THE

OF

CUTTING EDGE

ROBOTIC SURGERY
Juliette Hoedemakers - s1423592
1 November 2015
New Media (2015-1A)
Creative Technology
University Twente, Enschede
3194 words

ABSTRACT
A very promising and currently emerging technology is robotic surgery. However, due to
rapid advances in this field and the development of many different surgical robot prototypes, many ethical questions might arise too. The use robotically assisted surgical systems
in medical care has some (obvious) advantages like enhanced precision for the surgeon, less
risk for trauma to the patient and reduced costs for society, but there will be unwanted and
unpredictable side effects too and these have to be taken into consideration. What are the
ethics of robotic surgery? It is clear that this is a difficult question to answer. Even though
the future of robotic surgery is bright and the use of robots in clinical environments will
definitely expand enormously the next decades, there are also threats such as safety and
technical problems, investments and marketing and the reduced training opportunities for
upcoming surgeons.

TABLE OF CONTENTS
1.
BACKGROUND P. 01
2.
METHOD P.03
3.
SUMMARY P.07
4.
CONCLUSION P.10
5.
IDEAS FOR FURTHER INVESTIGATION
P.11
6.
REFERENCES P.12

BACKGROUND
Technological developments in the Robotic and Artificial Intelligence sector are growing
very rapidly and they are incredibly fascinating. Nowadays, mechanical robots are an indispensable part of major manufacturing industries. Robots in combination with smart software
have taken over many of the tasks that require speed, endurance and high precision. Due
to their success they have been able to replace a lot of human labour. Advanced operating
systems are able to work almost autonomous and we are implementing more and more artificial intelligence (AI) in everyday software. The way this new technology has conquered
the world and quickly has been implemented in various applications is truly amazing.. This is
fascinating because it proves that humans have the ability to do more than they have ever
imagined themselves, especially compared to what man thought was possible a century
ago. As time passes more and more discoveries are made and further achievements seem
almost endless.
The first telesurgical laparoscopic cholecystectomy was performed with success in March
1997 by Cadire [1]. Ever since, minimally invasive robot-assisted surgery is more alive than
ever and will continue to grow exponentially. In 2000 the use of the da Vinci Surgical
System for performing robotically assisted surgery has been legally acceded. The da Vinci
Surgical System (Intuitive Surgical Inc. Sunnyvale, California) is a telesurgery system that
consists of a high-tech cart which has 3 robotic operative arms that are remotely controlled
by the surgeon. The operation team engages and observes the operation on a video-endoscopic unit (Figure 1). [2]

Figure 1: Representation of the da Vinci Surgical System

There are a few serious limitations in relation to traditional laparoscopy, which include the
inability to perform high-precision sutures, flat vision, unnatural positions for the surgeon
and limited ability to move [3]. The statute of legally implementing robotic surgery can
help vanquish all the restrictions in connection with conventional procedures. Not only
could this improve the efficiency of the operation but also increase the number of patients.
This sounds like a great addition to the different utensils that are available to surgeons but
many issues are still not properly defined or resolved. Many concerns have risen regarding
to the clinical practicality, the duration and level of mastery of the robotic tools and the
safety. Some studies claim that there are circumstances where robotic surgery is not any
safer than other types of surgery but it is more costly [4]. There are also reports and studies showing that robotic surgery is not advanced enough and can even be more dangerous
than regular surgery [5]. These issues have a profound legal and financial entanglement and
since the telerobotic industry is still changing and developing every day, there will be no
exact solution to settle the safety and cost dispute. However it is still valuable and profitable to discuss research and define whether there is an ethical breach of trust. Some have
claimed that commercial interests impel this new upcoming surgery [6]. To summarize it
is of interest to look at all the traditional facets of medical ethics like the duty to present
the best available care, informed consent, corporate marketing and the trust relationship
between the patient and the surgeon. These issues increase as future robotic systems gain
more sovereignty in surgical procedures.

METHOD
To gather information and gain knowledge about any scientific topic, it is very important to
first study the topic to a certain extent. This research strategy is very important in order to
prevent deviating too far from the research question itself and to avoid losing time due to
inefficient searching. To detect and trace articles for What are the ethics of robotic surgery? a list of relevant keywords has been constructed:
ROBOTIC / SURGERY / ETHIC / MORAL / ETHICS / LEGAL / ISSUES / ASSISTED / ASSIST
/ INVASIVE / ARTIFICIAL / INTELLIGENCE / PROBLEM / ROBOT / SURGEON / DOCTOR /
AUTOMATIC / INTELLIGENT / MEDICAL / MEDIC / MACHINE / AUTOMATION / PROCEDURE /
PROCEDURES / COMPUTER / CAPEBILITY / OPEN / TECHNICAL / TELEMEDICINE / DEVELOPMENT / TOOLS / REPLACE / SYSTEM / TELESURGERY
However most search terms were formed with only a selection of the keywords shown
above or with a sentence formed with some of these keywords.
TOTAL OF
RESULTS IN:

SCOPUS

IEEE XPLORE

GOOGLE
SCHOLAR

GOOGLE

Ethics of robotic 84
surgery

24,700

144,00

Ethical robot
medical

14

29

22,500

425,000

Legal issues in
telemedicine

16

31,600

438,000

Robots surgery
ethical dilemma

3,354

8,230

251,00

Robotic surgery
moral

18,800

233,000

Figure 2: Table of search results

When researching scientific subjects it is very convenient to also explore papers written by
predecessors. To find these papers I used search engines like Scopus, IEEE Xplore, Google and Google Scholar.
The first search was a direct search to find out about the ethics of robotic surgery. Since
this search is very specific and paper tittles can include other words, other searches were
also made. The most results came up for Legal Issues in Telemedicine, however the results
were very general and not specific to the ethical and moral roles in robotic surgery. Adding
a few key words or changing robot to robotic also made a difference and narrowed down
the search results.
After cross analysing the search results and clicking on relevant tittles a promising selection
of 10 prime articles were selected:
LIST OF 10 RELEVANT ARTICLES:
1. Ethical trust in the context of robot assisted surgery
http://doc.gold.ac.uk/aisb50/AISB50-S17/AISB50-S17-Sullins-Paper.pdf
2. Ethical Reflections on Health Care Robotics
http://people.na.infn.it/~tamburrini/pub/Datteri_Tamburrini_Ethics%20and%20Robotics.
pdf
3. The ethical controversy of a faulty design: Surgical Robotics
http://www.pitt.edu/~ewm15/EthicsFinal.docx
4. Carry on Automat(r)on: Legal and Ethical Issues relating to Healthcare Robots
http://www.scl.org/site.aspx?i=ed32369
5. Ethical Dilemmas in lapararoscopic, robotic and advanced surgical technology
http://laparoscopy.blogs.com/prevention_management_3/2010/10/ethical-dilemmas-in-laparoscopic-robotic-and-advanced-surgical-technology.html
6. Ethics, robotics and medicine development
http://www.researchgate.net/publication/210361386_Ethics_robotics_and_medicine_development
7. Legal and Ethical Issues in Telemedicine and Robotics
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=944833
8. Telesurgery and Robotic Surgery: Ethical and Legal Aspect
http://www.omicsonline.org/open-access/telesurgery-and-robotic-surgery-ethical-and-legal-aspect-2376-0214-1000355.pdf
9. Robotic technology in surgery: Past, present, and future
http://www.sciencedirect.com/science/article/pii/S0002961004003757
10. Robotics in general surgery: Personal Experience in a Large Community Hospital
http://archsurg.jamanetwork.com/article.aspx?articleid=395121&resultclick=1

After collecting 10 articles its time to narrow it down. The best 3 articles have to be selected which will then be encapsulated in the next chapter SUMMARY. In order to narrow
down the selection to 3 final articles it is important to create a rating system that evaluates
the relevance in relation to the research question. To do this in an organized way it is simple
to make a rating matrix. Each article will be rated and aided by a three-step scale.
An article can be rewarded stars. Each star is worth a point which will indicate which article
is the most useful. The articles will get either 0 stars, one star, or two stars.
The most important criteria are:
RELEVANCE: Does it answer your research question?
** : Yes, the research question is answered
* : A partial answer was given
0 : The research question was not answered
USEFULNESS: Is the article technological and specific?
** : Yes it is specific
* : There is a mix between technological and general information
0: The information given is very general with very little depth
COHERENCE: Does this article contain information that overlaps with other articles?
** : Yes, covers the same information
* : Some articles overlap
0: Information is not covered by any other articles
PEER-REVIEWED: Is the article peer-reviewed?
** : Yes, the article is peer-reviewed
0 : No, The article is not peer-reviewed

ARTICLE
NUMBERS

RELEVANCE

USEFULNESS

COHERENCE

PEERREVIEWED

TOTAL

**

**

**

**

**

**

**

**

**

**

**

**

**

**

**

**

**

10

**

**

**

**

Figure 3: Matrix of article selection

As seen from the matrix above, the 3 articles that are the most suitable are articles 1,9 and
10. Article 7 and 5 are also very relevant but are lacking in usefulness and coherence.

SUMMARY
1.Ethical trust in the context of robot assisted surgery
Robot assisted surgery is part of the area of modern medical care so there is much overlap
of ethical concerns in the existing literature of medical ethics. It is important to be aware
of how technologies of telemedicine affect ethical choices made within surgery. Ethical
trust is the primal question in this research since there is an asymmetry in what the patient
knows about their medical situation and what the surgeon believes is the best treatment to
quell the medical complication. A great deal of effort is put into maintaining a sociological
trustworthiness so that people feel confident putting their lives into the hands of care. Another point is professionalism in surgery since it is also important to take into account that
robotic aid will shrink the potential of other new upcoming medical professionals to develop
the skills that are necessary for their job since robotic surgical devices may even replace
humans entirely or reduce the role that humans play in the present. The medical practice of
surgery has very tight links to technology, sciences and social practices. Therefore this kind
of system is often cited as technoscience. Should the medical industry place more or less
trust in the technology of robotic surgery? This depends on how robotic technoloscience
has modified the original relationship between the patient and the surgeon. When examining this situation it is crucial to not reduce the patient to an object where surgery is performed on. There needs to be an assorted system where humans are treated with care after
and before surgery so that the distant telesurgery can establish ethical trust and consent
between the surgeon and their patients.
Obviously marketing also plays a role since the hospital now features expensive robotic
equipment that they want to use. This does not mean robotic surgery isnt the most beneficial decision to make but it could mean that some patients are misled. Robotic surgery
has the potential to be very beneficial but also completely change the medical industry as
we know it since more autonomous machines will be implemented and the profession of
surgery isnt as open to new practitioners as nowadays. These issues need to all be taken in
consideration when moving forwards.
9. Robotic technology in surgery: Past, present, and future
Almost 20 years has passed since the introduction of robots in the operating room. Since
those 20 years a lot of progression has been made when it comes to integrating robotic
technologies with surgical instrumentation.
However, to build on past success and to fully leverage the potential of surgical robotics
in the future, it is essential to maximize a shared understanding and communication among
surgeons, engineers, entrepreneurs and healthcare administrators.
This paper emphasizes the importance of collaboration between all of these different sectors and discusses future prospects for innovation. There are many advantages tied to robotic surgery and as they continue to evolve in the long term the costs will be outweighed.
Robots will continue to become smaller, easier to use and less expensive.

Something else very important to keep in mind with the development of telerobotics is the
Three Rules of Robotics[7]:
1. A robot may not injure a human being, or, through inaction, allow one to come to harm.
2. A robot must obey all orders given to it from humans, except where such others would
contradict the First Law.
3. A robot must protect its own existence, except when to do so would contradict the First
Law or the Second Law.
These rules provide a fair rational ethical framework for the expansion of robots applied to
the surgical industry.
Furthermore it is also to keep track of all the advantages and disadvantages that telerobotics can bring to the work floor. Surgeons and robots both have their advantages, disadvantages and limitations (Figure 4.)
Another important thing to define is the different roles robots can have in the operation
room:
1. Passive role: The role of the robot is limited in scope, or its involvement is largely low risk
2. Restricted role: The robot is responsible for more invasive tasks with higher risk, but is
still restricted from essential portions of the procedure
3. Active role: The robot is intimately involved in the procedure and carries high responsibility and risk.

Figure 4: Table of advantages and drawbacks for surgeons and robots

The last classification that proposes the expanding active role of robots is inaccurate since
these have been limited due to the lack of artificial intelligence. It is also significant to remember that such an active-role robot will need to be intensively supervised and require
human interaction, which will be draining for the surgeon. Next to that it is also self-evident
that completely autonomous robots will only be allowed to be involved in low risk surgery
(Passive Role). There are only a few truly active robotic instruments available in the medical
sector (Figure 5.)

Figure 5: Current robotic tools in relation to their role

All together it is best to think of medical robotic technology like something that is still very
much in the making. It is surprising how much is already possible but the technology is still
only yet in its infancy. Its natural to be cautious for the surprises this new technology will
bring in the feature and we should be ready to recognize them. According to this article the
rise medical robots needs to be embraced since they have a lot of functionality and utilities
in store for us that are currently beyond our dreams.
10. Robotics in general surgery: Personal Experience in a Large Community Hospital
The Department of General Surgery, Misericordia Hopistal, Grosseto, Italy has made a study
of robot-assisted surgery using the da Vinci Surgical System. 193 patients (74 males and
119 females ranging from 16-91 years old) underwent a minimally invasive robotic procedure
(Figure 6) between October 2000 and November 2002.
The perioperative morbidity rate was 9.3% (18/193 patients) and 6 patients (3.1%) required
a reoperation. The perioperative morbidity rate was 1.5% (3/193 patients.)[8]
Figure 6: Person experience with single robotic procedures
The initial experience at the hospital advocates that robotic surgery can be attainable in
clinical setting. Daily use is safe and can be managed for minimally invasive surgery but the
cost-benefit ratio needs to be assessed.

CONCLUSION
Article 9
Robotic technology in surgery: Past, present, and future provided the most general information. This information is crucial since it is important to obtain background information.
This improves the understanding of the subject and gives a base in case some interested
readers might not have a background in robotic surgery. The paper was quite lightly and
optimistically written and shed light on the many possibilities and great things that can be
achieved with the development of technology. The paper was more popularly written so
that it is accessible for a more general public.
Article 10
Robotics in general surgery: Personal Experience in a Large Community Hospital is an
actual study that offers a lot of data that can help exterminate speculations since it involves
testing. This scientific support keeps the research realistic and fact-driven. These facts help
depict the current situation more clearly.
Article 1
Ethical trust in the context of robot assisted surgery provided the most information and
research regarding the research question. The information was concentrated on the doubts
and where to draw the ethical line between patient and surgeon. This more cautious approach creates awareness for the dangers and the importance to also research the most
negative outcomes that robotic technology in surgery can bring.
The combination of the above articles answered my research question since they circumscribe the current situation, what the exact current ethical dilemmas are and what can be
obtained in the future. The reliability of these results can vary. The most reliable paper was
Article 10 since it is a fact based paper which was peer reviewed. This is the opposite from
Article 9 that is more opinion based.

10

IDEAS FOR FURTHER INVESTIGATION

To discuss this paper in relation to further investigation, there are a few things worth mentioning. The discussion of the ethics within robotic technology for surgery is endless and
needs to be strictly organized since it touches so many different disciplines. Since technology is developing so quickly some of the information can sadly quickly get outdated. It is
important to look at the most recent studies and tests and form solutions to problems from
there. It is true that robotic surgery could be capable of many wonderful and helpful things
but it is of uttermost importance to not get blindsided by the less vital things. The safety
of the patient and surgeon should always come first. In this scenario prevention of errors
would be a solution to most problems. Another crucial point is that most of the negativity
regarding this topic should not be ignored, but needs to be nuanced, since it is based on
trust and most papers are unfortunately still biased.

11

REFERENCES
[1]J. Himpens, G. Leman and G. Cadiere, Telesurgical laparoscopic cholecystectomy, Surgical Endoscopy, vol. 12, no. 8, pp. 1091-1091, 1998.
[2] da Vinci Surgery, Fact Sheet for da Vinci Surgery, 2013. [Online]. Available: http://
drwebbobgyn.com/documents/davinci-fact-sheet.pdf. [Accessed: 01- Nov- 2015].
[3]P. Giulianotti, Robotics in General Surgery, Arch Surg, vol. 138, no. 7, p. 777, 2003.
[4] W. Boggs, MD. Robotic Colectomy No Better, but More Expensive, Reuters Health
Information, reported on Medscape News. December 26, (2013), [Online] Available: http://
www.medscape.com/viewarticle/818302 [Accessed 17- Oct -2015].
[5]J. Carreyrou, Surgical Robot Examined in Injuries, WSJ, 2015. [Online]. Available: http://
www.wsj.com/articles/SB10001424052702304703104575173952145907526. [Accessed:
01- Nov- 2015].
[6] M.B Schiavone,., E.C. Kuo,. R.W.,Naumann, W.M.,Burke, S. N. Lewin, A. I. Neugut, et
al. The commercialization of robotic surgery: Unsubstantiated marketing of gynaecologic
surgery by hospitals. American Journal of Obstetrics and Gynecology,207, 174.e1 174.e17.
(2012).
[7]I. Asimov, The complete robot. Garden City, N.Y.: Doubleday, 1982.
[8.]P. Giulianotti, Robotics in General Surgery, Arch Surg, vol. 138, no. 7, p. 777, 2003.

12