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Fig. 3 The da Vinci surgical system and its components [38]
3 Equitable Access of Medical Technology and
Robotic-Assisted Surgery
While there is a growing list of available technologies that have promising
results in the improvement of diagnostic, aesthetic, and procedural
medicine, they are not yet considered a “standard of care” in healthcare
facilities. Surgical robotics have taken on an accepted role in head and neck
surgery by providing surgeons with the capability to perform endoscopic
otolaryngology procedures [33]. Many hospitals throughout the United
States and developing countries are not able to use this technology despite
these advantages, and this section will discuss the reasons as well as some
solutions for improving equitable access.
When compared with current laparoscopic procedures, the costs of
operating instruments and accessories for robotic-assisted surgery are
significantly higher. These robotic accessories are not meant to be used for
more than ten procedures, which indicates additional fees for instrument
replacement. As of 2018, there was no clinical data available to confirm the
necessity of these replacement specifications. Robotic surgery comes with
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additional fees unique to this application, including increased time in the
operating room, staff training, and necessary system upgrades, and these are
difficult to estimate [35–37].
Notably in the pediatric population, the potential cost of robotic-assisted
surgical devices may not be balanced by profit due to the low-volume
nature of such procedures. Aside from the high cost, these devices are not
ergonomically compatible with pediatric patients, due to the smaller
workspace and mechanical structure of da Vinci’s master-slave robotic
system [39].
Waran et al. explore the potential role of small-scale, focused, minipublic-private partnerships in providing sustainable advanced technology to
organizations with less overall financial support. Private finance initiatives
allowed them to create and maintain the Centre for Image Guidance and
Minimally Invasive Therapy (CIGMIT), despite COVID-related challenges.
Some of the described benefits included retention of senior clinical staff,
operating profits of 1.9 million dollars after 3years of operation, and
creation of a positive entrepreneurial work environment. At the time this
contract was developed, these advancements were primarily mechanical in
nature, and they discuss additional difficulties faced with newer softwaredependent technologies which require frequent costly updates. They
mention the potential for new financial negotiations dependent on
successful implementation, and their methodology should be investigated
further by the curious reader in the cited article [31].
4 Usability of Existing Technology
While the concerns mentioned previously are important in understanding
the potential inability of clinicians to access this new technology, the
relative usability should be another main focus of engineers while designing
the functional and structural aspects of these devices. The ability to perform
detailed procedures with accuracy and predictability using advanced
imaging capability is extremely valuable in procedural medicine, along with
the device’s ability to perform these advanced operations in very narrow
spaces. There are many discussions in the literature, including the robotic
capability of accessing the facial artery while preserving the hypoglossal
nerve in oropharyngeal defect reconstruction and successfully conducting
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head and neck reconstruction with a radial forearm flap perfused by this
hidden artery [26, 27].
Despite these advantages and recent clinical accomplishments, many
surgeons continue to prefer traditional techniques after experiences with
performing technology-assisted medical procedures. Traditional methods
often involve similar levels of detailed small-scale movements when
compared to robotic surgery, especially those performed in the craniofacial
region. Established surgeons are familiar with the hand motions required by
the previously established methods, and it takes a significant amount of
training and technical knowledge to translate these movements accurately
with assistance from robotic technology [28].
This field is developing quite rapidly, and these advancements may be
superseding our ability to learn how to use it. There are training courses in
development for the use of robotic-assisted devices, which will cover the
basics in a stepwise progression. Starting off with a review of observation
using robotic assistance, then building up to foundational operation in a dry
and wet lab setting, helps providers to develop the required skills.
Independent and supervised modular training, in addition to certification
programs, will be integral in maintaining the overall safety and surgical
outcomes [40, 41]. Figures 4 and 5 show a proposed outline for a
credentialing and training program for robotic-assisted ophthalmologic
surgery.
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Fig. 4 Proposed model of credentialing for proficiency in robotic-assisted surgery [42]
Fig. 5 Proposed model for a curriculum aimed toward proficient operation and understanding of
robotic-assisted surgical devices [42]
Advanced display technology is somewhat easier for users to operate, as
it can be applied to the current imaging modalities used throughout
hospitals worldwide. Augmented reality is one such example of this
technology in which digital images are superimposed onto real-time live
images for surgical guidance and diagnostic purposes. Much of the
literature published on AR integration is focused on clinical treatment
improvements, indicating a relatively more established use in practice. This
technology, among others, is discussed in detail throughout the next chapter.
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5 Future Directions in Research and Clinical
Applications
There is evidence in the literature to show that these advancements may be
beneficial for patients receiving medical care, despite the challenges faced
with clinical use. Currently, the major roadblocks impacting the access and
usability of medical technology include high costs, steep learning curves,
and clinician hesitancy, in addition to lack of compatible mechanics and
tactile output.
As of 2020, a review of 183 randomized controlled trials (RCTs) was
conducted to determine the current literature available on the efficacy and
safety of robotic surgery. Of these trials, 35% focused on urological
surgeries, 27% focused on obstetrics and gynecological surgeries, and
nearly 20% assessed colorectal and upper gastrointestinal surgeries (general
surgery). The available data assess efficacy and safety of robotic bladder
cancer, pelvic organ prolapse, and prostate cancer most commonly. At the
time of this review, the researchers did not encounter any RCTs for breast
surgery, plastic surgery, and oral or maxillofacial surgery. We agree with the
authors of this review that there is a need for additional research to be
conducted in this field, especially using variables better suited to
assessment of stepwise clinical care improvements and patient safety [34].
We encourage researchers to examine the cost-effectiveness of robotic
surgery, while appreciating the many benefits of these devices. When these
devices become affordable, operatable, and sustainable, their widespread
use will benefit many patients both intra-operatively and throughout all
clinical aspects of their care. To reach this point, additional clinical data
would be helpful in determining the most efficacious and affordable
materials in the structural engineering of these robots, as well as to
determine the lifetime of surgical accessories. Soon, we are expecting to see
improvements in the form of smaller-scale devices to accommodate smaller
surgical fields, as well as the advancement of intraoperative haptic feedback
technology. The following chapters will present the latest technology in the
medical field, as well as the potential for future advancements.
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57. Tokgöz, E., Levitt, S., Patel, V., Carola, N., & Sosa, D. (2023). Biomechanics of total knee
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58. Tokgöz, E., Carola, N., Levitt, S., Patel, V., & Sosa, D. (2023). Robotics applications in total
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