The implementation of
Robotic Assisted Surgery
Course Biomedical sciences and society
Bachelor Biomedical sciences
Vrije Universiteit Amsterdam
,Table of contents
Table of contents...............................................................................................................1
Introduction........................................................................................................................ 1
Methods............................................................................................................................. 2
Actors and Perspectives....................................................................................................5
Ethical and Societal Aspects..............................................................................................8
Legal and Economic Aspects...........................................................................................10
Discussion and Recommendation....................................................................................12
Introduction
Cardiac surgery has always been a specialty with high risk for the patient and high demand of the
doctors, both technically and physically, and it has become even more complex with the rapid
introduction of new technologies. As a result of these new technologies, the number of minimally
invasive surgical procedures being performed has substantially increased (Siqueira Batista et al.,
2016). The demand for more and more minimally invasive surgery caused a vast increase of robotics
in the operating room, because they assist the surgeon in making the surgery easier to perform and
minimize the trauma to the body of the patient. The robot mostly used in medical practices is the da
Vinci Surgical System with widespread use in laparoscopic, thoracoscopic and cervicoscopic
operations (Siqueira Batista et al., 2016). These robots have contributed to greater precision in
surgical procedures and have expanded the field of view in interventions that require greater surgical
skill. In comparison to a sternotomy approach, the most common and versatile incision, using these
robots in the operating room has a lot of benefits including a smaller incision, less post-operative
precautions, and shorter hospitalization and recovery (Yangawa et al., 2015). Therefore, bringing
these robotics in the operating room is recommended. The most common applications for these
robots in cardiac surgery are single and double vessel coronary artery bypass grafting (CABG), mitral
valve (MV) replacement, the resection of left atrial tumors and the repair of atrial septal defect (ASD).
A study at St. Mary’s Hospital has shown excellent MV repair rates, minimal need for coronary
reintervention, and a vastly lower morbidity profile shown in robotic cardiac surgery in comparison to
the sternotomy approach (Deeba et al., 2006). In other studies a significantly reduced length of stay,
complications, and mortality was shown in patients who underwent robotically assisted cardiac
surgery when compared with patients who underwent non-robotic cardiac surgery (Alvarez & Sloane,
2020). As a result, robotic assisted surgery (RAS) has been adopted by a growing number of
surgeons in their practices.
However, with the introduction of these robots a lot of questions arise not only about the effect on the
personnel and patients or finances of the hospital, but also about the effect on society and the legal
aspects of this new technology. During the beginning stages of RAS, ethical and societal implications
of these new technologies were largely ignored. However, over the past decade questions emerged
among the public regarding these robots.
As technology is gaining the upper hand in our society, some people still struggle deciding whether
these developments oppose the norms and values society is built on. In the case of robotic assistance
that is used for heart surgery it is largely controlled by surgeons and does not operate autonomously.
While current surgical robotics keep evolving and seem to have many advantages over human
treatment, some still have difficulties accepting these newly developed technologies. In a scenario
where the assisting robot performs surgery, resulting in complications that worsen the patient’s state,
questions about who can be held accountable, are not easily answered. Here, not only ethical issues
play a role, but legal implementations also have to be considered. Emerging technologies ask for new
laws that consider all involved actors regarding these assisting surgical robotics. To find a solution for
these issues, this paper discusses how desirable the implementation of robotic assisted surgery is
and what the most important points of attention are for its future development.
1
, Methods
Multiple scientific articles were reviewed to conduct research on the implementation of RAS. Literature
sources demonstrate what previous research has concluded and if there are common conclusions
among the scientific articles that are used. This is in alignment with the goals of this review and is the
reason why this review focuses on literature research. Every section has a separate methodology,
which is discussed below.
Actors and perspectives
To determine which actors are involved in RAS, a Google search was done for robotic surgery. The
articles found were analysed for actors involved in and affected by RAS. With the insight gained from
those articles these were the actors selected: doctors, patients, nurses, engineers, investment
companies, and hospital healthcare managers. To gain a further understanding on these actors'
perspectives on RAS, the online database Google Scholar was used because of its large collection of
articles. The articles were searched using a wide range of keywords often including a combination of
doctors/patients/nurses…, role, involvement and robotic surgery. Additionally Youtube and Google
searches were done using a combination of the keywords doctors/patients/nurses..., opinion,
experience and robotic surgery. For this section of the report only recently published articles were
selected as they reflect the current view of the actors on RAS, most sources used were published
within the past five years. The sources from Google Scholar, Google and Youtube searches were
analysed for information about the influence, opinions and experience of the chosen actors with RAS.
Sources found using Google were only used if the article was written by professionals in their field and
was published on a reliable or organizational website. This way the factual information needed to
determine the different actors’ influence on RAS was obtained via scientific articles, while for more
subjective things like the actors’ experience with RAS more opinionated articles and talks were used.
Ethical and societal aspects
VU library, Pubmed and Google scholar were used. These online libraries were used because of their
extensive collection of articles. Initially keywords such as ethical issue, societal issue, robotic surgery
and robot-assisted surgery were used mostly combined. From this search some review articles
discussing ethical and societal issues in RAS were selected. This was done to obtain a general view
of the multiple ethical and societal issues around this topic. From the information found in these
articles more specific keywords were added. With these new keywords like cost, trust, and future,
combined with the keywords mentioned earlier, a second VU library, Pubmed and Google scholar
search was done. Because not enough information could be obtained from this search, a Google
search was performed using the same keywords. Again, sources found using Google were only used
if the article was written by professionals in their field and was published on a reliable or
organizational website. This way websites and online news articles were found discussing ethical and
societal issues in RAS. For this part of the report, articles were selected on relevance by the date
published, so that the article contained current ethical and societal issues, and relevance to the
2
Robotic Assisted Surgery
Course Biomedical sciences and society
Bachelor Biomedical sciences
Vrije Universiteit Amsterdam
,Table of contents
Table of contents...............................................................................................................1
Introduction........................................................................................................................ 1
Methods............................................................................................................................. 2
Actors and Perspectives....................................................................................................5
Ethical and Societal Aspects..............................................................................................8
Legal and Economic Aspects...........................................................................................10
Discussion and Recommendation....................................................................................12
Introduction
Cardiac surgery has always been a specialty with high risk for the patient and high demand of the
doctors, both technically and physically, and it has become even more complex with the rapid
introduction of new technologies. As a result of these new technologies, the number of minimally
invasive surgical procedures being performed has substantially increased (Siqueira Batista et al.,
2016). The demand for more and more minimally invasive surgery caused a vast increase of robotics
in the operating room, because they assist the surgeon in making the surgery easier to perform and
minimize the trauma to the body of the patient. The robot mostly used in medical practices is the da
Vinci Surgical System with widespread use in laparoscopic, thoracoscopic and cervicoscopic
operations (Siqueira Batista et al., 2016). These robots have contributed to greater precision in
surgical procedures and have expanded the field of view in interventions that require greater surgical
skill. In comparison to a sternotomy approach, the most common and versatile incision, using these
robots in the operating room has a lot of benefits including a smaller incision, less post-operative
precautions, and shorter hospitalization and recovery (Yangawa et al., 2015). Therefore, bringing
these robotics in the operating room is recommended. The most common applications for these
robots in cardiac surgery are single and double vessel coronary artery bypass grafting (CABG), mitral
valve (MV) replacement, the resection of left atrial tumors and the repair of atrial septal defect (ASD).
A study at St. Mary’s Hospital has shown excellent MV repair rates, minimal need for coronary
reintervention, and a vastly lower morbidity profile shown in robotic cardiac surgery in comparison to
the sternotomy approach (Deeba et al., 2006). In other studies a significantly reduced length of stay,
complications, and mortality was shown in patients who underwent robotically assisted cardiac
surgery when compared with patients who underwent non-robotic cardiac surgery (Alvarez & Sloane,
2020). As a result, robotic assisted surgery (RAS) has been adopted by a growing number of
surgeons in their practices.
However, with the introduction of these robots a lot of questions arise not only about the effect on the
personnel and patients or finances of the hospital, but also about the effect on society and the legal
aspects of this new technology. During the beginning stages of RAS, ethical and societal implications
of these new technologies were largely ignored. However, over the past decade questions emerged
among the public regarding these robots.
As technology is gaining the upper hand in our society, some people still struggle deciding whether
these developments oppose the norms and values society is built on. In the case of robotic assistance
that is used for heart surgery it is largely controlled by surgeons and does not operate autonomously.
While current surgical robotics keep evolving and seem to have many advantages over human
treatment, some still have difficulties accepting these newly developed technologies. In a scenario
where the assisting robot performs surgery, resulting in complications that worsen the patient’s state,
questions about who can be held accountable, are not easily answered. Here, not only ethical issues
play a role, but legal implementations also have to be considered. Emerging technologies ask for new
laws that consider all involved actors regarding these assisting surgical robotics. To find a solution for
these issues, this paper discusses how desirable the implementation of robotic assisted surgery is
and what the most important points of attention are for its future development.
1
, Methods
Multiple scientific articles were reviewed to conduct research on the implementation of RAS. Literature
sources demonstrate what previous research has concluded and if there are common conclusions
among the scientific articles that are used. This is in alignment with the goals of this review and is the
reason why this review focuses on literature research. Every section has a separate methodology,
which is discussed below.
Actors and perspectives
To determine which actors are involved in RAS, a Google search was done for robotic surgery. The
articles found were analysed for actors involved in and affected by RAS. With the insight gained from
those articles these were the actors selected: doctors, patients, nurses, engineers, investment
companies, and hospital healthcare managers. To gain a further understanding on these actors'
perspectives on RAS, the online database Google Scholar was used because of its large collection of
articles. The articles were searched using a wide range of keywords often including a combination of
doctors/patients/nurses…, role, involvement and robotic surgery. Additionally Youtube and Google
searches were done using a combination of the keywords doctors/patients/nurses..., opinion,
experience and robotic surgery. For this section of the report only recently published articles were
selected as they reflect the current view of the actors on RAS, most sources used were published
within the past five years. The sources from Google Scholar, Google and Youtube searches were
analysed for information about the influence, opinions and experience of the chosen actors with RAS.
Sources found using Google were only used if the article was written by professionals in their field and
was published on a reliable or organizational website. This way the factual information needed to
determine the different actors’ influence on RAS was obtained via scientific articles, while for more
subjective things like the actors’ experience with RAS more opinionated articles and talks were used.
Ethical and societal aspects
VU library, Pubmed and Google scholar were used. These online libraries were used because of their
extensive collection of articles. Initially keywords such as ethical issue, societal issue, robotic surgery
and robot-assisted surgery were used mostly combined. From this search some review articles
discussing ethical and societal issues in RAS were selected. This was done to obtain a general view
of the multiple ethical and societal issues around this topic. From the information found in these
articles more specific keywords were added. With these new keywords like cost, trust, and future,
combined with the keywords mentioned earlier, a second VU library, Pubmed and Google scholar
search was done. Because not enough information could be obtained from this search, a Google
search was performed using the same keywords. Again, sources found using Google were only used
if the article was written by professionals in their field and was published on a reliable or
organizational website. This way websites and online news articles were found discussing ethical and
societal issues in RAS. For this part of the report, articles were selected on relevance by the date
published, so that the article contained current ethical and societal issues, and relevance to the
2
