Robotic Surgery

It is my privilege to guest-edit this issue of the Journal of Reconstructive Microsurgery, dedicated to the special topic of Robotic Surgery. The reader might initially think that a microsurgical journal is a peculiar venue for articles about a machine that has been predominantly used for prostatectomies. I hope to demonstrate that the opposite is true—that there are certain attributes of robotic technology that make it a perfect fit for microsurgery, and I sometimes wonder why it has taken so long for their paths to converge.

Looking back on the meandering history of robotic surgery, it is no wonder that the route to microsurgery has been so convoluted. Initially, robotic surgical research was funded by NASA and the military to facilitate remote operations in forward areas and near-space, where surgical sub-specialists are in short supply. It turned out that these remote applications were not immediately practical, and the technology was licensed to Intuitive Surgical, maker of the DaVinci, for minimally invasive, on-site surgery. The company designed the first generation surgical robot for minimally invasive cardiac surgery. Although this application never gained a strong foothold, a group of innovative urologists applied the platform to prostate surgery, and the modern era of robotic surgery was born.

Since then, robotic surgery has permeated minimally invasive applications in many surgical subspecialties, including gynecologic surgery, weight-loss surgery, hepato-biliary surgery, otolaryngologic surgery, and thoracic surgery. Plastic surgical applications are less obvious because we tend to operate on the skin or just beneath it. Even so, I have spent the last four years developing applications that fit well into the reconstructive armamentarium and provide real benefit to patients. One application, robotic oropharyngeal reconstruction, involves using the surgical robot to access deep portions of the oropharynx to reconstruct oncologic defects without dividing the mandible. This technique is now in use in at least five centers throughout the United States. Robotic harvest of the latissimus dorsi and rectus abdominis muscles are both feasible and effective procedures that save patients large incisions in visible locations. These applications are now in use in at least three centers in the United States.

It has become increasingly clear that, in addition to minimizing access incisions, the two principle benefits of the robotic platform are enhanced visualization and precision. The robot is capable of high-resolution, three-dimensional optics at 10× magnification, and ultra-precision with 100% tremor elimination and up to 5:1 motion scaling. It would seem that any technology seeking to improve upon conventional microsurgery would at least require these two features; so, with that in mind, I began to perform arterial micro-anastomoses robotically.

Eventually, I encountered five like-minded individuals across other disciplines, and in 2009 we formed a society called RAMSES, or Robotic Assisted Microsurgery and Endoscopy Society. This group is founded on the belief that the future of robotic surgery and microsurgery are inextricably intertwined. RAMSES had its first inaugural meeting in Orlando in 2011. There were speakers from every imaginable discipline and corner of the world, either interested in, or already practicing, versions of robotic microsurgery. Some of the proceedings of this meeting are summarized in this issue of the Journal.

Robotic surgery is still in its infancy. We are about to enter the steep part of a curve that will provide us with smaller, more organic machines, augmented reality systems, surgical decision algorithms, much higher levels of precision, life-like haptics and processing speeds beyond our wildest imaginations. This is a very exciting time to be a robotic surgeon, and an even more exciting time to be a robotic microsurgeon. The articles in this issue of JRM represent our earliest forays into this new discipline. As you read, try to imagine not just the applications for robotic microsurgery today, but the amazing possibilities that await us tomorrow.