Impact of Surgical Robotics in the Era of Data: A Comprehensive Review of Robot-Assisted Minimally Invasive Surgery

Robotic surgery, commonly known as telerobotic execution of minimally invasive surgery (MIS), involves the surgeon remotely controlling surgical instruments while physically separated from the patient. This approach also referred to as robotically assisted or robotic MIS (RAMIS), has gained popularity due to its compatibility with the modern MIS paradigm. RAMIS offers benefits such as reduced tissue trauma, improved ergonomics for surgeons, and various technological components for use in the operating room (OR). This article aims to highlight the technical capabilities of RAMIS systems with their clinical applicability, taking into account the regulatory environment. The market landscape is dominated by a single product, the "da Vinci surgical system" from Intuitive Surgical Inc., which has performed over 1.5 million procedures annually and remains the most widely used RAMIS system. The success of the da Vinci system can be attributed to factors such as advanced technology features, improved patient outcomes, targeted procedures with quality-of-life improvements, comprehensive training programs, legal responsibility remaining with the surgeon, extensive marketing efforts, and a solution-based business model. The patient's benefit has been a driving force behind the adoption of robotic programs, backed by significant clinical evidence, although some questions regarding long-term benefits compared to open surgery still exist. The adoption of robotic surgery correlates with costs, with higher adoption rates in countries with higher healthcare expenditures. Remote-controlled leader-follower robots are predominantly used in RAMIS, operating in telemanipulation mode where the surgeon controls the surgical tools indirectly [1]. Other classes of surgical or interventional robots with different architectures are also in clinical use. While various technical configurations exist, surgical robot systems generally employ robotic mechanisms to provide accurate guidance, assistance, or direct delivery of instruments or energy. This review focuses on full-scale, teleoperation surgical systems within the RAMIS classification, excluding image-guided interventional robotics, collaborative control, microsurgical systems, and endoluminal robots. The shared feature among these systems is the use of robotic mechanisms to perform precise surgical interventions based on preoperative planning and patient imaging data [2].

Simulation and training are crucial for surgeons to become proficient in using robot-assisted systems. Various simulators, both physical and virtual, have been developed to support skill development. The insights gained from training sessions have improved system usability and our understanding of human capabilities. Skill assessment is also gaining attention, with classical and machine learning-based methods being used to predict outcomes. Technologies such as eye-tracking systems can provide adaptive functionalities tailored to surgeons' needs. It's also important to assess non-technical skills, like stress management, which can significantly impact patient outcomes [3]. By continuously improving training and assessment, we can ensure better surgical outcomes (Figure 1)

Developing a robot-assisted surgical system for commercial use is a complex process that involves meeting strict regulatory requirements (Table 1). These regulations ensure the safety and reliability of medical devices. Standardization bodies are working on guidelines specific to robot-assisted surgery. However, the path from a functional prototype to a market-ready product is challenging and requires significant time and financial investment. Compliance with regulations is crucial but can be demanding. Despite these challenges, there are ongoing efforts to create sustainable and safe robotics solutions [4]. Funding is essential for research and development, and new entrants in the field should not be underestimated. Collaboration and adherence to ethical standards play a significant role in ensuring the success of robot-assisted surgeries (Figure 2).

Data plays a vital role in robot-assisted surgeries, bringing together information from various sources like robot movements, videos, and patient data. Managing and processing this data can be challenging, but with big data techniques, we can develop new applications using machine learning and artificial intelligence. These applications can help automate surgical tasks and provide personalized guidance. However, we still face challenges in obtaining large annotated datasets for training AI models. Researchers are exploring ways to generate synthetic datasets, speed up the annotation process, and develop self-learning methods. It's important to have diverse and representative datasets that capture anatomical variations and patient outcomes. Collaboration and open challenges are crucial to democratize surgical skills and improve the collaboration between surgeons and robots [5].

In robot-assisted surgeries, the interfaces used allow surgeons to manipulate instruments remotely and visualize the surgical site. The vision systems provide high-resolution 3D displays, creating an immersive experience. They can show additional information and augmented reality elements, enhancing the surgeon's understanding. We can also display other imaging modalities like ultrasound or preoperative planning models to assist in decision-making. However, there is room for improvement in providing haptic feedback, which gives a sense of touch. This can help surgeons better feel the surgical environment and adapt their actions accordingly [6]. Developing effective haptic feedback systems is complex but essential for enhancing surgical precision (Figure 3).

The cost of building RAMIS robots is high, especially as new restrictions come into force. New systems' success rely on cutting-edge technology. We want to ensure that AI-powered features enhance patient care without jeopardising security. The use of surgical robots is becoming more and more common, and numerous novel systems are being created. The vast number of RAMIS operations being carried out provides useful information that can aid in our improvement. Although AI has the potential to improve surgery even more, we must be cautious and ensure that patients stand to gain from it [7]. The systems may be more dependable if they have autonomous quality control and safety safeguards. Efforts are being made by standardisation organisations to make surgical robotics safer. Additionally, we're investigating fresh approaches to energy delivery to tissues, which may alter how RAMIS WORKS. The COVID-19 pandemic has shown us the importance of contactless surgery, and RAMIS can play a crucial role in maintaining access to surgeries during such times [8,9,10]. However, there's still work to be done to fully automate the surgical process (Figure 4)

RAMIS is currently the most common type of surgical robotics and it helps many patients. It requires a combination of advanced technology and strict safety measures. The data collected during RAMIS procedures is valuable and can help us improve the systems. We need to continue developing AI and machine learning to assist surgeons and ensure patient safety. The console is an important part of RAMIS, as it allows surgeons to control the robots and receive information. Training and human skills are also crucial for successful outcomes. We should always consider ethics and sustainability as we move forward with RAMIS.

All authors have declared that no financial support was received from any organization for the submitted work.

All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.