Robotic surgery, succeeding open and laparoscopic surgery, stands as the third revolution in surgical techniques. To date, numerous robotic surgical systems have been approved for use, such as AESOP, ZEUS, Da Vinci, and Enhance. Among these systems, the Da Vinci surgical system, developed by Intuitive Surgical, received US Food and Drug Administration (FDA) approval in 2000, marking the commencement of commercialization of surgical robots. Over four iterations, the Da Vinci surgical system has emerged as the most popular and widely used surgical robot worldwide.1
In China, the Da Vinci surgical system was first introduced in the Chinese People’s Liberation Army (PLA) General Hospital in 2006 and was applied in robotic-assisted laparoscopic radical prostatectomy (RARP). Although the installation of Da Vinci surgical systems in China had a slow start before 2019, it experienced rapid growth thereafter. By the end of 2022, a total of 314 Da Vinci surgical systems had been installed in 257 institutions, and more than 378,000 procedures had been performed (http://www.sse.com.cn, FUSUN PHARMA). Among those, robotic surgery was the most commonly used in urology, accounting for 46.2% of all procedures, followed by gastroenterological surgery (14.8%), thoracic surgery (14.3%), gynecologic surgery (11.2%), hepatobiliary surgery (7.8%), thyroid surgery (2.7%), cardiac surgery (1.0%), and other surgeries (2.0%) (Figure 1). The increasing use of robotic systems in China is transforming surgical procedures, providing patients with the benefits of greater precision and faster recovery.
Figure 1.
Summary of Da Vinci system installation, surgery volumes, and future directions in China
(A) The cumulative installation and surgical volumes of the Da Vinci system in China.
(B) The proportion of robot-assisted surgeries in different departments, with urology accounting for nearly half.
(C) The future direction of surgical robots.
The Chinese institutions that have made significant contributions to the literatures on robot-assisted surgery (RAS) are primarily the Department of Urology at the PLA General Hospital, the Department of Thoracic Surgery at the Northern Theater General Hospital, and the Department of Urology at Shanghai Ruijin Hospital et al. The Da Vinci surgical system has advantages over laparoscopy, including 3D high-definition vision, tremor filtering, and Endo Wrist instruments with 7 degrees of freedom and 90 degrees of articulation. It enhances precision, flexibility, and control during the operation and facilitates complex procedures with fewer complications and limited incisions.
RARP is the earliest and most widely used urological procedure of the robotic systems in China, followed by nephrectomy and cystectomy. Currently, RARP has become the gold standard surgical procedure for localized prostate cancer. It is associated with less blood loss, shorter hospitalization, and is more favorable for nerve-sparing procedures, although it does require a longer anesthesia time and is more costly. For localized renal cancer, robot-assisted partial nephrectomy assists surgeons in performing complex renal reconstruction procedure and improves the “trifecta” rate (negative surgical margin, minimal renal functional decrease, and no urological complications). For renal cancer accompanying inferior vena cava (IVC) tumor thrombus, radical nephrectomy and IVC tumor thrombectomy remain the standard management, which is a challenging procedure inherently associated with a high rate of perioperative morbidity and mortality. Prof Xu Zhang and his team at the PLA General Hospital have proposed systematic robotic-assisted surgical techniques, including strategies for IVC blockage, dissection, and reconstruction.2 The use of robotic techniques has reduced the perioperative mortality rate from 8.3% –37.5% to 1% and significantly improved the safety of the IVC tumor thrombectomy.2
The successful application of the Da Vinci surgical system in urologic surgery has paved the way for other surgical specialties. The volume of robot-assisted surgeries being performed in China is on the rise, with an expanding scope that includes pulmonary wedge resection, pulmonary lobectomy, hysterectomy, liver lobectomy, coronary artery bypass grafting, and thyroidectomy. Notably, on December 21, 2021, Prof Zhang and his team reached a milestone of 10,000 Da Vinci RAS cases, making them the first Asian and second global surgical team to achieve this feat. This achievement underscores the growing success of RAS in minimally invasive surgery and marks a significant advancement in the field.
While the majority of robotic surgeries in China are performed using the Da Vinci surgical system, there has also been considerable development in Chinese surgical robot companies.3 In 2010, Tianjin University developed the MircroHand A, the first domestically manufactured laparoscopic robotic surgical system. The MicroHand S surgical system was granted market approval by the National Medical Products Administration in Oct 2021, becoming the first domestically approved laparoscopic surgical robot. Other Chinese robotic surgical systems including the Edge MP1000, Toumai MT1000, and KangDuo SR1000 have received medical device registration approval. In July 2022, the SkyWalker system, developed by Shanghai MedBot, obtained FDA certification, becoming the first Chinese robotic surgical system to receive such approval. In addition to pursuing high quality and reliability, Chinese mainland surgical robot companies have a higher cost-effectiveness ratio. With continuous advancement of technology and cultivation of the medical market, Chinese robotic surgical systems are sure to make breakthroughs in their future development.
Despite the widespread adoption of robotic surgery worldwide, there are still several limitations associated with this technology, such as the lack of haptic force feedback, low cost-effectiveness, large size, and complex installation. As technology continues to develop, surgical robots are evolving toward miniaturization, non-invasiveness, telesurgery, digitalization, and intelligence. These advancements can potentially overcome certain limitations.
Single-port robotic-assisted laparoscopy (Sp-RAL)
Sp-RAL can minimize surgical trauma, provide better cosmetic outcomes, and can perform natural orifice translumenal endoscopic surgery. The first Sp-RAL in China was reported by Prof Ma and his team in 2014, which involved robotic transumbilical laparoendoscopic single-site renal cyst decortication. Domestic single-port robotic surgical systems are undergoing rapid development and clinical trials, such as the ShuRui Single-port Robot, the Edge SP1000, and the Toumai SA1000. In March 2022, Shanghai Ruijin Hospital successfully performed a radical colectomy using the ShuRui Single-port Robot, which marked the first-ever surgical application of domestically produced Single-port Robot in China.
Telesurgery
In 2003, the Naval General Hospital in China performed a stereotactic biopsy of brain tumors with the "Li Yuan" system, which marked the first telesurgery in China. However, the use of traditional tele-networks with slow speeds and high latency made it difficult to implement telesurgery safely. Due to the high speed, high reliability, and low latency advantages of 5G networks, the clinical application of Tele-RAS has accelerated significantly. In September 2020, the world’s first 5G remote, robot-assisted radical cystectomy was performed in Qingdao University Affiliated Hospital using the MicroHand surgical system. The success of the operation paved the way for 50 additional remote urological surgeries to be performed in Shandong Province, all of which were completed successfully.4
Haptic force feedback
In open surgery, surgeons can easily perceive the haptic force feedback through direct contact with tissues and organs, allowing operations with the appropriate manipulation. However, in RAS, surgeons only rely on visual feedback, which increases the risk and uncertainty of the operation. To address this issue, there are currently three technological solutions for haptic force feedback in RAS: force/torque sensors, robot’s dynamic modeling, and deformation-based force estimation. The most used solution is to install force/torque sensors on the robotic arm.
Intraoperative navigation and artificial intelligence (AI)
The ultimate goal of RAS is fully autonomous surgery. Intraoperative navigation technology based on preoperative imaging has enabled the digitalization of surgical robots, assisting surgeons in performing precise operations. In 1997, Shanghai Huashan Hospital introduced the Medtronic StealthStation navigation system for the first intraoperative navigation surgery in China. Since then, numerous domestic surgical navigation companies have emerged, including Visual 3D, Sinovation, and Ariemedi, etc.
If intraoperative navigation technology is the "eyes" of surgical robots, then the AI system is their "brain." Benefiting from the development of AI algorithms, robotic surgical systems are becoming increasingly intelligent. In Jan 2022, Johns Hopkins University researchers reported the Smart Tissue Autonomous Robot had performed in vivo robotic laparoscopic intestinal anastomosis on porcine models with a high level of autonomy.5 In the future, AI-based surgery will run through total operative steps, from preoperative disease diagnosis and surgical planning, intraoperative autonomous operation to postoperative histological diagnosis.
Currently, China is experiencing a golden age of clinical application and technological exploration of surgical robots. With the advancement of mobile networks, AI algorithms, and computational imaging, robotic surgery in China will undoubtedly see new development opportunities. In conclusion, the integration of intraoperative navigation technology and AI-based systems holds great potential for the future of surgical procedures in China and worldwide.
Acknowledgments
The authors are grateful to Dr. Hongzhao Li, Dr. Baojun Wang, Dr. Qingbo Huang, and Dr. Peng Zhang from the Department of Urology at the Chinese PLA General Hospital for their valuable contributions and insightful discussions pertaining to the subject matter of this commentary.
Declaration of interests
The authors declare no competing interests.
Published Online: August 16, 2023
Contributor Information
Kunlun He, Email: kunlunhe@plagh.org.
Xin Ma, Email: mxin301@126.com.
Xu Zhang, Email: xzhang301@163.com.
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