[CMT&CHTV Literature Highlights]
Introduction: As one of the important components of the 2024 Service Trade Fair, the National Health Commission’s People’s Health Channel (CHTV) is scheduled to hold the “2024 Capital International Medical Conference Parallel Forum – Intelligent Medical and Medical Artificial Intelligence Innovation Forum” in Beijing on September 13. CHTV & Medical Forum Network will bring you a series of reports on AI-enabled healthcare.
On June 7, 2024, Professor Zhang Xu, an academician of the Chinese Academy of Sciences and director of the Department of Urology at the Third Medical Center of the PLA General Hospital, led a team to participate in the European Laparoscopic and Robotic Surgery Challenge Conference in Rome, Italy. They successfully completed and demonstrated the “longest distance” remote radical prostatectomy across the Eurasian continent using a domestically produced remote surgical robot. At the forum, Academician Zhang Xu will give a keynote report titled “New Advances in Remote Urology and Artificial Intelligence”. Before the forum, let us understand robotic surgery and Academician Zhang Xu’s achievements in the field of robotic surgery. We will explain this in three parts, with this issue focusing on a basic introduction to robotic surgery.
Robotic surgery, a field that integrates cutting-edge technology and medical expertise, has played an increasingly important role in medical practice since the end of the 20th century. Robotic surgical systems not only greatly enhance the precision and safety of surgeries but also provide patients with less trauma and faster postoperative recovery. Since the da Vinci system received FDA approval in 2000, over 7,500 installations have been made globally, performing more than 11 million robotic surgeries[1].
The development of robotic surgical systems, especially the da Vinci system, has undergone several generations of technological innovations. From the initial three robotic arms and lack of bipolar instruments to the later introduction of a fourth arm, longer arms, bipolar hemostasis, and HD vision, these technological advancements have greatly expanded the application range and functionality of robotic surgery. With technological progress, robotic surgical systems can now offer better ergonomic designs, more refined surgical tools, and advanced imaging technologies, making surgeries safer and more effective.
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What Surgeries Can Be Performed?
The application range of robotic surgery is extremely broad, penetrating multiple medical fields such as urology, gynecology, general surgery, orthopedics, neurosurgery, spinal surgery, as well as endoscopic and intraluminal surgeries. According to a review published in J Robot Surg in January 2024, titled “Clinical Applications of Robotic Surgery Platforms: a Comprehensive Review”, robotic surgery platforms like the da Vinci system (Figure 1) have been used for various soft tissue surgeries, such as urological surgeries, gynecological surgeries, general surgical procedures, and head and neck surgeries, which typically require high precision and involve complex operational steps. In orthopedics, robotic surgery is mainly used for joint replacement surgeries, for example, the Mako surgical system, mainly used for total hip replacement and partial knee replacement surgeries, which improves surgical precision and efficiency through preoperative 3D CT planning and intraoperative navigation. Neurosurgery and spinal surgeries require high precision. For instance, the ROSA system has been used in various neurosurgical and spinal surgeries, providing precise instrument placement and reducing hand tremors during the procedure. Endoscopic surgeries, such as cardiovascular interventions, bronchoscopy, and gastrointestinal endoscopy, have also begun to utilize robotic technology. For example, the CorPath system, used for cardiovascular interventions, reduces radiation exposure for both doctors and patients and shortens the surgical duration[1].
Note: (A) da Vinci surgical console; (B) da Vinci multi-arm system; (C) da Vinci SP.Figure 1 Explanation of Soft Tissue Robotic Platforms
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Safety of Robotic Surgery
As a cutting-edge technology in minimally invasive surgery, the safety of robotic surgery has always been a focus of attention in the medical community. In discussions about the safety of robotic surgery, a 2023 article published in Int J Surg, titled “Comparison of Safety and Effectiveness between Robotic and Laparoscopic Major Hepatectomy”, provides us with an in-depth understanding. This article compiled 12 retrospective cohort studies, including 1,657 patients, comparing the safety of robotic surgery and laparoscopic surgery. The results showed no significant difference in surgical mortality and overall postoperative complications between robotic and laparoscopic surgeries. However, robotic surgery displayed potential advantages in reducing the incidence of severe complications, decreasing the rate of conversion to open surgery, minimizing intraoperative blood loss, and shortening postoperative hospital stays (Figure 2)[2].
Figure 2 Comparison of mortality, overall postoperative complications, severe postoperative complications, and conversion to open surgery between robotic and laparoscopic surgeries
Another review published in J Robot Surg, titled “Robotic Versus Laparoscopic General Surgery in the Emergency Setting: a Systematic Review”, also explored the safety of robotic surgery. This review compared the performance of robotic surgery and laparoscopic surgery in emergency surgical settings, covering data from 1,063 patients. The study found that under specific conditions, the incidence of postoperative complications for robotic surgery was as low as that for laparoscopic surgery, although it may require longer surgical times. Additionally, although robotic surgery has higher costs, it can shorten patient hospital stays (Table 1). In laparoscopic bowel resection surgeries involving inflammatory bowel disease, the complication rate was higher, while no significant differences were found in other surgeries[3].
Table 1 Comparison Results between Robotic and Laparoscopic Surgeries
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Artificial Intelligence and Robotic Surgery
The integration of artificial intelligence (AI) is significantly enhancing the precision and efficiency of robotic surgery. AI can analyze and recognize vast amounts of medical imaging data through deep learning algorithms. For instance, in liver surgeries, AI algorithms can analyze preoperative images to predict the presence of microvascular invasion with an accuracy of up to 94%[4]. Moreover, AI applications during surgery, such as optical biopsy technology, can identify tumors based on static images and dynamic videos during the procedure, providing real-time decision support for surgeons. In surgical training, AI technology can reduce training time and improve educational efficiency by providing automatic metrics such as instrument usage and hand movement tracking. AI-generated realistic surgical simulation images and videos offer extensive surgical education at a lower cost, helping to improve surgical skills and shorten learning time (Figure 3).
Figure 3 Integration of Artificial Intelligence in Robotic Surgery
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Outlook for Robotic Surgery
In the future, robotic surgery is expected to achieve higher levels of automation, while optimizing remote surgical technology will enable doctors to perform surgical operations from thousands of miles away, providing high-quality medical services to areas with scarce medical resources. In March 2024, Academician Zhang Xu, director of the Urology Department at the PLA General Hospital, led surgical teams from Beijing and Hainan, manipulating a surgical robotic arm located over 3,000 kilometers away in real-time to perform a radical prostatectomy for a patient at the PLA General Hospital’s Hainan Hospital. In June, Academician Zhang Xu used a domestically developed surgical robot, successfully performing remote surgery for a patient in Beijing while he was in Rome, Italy. The development of remote surgical technology will enable doctors to perform surgeries over greater distances, contributing to the improvement of global healthcare standards.
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Conclusion
The rapid development of robotic surgery technology has brought patients more precise and efficient treatment options. Looking ahead, we have reason to believe that robotic surgery will continue to bring profound changes to the medical field with its unique advantages. Stay tuned for the next installment, where we will provide a detailed analysis of the progress in remote robotic surgery.
Introduction
Academician Zhang XuAcademician of the Chinese Academy of Sciences, chief physician, professor, professional technical level two, military rank one, member of the Communist Party of China, director of the Urology Department at the PLA General Hospital. Member of the Central Health Care Committee Expert Group, incoming chairman of the Urological Surgery Branch of the Chinese Medical Association. A pioneer in laparoscopic and robotic surgery in China, he has established a minimally invasive surgical technology and theory system represented by laparoscopic techniques, widely promoted and applied both domestically and internationally, becoming the standard technology in the field of urology in China. Recipient of the National Outstanding Youth Science Fund, leading talent in military science and technology, chief expert of the National High Technology Research and Development Program, and winner of two second-class National Science and Technology Progress Awards.
References
[1] GAMAL A, MOSCHOVAS M C, JABER A R, et al. Clinical applications of robotic surgery platforms: a comprehensive review[J]. J Robot Surg, 2024, 18(1): 29. DOI: 10.1007/s11701-023-01815-4.
[2] MAO B, ZHU S, LI D, et al. Comparison of safety and effectiveness between robotic and laparoscopic major hepatectomy: a systematic review and meta-analysis[J]. Int J Surg, 2023, 109(12): 4333-4346. DOI: 10.1097/JS9.0000000000000750.
[3] ANYOMIH T T K, MEHTA A, SACKEY D, et al. Robotic versus laparoscopic general surgery in the emergency setting: a systematic review[J]. J Robot Surg, 2024, 18(1): 281. DOI: 10.1007/s11701-024-02016-3.
[4] ZHANG C, HALLBECK M S, SALEHINEJAD H, et al. The integration of artificial intelligence in robotic surgery: a narrative review[J]. Surgery, 2024, 176(3): 552-557. DOI: 10.1016/j.surg.2024.02.005.
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