In the field of general surgery, there has been a significant rise in the utilization of both robotic and laparoscopic techniques. Robotic surgery, which involves minimal incisions, has advanced rapidly over a short period, benefiting both patients and surgeons alike. Consequently, robotic platforms and tools are becoming increasingly common in general surgery. In the fast-paced world of research and development, the primary aim of this review is to explore the current and emerging technologies in surgical robotics. The future progress in robotics will primarily focus on developing more robust haptic systems to provide tactile and kinesthetic feedback, miniaturization and micro-robotics, improved visual feedback with higher fidelity and magnification, and autonomous robotic systems. It is highly recommended to establish a structured training program with defined benchmarks for success and evidence-based training strategies. This program should encompass a step-by-step progression, beginning with observation, assisting in the programming and manipulation of surgical instruments, acquiring fundamental robotics skills in controlled lab settings, mastering non-technical skills at both individual and team levels, and supervised modular console training, leading to autonomous practice. Prior to independent practice, the mastery of basic robotic skills and procedural activities is imperative as part of robotic surgical training. Additionally, it is advisable to create a systematic training program with performance indicators and research-based instructional techniques.
Introduction and background

Advancements in technology have significantly impacted surgical procedures, necessitating the development of new techniques for evaluating their effectiveness, particularly in technical, legal, and bioethical aspects. The integration of humans and machines has given rise to complex ethical dilemmas that require careful consideration. While the concept of robots assisting humanity has been explored in science fiction works such as those by Isaac Asimov, it is now becoming a reality as robots find their place in our daily lives, performing tasks and assisting individuals both at home and in the workplace. Robots are poised to become integral companions of humans in the near future. For instance, consider BINA48, a robot capable of understanding, interacting with humans, and expressing emotions. Robotic surgery represents a cutting-edge innovation in healthcare, pushing the boundaries of technical prowess to achieve better clinical outcomes. This review delves into the progression of five generations of robotic surgical platforms, including stereotactic, endoscopic, bioinspired, millimeter-scale microbots, and the future development of autonomous systems. Through the incorporation of anatomical and immune-histological imaging, data assimilation, improved visualization, haptic feedback, and robot-surgeon interfaces, we examine the challenges, drawbacks, and potential of robotic surgery. We also consider existing data, cost-effectiveness, learning curves, and the ongoing pursuit of improvements in surgical operative care. The novel impact of this technology has the potential to yield substantial clinical enhancements.
Review
Asimov’s Three Laws of Robotics serve as a foundation for the principles that guide the implementation of robotic surgery. The adoption of robotic surgery in the medical community has surged due to the rapid advancement of technology and the adaptation of existing laparoscopic procedures. Robots are increasingly taking on roles traditionally performed by human surgeons. However, it’s essential to note that many of these developments have not been rigorously evaluated through randomized prospective studies. There are currently three primary categories of robotic surgical systems in use: active, semi-active, and master-slave. Active systems function autonomously, carrying out pre-programmed tasks with minimal surgical team intervention. Notable examples of active systems include PROBOT and ROBODOC. Semi-active systems combine pre-programmed elements with surgeon-driven inputs, while master-slave systems, exemplified by the da Vinci® and ZEUS platforms, offer surgeons complete control without pre-programmed features. The concept of telepresence, developed through a collaboration between Stanford and NASA’s Ames Research Centre, played a pivotal role in advancing laparoscopic procedures. The idea of remotely connecting doctors to patients using robotic platforms presented a breakthrough opportunity for the US military to reduce the morbidity and mortality of service members in conflict zones. Researchers initially involved in this military initiative later transitioned to public and private sectors to market their ideas. The dream of replicating human functions through mechanical robots has been present for thousands of years, but robotics in medicine has only been in use for a few decades. The PUMA 200 was the first “robot surgeon” to operate on a human patient in 1985. The concept of “master-slave” robots, featuring remote manipulators controlled by a surgeon at a workstation, was introduced in the 1990s. However, the high cost and limited haptic feedback have hindered the widespread adoption of current robotic technology in minimally invasive surgery. Reducing costs, developing and testing curricula and virtual simulators, conducting randomized clinical studies to identify the most appropriate applications of robotics, and introducing new platforms and technologies are essential for the future of robotic surgery.
Surgical intervention and practice have been significantly transformed by robotic surgery, with various platforms employed to perform a wide range of procedures. These platforms have demonstrated improved outcomes compared to traditional laparoscopy, owing to technological advances such as three-dimensional interfaces, vibration filtering, enhanced wrist motion freedom, motion scalability, and improved ergonomics through user-friendly interfaces. Robotic surgical systems are now utilized across various medical specialties, including cardiology, urology, endocrinology, metabolic and bariatric surgery, head and neck surgery, and intra-abdominal surgical subspecialties. The use of robotic surgery in urology, in particular, has highlighted the importance of formal training. Early research on robotic surgery raised questions about the technology’s future role. A study conducted in 2006 involving 372 residents and 56 program directors revealed limited experience and considerable uncertainty regarding the current use of robotics in surgery. A little over 15% believed that robotics was a transient trend, 35% considered it here to stay, and 50% remained unsure. Most residents and program directors anticipated an increase in robotic surgery usage in the coming years. A similar percentage of senior urology residents in Canada in 2007 and 2008 had expectations for performing robotic surgery in the future (ranging from 29% to 39%) and believed that robotic surgery utilization would expand (71% to 75%). The current definition of robotic surgery involves the use of small wristed tools connected to a robotic arm to conduct surgical procedures. Surgeons control the device to achieve high-definition magnification while harnessing the precision and miniaturization capabilities of the robotic arm. Despite the relatively recent introduction of robots into the medical field, especially in the realm of surgery, they have quickly become one of the fastest-growing segments. For head and neck surgeons, transoral robotic surgery (TORS) has emerged as a useful and safe technology.

Robotic surgery has progressed from a simple controller to the state-of-the-art da Vinci Xi robot with four arms, each serving specific functions. The use of a binocular device and the ability to observe surgeries on a screen, along with the use of a microphone for effective communication, are also illustrated.
Robotic Surgery: How It Works Traditional mechanical robots operate by translating the surgeon’s hand movements into surgical tool actions through vibrational movements. Future generations of surgical robots will rely on 3D digital segmentation created before surgery to adapt human-initiated activities to a customized surgical plan. The development of intelligent robots has surged across various domains due to advancements in cloud computing, big data analytics, and artificial intelligence. Several surgical companies are collaborating with technology giants to create intelligent surgical robots, driven by the success of deep learning. To create and deploy deep learning models for autonomous robots, key phases in processing and analyzing massive data are highlighted. In 2017, the use of robotic-assisted surgery in typical general surgical procedures increased by 10 to 40 times compared to traditional laparoscopic surgery. The rapid adoption of robotic-assisted surgery necessitates a comprehensive training program, and many such programs are currently in development. Additionally, improvements in virtual simulation tools have made them more accessible for training in robotic surgery. This review aims to shed light on the validation processes associated with existing curricula and training simulators for robotic-assisted surgery.

Robotic head and neck surgery leverages the unique anatomy and natural access points for minimally invasive procedures. Surgical robotics has revolutionized head and neck surgery, building upon a foundation of minimally invasive endoscopic otolaryngology procedures. Despite anatomical constraints that limit visibility and surgical options, surgeons have overcome significant challenges. The field of pediatric robotic surgery presents unique challenges within this rapidly evolving discipline. The adoption of this cutting-edge technology for what are essentially low-volume, complex cases carries a significant cost. Many pediatric surgical centers around the world have been slow to embrace this technology due to the need for equipment primarily designed for adults and financial constraints. The ergonomic challenges posed by the da Vinci® master-slave platform in the limited workspace of pediatric patients add to the hurdles in this context. Robots designed for eye surgery must adhere to fundamental principles, with three design approaches emerging: the steady hand, co-manipulation tools, and telemanipulators with either a fixed or virtually remote center of action. These techniques have been successfully used to perform eye surgery. The da Vinci Surgical System, although not designed for ophthalmic procedures, has demonstrated success in ex-vivo corneal surgery and the correction of pterygia in humans. Transoral robotic surgery has transitioned from an experimental concept to wide acceptance in the treatment of head and neck tumors and other medical conditions over nearly a decade, from 2005 to 2015. It has proven effective in the treatment of laryngeal and pharyngeal cancer, with education and training playing a pivotal role in its widespread adoption.
Robotic surgery has become a valuable addition to the treatment of pelvic organ prolapse (POP), allowing pelvic surgeons to transition from the “gold standard” abdominal sacral technique to a minimally invasive approach with shorter postoperative recovery periods. While robotic surgery offers advantages such as simplified suturing and dissection during procedures, the cost of the technology must be carefully weighed against these benefits. Robotic surgery has simplified total mesorectal excision treatments for rectal cancer, resulting in reduced conversion rates and faster recovery of urogenital function compared to conventional laparoscopic surgery. The primary challenges of robotic surgery are extended operating times and the substantial costs associated with the technology.
The use of laparoscopic surgery for colon cancer has gained recognition as a less invasive approach. However, laparoscopic surgery for rectal cancer, especially lower rectum cancer, remains technically challenging due to limited access. Robotic surgery offers distinct advantages, including 3D imaging, dexterity and ambidextrous capabilities, reduced vibration, motion scaling, and a shorter learning curve. It also overcomes the anatomical limitations of laparoscopy. Robotic colorectal surgery is becoming increasingly popular, benefiting both patients and surgeons. While robust evidence supports its use in pelvic surgery, there is less data on its advantages in abdominal surgery. Newer generations of robotic platforms have addressed some of the technical limitations associated with robotic surgery, indicating potential for expanded use in the near future. The surgical field has embraced emerging technologies, particularly the use of modern robotic systems consisting of a vision device, a motor device responsible for surgical tools, and, in some cases, a vocal command system to facilitate surgeon-device interaction. In some cases, the inclusion of a vocal command system simplifies device management for the surgeon. Complex surgical procedures have been revolutionized by robotic surgical technology over the past 15 years, integrating technical and clinical innovations to enhance surgical quality and patient outcomes. However, the standardization of training and certification for robotic surgeons remains a work in progress.
Conclusions
The role of robots in modern life has evolved significantly since their initial conceptualization. Robots are now found in settings where human limitations pose constraints, and they play crucial roles in various scientific domains, including healthcare. This review has focused on the progress of robots in surgical procedures, emphasizing the substantial benefits they bring to diverse therapies. As the field of robotic surgery continues to evolve, bioethical discussions regarding its integration into medical practice are becoming increasingly important. To facilitate decision-making when robots are involved in patient care, it is essential to establish training programs with well-defined proficiency assessments at each stage. Such programs should encompass the acquisition of non-technical skills in controlled laboratory environments, followed by modular training, culminating in independent practice. Competence and safety in performing fundamental robotic skills and procedural tasks should be demonstrated before independent practice is permitted. Furthermore, the development of a systematic training program with performance indicators and research-based instructional techniques is recommended.