G.J Urol. 2002 Sep; 168(3):945-9.
2. Menon M, Tewari A, Baize B, Guillonneau B, Vallancien G. Prospective comparison of radical retropubic
prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute
experience. Urology. 2002;60:864–868.
3. Ficarra V, Novara G, Rosen RC, Artibani W, Carroll PR, Costello A, et al. Systematic review and meta-

21. Robot-assisted partial nephrectomy (RAPN)
 The "trifecta" (which comprises a WIT<25 minutes,
negative surgical margins and zero perioperative
complications) has been used as a marker for quality of
surgery in patients undergoing partial nephrectomy
 In a single-surgeon series of 500 patients, RAPN achieved
the "trifecta" in almost 30% of the cases, with better
operative outcomes and lower perioperative complications
than compared to Laparoscopic partial nephrectomy.
 Oher studies-RAPN associated with a decreased length of
stay, decreased intraoperative blood loss, and is less
affected by the complexity of the renal tumor
 RAPN also offers a shorter WIT, which improves final
outcomes.
1. Dev HS, Sooriakumaran P, Stolzenburg JU, Anderson CJ. Is robotic technology facilitating the minimally
invasive approach to partial nephrectomy? BJU Int. 2012;109:760–768
2. Aboumarzouk OM, Stein RJ, Eyraud R, Haber GP, Chlosta PL, Somani BK, et al. Robotic versus
laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol. 2012;62:1023–1033
3. Benway BM, Bhayani SB, Rogers CG, Dulabon LM, Patel MN, Lipkin M, et al. Robot assisted partial
nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of
perioperative outcomes. J Urol. 2009;182:866–872.
4. Long JA, Yakoubi R, Lee B, Guillotreau J, Autorino R, Laydner H, et al. Robotic versus laparoscopic
partial nephrectomy for complex tumors: comparison of perioperative outcomes. Eur Urol. 2012;61:1257–

22. Other robotic platforms
 Robotic single site surgery: using multiport da
Vinci instruments docked through a single incision.
Dedicated set of instruments(semi rigid instruments,
curved cannulae) released. Predominantly for
robotic cholecystectomy, rectal surgeries.
 Use of intra operative infra red floroscence
imaging system to visualise blood flow, lymph node
mapping and intra operative cholangiography
1. Hagen ME, Wagner OJ, Inan I, Morel P, Fasel J, Jacobsen G et al (2010) Robotic single-incision transabdominal
and transvaginal surgery: initial experience with intersecting robotic arms. Int J Med Robot 6(3):251–255
2. Spinoglio G, Lenti LM, Maglione V, Lucido FS, Priora F, Bianchi PP et al (2012) Single-site robotic
cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning
curves. First Eur Experience Surg Endosc 26(6):1648–1655.
3. Hellan M, Spinoglio G, Pigazzi A, Lagares-Garcia JA (2014) The influence of fluorescence imaging on the location
of bowel transection during robotic left-sided colorectal surgery. Surg Endosc
4. Buchs NC, Hagen ME, Pugin F, Volonte F, Bucher P, Schiffer E, et al (2012) Intra-operative fluorescent

23. Advances in development of robotic
surgery
 “Verro Touch”- in development by UPenn-
addition of haptic capabilities to da Vinci system
by providing tactile and auditory feedback to a da
Vinci operator based on instrument vibration.
 The DLR MIRO- modular system of robotic arms
by Institute of Robotics Germany. Can be used
alone/in groups to performs a variety of surgical
tasks. Can also be used in conjunction with a
human surgeon- Currently under development.
Kuchenbecker KJ, Gewirtz J, McMahan W, Standish D, Martin P, Bohren J,
Mendoza PJ, Lee DI (2010) VerroTouch: high-frequency acceleration feedback for
telerobotic surgery. In Proceedings, EuroHaptics, pp 189–196