INTRODUCTION

WHAT IS SURGERY?
Surgery (composed of , "hand", and , "work"),
via Latin: chirurgiae, meaning "hand work") is an ancient medical
specialty that uses operative manual and instrumental techniques on
a patient to investigate and/or treat a pathological condition such
as disease or injury, to help improve bodily function or appearance or to
repair unwanted ruptured areas (for example, a perforated ear drum).
Or could be expressed as
Surgery is a technology consisting of a physical intervention on tissues.
As a general rule, a procedure is considered surgical when it involves
cutting of a patient's tissues or closure of a previously sustained wound.
Other procedures that do not necessarily fall under this rubric, such
as angioplasty or endoscopy, may be considered surgery if they involve
"common" surgical procedure or settings, such as use of a sterile
environment, anesthesia, antiseptic conditions, typical surgical
instruments, and suturing or stapling. All forms of surgery are considered
invasive procedures; so-called "noninvasive surgery" usually refers to an
excision that does not penetrate the structure being excised (e.g. laser
ablation of the cornea) or to a radiosurgical procedure (e.g. irradiation of
a tumor).

WHY SURGERY IS NEEDED?

Surgery, whether elective or emergency, is done for many reasons. A
patient may have surgery to:

Further explore the condition for the purpose of diagnosis

Take a biopsy of a suspicious lump

Remove or repair diseased tissues or organs

Remove an obstruction

Reposition structures to their normal position

Redirect blood vessels (bypass surgery)

Transplant tissue or whole organs

Implant mechanical or electronic devices

Improve physical appearance

HOW SURGERY EVOLVED IN INDIA?

Remains from the early Harappan periods of the Indus Valley
Civilization (c. 3300 BCE) show evidence of teeth having been drilled
dating back 9,000 years.] Susruta was an
ancient Indian surgeon commonly credited as the author of the
treatise Sushruta Samhita. He is dubbed as the "founding father of
surgery" and his period is usually placed between the period of 1200 BC
600 BC. One of the earliest known mention of the name is from
the Bower Manuscript where Sushruta is listed as one of the ten sages
residing in the Himalayas. Texts also suggest that he learned surgery
at Kasi from Lord Dhanvantari, the god of medicine in Hindu
mythology. It is one of the oldest known surgical texts and it describes in
detail the examination, diagnosis, treatment, and prognosis of numerous
ailments, as well as procedures on performing various forms of cosmetic
surgery, plastic surgery and rhinoplasty.
DISADVANTAGES OF TRANDITIONAL METHODS OF SURGERY ?
1.
2.
3.
4.

This kind of surgery require a lot of time.

This kind of surgery is done with lesser efficieny .
This of kind of surgery is done with lesser precision.
This kind of surgery is expected to have a severe post-operative
pain.
5. This kind of surgery is expected to have some side effects like
cancer.

ALL THESE DIADVANTAGES LED TO EVELOPMENT OF ROBOTS

AND THEIR USES IN TERMS OF SURGERY.

WHAT IS ROBOT ASSISSTIVE SURERY?

Robotic surgery, computer-assisted surgery, and robotically-assisted
surgery are terms for technological developments that use robotic
systems to aid in surgical procedures. Robotically-assisted surgery was
developed to overcome the limitations of pre-existing or traditional
surgical methods and to enhance the capabilities of surgeons performing
open surgery.
In the case of robotically-assisted minimally-invasive surgery, instead of
directly moving the instruments, the surgeon uses one of two methods to
control the instruments; either a direct telemanipulator or through
computer control. A telemanipulator is a remote manipulator that allows
the surgeon to perform the normal movements associated with the
surgery whilst the robotic arms carry out those movements using endeffectors and manipulators to perform the actual surgery on the patient.
In computer-controlled systems the surgeon uses a computer to control
the robotic arms and its end-effectors, though these systems can also
still use telemanipulators for their input. One advantage of using the
computerised method is that the surgeon does not have to be present,
but can be anywhere in the world, leading to the possibility for remote
surgery.
In the case of enhanced open surgery, autonomous instruments (in
familiar configurations) replace traditional steel tools, performing certain
actions (such as rib spreading) with much smoother, feedback-controlled
motions than could be achieved by a human hand. The main object of
such smart instruments is to reduce or eliminate the tissue trauma
traditionally associated with open surgery without requiring more than a
few minutes' training on the part of surgeons. This approach seeks to
improve open surgeries, particularly cardio-thoracic, that have so far not
benefited from minimally-invasive techniques.
EVOLUTION OF ROBOTS

The genesis of robots goes back to the 1980s when a group of

researchers at the NASA collaborated with engineers of the Stanford
Research Institute. The first effort of this combined venture was the
development of a Telepresence surgical system to improve dexterity in
microscopic hand surgery.
The US Department of Defense soon got interested in this technology.
The Military wanted a remote-operated surgical system wherein the
wounded in the battle could be operated upon by surgeons away from
the frontline. This was called as the SRI Telepresence Surgery System.
The SRI system was intended to be a battlefield surgical system for
combat casualty care in which a mobile robotic system remote-controlled
by a surgeon could do temporizing, lifesaving vascular surgeries.
Although this concept could not be further developed in the military, it led
to the eventual development and marketing of the da Vinci Surgical
System.
A prototype robot was developed by Nanyang Technological University
of Singapore in the 90s called Urobot meant for limited uses in laser
prostatectomies.Johns Hopkins University developed PAKY, a robotically
controlled device for percutaneous access to the kidney.However
ROBODOC hip replacement milling device was the first robotic surgical
device to be marketed in 1992. The first robotic resection of tissue in
humans was done in March 1991 by PROBOT in London when it was
used for TURP.
The da Vinci Surgical System was released in April 1997 and received
FDA approval in 2000 for laparoscopic surgeries.
Today the da Vinci surgical system is being used in urology,
cardiothoracic surgery orthopedics and general surgery. It has also been
used in gynecology for tubal ligation reversal.
With this background, let us discuss the role of robotic assisted surgeries
in surgical practice.
ADVANTAGES OF ROBOT ASSISSTIVE SURGERY?

Let us discuss in detail about the purported advantages of robots and

see whether the arguments made by the manufacturers and proponents
of robotic surgery are valid.
1) The most common argument in favor of robots is that they make the
surgery minimally invasive. But minimally invasive surgery is not an
inherent property of robotics. Minimally invasive surgery can be done
and is being done all over the world by surgeons without recourse to
expensive robots. The truth is robotics is only one of the ways of doing
minimally invasive surgery.
2) Robotics makes surgeries extremely precise by eliminating hand
tremors and movement scaling resulting is fewer errors.

True. Robots eliminate tremors and help in movement scaling. However,

these impressive facts hide a truth. Modern surgeries fail not because of
tremors or awkward surgeons hand movements but because surgical
treatment has its own limitations. The results of surgery depend on
patient factors, tissue factors, infection and the incorrect application of
surgery to an individual patient.
Modern optics, suture materials and instruments have resulted in
unparalleled technical finesse in surgeries. CABG failure due to
surgeon's tremors or awkward hand movements is very rare. It is more
likely to fail because the original disease of the patient is left untreated. A
renal transplant rarely fails if the vascular anastomosis is done well. It
commonly fails because of the human immune system. Even a perfectly
computer matched and milled hip replacement fails because of
mechanical wear and tear of the device after a few years.
Is extreme precision needed in a majority of the surgeries? Let us take
the example of radical prostatectomy. Preserving neurovascular bundle
needs precise dissection. Laparoscopic surgery achieves a
neurovascular bundle saving rate of close to 90%. The most impressive
results in radical prostatectomy in terms of potency and sphincter
preservation are from Detroit. However, these superb results of VIP
Technique are mainly due to a major change in technique by preserving
the Veil of Aphrodite rather than due to robotic surgery per se.

3) Robots reduce the learning curve for laparoscopic surgery.

This claim is very appealing to all surgeons who are beginning their
surgery careers with minimum or no laparoscopic surgery training. The
majority of surgeons who are doing robotic surgery today are
laparoscopy-trained and hence it has not been proved whether it is true
or not. However, according to Mani Menon et al., it is unclear whether
Robotic Radical Prostatectomy reduces the learning curve for
laparoscopic surgery.
4) Robotic surgeries are ergonomically superior and cause less fatigue
for surgeons in prolonged surgeries.
Yes. It is true. However, the majority of surgeons are used to operating
with minimal fatigue for three to four hours. Fatigue is a factor only in
surgeries longer than this. There are very few urological laparoscopic
surgeries which get prolonged to such extended time. Moreover, is any
urologist prepared to spend 1.4 million dollars for a comfort which can be
experienced in less than 10% of his surgeries?

THE ECONOMIC ASPECTS OF ROBOT ASSISSTIVE SURGERYIt may initially seem that robotic surgery would be more expensive than
open surgery as it requires a large initial investment in the order of US$1
million to US$2 million and ongoing annual maintenance costs of
approximately of US$250,000, costs that are not present in open
surgery. Additionally, robotic surgery requires disposable or limited use
instruments (e.g., shears, needle drivers, graspers, forceps) with an
average cost of approximately US$2,000 per instrument, which are
replaced every 10 surgeries versus the mostly reusable instruments in
open surgery. However, reports have shown that the overall hospital
costs were significantly lower for robotics compared with traditional
surgery, and that, in some cases, the hospital could break even on their
robotic investment after as few as 90 surgeries.
Not only is Robotic Surgery already cost-effective for insurance
companies and hospitals and a better option for the patients recovery,
but as robotic technology expands and improves, as is the case with
most other technologies, costs will further decrease it is only a matter
of time before that is passed on to consumers.

SOCIAL IMPACTS OF ROBOT ASSISSTIVE SURGERYSocial shaping of technology (SST) demonstrates the interchangeable
influence of society on technology and vice versa in social informatics.
SSTs view technology as a product of human use and creation rather
than technology being autonomous and casual agents, which are
steered by features-focused and internal technical logic (MacKenzie &
Wajcman in Kling & McKim, 2000). Technology is developed and it is
used, shaped, changed and reconstituted within the society. Society
influences the technology to become what it is. Robotic surgery exists
because of a societal need. It has stemmed from an inherent physical
need for surgery and has evolved to become what it has by means of
improving previous processes. Robotic surgery strengthens and
enhances the surgical procedure, by filling in the gap that surgeons own
physical limitations present. Robots provide good geometric accuracy,
stability and untiring stamina, can be sterilised, resistant to infection and
radiation and can also use diverse sensors such as chemical, acoustic
and force in control (Au et al., 2005). These are driven by the influence
of society.
In turn, surgeons are trained to use these technologies, demonstrating
the opposite influence, that of technology on society. Robotic surgery
also has the positive influence on society with its positive surgical
outcomes as a results of using robotic technology in procedures.

Limitations of Robotic Surgery

Although rapidly developing, robotic surgical technology has not
achieved its full potential owing to a few limitations. Cost-effectiveness is
a major issue; 2 recent studies comparing robotic procedures with
conventional operations showed that although the absolute cost for
robotic operations was higher, the major part of the increased cost was
attributed to the initial cost of purchasing the robot (estimated at
$1,200,000) and yearly maintenance ($100,000). Both factors are
expected to decrease as robotic systems gain more widespread
acceptance. However, it is conceivable that further technical advances
may at first drive prices even higher. Decreasing operative time and
hospital stay will also contribute to the cost-effectiveness of robotic
surgery.

Other drawbacks to robotic surgery include the bulkiness of the robotic

equipment currently in use. Lack of tactile and force feedback to the
surgeon is another major problem, for which haptics (ie, systems that
recreate the "feel" of tissues through force feedback) offers a promising,
although as yet unrealized, solution.

Conclusion
Although still in its infancy, robotic surgery is a cutting-edge development
in surgery that will have far-reaching implications. While improving
precision and dexterity, this emerging technology allows surgeons to
perform operations that were traditionally not amenable to minimal
access techniques. As a result, the benefits of minimal access surgery
may be applicable to a wider range of procedures. Safety has been well
established, and many series of cases have reported favorable
outcomes. However, randomized, controlled trials comparing roboticassisted procedures with laparoscopic or open techniques are generally
lacking.
Telerobotic surgery stands out as a way of delivering surgical care to
patients who have no direct access to a surgeon; however, costs are
prohibitive to the spread of such technology to underserved areas that
need it most. Even in the United States, surgical robots are mainly
available in large academic centers. The issues of cost, technical
drawbacks, and clinical effectiveness need to be resolved before robotic
procedures can become mainstream, everyday surgical procedures.
New technologies, such as virtual reality, haptics, and telementoring, can
powerfully ally with surgical robots to create a new medium for
acquisition and assessment of surgical skills through simulation of all
operations that can be done via the robot. Performance of robotic
procedures requires specialized training. However, the majority of
residency programs in the United States do not provide formal training in
robotic surgery skills. Students, residents, and residency programs
should strive to keep up with this new development in surgical
technology that is likely to reshape the way we practice surgery.