Figure 1¹

The origin of surgery can be regarded as old as humanity itself.² Estimated to have begun 3000 BCE it is held to have evolved from trephining or trepanning³ which involved the creation of a hole in the skull to allow “evil spirits” or diseases to escape primarily performed by so-called “witch doctors”.³

Figure 2: Trephining/Trepanning^{4, 5, 6}

Centuries later, during the 11^th century, barbers who were specifically trained in the use of sharp instruments would perform invasive surgical tasks at the request of physicians.⁷ This practise intensified to such an extent that in the 1540s an organised society of barber surgeons was established called the “United Company of Barber Surgeons of London” and this marked the introduction of the regulation of those qualified to practise this rudimentary surgery.² This organization was actually the precursor of the Royal College of Surgeons of England which was founded in 1800 as a breakaway from the barber-surgeons as an independent professional body.⁸

Robotic surgery is a more recent phenomenon, having its early inception in the 1970s when NASA experimented with the idea of remote surgery, also known as “telesurgery”, to assist astronauts in space.⁹ The military also used remote surgical procedures for limited long-distance battlefield surgery. It was however not until the mid-1980s that the first record of robotic surgery took place in an effort to reduce hand tremors. PUMA 560 was the first surgical robot and was used in a brain biopsy procedure. This was followed three years later by PROBOT which was used in a transurethral prostrate procedure. The early 1990s witnessed the development of ROBODOC in a hip replacement procedure. By the end of the 1990s, three different surgical robotic systems were launched: the da Vinci Surgical System, the AESOP, and the Zeus surgical systems.⁹ The usage of surgical robots has escalated exponentially in the twenty-first century with there already being on average three robots to every million people In Europe.¹⁰

Essentially robotic surgery, or more precisely, robotic-assisted surgery, entails the use of mechanical arms with surgical instruments as well as a camera arm. The camera arm is connected to a computer that displays a magnified 3D image of the operating site for the surgeon who controls the arms.¹¹

The applications of robotic surgery are endless, the most frequent usages being urology for prostatectomy and nephrectomy, gynaecology for hysterectomy and oophorectomy¹² as well as in neurology for spinal surgery.⁹

Figure 3: Robot assisted prostatectomy¹³

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Upside to robotic surgery

Robotic surgery is a form of minimal invasive surgery and has advantages over conventional open surgery. These include smaller incisions and less tissue damage. This leads to a reduced chance of infection, decreased blood loss and a faster recovery time.¹¹ Robotic surgery also has reduced the patient’s exposer to radiation by decreasing the need for constant medical imaging in the form of X-rays during surgery known as fluoroscopy.¹⁵  Robotic surgery corrects human error due to hand tremors and uses robotic navigational platforms such as ExcelsiusGPS¹⁶ to monitor and adapt to the patient’s movements during the surgery, increasing the accuracy of surgery leading to less complications.¹⁷

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Downside to robotic surgery

The main disadvantage of robotics surgery is cost.¹⁰ On average, one machine costs $2 million (R32 143 800.00) and there are also additional costs as some of the attachments are disposable. Each surgery will cost on average between $3 000 and $6 000 (R48 215.70 – R96 431.40).¹⁸ Due to the high cost of surgery, it is currently an unrealistic aspiration for developing countries. Robotic surgery is revolutionising how surgery is typically done and therefore requires additional training and expertise, which could lengthen qualification time. These robotic surgeries are reported to take longer than other surgeries. An hour longer than open surgeries and half an hour longer than laparoscopic surgeries. This therefore has an additional anaesthetic risk which lengthens the recovery time from anaesthesia. There are also increased risks of post-surgery blood clots and pneumonia.¹⁷

Conclusion

Prof Richard SC Kerr, neurosurgeon and member of the council of the Royal College of Surgeons of England, is of the opinion that robots will at this stage and in the foreseeable future not be “able to perform an entire surgical procedure autonomously and handle the unpredictability of its possible complications”.

He concludes that it “seems highly unlikely that [robotic surgeons] could replace surgeons” but rather robotics will continue to represent “highly complex and sophisticated tools for surgeons and their teams to use”. In sum, robotic surgeons will not be substitutes for surgeons! (For now, it is game, set and match for surgeons!)¹⁰