A robotically assisted surgical system used for prostatectomies, cardiac valve repair and gynecologic surgical procedures
|Other names||Robotically-assisted surgery|
Robotic surgery are types of surgical procedures that are done using robotic systems. Robotically-assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures 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 administer the instruments. These include using 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. The robotic arms carry out those movements using end-effectors and manipulators to perform the actual surgery. 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 computerized method is that the surgeon does not have to be present, leading to the possibility for remote surgery.
Robotic surgery has been criticized for its expense, with the average costs in 2007 ranging from $5,607 to $45,914 per patient. This technique has not been approved for cancer surgery as of 2019 as the safety and usefulness is unclear.
As of 2004, three types of heart surgery are being performed using robotic surgery systems.
- Atrial septal defect repair – the repair of a hole between the two upper chambers of the heart,
- Mitral valve repair – the repair of the valve that prevents blood from regurgitating back into the upper heart chambers during contractions of the heart,
- Coronary artery bypass – rerouting of blood supply by bypassing blocked arteries that provide blood to the heart.
Robotic surgery has become more widespread in thoracic surgery for mediastinal pathologies, pulmonary pathologies and more recently complex esophageal surgery.
Multiple types of procedures have been performed with either the 'Zeus' or da Vinci robot systems, including bariatric surgery and gastrectomy for cancer. Surgeons at various universities initially published case series demonstrating different techniques and the feasibility of GI surgery using the robotic devices. Specific procedures have been more fully evaluated, specifically esophageal fundoplication for the treatment of gastroesophageal reflux and Heller myotomy for the treatment of achalasia.
Robot-assisted pancreatectomies have been found to be associated with "longer operating time, lower estimated blood loss, a higher spleen-preservation rate, and shorter hospital stay[s]" than laparoscopic pancreatectomies; there was "no significant difference in transfusion, conversion to open surgery, overall complications, severe complications, pancreatic fistula, severe pancreatic fistula, ICU stay, total cost, and 30-day mortality between the two groups."
Robotic surgery in gynecology is of uncertain benefit as of 2019 with it being unclear if it affects rates of complications. Gynecologic procedures may take longer with robot-assisted surgery but may be associated with a shorter hospital stay following hysterectomy. In the United States, robotic-assisted hysterectomy for benign conditions has been shown to be more expensive than conventional laparoscopic hysterectomy, with no difference in overall rates of complications.
This includes the use of the da Vinci surgical system in benign gynecology and gynecologic oncology. Robotic surgery can be used to treat fibroids, abnormal periods, endometriosis, ovarian tumors, uterine prolapse, and female cancers. Using the robotic system, gynecologists can perform hysterectomies, myomectomies, and lymph node biopsies. The Memic robotic system is aimed to provide a robotic platform for natural orifice transluminal endoscopic surgery (NOTES) for myomectomy through the vagina.
Robots are used in orthopedic surgery.
Robotic devices started to be used in minimally invasive spine surgery starting in the mid-2000s. As of 2014, there were too few randomized clinical trials to judge whether robotic spine surgery is more or less safe than other approaches.
As of 2019, the application of robotics in spine surgery has mainly been limited to pedicle screw insertion for spinal fixation. In addition, the majority of studies on robot-assisted spine surgery have investigated lumbar or lumbosacral vertebrae only. Studies on use of robotics for placing screws in the cervical and thoracic vertebrae are limited.
The first fully robotic kidney transplantations were performed in the late 2000s. It may allow kidney transplantations in people who are obese who could not otherwise have the procedure. Weight loss however is the preferred initial effort.
With regards to robotic surgery, this type of procedure is currently best suited for single-quadrant procedures, in which the operations can be performed on any one of the four quadrants of the abdomen. Cost disadvantages are applied with procedures such as a cholecystectomy and fundoplication, but are suitable opportunities for surgeons to advance their robotic surgery skills.
Robotic surgery in the field of urology has become common, especially in the United States. There is inconsistent evidence of increased benefits compared to standard surgery to justify the increased costs. Some have found tentative evidence of more complete removal of cancer and fewer side effects from surgery for prostatectomy. In 2000, the first robot-assisted laparoscopic radical prostatectomy was performed.
The first robot to assist in surgery was the Arthrobot, which was developed and used for the first time in Vancouver in 1985. This robot assisted in being able to manipulate and position the patient's leg on voice command. Intimately involved were biomedical engineer James McEwen, Geof Auchinleck, a UBC engineering physics grad, and Dr. Brian Day as well as a team of engineering students. The robot was used in an orthopaedic surgical procedure on 12 March 1984, at the UBC Hospital in Vancouver. Over 60 arthroscopic surgical procedures were performed in the first 12 months, and a 1985 National Geographic video on industrial robots, The Robotics Revolution, featured the device. Other related robotic devices developed at the same time included a surgical scrub nurse robot, which handed operative instruments on voice command, and a medical laboratory robotic arm. A YouTube video entitled Arthrobot- the world's first surgical robot illustrates some of these in operation.
In 1985 a robot, the Unimation Puma 200, was used to orient a needle for a brain biopsy while under CT guidance during a neurological procedure. In the late 1980s, Imperial College in London developed PROBOT, which was then used to perform prostatic surgery. The advantages to this robot was its small size, accuracy and lack of fatigue for the surgeon. In 1992, the ROBODOC was introduced and revolutionized orthopedic surgery by being able to assist with hip replacement surgeries. The latter was the first surgical robot that was approved by the FDA in 2008. The ROBODOC from Integrated Surgical Systems (working closely with IBM) could mill out precise fittings in the femur for hip replacement. The purpose of the ROBODOC was to replace the previous method of carving out a femur for an implant, the use of a mallet and broach/rasp.
Further development of robotic systems was carried out by SRI International and Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system. The first robotic surgery took place at The Ohio State University Medical Center in Columbus, Ohio under the direction of Robert E. Michler.
AESOP was a breakthrough in robotic surgery when introduced in 1994, as it was the first laparoscopic camera holder to be approved by the FDA. NASA initially funded the company, Computer Motion, that had produced AESOP, for its goal to create a robotic arm that can be used in space, but ended up becoming a camera used in laparascopic procedures. Voice control was then added in 1996 with the AESOP 2000 and seven degrees of freedom to mimic a human hand was added in 1998 with the AESOP 3000.
ZEUS was introduced commercially in 1998, and was started the idea of telerobotics or telepresence surgery where the surgeon is at a distance from the robot on a console and operates on the patient. Examples of using ZEUS include a fallopian tube reconnection in July 1998, a beating heart coronary artery bypass graft in October 1999, and the Lindbergh Operation, which was a cholecystectomy performed remotely in September 2001. In 2003, ZEUS made its most prominent mark in cardiac surgery after successfully harvesting the left internal mammary arteries in 19 patients, all of which had very successful clinical outcomes.
The original telesurgery robotic system that the da Vinci was based on was developed at Stanford Research Institute International in Menlo Park with grant support from DARPA and NASA. Ademonstration of an open bowel anastomosis was given to the Association of Military Surgeons of the US. Although the telesurgical robot was originally intended to facilitate remotely performed surgery in the battlefield and other remote environments, it turned out to be more useful for minimally invasive on-site surgery. The patents for the early prototype were sold to Intuitive Surgical in Mountain View, California. The da Vinci senses the surgeon's hand movements and translates them electronically into scaled-down micro-movements to manipulate the tiny proprietary instruments. It also detects and filters out any tremors in the surgeon's hand movements, so that they are not duplicated robotically. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console. Compared to the ZEUS, the da Vinci robot is attached to trocars to the surgical table, and can imitate the human wrist. In 2000, the da Vinci obtained FDA approval for general laparscopic procedures and became the first operative surgical robot in the US. Examples of using the da Vinci system include the first robotically assisted heart bypass (performed in Germany) in May 1998, and the first performed in the United States in September 1999; and the first all-robotic-assisted kidney transplant, performed in January 2009. The da Vinci Si was released in April 2009 and initially sold for $1.75 million.
In 2005, a surgical technique was documented in canine and cadaveric models called the transoral robotic surgery (TORS) for the da Vinci robot surgical system as it was the only FDA-approved robot to perform head and neck surgery. In 2006, three patients underwent resection of the tongue using this technique. The results were more clear visualization of the cranial nerves, lingual nerves, and lingual artery, and the patients had a faster recovery to normal swallowing. In May 2006 the first artificial intelligence doctor-conducted unassisted robotic surgery was on a 34-year-old male to correct heart arrythmia. The results were rated as better than an above-average human surgeon. The machine had a database of 10,000 similar operations, and so, in the words of its designers, was "more than qualified to operate on any patient". In August 2007, Dr. Sijo Parekattil of the Robotics Institute and Center for Urology (Winter Haven Hospital and University of Florida) performed the first robotic-assisted microsurgery procedure denervation of the spermatic cord for chronic testicular pain. In February 2008, Dr. Mohan S. Gundeti of the University of Chicago Comer Children's Hospital performed the first robotic pediatric neurogenic bladder reconstruction.
On 12 May 2008, the first image-guided MR-compatible robotic neurosurgical procedure was performed at University of Calgary by Dr. Garnette Sutherland using the NeuroArm. In June 2008, the German Aerospace Centre (DLR) presented a robotic system for minimally invasive surgery, the MiroSurge. In September 2010, the Eindhoven University of Technology announced the development of the Sofie surgical system, the first surgical robot to employ force feedback. In September 2010, the first robotic operation at the femoral vasculature was performed at the University Medical Centre Ljubljana by a team led by Borut Geršak.
Comparison to traditional methods
Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Due to robotic use, the surgery is done with precision, miniaturization, smaller incisions; decreased blood loss, less pain, and quicker healing time. Articulation beyond normal manipulation and three-dimensional magnification help to result in improved ergonomics. Due to these techniques, there is a reduced duration of hospital stays, blood loss, transfusions, and use of pain medication. The existing open surgery technique has many flaws like limited access to the surgical area, long recovery time, long hours of operation, blood loss, surgical scars, and marks.
The robot's costs range from $1 million to $2.5 million for each unit, and while its disposable supply cost is normally $1,500 per procedure, the cost of the procedure is higher. Additional surgical training is needed to operate the system. Numerous feasibility studies have been done to determine whether the purchase of such systems are worthwhile. As it stands, opinions differ dramatically. Surgeons report that, although the manufacturers of such systems provide training on this new technology, the learning phase is intensive and surgeons must perform 150 to 250 procedures to become adept in their use. During the training phase, minimally invasive operations can take up to twice as long as traditional surgery, leading to operating room tie-ups and surgical staffs keeping patients under anesthesia for longer periods. Patient surveys indicate they chose the procedure based on expectations of decreased morbidity, improved outcomes, reduced blood loss and less pain. Higher expectations may explain higher rates of dissatisfaction and regret.
Compared with other minimally invasive surgery approaches, robot-assisted surgery gives the surgeon better control over the surgical instruments and a better view of the surgical site. In addition, surgeons no longer have to stand throughout the surgery and do not get tired as quickly. Naturally occurring hand tremors are filtered out by the robot's computer software. Finally, the surgical robot can continuously be used by rotating surgery teams. Laparoscopic camera positioning is also significantly steadier with less inadvertent movements under robotic controls than compared to human assistance.
There are some issues in regards to current robotic surgery usage in clinical applications. There is a lack of haptics in some robotic systems currently in clinical use, which means there is no force feedback, or touch feedback. Surgeons are thus not able to feel the interaction of the instrument with the patient. Some systems already have this haptic feedback in order to improve the interaction between the surgeon and the tissue.
The robots can also be very large, have instrumentation limitations, and there may be issues with multi-quadrant surgery as current devices are solely used for single-quadrant application.
Critics of the system, including the American Congress of Obstetricians and Gynecologists, say there is a steep learning curve for surgeons who adopt the use of the system and that there's a lack of studies that indicate long-term results are superior to results following traditional laparoscopic surgery. Articles in the newly created Journal of Robotic Surgery tend to report on one surgeon's experience.
Complications related to robotic surgeries range from converting the surgery to open, re-operation, permanent injury, damage to viscera and nerve damage. From 2000 to 2011, out of 75 hysterectomies done with robotic surgery, 34 had permanent injury, and 49 had damage to the viscera. Prostatectomies were more prone to permanent injury, nerve damage and visceral damage as well. Very minimal surgeries in a variety of specialties had to actually be converted to open or be re-operated on, but most did suffer some kind of damage and/or injury. For example, out of seven coronary artery bypass grafting, one patient had to go under re-operation. It is important that complications are captured, reported and evaluated to ensure the medical community is better educated on the safety of this new technology.
There are also current methods of robotic surgery being marketed and advertised online. Removal of a cancerous prostate has been a popular treatment through internet marketing. Internet marketing of medical devices are more loosely regulated than pharmaceutical promotions. Many sites that claim the benefits of this type of procedure had failed to mention risks and also provided unsupported evidence. There is an issue with government and medical societies promotion a production of balanced educational material. In the US alone, many websites promotion robotic surgery fail to mention any risks associated with these types of procedures, and hospitals providing materials largely ignore risks, overestimate benefits and are strongly influenced by the manufacturer.
- Barbash GI, Glied SA (August 2010). "New technology and health care costs--the case of robot-assisted surgery". The New England Journal of Medicine. 363 (8): 701–4. doi:10.1056/nejmp1006602. PMID 20818872.
- Center for Devices and Radiological Health. "Safety Communications - Caution When Using Robotically-Assisted Surgical Devices in Women's Health including Mastectomy and Other Cancer-Related Surgeries: FDA Safety Communication". www.fda.gov. Retrieved 6 March 2019.
Understand that the FDA has not cleared or approved any robotically-assisted surgical device based on cancer-related outcomes such as overall survival, recurrence, and disease-free survival.... The safety and effectiveness of robotically-assisted surgical devices for use in mastectomy procedures or prevention or treatment of cancer has not been established.
- Kypson AP, Chitwood Jr WR (2004). "Robotic Applications in Cardiac Surgery". International Journal of Advanced Robotic Systems. 1 (2): 87–92. arXiv:cs/0412055. Bibcode:2004cs.......12055K.
- Melfi FM, Menconi GF, Mariani AM, et al. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8.
- Hyun MH, Lee CH, Kim HJ, Tong Y, Park SS (November 2013). "Systematic review and meta-analysis of robotic surgery compared with conventional laparoscopic and open resections for gastric carcinoma". The British Journal of Surgery. 100 (12): 1566–78. doi:10.1002/bjs.9242. PMID 24264778.
- Talamini MA, Chapman S, Horgan S, Melvin WS (October 2003). "A prospective analysis of 211 robotic-assisted surgical procedures". Surgical Endoscopy. 17 (10): 1521–4. doi:10.1007/s00464-002-8853-3. PMID 12915974.
- Melvin WS, Needleman BJ, Krause KR, Schneider C, Ellison EC (2002). "Computer-enhanced vs. standard laparoscopic antireflux surgery". Journal of Gastrointestinal Surgery. 6 (1): 11–5, discussion 15–6. doi:10.1016/S1091-255X(01)00032-4. PMID 11986012.
- Melvin WS, Dundon JM, Talamini M, Horgan S (October 2005). "Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy". Surgery. 138 (4): 553–8, discussion 558–9. doi:10.1016/j.surg.2005.07.025. PMID 16269282.
- Shaligram A, Unnirevi J, Simorov A, Kothari VM, Oleynikov D (April 2012). "How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia". Surgical Endoscopy. 26 (4): 1047–50. doi:10.1007/s00464-011-1994-5. PMID 22038167.
- Zhou JY, Xin C, Mou YP, Xu XW, Zhang MZ, Zhou YC, Lu C, Chen RG (2016). "Robotic versus Laparoscopic Distal Pancreatectomy: A Meta-Analysis of Short-Term Outcomes". PLOS ONE. 11 (3): e0151189. Bibcode:2016PLoSO..1151189Z. doi:10.1371/journal.pone.0151189. PMC 4790929. PMID 26974961.
- Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G (April 2019). "Robot-assisted surgery in gynaecology". The Cochrane Database of Systematic Reviews. 4: CD011422. doi:10.1002/14651858.CD011422.pub2. PMC 6464707. PMID 30985921.
- "Committee opinion no. 628: robotic surgery in gynecology". Obstetrics and Gynecology. 125 (3): 760–7. March 2015. doi:10.1097/01.AOG.0000461761.47981.07. PMID 25730256.
- Herron DM, Marohn M (February 2008). "A consensus document on robotic surgery". Surgical Endoscopy. 22 (2): 313–25, discussion 311–2. doi:10.1007/s00464-007-9727-5. PMID 18163170.
- Wang T, Tang H, Xie Z, Deng S (October 2018). "Robotic-assisted vs. laparoscopic and abdominal myomectomy for treatment of uterine fibroids: a meta-analysis". Minimally Invasive Therapy & Allied Technologies. 27 (5): 249–264. doi:10.1080/13645706.2018.1442349. PMID 29490530.
- Zanagnolo V, Garbi A, Achilarre MT, Minig L (16 January 2017). "Robot-assisted Surgery in Gynecologic Cancers". Journal of Minimally Invasive Gynecology. 24 (3): 379–396. doi:10.1016/j.jmig.2017.01.006. PMID 28104497.
- DiGioia AM, Jaramaz B, Picard F, Nolte L, eds. (30 December 2004). Computer and robotic assisted hip and knee surgery. Oxford University Press. pp. 127–156. ISBN 978-0-19-850943-1.
- Shweikeh F, Amadio JP, Arnell M, Barnard ZR, Kim TT, Johnson JP, Drazin D (March 2014). "Robotics and the spine: a review of current and ongoing applications". Neurosurgical Focus. 36 (3): E10. doi:10.3171/2014.1.focus13526. PMID 24580002.
- Huang J, Li Y, Huang L (2019). "Spine surgical robotics: review of the current application and disadvantages for future perspectives". Journal of Robotic Surgery. 59 (5): 465–78. doi:10.1007/s11701-019-00983-6. PMID 1243701.
- Hameed AM, Yao J, Allen RD, Hawthorne WJ, Pleass HC, Lau H (October 2018). "The Evolution of Kidney Transplantation Surgery Into the Robotic Era and Its Prospects for Obese Recipients". Transplantation. 102 (10): 1650–1665. doi:10.1097/TP.0000000000002328. PMID 29916987.
- Lee DI (April 2009). "Robotic prostatectomy: what we have learned and where we are going". Yonsei Medical Journal. 50 (2): 177–81. doi:10.3349/ymj.2009.50.2.177. PMC 2678689. PMID 19430547.
- Williams SB, Prado K, Hu JC (November 2014). "Economics of robotic surgery: does it make sense and for whom?". The Urologic Clinics of North America. 41 (4): 591–6. doi:10.1016/j.ucl.2014.07.013. PMID 25306170.
- Ramsay C, Pickard R, Robertson C, Close A, Vale L, Armstrong N, Barocas DA, Eden CG, Fraser C, Gurung T, Jenkinson D, Jia X, Lam TB, Mowatt G, Neal DE, Robinson MC, Royle J, Rushton SP, Sharma P, Shirley MD, Soomro N (2012). "Systematic review and economic modelling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer". Health Technology Assessment. 16 (41): 1–313. doi:10.3310/hta16410. PMC 4780976. PMID 23127367.
- Finkelstein J, Eckersberger E, Sadri H, Taneja SS, Lepor H, Djavan B (2010). "Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US Experience". Reviews in Urology. 12 (1): 35–43. PMC 2859140. PMID 20428292.
- "Medical Post 23:1985" (PDF).
- Day B (8 January 2014), Arthrobot - the world's first surgical robot, retrieved 14 April 2019
- Kwoh YS, Hou J, Jonckheere EA, Hayati S (February 1988). "A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery". IEEE Transactions on Bio-Medical Engineering. 35 (2): 153–60. doi:10.1109/10.1354. PMID 3280462.
- Paul HA, Bargar WL, Mittlestadt B, Musits B, Taylor RH, Kazanzides P, Zuhars J, Williamson B, Hanson W (December 1992). "Development of a surgical robot for cementless total hip arthroplasty". Clinical Orthopaedics and Related Research (285): 57–66. doi:10.1097/00003086-199212000-00010. PMID 1446455.
- Lanfranco AR, Castellanos AE, Desai JP, Meyers WC (January 2004). "Robotic surgery: a current perspective". Annals of Surgery. 239 (1): 14–21. doi:10.1097/01.sla.0000103020.19595.7d. PMC 1356187. PMID 14685095.
- "ROBODOC: Surgical Robot Success Story" (PDF). Retrieved 25 June 2013.
- Meadows M. "Computer-Assisted Surgery: An Update". FDA Consumer magazine. Food and Drug Administration. Archived from the original on 1 March 2009.
- McConnell PI, Schneeberger EW, Michler RE (2003). "History and development of robotic cardiac surgery". Problems in General Surgery. 20 (2): 20–30. doi:10.1097/01.sgs.0000081182.03671.6e.
- Unger SW, Unger HM, Bass RT (1 September 1994). "AESOP robotic arm". Surgical Endoscopy. 8 (9): 1131. doi:10.1007/BF00705739. PMID 7992194.
- Baek SJ, Kim SH (May 2014). "Robotics in general surgery: an evidence-based review". Asian Journal of Endoscopic Surgery. 7 (2): 117–23. doi:10.1111/ases.12087. PMID 24877247.
- Leslie Versweyveld (29 September 1999). "ZEUS robot system reverses sterilization to enable birth of baby boy". Virtual Medical Worlds Monthly.
- "Robotics: the Future of Minimally Invasive Heart Surgery". Biomed.brown.edu. 6 October 1999. Retrieved 29 November 2011.
- "Linbergh Operation – IRCAD/EITS Laparoscopic Center". Retrieved 19 January 2011.
- Boyd WD, Rayman R, Desai ND, Menkis AH, Dobkowski W, Ganapathy S, Kiaii B, Jablonsky G, McKenzie FN, Novick RJ (October 2000). "Closed-chest coronary artery bypass grafting on the beating heart with the use of a computer-enhanced surgical robotic system". The Journal of Thoracic and Cardiovascular Surgery. 120 (4): 807–9. doi:10.1067/mtc.2000.109541. PMID 11003767.
- Boyd WD, Kiaii B, Kodera K, Rayman R, Abu-Khudair W, Fazel S, Dobkowski WB, Ganapathy S, Jablonsky G, Novick RJ (February 2002). "Early experience with robotically assisted internal thoracic artery harvest". Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 12 (1): 52–7. doi:10.1097/00019509-200202000-00009. PMID 12008763.
- "Telerobotic Surgery". SRI International. Retrieved 30 September 2013.
- Satava RM (February 2002). "Surgical robotics: the early chronicles: a personal historical perspective". Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 12 (1): 6–16. doi:10.1097/00129689-200202000-00002. PMID 12008765.
- Sung GT, Gill IS (December 2001). "Robotic laparoscopic surgery: a comparison of the DA Vinci and Zeus systems". Urology. 58 (6): 893–8. doi:10.1016/s0090-4295(01)01423-6. PMID 11744453.
- "New Robot Technology Eases Kidney Transplants". CBS News. 22 June 2009. Retrieved 8 July 2009.
- "da Vinci Si Surgical System". Intuitive Surgical. Retrieved 30 September 2013.
- Oliveira CM, Nguyen HT, Ferraz AR, Watters K, Rosman B, Rahbar R (2012). "Robotic surgery in otolaryngology and head and neck surgery: a review". Minimally Invasive Surgery. 2012: 286563. doi:10.1155/2012/286563. PMC 3337488. PMID 22567225.
- Weinstein GS, O'malley BW, Hockstein NG (July 2005). "Transoral robotic surgery: supraglottic laryngectomy in a canine model". The Laryngoscope. 115 (7): 1315–9. doi:10.1097/01.MLG.0000170848.76045.47. PMID 15995528.
- Lee SY, Park YM, Byeon HK, Choi EC, Kim SH (August 2014). "Comparison of oncologic and functional outcomes after transoral robotic lateral oropharyngectomy versus conventional surgery for T1 to T3 tonsillar cancer". Head & Neck. 36 (8): 1138–45. doi:10.1002/hed.23424. PMID 23836492.
- "Autonomous Robotic Surgeon performs surgery on first live human". Engadget. 19 May 2006.
- "Robot surgeon carries out 9-hour operation by itself". Phys.Org.
- Parekattil S. "Robotic Infertility". Retrieved 11 October 2012.
- "Surgeons perform world's first pediatric robotic bladder reconstruction". Esciencenews.com. 20 November 2008. Retrieved 29 November 2011.
- "neuroArm : revolutionary procedure a world first". ucalgary.ca. 16 May 2008. Retrieved 14 November 2012.
- Hagn U, Nickl M, Jörg S, Tobergte A, Kübler B, Passig G, et al. (2008). "DLR MiroSurge – towards versatility in surgical robotics". Jahrestagung der Deutschen Gesellschaft für Computer und Roboterassistierte Chirurgie; Proceedings of CURAC. 7: 143–146.
- "Beter opereren met nieuwe Nederlandse operatierobot Sofie" (in Dutch). TU/e. 27 September 2010. Archived from the original on 24 July 2011. Retrieved 10 October 2010.
- "V UKC Ljubljana prvič na svetu uporabili žilnega robota za posege na femoralnem žilju" [The First Use of a Vascular Robot for Procedures on Femoral Vasculature] (in Slovenian). 8 November 2010. Retrieved 1 April 2011.
- "UKC Ljubljana kljub finančnim omejitvam uspešen v razvoju medicine" [UMC Ljubljana Successfully Develops Medicine Despite Financial Limitations] (in Slovenian). 30 March 2011.
- Estey EP (December 2009). "Robotic prostatectomy: The new standard of care or a marketing success?". Canadian Urological Association Journal. 3 (6): 488–90. doi:10.5489/cuaj.1182. PMC 2792423. PMID 20019980.
- O'toole MD, Bouazza-Marouf K, Kerr D, Gooroochurn M, Vloeberghs M (2009). "A methodology for design and appraisal of surgical robotic systems". Robotica. 28 (2): 297–310. doi:10.1017/S0263574709990658.
- Kolata G (13 February 2010). "Results Unproven, Robotic Surgery Wins Converts". The New York Times. Retrieved 11 March 2010.
- Gerhardus D (July–August 2003). "Robot-assisted surgery: the future is here". Journal of Healthcare Management / American College of Healthcare Executives. 48 (4): 242–51. doi:10.1097/00115514-200307000-00008. PMID 12908224.
- Kavoussi LR, Moore RG, Adams JB, Partin AW (December 1995). "Comparison of robotic versus human laparoscopic camera control". The Journal of Urology. 154 (6): 2134–6. doi:10.1016/S0022-5347(01)66715-6. PMID 7500476.
- Spinelli A, David G, Gidaro S, Carvello M, Sacchi M, Montorsi M, Montroni I (September 2017). "First experience in colorectal surgery with a new robotic platform with haptic feedback". Colorectal Disease. 20 (3): 228–235. doi:10.1111/codi.13882. PMID 28905524.
- Breeden, James T., MD, President of ACOG,  Statement on Robotic Surgery, 14 March 2013
- "Robotic Surgery: Risks vs. Rewards". AORN Journal. 106 (2): 186–157. August 2017. doi:10.1016/j.aorn.2017.05.007. PMID 28755672.
- Mirkin JN, Lowrance WT, Feifer AH, Mulhall JP, Eastham JE, Elkin EB (April 2012). "Direct-to-consumer Internet promotion of robotic prostatectomy exhibits varying quality of information". Health Affairs. 31 (4): 760–9. doi:10.1377/hlthaff.2011.0329. PMC 3897330. PMID 22492893.
- Basto M, Cooperberg MR, Murphy DG (February 2015). "Proton therapy websites: information anarchy creates confusion" (PDF). BJU International. 115 (2): 183–5. doi:10.1111/bju.12667. PMID 25756133.
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