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90 New Medical Technology in Patient Care: A Physician’s Guide
Autonomous vs Semiautonomous Robots
Autonomous robots in medicine operate independently within a predefined scope; these robots can perform medical tasks without human intervention but within a limited and clearly defined range of operations. This
limitation is essential for safety and efficacy. A notable example is the
CyberKnife,1 a robotic radiosurgery system that autonomously targets and
treats tumors with high-dose radiation, as detailed by Adler et al.2 in their
1997 study published in Stereotactic and Functional Neurosurgery.
In contrast, a semiautonomous surgical robot combines human control
with autonomous capabilities. This means that the robot can assist the
surgeon with specific tasks, but the overall control of the operation
remains with the surgeon. An example of this type of robot is the da Vinci
Surgical System, which requires human oversight. The surgeon controls
the robot’s arms while viewing a high-definition 3D surgical site image.
3
Medical Robots by Application
Medical robots can also be categorized based on their applications. These
applications include surgical robots, rehabilitation robots, telepresence
robots, and telesurgery robots.
Surgical robots, exemplified by systems like the da Vinci Surgical
System, have significantly advanced medical technology, particularly in
performing minimally invasive surgeries. These robots, controlled by surgeons, offer enhanced precision, control, and flexibility, crucial for complex surgeries. Their ability to perform intricate movements in confined
spaces surpasses human capabilities, reducing the risk of surgical errors.
A vital advantage of these robots is their design for minimally invasive procedures, leading to smaller incisions, less pain, and quicker patient
recovery times. This benefit is particularly notable in laparoscopic surgeries. Additionally, they provide magnified, high-definition, 3D views of the
surgical site, offering surgeons a clarity of field and detailed perspective
essential in delicate operations such as neurosurgery or microsurgery.
Ergonomics is another important aspect of these systems. For example,
in the da Vinci system, surgeons operate seated at a console, reducing
physical strain during lengthy procedures. Furthermore, integrating machine
Robots in Medicine 91
learning and advanced data processing in robotic surgery enhances precision and effectiveness, with AI algorithms providing data-driven insights
and augmenting the surgeon’s skills.
Studies, including those published in the Journal of the American
Medical Association, have shown positive patient outcomes with robotic
surgery.
4,5
These include a 52% reduction in readmission rates and a 77%
decrease in the incidence of blood clots such as deep vein thrombosis and
pulmonary embolisms compared to open surgery. These findings highlight
the advantages of robotic surgery in improving patient safety and reducing
complications.
The widespread adoption of surgical robots, such as the da Vinci system, is evident with over 5,500 installations worldwide and usage in over
12 million surgeries. The United States leads in robotic surgeries, particularly in general surgery. However, concerns about cost-effectiveness persist, as robotic surgery can be more expensive than traditional methods.
The initial learning curve for surgical teams is also a consideration,
though outcomes tend to improve with experience and technological
advancements.
Regarding hospital efficiency and patient safety, robot-assisted surgery (RAS) has made a significant impact. RAS contributes to shorter
hospital stays and minimizes tissue damage and bleeding, leading to fewer
complications and faster healing.6 This efficiency reduces healthcare costs
and improves long-term patient outcomes, including reduced pain and
improved quality of life. While initial investments in RAS are high, the
long-term benefits for hospitals and patients are substantial, with ongoing
technological advancements likely to increase its prevalence in the surgical field.
Surgical Robots
A surgical robot is a type of semiautonomous robotic system specifically
designed to assist in performing surgical procedures. These robots are
typically controlled by surgeons and facilitate the precision, control, and
flexibility required during complex surgeries.
Since their introduction in 2000,7 surgical robots have represented
a significant advancement in medical technology, enhancing surgeons’
92 New Medical Technology in Patient Care: A Physician’s Guide
capabilities in various ways. Robotic surgery is increasingly prevalent
globally. Currently, over 50,000 surgeons are certified in this technique,
and upward of 6,730 surgical robots are in use across 69 different
countries.
8,9
Robotic-assisted surgery (RAS) has been adopted across a wide range
of surgical subspecialties,10 receiving approval for use in urology, gynecology, cardiothoracic surgery, general surgery, and otolaryngology. In
2023, robotic surgery will account for more than 15% of all general surgical procedures.4 The most common procedure performed with a robotic
system is the laparoscopic cholecystectomy.
4
These robots are known for their enhanced precision and control. The
robotic arms can surpass the limitations of human hands because they can
rotate and maneuver in ways that human hands cannot. The advantages of
manipulation involve articulated instruments, offering seven degrees of
freedom in movement, counteracting the fulcrum effect, filtering out tremors, and enabling the scaling of movements.
11,12
The delicate movements of robotic arms, which minimize tissue damage and bleeding, lead to fewer complications and faster healing.
13,14
This
is particularly evident in procedures requiring intricate movements in
confined spaces. They can perform repetitive and precise tasks without
fatigue. These capabilities can help to reduce the risk of surgical errors.
This reduces the need for blood transfusions and additional surgeries,
ultimately improving patient safety and lowering healthcare costs.
15
Furthermore, surgical robots often provide well-lit, magnified, highdefinition, and 3D views of the surgical site. This advanced visualization
surpasses traditional methods, offering surgeons a more precise and
detailed view of the pivotal operating area in delicate surgeries such as
neurosurgery or microsurgery.
Ergonomics is also a significant consideration in the design of surgical robots. These systems can reduce surgeon fatigue by offering more
comfortable and ergonomic ways to perform surgeries, which is especially
beneficial during lengthy procedures. Indeed, surgeons reported substantially less physical discomfort when using the robotic platform than traditional laparoscopic and open surgery.16 The ergonomic design of these
robotic surgical systems is evident in the da Vinci system, where surgeons
Robots in Medicine 93
can operate from a seated position at a console, with their head up looking
at a display rather than with their necks flexed, reducing physical strain.
In addition, survey data were evaluated, indicating that, regardless of
surgeons’ experience, tasks completed on the robotic platform involved
less cognitive workload than the same tasks completed with laparoscopy.17
Less physical and mental fatigue should allow surgeons to perform at a
higher skill level for longer durations of time, and it may even extend their
careers.
Lastly, integrating machine learning and advanced data processing is
a frontier in robotic surgery. Advanced systems can integrate with preoperative imaging data and utilize machine learning algorithms to assist in
planning and executing surgical procedures, enhancing the overall precision and effectiveness of surgeries.
Studies of robotic surgical procedures have generally shown positive
patient outcomes
5,18
and high levels of patient satisfaction, especially in
terms of reduced pain, shorter hospital stays,19 and quicker return to normal activities.20 The advantages of robotic-assisted surgery are well documented in both general surgery and surgical oncology. Compared to
traditional laparoscopic techniques, patients in these fields enjoy benefits
that traditional laparoscopic techniques often struggle to match. Patients
reap the rewards of a gentler touch, thanks to robotic procedures’ minimally invasive nature. This translates to less tissue manipulation and,
consequently, reduced postoperative pain.21 The benefits go beyond
immediate comfort, however. Surgeons adept in robotic techniques can
tackle complex procedures laparoscopically, significantly lowering the
open conversion rate and the extended recovery time.22 This means shorter
hospital stays and a quicker return to the familiar rhythms of life for
patients.
For instance, a study published in the Journal of the American
Medical Association found that robotic-assisted surgeries could reduce
patient hospital stays by 21% compared to traditional methods.23 This
comparison underscores the significant advantages of robotic surgery over
conventional open surgical procedures.
Robotic surgery can result in fewer complications.24 For example,
a recent study featured in the Journal of the American Medical Association25
94 New Medical Technology in Patient Care: A Physician’s Guide
reports a notable decrease in readmission rates, by 52%, for patients
undergoing robotic surgery compared to those who had open surgery.
Additionally, the study highlights a remarkable reduction, by 77%, in the
incidence of blood clots, including deep vein thrombosis and pulmonary
embolisms. These conditions are known for their profound impact on
health and morbidity. Also, the journal Surgery recently reported on a
national study of abdominal surgeries comparing outcomes in RAS to
those in laparoscopic surgery. It showed a 2.2% reduction in complications in the RAS surgery.
26
All told, robotic-assisted surgery promises a smoother, faster road to
recovery, a welcome advantage in the often-daunting landscape of general
and oncological surgery.
Surgical robots like the da Vinci Surgical System stand at the forefront
of this technological revolution. These systems have been widely adopted
for various procedures, including urologic, gynecologic, and cardiac surgery. Intuitive Surgical, the manufacturer of the da Vinci systems, reported
that over 5,500 da Vinci Surgical Systems were installed worldwide.27 The
da Vinci system has been used in over 12 million surgeries globally,28
indicating its effectiveness and global adoption. The United States now
performs more robotic surgeries than anywhere else, with the majority
being in general surgery.
29
Surgical Robots and AI
Integrating AI and machine learning with medical robotics opens new
frontiers in personalized and precision medicine. AI algorithms are
enhancing the capabilities of surgical robots by providing data-driven
insights and augmenting the surgeon’s skills.
AI systems can rapidly process extensive datasets, a capability that far
exceeds human limitations. This feature enables surgical robots to assimilate knowledge from thousands of recorded surgeries, offering a comprehensive learning tool for surgeons at various stages of their careers. This
process is reminiscent of how Google’s DeepMind AI, AlphaGo, mastered
the game of Go by analyzing millions of expert moves.
In identifying new trends, AI excels in sifting through global surgical
data to uncover emerging patterns and techniques. This could lead to the
30
Robots in Medicine 95
standardization of surgical practices globally, much like AlphaGo’s development of unprecedented strategies in Go.
AI also plays a crucial role in alleviating surgeons’ cognitive and
physical stress. By aiding in surgical planning, tool selection, real-time
guidance, and operation monitoring, AI streamlines surgical procedures,
enhancing efficiency and reducing surgeons’ strain. This application of AI
is akin to the Flyways31 system used by Alaska Airlines, which optimizes
flight paths, increases safety, and eases the cognitive load on pilots and air
traffic controllers, showcasing AI’s ability to boost efficiency and minimize stress.
Furthermore, AI is poised to transform surgical care, particularly in
making advanced surgical techniques more accessible worldwide,32 even
in underserved areas. By offering preoperative planning, image analysis,
and educational33 and practical support to surgeons, regardless of the location, AI-enhanced robotic surgery can broaden the scope of surgeons’
procedures, thereby improving global access to high-quality surgical care.
For example, surgical stapling is a technique used in organ removal,
tissue cutting, sealing, and creating connections between structures.
Achieving an effective staple line crucially depends on compressing the
right amount of tissue between the staple jaws before activation. This
skill, blending art with science, is traditionally acquired by surgeons
through extensive hands-on practice across various cases and types of
procedures.
The engineers at Intuitive have created a stapler that can measure tissue thickness in real time. The company’s SureForm34 staplers are
enhanced with intelligent technology and designed to deliver more uniform and ideally formed staple lines. These staplers perform over a thousand measurements every second, making real-time adjustments during
the stapling process. This technology not only ensures a consistent staple
line but also minimizes tissue damage, accommodating a variety of tissue
thicknesses.
Ongoing studies are focused on creating fully independent surgical
systems capable of handling intricate tasks with deformable soft tissues,
such as stitching and connecting intestinal tissues, in open surgery environments. Initial findings suggest that these supervised autonomous
operations may surpass the effectiveness and consistency of surgeries
96 New Medical Technology in Patient Care: A Physician’s Guide
conducted by seasoned surgeons and those assisted by robots.35 The progress in autonomous robotic surgery indicates a promising future for
enhancing surgical results and broadening access to refined surgical
methods.
Challenges and Concerns
While the advantages of healthcare robotics are evident, the practical
application of these technologies often needs to be improved. These gaps
can lead to unique forms of harm that may not be easily correctable or
monitored by human intervention.36 For example, safety concerns, including the risk of injury or death, can occur if surgical robots unexpectedly
shut down during a procedure or perform unintended actions.
While robotic surgical platforms can enhance a surgeon’s operating
ability with advantages such as superior wrist articulation and magnified
visualization, their lack of tactile feedback presents a significant hurdle.
A study analyzing the learning curve for robotic procedures revealed that
surgeons struggled to overcome the absence of the natural touch39 (haptic
feedback) they rely on, relying solely on visual cues. As a result, mastering robotic techniques can be challenging.
There are growing concerns regarding the cost-effectiveness of robotic
surgery.
Implementing robotic surgery is associated with significant up-front
costs in several critical areas, including acquisition cost, training, and
maintenance.
40,41
The robotic platform itself is a considerable expense,
easily costing between $1 and 2 million depending on the specific system
and manufacturer; additional equipment can add another $500,000.
Implementing robotic surgery requires significant training and adaptation
for surgical teams that can exceed $100,000. The learning curve can
impact the initial outcomes but tends to improve with experience and
technological advancements.42 These sophisticated machines require regular servicing and potential upgrades for peak performance. Maintenance
and service contracts can cost $100,000–$200,000.
Quantifying the exact cost of implementing a surgical robot is diffi-
cult, as factors such as the surgical procedures offered, the volume of
37,38
Robots in Medicine 97
surgeries performed, and the chosen platform play a role. Studies have
indicated that robotic surgery can be more expensive, with some findings
suggesting that it may incur up to 25% higher costs compared to traditional laparoscopic surgery.
43,44
A 2010 study across various surgical specialties offers some insight.
They found that incorporating the robotic platform increased perpatient costs by an average of $1,600 compared to laparoscopy. The
costs can exceed $3,200 if the initial acquisition cost is factored in. The
cost differential can decrease with an increasing volume of robotically
performed surgeries.
45,46
A more recent risk-adjusted trend analysis
revealed that the cost discrepancy between laparoscopic and roboticassisted surgery persisted and widened from $1,600 in 2010 to $2,600
in 2019.29 Indeed, this study of surgical costs showed that regardless of
the procedure type, all robotic-assisted operations had higher costs than
laparoscopic operations, with average hospitalization costs for the laparoscopic cases equaling $16,000 compared with $18,300 for the
robotic-assisted cases.
Additionally, the effectiveness of robotic surgery in comparison to
other established surgical methods, such as conventional laparoscopic and
open surgeries, has been questioned.
47,48
This is particularly relevant in
procedures where the advantages of robotic surgery are not established or
theoretically justified, such as inguinal hernia repairs. The rapid expansion of robotic surgery in areas lacking robust evidence to support its use
or where there is minimal theoretical or clinical advantage has also raised
concerns, with calls for more clinical scrutiny and regulation.
49
Internet of Things and Medical Robotics
The Internet of Things (IoT) is significantly influencing the evolution of
medical robotics, particularly in surgical applications. IoT, fundamentally,
refers to a network linking uniquely identifiable physical devices that
facilitate data collection, transmission, storage, and retrieval over the
internet.
with asthma and chronic obstructive pulmonary disease (COPD).52 Smart
inhalers are equipped with sensors that track the usage of the medication.
50,51
For example, intelligent inhaler devices are helping patients
98 New Medical Technology in Patient Care: A Physician’s Guide
They can record the time and place of each dose and sync this data with a
smartphone app. This technology helps ensure patient adherence to medicines, monitor the frequency of use, and identify environmental triggers
for asthma attacks.
IoT plays a pivotal role in enhancing data integration and analysis. By
allowing medical robots to access comprehensive patient data, IoT can
enable, for example, a more informed and precise surgical procedure.53
This integration is not just about data volume but also about the quality
and relevance of data, which is crucial for tailoring robotic-assisted surgeries to individual patient needs.
Remote operation and telemedicine represent another significant
application of IoT in surgical robotics.54 This aspect of IoT is particularly
transformative, making high-quality care accessible in remote or underserved areas. However, it also brings to the fore the need for robust network infrastructures, especially in regions where connectivity is unreliable.
The dependence on stable internet connections for remote surgeries poses
a limitation that needs addressing for this technology to reach its full
potential.
IoT-facilitated predictive maintenance of medical robots ensures
operational efficiency and reduces equipment downtime. This aspect is
crucial for healthcare settings where equipment availability directly
impacts patient care. IoT-enabled predictive maintenance can preemptively identify potential issues, allowing for timely interventions before
critical failures occur.
In training and simulation, IoT-connected robots provide realtime data and feedback, significantly enhancing the skills of medical
professionals. This application is about improving technical skills and
understanding patient-specific scenarios, which can be simulated more
accurately with IoT data integration. Customized prosthetics and implants,
created based on specific patient data gathered through IoT-connected
devices, exemplify the personalized approach enabled by this technology.
The integration of IoT in pharmacy automation systems is a practical
example of its broader applications. Real-time inventory tracking and
enhanced medication management facilitated by IoT improve efficiency
and patient safety by reducing errors in medication dispensing.
Robots in Medicine 99
Despite these advancements, the field faces several challenges. The
significant concerns center around the system’s reliability and robustness
and the data transmission’s security.55 Also, the complexity of healthcare
data security and privacy concerns must be addressed. Ensuring the integrity and confidentiality of patient data in an IoT-enabled environment is a
critical issue that requires ongoing attention and innovative solutions.
56
Integrating IoT with surgical robotics requires a careful balance
between innovation and patient safety. Ethical considerations are paramount for patient autonomy and consent in an increasingly automated
healthcare environment. Additionally, the economic implications of adopting
such advanced technologies must be considered, especially regarding
accessibility and equity in healthcare.
Rehabilitation Robots
Rehabilitation robots are specialized technology designed to aid
individuals recovering from physical injuries, surgeries, or neurological
disorders.
Robot-assisted rehabilitation has been widely shown to enhance functional recovery, such as gait and upper limb function, for patients suffering
from conditions such as traumatic brain injury (TBI), spinal cord injuries
(SCIs), stroke, cerebral palsy, Parkinson’s disease, and multiple
sclerosis.
assist, enhance, and document rehabilitation.
types of robots: therapeutic robots and assistive robots. Each type plays a
distinct role in the rehabilitation process.
57,58
These robots are increasingly used in therapeutic settings to
The term rehabilitation robotics primarily encompasses two main
Therapeutic Robots
These robots are used in the active rehabilitation process. They are
designed to facilitate motor recovery and are often used in the rehabilitation of patients who have suffered from strokes, SCIs, or other conditions
that affect motor function. Therapeutic robots provide repetitive, controlled, and intensive training, which is essential for neuroplasticity and