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Surgical Robotics in Otolaryngology David J. Terris Key Points Surgical robotics have evolved from rudimentary scope holders to sophisticated and precise telerobotic systems with 'wristed' technology and true three-dimensional visualization. Experimental robotic surgery investigation has centered on neck and thyroid, skull base, and oropharyngeal applications. Clinical robotic applications have so far been restricted to thyroid and oropharyngeal procedures. There is a burden with robotic surgery to balance increased time, expense, and technologic challenges with improvements in outcomes or other definable advantages. Despite a number of hurdles, it seems likely that the future will bring more indications for robotic assistance, rather than fewer. History of Robotics The origins of robotics may be traced to early in the twentieth century, when the Czechoslovakian Capek brothers introduced the concept of automated devices. Joseph Capek wrote the short story 'Opilec' in which automats were described, and Karel Capek wrote 'Rossum'sUniversal Robots.' This introduction of the term robot(deriving from the Czech word robota , which means serf or laborer) was part of a fictional depiction of the increasing sophistication of robots, which eventually rose up against their human inventors. 1 The next seminal spark of the collective imagination of scientists and society alike occurred with Isaac Asimov's collection of short stories in the 1940s. 2He developed the three laws relating to robot behavior, which were recently popularized in Will Smith's 'I, Robot': 1. A robot may not injure a human being or through inaction allow a human to come to harm. 2. A robot must obey orders given it by humans except when doing so conflicts with the first law. 3. A robot must protect its own existence as long as this does not conflict with the first or second law. Other Hollywood productions stimulating public interest in robotics included the 'Star Wars' series, the 'Terminator' trilogy, and 'Bicentennial Man,' starring Robin Williams. 1 / 18Simultaneous with sensational depictions of the potential for common robotic applications, gradual and stepwise breakthroughs in electronics and computers paved the way for the development and production of the first meaningful robot in 1958, dubbed 'the Unimate' by General Motors. Its use in assembly lines to facilitate automobile production in 1961 was the first in what eventually became widespread application of automation in the automobile industry. Honda has been particularly innovative in its development of robotic humanoids, culminating in the ASIMO, which not only can walk but also can negotiate stairs (Fig. 4A-1). A growing number of other applications for robotics have quickly emerged, including military uses and purposes as far-reaching as exploration of deep sea and space and as mundane as lawn care and use of home appliances. These robots can be characterized in a variety of ways: automated arms, mobile devices, mills, or telerobotic devices. With the advent of these many and varied robots, specific nomenclature has evolved to classify their actions and mechanisms. Definitions As the presence of robotics in the operating room becomes more pervasive, a basic knowledge of the language of robotics is desirable. The following terms represent the essential foundation of robotic lexicography 3 : Robotic surgery -implies the use of a powered device that functions under programmable computerized control and may be used to manipulate instruments and perform surgical tasks. Active robotics -refers to a robot that is programmed to independently perform a complete task without operator control. Semiactive robotics -requires the input of an operator to perform defined, powered tasks. Passive robotics -functions only at the direction of the operator, without independently powered movements (sometimes referred to as a telemanipulator ). Telerobotic surgery -refers to a system in which the operator controls a robot from a console containing a virtual three-dimensional visualization framework and from which robotically controlled manipulations are reproduced. Telepresence -extension of telerobotic surgery to a remote site so that the console from which the operator issues commands is located at a distance from the robot; the robotic surgeon may therefore never have contact with the patient. Telementoring -when coupling an experienced surgeon with a trainee at a remote location, telepresence provides the technologic framework for distance training or so-called telementoring . 2 / 18History of Medical Robotics While the earliest applications of robotics were in the automobile industry, the Department of Defense recognized the potential value of remotely controlled robotics, both for the military options they afforded and for the possibility of providing care to wounded soldiers on the battlefield with the surgeon safely out of harm's way. This concept of so-called virtual insertion of the surgeon into the battlefield was championed and funded by the Pentagon'sDefense Advanced Research Projects Agency (DARPA). Similarly, theNational Aeronautics and Space Administration (NASA) teamed up with the Ames Research Center (Mountain View, CA) and the Stanford Research Institute (Palo Alto, CA) to develop both a head-mounted virtual reality display (Fig. Figure 4A-1. The ASIMO from Honda is a humanoid robot that is capable not only of walking, but of negotiating stairs. 4A-2A) and a data-glove (see Fig. 4A-2B), by which the user could cause and witness his own interactions within a virtual environment. Less sophisticated technology was used to accomplish the first robot-assisted surgical procedure in 1985, a stereotactic brain biopsy. 1 In 1992, the Robodoc (a computer-guided mill used to core the femoral head) was introduced in Europe for use in hip replacement surgery, and later the Acrobot was developed for knee replacement and temporal bone surgery. These have yet to receive U.S. Food andDrug Administration approval for use in the United States, largely because of concerns regarding complication rates. 3 / 18The growing interest in surgical robotic applications, along with ample funding, spawned a number of market leaders in medical robotics, including the companies Computer Motion, Inc., and Intuitive Surgical, Inc. Computer Motion developed the automated endoscopic system for optimal positioning (AESOP) system (Fig. 4A-3), which was combined withHermes voice-activation movement technology, and has seen limited adoption in laparoscopic surgical procedures. Computer Motion was also responsible for creating the Zeus telerobotic system (Fig. 4A-4). Computer Motion was eventually acquired by Intuitive Surgical, the Zeus was retired, and the daVinci system has become the industry standard for surgical robotics. The current leading applications include prostate surgery, 4 cardiothoracic surgery, 5 and advanced gynecologic surgery. 6 More than 50% of radical prostatectomies, for example, are performed using the daVinci system. The first trans-Atlantic telerobotic surgery received relatively little attention because of the temporal relationship to the 9/11/01 terrorist attacks on the United States. On September 7, 2001, Jacques Marescaux was seated inNew York City while he performed a laparoscopic cholecystectomy on a patient who was 3800 miles away in Strasbourg, France. Dubbed the Lindbergh Operation (in tribute to Charles Lindbergh, who was the first to accomplish a trans-Atlantic solo flight), the procedure was a collaboration between Marescaux and Michel Gagner of Mount Sinai Hospital inNew York. Highspeed fiberoptic connections provided by French Telecom were necessary to minimize the time-lag between surgeon commands and robotic movements, and the response-delay achieved was 155 msec. Even though sensational events like these prompt high expectations, the implementation of robotics into fields such as otolaryngology-head and neck surgery has been a much more gradual and deliberate process. Robotic Applications in Otolaryngology A role for this technology in otolaryngology is beginning to emerge, particularly where precision is required or visualization is limited, and there are a number of pioneering contributions. The first otolaryngoFigure 4A-2. The combination of a virtual reality headset(A) and a data-glove (B) allow the user to interact with his virtual environment while witnessing the activity. 4 / 18n logic application of robotics occurred as early as 2002 with several reports from the Terris group at the Medical College of Georgia exploring endoscopic neck procedures. 7-10 The first human application was described by McLeod and Melder 11 with a case report of excision of a vallecular cyst. Hockstein and colleagues further pursued oral and oropharyngeal applications of robotic technology with a stepwise experimental approach. 12,13 Finally, interest in robotic skull base surgery has emerged with the work of Hanna and colleagues. 14 Experimental Origins The first use of robotics for otolaryngologic applications was explored in a porcine model of neck surgery that included parotidectomy, submandibular gland resection, and selective neck dissection. 8 This work built on previous promising findings for totally endoscopic neck surgery (also described by Terris and collaborators 15,16 ) and provided proof of principle, in that the safety and efficacy of endorobotic neck surgery was demonstrated, and quickly established that advantages in duration of surgery could be easily achieved with the addition of robotic technology. Figure 4A-3. The AESOP (automated endoscopic system for optimal positioning) combines robotics with voice activation to accomplish precise camera positioning during endoscopic surgery. 5 / 18The first investigative protocol 8 was represented by a prospective nonrandomized investigation in a porcine model in which four different types of neck surgery were accomplished using the daVinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA) (Fig. 4A-5). This system employs robotics to enable microsurgery in an endoscopic environment. It consists of a surgeon's console with two control handles and a virtual three-dimensional vision projection system, and a patient side cart with three or four robotic arms, three of which manipulate operative instruments and a fourth that controls a video endoscope. The video system contains twin-mounted endoscopes, with projection of one image to one eye of the console and the other image to the other eye (Fig. 4A-6). This therefore produces true three-dimensional images at the tip of the scope. The robotic arms permit utilization of a full range of articulated instruments (Fig. 4A-7) that are used for clamping, cutting, suturing, and tissue manipulation, including electrocautery, forceps, clip appliers, and scissors. These instruments are equipped with EndoWrist technology, which provides up to 7 degrees of freedom (unlike the 4 degrees associated with conventional endoscopic instrumentation), allowing the surgeon's endoscopic movements to closely mimic those of the human wrist. The daVinci tracks the surgeon's hand movements 1300 times each second and relays the data to the instrument tips, reproducing the surgical maneuvers. While the primary surgeon controls the robotic instruments and the camera, an assistant changes and adjusts the instruments. 6 / 18The procedures performed in this original investigation included one thymectomy, one partial parotidectomy, three submandibular gland resections, and three neck dissections (Fig. 4A-8). There were no complications, and no conversions to open surgery were necessary. Because of the substantial preparation required to ready the robotic system for use, careful documentation of the time that transpired during the establishment of the operative pocket and the time needed to assemble and position the robotic arms was undertaken. Despite a total setup time exceeding 30 minutes, there was still a savings in overall operative duration when comparing robotic submandibular gland resection and neck dissection to historical controls (conventional endoscopic procedures) (Fig. 4A-9). The natural next model for systematic exploration of feasibility of robotic neck surgery was the fresh cadaver. Terris and colleagues described a series of 11 endorobotic submandibular gland resections that were accomplished in six fresh cadavers. 9 The port placement was similar to that which had been previously described. 17 A 14-mm incision was created approximately 9 cm lateral to the sternal notch over the clavicular head of the sternocleidomastoid muscle for the camera port, and two 10- mm incisions were created approximately 4 cm to each side of the camera port for 8-mm instrument trocars (Fig. 4A-10). The submandibular gland was accessed by approaching inferiorly in the subplatysmal plane. The facial artery and vein and submandibular duct were ligated using the robotic clip appliers. After the submandibular gland was completely mobilized, the robotic camera was repositioned into one of the 8-mm ports and the specimen was retrieved through the 14-mm trocar incision. Figure 4A-4. The Zeus telerobotic system consists of a patient-side cart(A) and a console (B) . It was the precursor to the daVinci surgical system, which also consists of a console and a patient-side cart. It has been retired, leaving the daVinci as the only commercially available surgical robot in the United States. 7 / 18Figure 4A-5. With the daVinci surgical system, the surgeon manipulates the robotic instruments of the master console, which is located within several feet of the operating table.(Reprinted with permission from Haus BM, Kambham N, Le D, et al. Surgical robotic applications in otolaryngology. Laryngoscope. 2003;113[7]:1139-1144.) Because prior conventional endoscopic procedures had been accomplished by the same investigators, 17 a noncontemporaneous comparison of outcomes to historical controls was possible and showed a significant reduction in median surgical times, from 65.5 minutes to 48 minutes. Stimulated by the promising findings in these seminal studies, Hockstein and colleagues likewise embarked on a series of experiments, first in an inanimate model(mannequin 12 ) and then in cadaver studies 13 to evaluate the feasibility and potential benefit of robot-assisted oropharyngeal surgery. In their first publication in 2005, Hockstein and colleagues used a mannequin with the same daVinci device to define the optimal configuration for exposing the oropharynx (McIvor mouthgag combined with the 30-degree three-dimensional endoscope) and relationship of the robot to the operating table and patient(Fig. 4A-11). In a subsequent study, the same group accomplished several procedures on a single cadaver using a Dingman mouthgag for exposure. These included vocal cord strippings and arytenoidectomies (Fig. 4A-12). These exploratory investigations provided the foundation for subsequent clinical protocols. 8 / 18Clinical Applications With McLeod and Melder's 11 report on a patient with a robotically assisted vallecular cyst marsupialization in 2005, and then with the subsequent report by Lobe and colleagues 18 of a successful robotic axillary thyroidectomy later that year, the first human applications of robotic surgery in otolaryngology were realized. A number of other applications of this technology have quickly followed, and with increasing versatility of the robot combined with miniaturization, expansion of the indications for its use seems likely. The only commercially available surgical robot remains the daVinci(Intuitive Surgical, Inc.). A number of challenges are posed by this technology and need to be overcome to justify its use in surgical procedures. 19 Figure 4A-6. The image obtained with the daVinci system is truly threedimensional, in that one image of the twin-mounted endoscopes (either 30 degree or 0 degree, depicted in A ) is projected to one eye on the console, and the other image is projected to the other eye (as seen through the console in B ). 9 / 1810 / 18