FRONTIERS OF ROBOTIC SURGERY
More precision. Smaller incisions. Faster post-op recovery. Robots have been helping surgeons and patients with better outcomes for years now, so what’s next?
Written by Poornima Apte
WHEN MOBILE, ALA.-BASED SURGEON Daniel McMahon performs a hernia repair, he does not stand by or sit at the operating table. Instead, he positions himself at a console in the operating room, slides a couple of fingers into a controller—think joystick operation in a video game—and peers through a set of binocular glasses into the patient’s operating field. As McMahon moves his hands, a set of robotic arms translates his motions into surgical actions on the patient.
The entire apparatus is part of the da Vinci Xi robotic system from Intuitive Surgical, known for its adeptness at soft-tissue minimally invasive surgeries. While it took some getting used to, McMahon now routinely performs hernia surgeries with the machine.
Robotic systems like the da Vinci Xi are not new. The original da Vinci, which won FDA approval in 2000, spun out of a program for the Defense Advanced Research Projects Agency (DARPA).
And while the da Vinci series is the most recognizable player in the field of robotic surgery—as of May 2023, more than 12 million robotic surgery procedures had used the da Vinci system—it is by no means the only one. The Maestro from Moon Surgical is one of the many newer entrants in the field, promising smaller and more adaptable systems. And beyond soft tissue surgery, robotics are changing medicine in other ways, from how dental implants are placed to how cancerous tumors are destroyed, and even how physicians look inside the human gut.
A Maestro ASM010 with the front raised and equipped with tools. Image: Moon Surgical
“Usually when you’re performing a surgery, an assistant is holding the camera with their hands, you have to continually give them verbal input to zoom in and out, or to the right. With a robot, you control all that on your own. Having that autonomy, the control of the camera and the stability, those capabilities really enhance the surgical experience.”
—Daniel McMahon, assistant professor of surgery, University of South Alabama
WHY ROBOTS IN SURGERY
To understand the growth of robots in the field, it helps to trace the evolution of surgeries. Most surgeries before the 1990s would involve making an incision, usually in the abdominal area, large enough to accommodate the surgeon’s hands and enable a full view of the body cavity to execute complex maneuvers. Over the years, less invasive laparoscopic surgeries have become more popular. Healthcare professionals perform around 15 million laparoscopic procedures worldwide annually according to research firm MarketsandMarkets. Laparoscopy needs smaller incisions, which leads to better post-surgery outcomes.
While laparoscopic surgeries have many advantages for patients, they’re challenging for surgeons, said Steve Bell, an industry expert in surgical robotics. A standard “straight-stick” laparoscopic procedure involves threading a stick with a camera at its end through a small incision for views into the body cavity. The surgeon uses this camera image, projected onto a larger TV, to guide necessary surgical tools. In most traditional laparoscopic procedures, the surgeon performs the procedure while an assistant holds the camera. You can only see in 2D and lose wrist movement. The procedure is not intuitive either: If you want the tip of the instrument to go down, you move your hand up.
A robotic system eliminates many of the disadvantages of laparoscopic surgeries while preserving the advantages. It restores 3D vision, you don’t rely on someone else to hold a camera, and you get wristed instruments.
“Usually when you’re performing a surgery, an assistant is holding the camera with their hands, you have to continually give them verbal input to zoom in and out, or to the right,” McMahon explained. “With a robot, you control all that on your own. Having that autonomy, the control of the camera and the stability, those capabilities really enhance the surgical experience.” Tremor filtration, or correcting for hand tremors, is another perk
NASA astronaut and Expedition 70 Flight Engineer Loral O’Hara holds spaceMIRA on board the International Space Station. In February 2024, the robot was used to perform simulated operations on the ISS while being controlled by surgeons in Lincoln, Neb. Photo: NASA
INCREASINGLY COMPACT
Over the years, the da Vinci itself has evolved to include more arms and instruments. The side-loading version has given way to a top-loading form so that it comes over the bed, Bell pointed out. “It now means that the arms can swivel and turn en masse and you can do multi-quadrant surgery,” he said.
For some, the bulk of the da Vinci system can’t be ignored—the da Vinci XI weighs approximately 1,800 pounds—even if it grants impressive stability, Bell said.
“When you’ve got such a large and heavy device, you’d need a very special service elevator or crane to move it between hospital floors,” he continued. “That’s why there are a lot of newer systems coming that are smaller, lighter, and modular.”
One of those newer systems is the Maestro from Moon Surgical, which David Noonan, chief technology officer at Moon, labels as the first digital surgical assistant for minimally invasive surgery. The system aims to serve the market niche between manual laparoscopy and da Vinci laparoscopy, he said.
This collaborative system works right alongside the surgeon, functioning as an additional set of arms, instead of having the surgeon sit a distance away from the action. The Maestro offloads responsibilities from the surgeon’s assistant, who usually holds the laparoscopy camera or a retraction device, allowing them to focus on more patient-centric tasks. Instead, the surgeon works with the Maestro, moving its arms to the right place. The system detects when motion pauses and locks and holds everything in place.
“The arms of our system were originally architected as haptic input devices, sort of fancy joysticks that you can manipulate to measure the movement of a surgeon’s hand and also render forces back,” Noonan said. “The design allows us to have a collaborative approach for how the surgeon uses the system as opposed to a tele-manipulative approach, which is what systems like da Vinci use. We do not have a surgeon console and a patient-side console, we have only one console, which is the Maestro, and the surgeon interacts with it directly.”
Another company advancing the compact systems trend is Virtual Incision. Its MIRA Surgical System, the world's first miniaturized robotic-assisted surgery (RAS) device, became commercially available for use in adults undergoing colorectal procedures in the U.S. in 2024. MIRA is a small minibot under two pounds that confers the advantages of RAS without having to organize the entire operating room around the technology. The size makes it more portable, which could improve RAS accessibility for hospitals and patients.
Toumai's Laparoscopic Surgical Robot. Image: MicroPort
TELESURGERY AND DEMOCRATIZING ACCESS
Improving access could also mean using robotics for remote telesurgery, a field that is registering systematic advances.
In 2022, the Toumai Laparoscopic Surgical Robot from MicroPort successfully completed two ultra-long-range 5G robotic surgeries in urology through a 5G connection between Xinjiang Kezhou People’s Hospital in northwest China and Jiangsu Provincial People’s Hospital, located approximately 3,100 miles away on the east coast.
Moving the possibilities of remote robotic surgery even further, in January 2024, a specially designed space-focused iteration of MIRA, spaceMIRA, became the first surgical robot to launch to the International Space Station (ISS). While in orbit, six surgeons in Lincoln, Neb., successfully directed the movements of spaceMIRA to complete simulated surgical tasks like grasping and cutting simulated tissue (rubber bands). This marked the first time in history that robotic surgery had been simulated in space.
Bell is excited about the potential use of robotic systems from a distance for treating strokes. Even if a fair number of health centers can manage strokes, only a limited number of professionals can conduct thrombectomies—a surgical procedure to remove a stroke-inducing blood clot from an artery or vein. This is a problem because every hour spent after a stroke without intervention causes a set amount of brain loss (estimated at 2 million neurons a minute).
Meanwhile, startup XCath’s system is on the frontier of surgical robotics, building a telerobotic solution for stroke, said Eduardo Fonseca, the company’s CEO. In August 2024, the startup demonstrated the world’s first public model thrombectomy procedure using telerobotics. From a surgeon console in Abu Dhabi, a neurosurgeon successfully performed a robot-assisted thrombectomy on a simulated patient in South Korea. XCath is building pre-clinical evidence and planning to engage with regulators, Fonseca said.
“We are incredibly interested in what can be done with robots that have tiny little legs, robots that have moving tails, with snippers at the front and cauterizing elements at the back, that could crawl through layers of tissue or blood vessels and conduct even brain surgery.”
—Torrey Smith, CEO, Endiatx
HistoSonics's Edison System offers a non-invasive method to mechanically destroy tumors via histotripsy. Image: HistoSonics
BEYOND THE BASICS
Robots are “doing practically every type of surgery that you can imagine,” Bell said, from thoracic to cardiovascular, hepatic, gastrointestinal, bariatric, gynecologic, and urologic. Endovascular robots will place stents or shunts in the brain for stroke patients. Cardiac robots work in the vasculature system to get to the heart and install new valves.
Yomi, a robotic surgery system from Neocis, helps dentists to plan dental implant procedures in software relative to a preoperative CT scan, which is commonplace in dental implant surgery.
“That digital plan is immediately transmitted to the robotic system. The robotic system provides visual, audio, and physical guidance to the dentist to ensure that the dentist stays exactly on plan,” explained Alon Mozes, CEO of Neocis.
The robotic arm holds the drill, but the system is not autonomous. It works using haptics, relying on the dentist to move the drill hand-in-hand with the robot arm, while the robot arm constrains the dentist's motion.
“The patient is tracked in real-time so the system can adjust to any patient movement and the visual on-screen feedback can give the dentist confirmation that the procedure is proceeding according to the plan,” Mozes said.
Robot mechanics are also in play in PillBot from Endiatx, a healthcare robotics company. The PillBot is a drone pill that a patient swallows, acting as a virtual endoscope to peer into the stomach. Using a PillBot avoids the hassles of multiple doctor visits for a procedure that requires anesthesia and a tube slid down the throat.
A PillBot has a tail and nose cone. Inside the tail cone are tiny 3D-printed propellers that push and pull water through the robot so it can move through the stomach. An “origami” folding circuit board is tucked inside the pill and contains four LEDs and a camera for live video feeds.
While pill cameras are already on the market, the PillBot differentiator is that the physician can “steer” the robot inside the stomach for better views. A USB-like dongle that plugs into a phone or laptop communicates between the robot and the outside world through a low-frequency radio link.
This is just one of the uses such robotic systems can fill, said Torrey Smith, the CEO at Endiatx.
“We are incredibly interested in what can be done with robots that have tiny little legs, robots that have moving tails, with snippers at the front and cauterizing elements at the back, that could crawl through layers of tissue or blood vessels and conduct even brain surgery,” Smith said. “The human stomach is the most appropriate first place.”
Bell is also excited about companies like HistoSonics, which use robot-driven ultrasonic therapies to destroy tumors in the body. “You don't even need to cut the body open,” he noted.
Endiatx's PillBot is a maneuverable camera that offers physicians 10 minutes of real-time video from inside a patient but is affordable enough to flush down the toilet. Video: Endiatx
AUTONOMOUS ROBOTS?
The integration of AI capabilities into surgical robotics is also worth keeping an eye on. Using AI can help enhance visualization, for example. By cross-referencing a CT scan, the system can highlight areas on the screen for better views. It can help guide dissection in a safer way, McMahon explained. Machine learning algorithms might spot other troublesome tissue during surgeries and bring these to the surgeon’s attention.
As for the robots themselves, fully autonomous surgery is still a long way off, Bell predicted. He likens robots in surgery to advanced driver assistance systems (ADAS) in vehicles.
“First you got lane assist, then a bit of automatic parking, and now there’s slow movement toward autonomous driving,” Bell said. “There’s similar stuff going on in surgery. A lot of assistance, but autonomy in surgery is still a ways away.”
Even if the mechanics of remote robotic systems for surgery improve enough for autonomy, Bell predicts the big challenge will be related to regulatory protocols.
“If a system autonomously sutures and ties a knot, the question becomes, who owns the knot? Is it the robot? Is it the hospital? Is it the manufacturer? Is it the software engineer that modeled the knot? Is it the surgeon? And what if we tie that knot over telesurgery?” Bell postulated. “If I press the button in New York, and it ties the knot in Tokyo, and something goes wrong, is it the surgeon in Tokyo that said it was okay because it was their patient? Is it the surgeon in New York?”
For now, McMahon is happy to work with the da Vinci Xi and is tracking progress in the field closely.
“Twenty years ago, I would never have thought that things would be moving this fast but it’s picking up speed and there’s a lot of capital being poured into surgical robotics. It really is an interesting time,” he said.
Poornima Apte is a technology writer based in Walpole, Mass.
The Yomi robotic surgery system helps dentists plan dental implant procedures digitally. Image: Neocis
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