Editorial: Robotics in the performance, safety and learning of surgery - what next?

Abstract

uptake of generative AI may have influenced health administration, workflow, electronic charting, disease interrogation for information and learning, utility of AI or the notion of autonomous microsurgery is still somewhat remote. 4 Is it thus time to revisit the role of machine advances with digital innovation, AI and automation in robotic system for surgery? And how it influences performance, safety and learning to envision a quantifiable and standardizeable paradigm in surgical care? With principles of industry 4.0 reshaping the world, can OR and surgery be the next frontier …, albeit one that demands a pragmatic, scientific and clinical consideration across surgical subspecialties 4 . The contributions in this journal issue attempt to highlight this evolving landscape.Minimally invasive procedures being a key motivation and driver in robotassisted surgery, Zhiyuan et al., demonstrate through a case-control series using the TiRobot ForcePro Superior system, that the robotic screw implantation was associated with significantly reduced intraoperative blood loss, shortened incision length, alleviated pain, and better recovery of shoulder joint function. Relative to workflow and integration of robotics in the OR, accuracy of screw placement, OR time, length of hospital stay and post-op complications were comparable between robot-assisted and conventional surgery.Challenging the perception that robotic systems lack of flexibility, Fritsch and Overschmidt present an algorithmic framework for real-time configuration to a target pose for a hyper-redundant robotic end-effector. In an era where mathematical modelling and simulation offer close real-world representations, this novel inverse kinematic model suggests a potential pathway towards scalable multi-joint and multipurpose dextrous robotic endeffector.Virtual reality (VR) simulations in robotics continue to be an area of interest, with its importance explored and often established in the learning/training of surgery in riskfree environment. Kawahima and colleagues, use an early non-inferiority of headmounted VR simulation for robot-assisted suturing task, as opposed to conventional console based simulation. With early signal suggesting a faster learning towards proficiency amongst VR simulation group, further work and validation will help establish its significance and potential for efficient training paradigms.In the constrained anatomy of dental procedures, where high-volume care expected, Thieringer et al. explore the utility of digital planning systems tailored to patient-specific problem. While ongoing advances in digital infrastructure of robotic platforms with iterative improvement may enable real-world integration, this work highlights the inherent challenges in translating concept to routine and implications on workflow.In neurosurgery, accurate target localization is fundamental, influencing surgical planning and execution. Using established neuronavigation software within a miniature robotic unit, Stealth AutoGuide TM (Medtronic USA), Bath et al. examine the value of learning curve and workflow optimization in stereotactic biopsy procedures. The findings show promising levels of surgeon-independent accuracy and relatively seamless integration into the OR workflow, including procedural safety for biopsy. These are indicative of continued maturation of procedure-specific robotic units with built in navigation capability.Discussion of surgical robotics would be incomplete without reference to endoscopy, both for its minimal-invasiveness, and the potential for recreating an algorithmic advantage over traditional systems. Through interchangeable articulated robotic end-effectors in endoscopic trans-nasal approach, Dmitrikakis and colleagues overcome limitations of current conventional endoscopic toolset. Although pre-clinical, the work demonstrating improved operative access and surgeon dexterity, marks a viable proposition in extending robotic systems to include endoscopy.While this small collection highlights the work of our peers and robot enthusiasts driving the march of robotics into surgery, these and multiple devices including surgical team, add to the ever expanding data-rich environment of OR -underutilized for digital innovation and seemingly closed door for health data safety and compliance. Drawing inspiration from aerospace industry where machine precision, digital inter-connectivity, quantification, standardization, and automation are deeply embedded, surgery continues to be reliant on human operator. Despite text-book knowledge and prolonged training for proficiency, variability is an unavoidable reality.Robotics and AI offers an opportunity to address this variability. Present day robotics not only lack finesse and flexibility required for microsurgery, but also a structured and integrated digital intelligence necessary to mimic human expertise, experience and judgement. When merged with the memory, high-dimensional computation and predictive algorithms of AI, an ideal human-robot formation is conceivable. Autonomous microsurgery would then be an achievable proposition.For this to be realized, robust and scalable digital infrastructure is imperative, incorporating transparent AI, explainability, traceability and validity of digital signatures within the system. Post-quantum level cybersecurity offer a promise within the digital interplay of machine to machine authentication. 5 At the same time, the rapid release of new algorithms and open-source platforms suggest that increasingly adaptive, agile and interconnected robotic systems are within reach -a necessary equalizer and next disruptor in the OR. When controlled for cost, affordability and scalability, a broader adoption of robotics is inevitable -a paradigm for quantifiable and standardizable surgery, a necessary antidote for human variability.In the complex and dynamic landscape of surgery, robotics, its knowledge and predictive autonomy, may well help level the playing field, while empowering new discovery and innovations in perpetuity.