The Cost Of Robotic Surgery

Robotic Surgery Running head: THE COST OF ROBOTIC SURGERY

The Cost of Robotic Surgery: Mechanizing Healing Julia Lange University of California Santa Barbara

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Abstract In the field of robotic minimally invasive surgery, it is apparent that advances in technology have conferred increased precision during—and the decreased risk of complications after—a wide range of surgical procedures. Furthermore, patients who are operated on by robots controlled by surgeons enjoy shorter recovery times and fewer visible post-operative scars than those subject to traditional open-surgical procedures. Contemporary robotic hardware serves as a platform with many affordances to further develop autonomous software for minimally-invasive surgical techniques. The evolution of surgery has engaged human hands as primary tools equipped with secondary trinkets to cut, sew, and maneuver within and around patient organs. Delicate control, a fine-tuned dexterity of hand, and refined expertise have been essential in defining standard procedure for surgeons. A traditional surgeon must feel resistance under the scalpel and gauge if more or less force is necessary to exert. It is the surgeon's hand that has ultimately provided the impetus to guide the knife in surgery and the surgeon's muscle has been the engine of repair and healing for centuries. With advances in robotic technology in the operating room, though, the surgeon's hand is no longer the driving force behind the scalpel. Soon, the surgeon's mind will not even be the director of where the robot makes the incision. Research in robotic surgery acknowledges the challenges of integrating new technology in surgical wards, but does not focus enough on the repercussions that the advance in technology will have on the role of the surgeon in the operating room and in society. More fundamentally, as technology advances and slowly displaces the human surgeon from his or her traditional role, the deep-seated ideals of the ancient pact between patient and surgeon are compromised. What it means to wield a scalpel—cutting to heal, slashing to repair, hacking to mend, and extirpating to cure—changes entirely when the human component is removed from above the operating table. In my research, I argue that the robotic lack of intuition, empathy, basic human emotion, and responsibility as surgical tools is harmful to surgery’s practice, its history, and fundamental goals. Surgery plays a central role in medicine, and its history has shaped it into the current practice surgery has become. With every advancement, there has remained a human wielding the rock, bone, or metallic instrument. The ancient art of surgery has always emphasized the humanness of the surgeon. Advances in technology, especially those that threaten the very practitioners, undermine the original sentiment of the ancient practice of surgery and compromise the role of the surgeon (Priestley, 1957). Recognizing the technology-driven ideological shift in the operating room is significant due to the social implications for surgeons as well as all other medical professionals and patients. The philosophy that has existed for thousands of years, since man began healing his fellow human, is at stake. When further advances universalize artificially-intelligent autonomous robot surgeons, human surgeons will become obsolete, the patient-doctor relationship will vastly change, and the definition of surgery will be altered forever.

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An Introduction to Robotic Surgery Twenty-five years ago, if a patient were dispatched to the operating room with twisting pain due to an acute pancreatitis, a surgeon would swiftly make a nearly foot-long incision in her abdomen to investigate the cause and excise diseased tissue. She would be at risk for complications during surgery and recovery. Extensive post-operative bleeding and pain would have her taking painkillers, and she would potentially incur adverse side effects or develop a dependence on them. Her 12-inch laceration would require nursing and extensive soft tissue inflicted during surgery would keep her in the recovery ward for over one week (Park, 2006). Today, this radical invasiveness and prolonged recovery time is almost unheard of in such surgical procedures. Robotic technology has enabled surgeons to perform once-disfiguring procedures with few complications, faster recovery time, and only minute scars. Arising from ideologies of the laparoscopic movement toward minimally invasive surgical technique, robotic technology has quickly evolved in the last two decades. Two popular robotic surgical systems are in widespread use across the United States, the da Vinci Surgical System and the Zeus Robotic Surgical System. Though costly—both in the vicinity of US $1.5 million (Guidarelli, 2006)--almost 1000 systems are in use in United States hospitals (IntuitiveSurgical.com). The FDA-approved operation list for these machines is constantly expanding, and more types of robot-assisted surgeries are being performed every year. During earliest-developed robotic surgery, robots controlled by surgeons make centimeter incisions as ports for the insertion of miniature CT and MRI scanners, clamps, needles, and knives. Surgeons can perform many different procedures with robotic systems, including

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urological, gastrointestinal, gynecological, orthopedic, and other various general surgical procedures (Lanfranco, 2004). Surgeon-directed robotic operations have proven more successful in certain procedures than traditional open surgical or laparoscopic and endoscopic techniques. Public support has led to a recent increase in demand for surgical wards to pursue this technology. The post-operative benefits conferred by robotic surgery are too considerable for hospitals to overlook, and future evolution is easy to envision. Further developments have afforded experimental surgeries that have recently proven the viability of autonomous, artificially intelligent robots capable of executing surgeries without human control. Stand-alone robotic surgeons integrating artificial intelligence and advanced three-dimensional visualization techniques are being tested (Akasie, 2008). These robotic systems, though, distance surgeon and patient, putting a surgeon control interface meters away from the operating table. At the table, robotic arms execute physical incisions, repairs, and suturing instructed by the surgeon. However great technological breakthroughs seem, the future of robotic surgery will bring unavoidable impacts of mechanizing the once fundamentally human endeavor of opening a live patient in order to heal. Patient-doctor relationships and pacts must change. According to Stellato (2007), the antiquated role of the surgeon has him greeting his patient, discussing her options, helping her make an informed decision, and describing the procedure. He can relate to her, discuss her choices and let her know the risks. The author highlights that the patient can be confident that a human surgeon with emotions will be cutting and healing her, and making sensitive decisions if the need arises. Robots are physically incapable of empathy or a warm touch that has always been an integral part of surgical undertakings. The role of surgeons in the medical community and in

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society as a whole will undoubtedly change as artificial intelligence evolves medical robots to perform stand-alone surgery without human guidance. When any industry is mechanized, workers will be displaced from their jobs. This will be the first technology to replace the everessential medical worker. Altering the human component will alter the ideals of surgery as a whole practice as well. In this research, I discuss how surgery is an ancient, sacred endeavor between two human entities, and the replacement of this established humanitarian career will undoubtedly trigger controversy. Modern robotic systems in wide use only distance the patient and surgeon, obscuring the transition from human to robot in a stepwise manner. Revered surgical practitioners have already made the progression from commander of the OR (operating room) to a highly-skilled technician to the robot surgeon. The eventual elimination of OR surgeons–after they have designed software to replace them—will be gradual but tangible. The relationship between doctors and their patients will change on a fundamental level, and being a surgeon will never hold the same meaning that it once did. What is Robotic Surgery? Contemporary robotic surgery is essentially the continuation of endoscopic visualization techniques and laparoscopic minimum invasiveness, involving the implementation of robotic systems as the physical actor at the operating table. There are two major popular robotic surgical systems in widespread use across the United States. These systems are the da Vinci Surgical System and the Zeus Robotic Surgical System. Both utilize a surgeon console and robotic apparatus suspended above the patient. The surgeon control interface is meters from the operating table, where robotic arms execute the physical incisions, repairs, and suturing

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instructed by the surgeon. According to Marescaux (2008), communications technology has also afforded remote telesurgery via satellite, with surgeons and patients thousands of miles apart. Practicality places limitations on such use of the technology, and the most common usage is found in scenes similar to that above, the robotics utilized in minimally invasive surgeries (Marescaux, 2008).

Figure 1. The da Vinci Surgical System (n.d.). Source: IntuitiveSurgical.com

The da Vinci and Zeus Robotic surgery systems work in essentially the same manner. According to Guidarelli (2006), with the da Vinci system, surgeon and team prepare for the operating room in the same manner as in non-robotic surgeries, except that the machine requires extensive sterilization and set-up. Guidarelli notes that the standard setting up and testing procedures for the robotic system before each surgery, usually carried out by nurses and surgical assistants, takes at least 15 minutes. The patient, already anesthetized, is brought into the OR and positioned under the robotic arms. The surgeon then enters, is seated at the console interface— shown in figure 1—and after brief communication with the assistants at the table, begins directing the robot in the procedure. Throughout the surgery, the surgeon does not approach the

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table or patient (Guidarelli, 2006). Further developments in the field of robotic surgery are in artificially intelligent software compatible with the already-developed hardware employed in the da Vinci and Zeus systems. Duke University, for example, is in the final stages of testing an autonomous, programmable surgical system that can perform operations without input from any human (Akasie, 2008). Butter (2006) also recognizes engineer's efforts to integrate MRI and CT technology in software to implement with hardware presently in production. These technological advancements in software will eliminate the surgeon altogether from the OR. The platform for most of this technology is the hardware used in the da Vinci and Zeus surgical systems. Though specific procedures are undeniably more efficient, faster, and less invasive or risky when utilizing the da Vinci or Zeus surgical systems, few in-depth studies of these systems have been documented. Statistical data comparing traditional laparoscopic surgical methods and robotic methods has shown that utilizing robots in the operating room only confers certain procedures an overall advantage (Guidarelli, 2006). Marescaux (2008) argues that further studies and clinical trials are needed to approve the use of these two, and other, systems for different operations. History Preceding Robotic Surgery: An Overview In compiling a history of important events preceding the emergence of robotic surgery, one observes that several widely different histories needed to converge before this new technology could be instituted in the medical field. First, the surgeon—the very human entity that future developments in robotic surgery threaten to replace—has been a crucial member of medical communities and societies for hundreds of years, and has historically taken a sacred

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oath. The history of the surgeon's oath is central to investigating the impact of mechanizing surgery. Second, the seemingly unrelated history of robotics, predating the emergence of the current status of the surgeon, is a fundamental aspect of robotic surgery development. In recent years, historical robotics have become entwined in the history of surgeons. Finally, the direct, linear history of surgical tools, ideologies, and demands adopted by medical professionals— eventually affording robotic surgical systems—is essential to investigating today's procedures and tomorrow's technological fantasies. A Brief History of Surgeons' Oath For thousands of years, educated individuals have taken initiative in opening and curing another's diseased body by accepting responsibility and unmistakable risks. It is believed that around 400 BC, Hippocrates, the founder of Western medicine, wrote the first Hippocratic Oath, highlighting the importance of ethically practicing medicine and the notion of a medical professional's closeness to—and responsibility for—another's life (Markel, 2004). The Oath has been vastly changed throughout the centuries, but holds the ancient sentiment of the doctorpatient pact. Markel points out that Hippocrates' Oath lost popularity for hundreds of years until the early 1500s, when Germany's University of Wittenberg Medical School began incorporating the oath as a mandatory graduation proceeding for each newly sworn doctor. Markel argues that the present day's modified Hippocratic Oath most closely relates to the rendition introduced upon the resurgence of bioethics after World War II. It is clear that throughout history, regardless of doctors' application of a specific oath, society as a whole recognizes the sacred rights bestowed upon medical professionals as fellow human beings with whom others entrust their lives. A Brief History of Robots

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The accepted definition of a “robot” encompasses three levels of tasks. Robots carry out programmed tasks, can be reprogrammed, and are able to modify responses in a human learninglike manner. Hegarty (2008) argues that robots have been an integral part of society for over two thousand years, beginning in 400 BC when Archytas of Tarentum built a self-propelled flying machine. Later, Leonardo da Vinci invented an impressive human-like robot with mechanical features around 1500 AD. With practicality of robots becoming more obvious during the Industrial Revolution, machines aiding manufacturing boomed in this period. Robots of the mid 1900s increasingly served man to simplify life by taking on stressful or humanly impossible tasks. Bulkiness kept robots in specific factory roles until the last five decades when technological advances could shrink and mobilize them (Hegarty, 2008). Modern robotic systems have gained advancement unimagined of even fantastical science fiction novels of the 1920s and on. The great potential of robotics in health care, in parallel with advantages in all other facets of society, is undeniable. The History of Surgical Technology: From Open Surgery to the artificially-intelligent Robot Surgeon Surgery, more than any other medical field, has always faced the difficulty of visualization. The dark interior of the human body disaffords necessary investigation without full invasion of tissues and organs. Even when medical professionals are able to identify malfunctions and afflictions to decide upon best mode of action, there still remains the issue of how to heal in the dark. Long after the causes of disease symptoms were identified, understood, and treatable, there remained the question of how to diagnose and operate without visualizing the problem. For

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example, Lau (1997) claims that the occurrence of gallstones in the gallbladder has been historically recognized as the cause of immense pain, digestive problems, jaundice, pancreatitis, and sometimes eventual death. Historical medical doctors identified these cholesterol and calciferous salt deposits in cadaver gallbladders, but were unable to diagnose the problem in live patients until after the fact (Lau, 1997). Once diagnostic techniques were developed, operating remained a difficulty. Simply opening the patient to investigate risks damaging tissues and introduces viruses and bacteria. According to Lau (1997), in 1882, the first open surgical procedural cholecystectomy—the removal of the gallbladder—was performed. Successive procedures, though, did not see successful recovery statistics due to the large incisions and great invasiveness necessary for the surgeon to identify and remove the organ. Lau points out that during that time period, patients often died in hospitals due to complications from infected wounds. There needed to be a better way to see inside a patient than carving the person open to expose internal organs. According to Lau (1997), endoscopy began with the invention of a primitive gastroscope (for investigation of the GI tract) in 1957, followed by a fiberscope in 1960, and several advanced ultrasonic endoscopes in 1980. The first surgery to adopt endoscopy as standard procedure was the cholecystectomy, aided by the first bile duct visualization by endoscope in 1970 (Lau, 1997). This would eventually become the first and a model operation for noninvasive surgery with the notion of how to avoid blatant carving and trespassing into the patient's fragile body cavities. The most recent distinguishable phase of surgical technology, ultimately triggering patient and hospital demand, rallying medical engineers, and preparing the market for robotic

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surgical systems, is laparoscopy. Laparoscopic techniques arose in the era of endoscopy, where endoscopes and laparoscopes could be inserted into the patient to afford visualization through an eyepiece. Minimal invasiveness was the initial ideology that put laparoscopic surgery into the medical spotlight, as laparoscopes shrank and could be inserted alongside slim instruments of the time (Berlinger, 2006). As Lau (1997) recognizes, when smaller incisions are used to insert tools into the patient, unnecessary damage, infection, and complications are reduced, recovery time is shortened, and scarring minimized. Though many surgeons attempted to apply minimally invasive techniques to various procedures using early laparoscopic tools, Park (2006) argues that early trials were met with poor results and angry patients and families who would have preferred more established techniques. Park (2006) believes that the first procedures proven more effective when executed laparoscopically were also cholecystectomies, the surgical removal of the gallbladder and subsequent reconnection of the common bile duct and cystic duct. The nature of this surgery, with easily-damaged hepatic ducts and veins in close proximity to the gallbladder, requires great visualization and dexterity within the patient. Traditional open surgical methods of the 1880s to the 1980s thus required large incisions of up to 18 centimeters, Park argues, with lengthy recovery times of several weeks. Park further explains that when minimally invasive surgery dawned in the early 1980s and laparoscopic tools affording smaller incisions were introduced, the cholecystectomy was an optimal candidate for trials. Early success of laparoscopic cholecystectomies led to widespread use of the new laparoscopic ideology and tools by 1987 (Park, 2006). As laparoscopy advanced and more dexterous tools were invented, smaller incisions

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became necessary. Berlinger (2006) notes that robotic arms were first introduced in the operating room in the early 1990s, conferring greater precision, originally designed to minimize surgeon's accidental hand tremors that can lead to mortal mistakes in surgery. Robotic surgery lacks extensive clinical trials, but has proven incredibly useful in minimally invasive surgical procedures, delivering capabilities such as filtering surgeons' trembling hand motions to provide smooth incisions (Marescaux, 2008). Guidarelli (2006) points to prostatectomies, in patients with advanced prostate cancer, as one of the first procedures recognized as much more successful when robots were utilized, and standard procedure quickly recommended the use of early robotic arms. Due to the conferred precision of multiple necessary perforations, patients avoid infection, impotency, and recover much quicker after robotic prostatectomies (Guidarelli, 2006). The use of robots in the operating room has become widespread in recent years. According to Berlinger (2006), originally propelled by the United States government and NASA fantasizing about remote telesurgery via satellite and autonomous robotic surgeons on the battlefield, robotic surgery gained practicality when surgical laparoscopic and endoscopic ideology gained popularity in the late 1980s. Lanfranco (2004) emphasizes that minimallyinvasive surgical procedures were introduced in this period, minimizing surgical complications, recovery time, and post-operative scars. The advantages conferred by minimally invasive surgery were recognized immediately, and public interest created demand for advanced tools that could afford greater visualization and dexterity within the patient (Lanfranco, 2004). Beginning with only endoscopes and other breakthrough technologies of the period, biological engineers quickly designed mechanized tools, increasing degrees of freedom and precision within patients' bodies. Presently, robotic technology has afforded NASA's initial dream of remote telesurgery,

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with the da Vinci and Zeus, popular robotic surgical systems that are in widespread use across the United States. These surgeon-directed operations have proven more successful in certain procedures—such as prostatectomies and cholecystectomies—than traditional open surgical or laparoscopic and endoscopic techniques (Guidarelli, 2006). Public support has led to hospital purchases of thousands of robotic systems worldwide (IntuitiveSurgical.com). These robotic systems, though, distance surgeon and patient, with a surgeon control interface meters away from the operating table, where robotic arms execute the physical incisions, repairs, and suturing instructed by the surgeon. Debate regarding the use of robot technology focuses on the cost versus benefits conferred by these systems. Primarily, the monetary cost of robotic surgery implementation cannot be ignored. All hospitals and doctors recognize that these systems are costly and as of 2009, many under-funded hospitals are still unable to afford the $1.5 to $2 million US dollar systems (Guidarelli, 2006). Many argue that these funds can be put to better use in staffing emergency rooms and buying more basic, necessary and proven technology—such as advanced dialysis machines for patients suffering kidney failure. Why would a hospital invest such a large amount of money in a new, perhaps only slightly more successful surgical system when there are other wards desperately in need of basic staffing? Proponents of funding for da Vinci and Zeus systems argue that prices are declining and the investment is sound if new surgeons can perfect their use of such systems, increase hospital success rate statistics, and develop new uses for the robotic systems' purchases in the future. Some argue that the learning curve for surgeons to operate robotic arms effectively is a steep one. Park (2006) argues that while more traditional open surgical techniques can be taught

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in groups, laparoscopic techniques employing more advanced robotic tools must be taught oneon-one due to the specific sensitivity of the instruments and difficulty visualizing the procedure. He claims that such technology complicates the issue of training and puts strains on hospital budgets and expert surgeon schedules (Park, 2006). It is clear from figure 1 (IntuitiveSurgical.com) that the surgeon interface console can only accommodate one person at a time. How are residents supposed to train under an expert surgeon if they cannot see what the surgeon is doing to manipulate the robot? The history of robotic surgery continues presently and extends into the future. Dreams of the 1980s for autonomy in robotic surgeons are being realized, though yet only experimentally. Implications of these new technologies for surgeons are wide and diverse. Surgeons will have to face changing issues of proper training procedures, malpractice liability and insurance, and licensing to use different technology. Akasie (2008) argues that despite challenges, breakthroughs—such as recent MRI technology integration with endoscopy visualization techniques—guide surgeons' utensils toward tumors to extirpate, and away from easilypunctured, fragile arteries. Artificial intelligence software to compliment the da Vinci and Zeus surgical system hardware is quickly evolving. New technology for the operating room and, recently, for diagnostic testing, has been developed (Lanfranco, 2004). The Human Behind the Mask Hippocrates' ancient Oath, as Markel (2004) notes, is taken by all graduating surgeons. It emphasizes the closeness of surgeon and patient and reminds both parties of the sacred pact that they share. The Hippocratic Oath also emphasizes the immense responsibility taken on by a surgeon in agreeing to open a patient to cure him of his ills. Markel further argues that surgeons

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have an especially close relationship with their patients due to the riskiness of surgery. Of all medical professions, surgeons by far have the most intimate connection with the human body. In no other profession is one given such access to another's organs. No other medical professional ever gets as physically close to a patient. The blood on surgeon's hands during surgery is proof to this. Robotic technology has afforded surgeons the ability to perform remote telesurgery, further removing surgeon and patient. This has sparked surgeon's dreams of bringing the skills of expert surgeons to regions with few knowledgeable doctors. With dreams come nightmares for the surgical profession. The mechanization involved in robotic laparoscopic surgery shrinks the world in the same way as a global economy does. With technology that can span continental divides and world oceans, surgery has the ability to become even less personal. The deep-rooted fear of job replacement is evident in any career field, and laparoscopic robotic breakthroughs help extend that anxiety to the once inviolable surgeon. Public distress over telemarketing jobs being outsourced to India may become tomorrow's concern of Chinese surgeons operating at UCSF's surgical ward via satellite from a computer in Taipei. Artificially intelligent software to afford autonomic robotic surgery is now in the late stages of design and testing. One such project, at Duke University, aims to integrate threedimensional imaging techniques with pre-programed surgical schemes to build a stand alone robotic surgeon in the hope to increase efficiency in the OR (Akasie, 2008). Despite promising prospects for the future. these research endeavors pose a true threat to the surgeon's role at the operating table. For modern surgeons in an imperfect science constantly striving for perfection, the opportunity—the promise—to boost success rate, increase efficiency, improve lives and

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science together, is self-evidently not ignorable. The possibilities for robotic surgery appear endless for future technologies in surgical wards worldwide. New software, for example, could measure and analyze an emergency room patient's vital signs in five seconds, integrate data to diagnose the problem in ten seconds, and quickly scan databases of millions of similar cases and outcomes to determine the best mode of action. Software has become a viable instrument for future technology, utilizing the platform of human surgeon-controlled robots. Even the most experienced surgeon holds first-hand exposure to only about a few thousand cases and must make quick decisions based upon intuition alone. Though surgical robots can monitor patient stats during procedures, artificial intelligence software is yet unable to afford ability to integrate outcomes and change scheme during the operation (Butter, 2008). Butter establishes that the foremost experimental technologies and future innovations of operating room robotic surgeons first employ MRI and CT technology to create pre-surgical procedural plans. The robotic surgeon, equipped with information from tens of thousands of surgeries, then proposes courses of action and is programmed with a carefullydesigned procedural schematic, verging on integration levels comparable to that of humans, Butter further argues. Artificially-intelligent, pre-programmed robot surgeons are now in the stages of development. Novel breakthroughs allowing for more human-like cognition occur every year in this research, bringing the future of autonomous robotic surgeons within grasp. Intuition still plays a key role as long as a human mind with memories, goals, and emotions, controls the robotic arm. For example, when presented a four-year-old girl with a burst appendix, the surgeon may, remember when his or her own young daughter faced an acute appendicitis. The practitioner can use memory and emotion to achieve the goal to give full effort

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in saving the girl's life and ensuring a full recovery. While a robot may be programmed to check for unfavorable signs during a procedure, only the surgeon can recall past procedures, sense subtle red flags, and investigate other underlying problems. Parents of the young patient can be assured that a human who can relate to their own situation is doing everything possible to save her. For now, mechanized robotic surgical technology is in its infancy. The da Vinci and Zeus Robotic Surgical systems, as described earlier, distance the surgeon and patient, but ultimately still require human judgment in deciding to make an incision, choosing the right duct to sever, or excising the entire cancer. However, the further mechanization of minimally invasive surgery continues to shape future surgical procedure toward metal cutting flesh without sympathy, empathy, or latex gloves. Skeptics of mechanized surgery, though, assert that the robotic lack of intuition as a surgical tool is harmful to the practice and fundamental goals. A human, given the right to cut open another, defacing a body to heal it, understands the implications of his or her work. The surgeon sympathizes with the patient and he or she knows what it means to lose a finger, limb, or the ability to walk. Most surgeons have experienced death in their own families or have had a first hand experience with dying. A non-human surgical entity with any amount of artificial intelligence will never be afforded the understanding of what it means to lose a family member. A surgeon is a human, and though this ensures fallibility, many patients prefer mortal warmth over statistics (Priestley, 1957). Results, though, in hard survival rates, numbers and figures, sometimes occlude the patient's want for humanistic care. One such skeptic of mechanized surgery is J. Priestley, M.D., writing for a Canadian Medical journal in 1957. Though dated, Priestley's sentiments continue to convey relevance. The

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1950s saw technological advances in the surgical field that challenged ideologies, not unlike the present situation. Priestley emphasizes the continued need for humanistic approaches to surgery, regardless of advancements in technology. Looking to recent American history, the surgeon was a respected community member, earning a small income but enjoying his work with what Priestley (1957) describes as, “kindness, genuine concern for the patient's welfare, a feeling of responsibility...generating a reciprocal feeling of affection and confidence on the part of his patients and the public at large” (p. 149). Surgeons must be careful to continue relating to the humanity of each patient, as he has done for centuries, and prevent seeing each as an entity of diseased platelets and medical challenges to be executed and overcome with technology. Priestley warns surgeons to remember to act in a way to treat the patient as a whole, acting in her best interest, despite advancing technology and procedural specialization leading surgery toward a non-humanitarian future. Priestley (1957) asks, “Have we, with all these scientific and technical developments of the past half a century, lost anything of value?” (p. 149). The ancient ideal of this fundamentally human endeavor will be changed and forever lost if robotic surgery adapts artificial intelligence as a mode of control. The surgeon will be eliminated from the console manipulating the knives. Once a man or woman loses control of the already non-human hand wielding the tools of healing, surgery cannot be the same. As Stellato writes of the art of surgery, technological advancement has only hurt the surgeons' career and reputation (Stellato, 2007). Stellato (2007) quotes two noted doctors on the advancement of technology in this field, Dr. Selzer and Dr. Organ. Dr. Selzer writes; “Yes, time was, surgeons were exalted figures, heroes to whom seemingly miraculous cures were attributed. Nowadays, the surgeon is seen more as a kind of

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supertechnician, his work a step or two beyond the plumber’s” (p. 437). According to Stellato, another doctor, Dr. Organ, fears, “we are surrounded by machines that have become substitutes for common sense and reason. With increasing frequency attempts are being made to substitute technology for the surgeon” (p. 437). What both Priestley and these doctors fear encompasses the loss of intimate patientdoctor relations to impersonal patient-robot interactions, and the ever-pressing concern—as in any technological revolution—of mechanization eliminating jobs in one of the oldest career forms. Mixed public response even further complicates the notion of an ironical laparoscopic, robotic surgery movement aimed at minimizing itself. In the medical field, fear of replacement is unique to surgeons.. As the automobile plant worker, any worker in a career primarily focused in the dexterity of hand is prone to be replaced by faster, more precise machinery. With technological breakthroughs, and now the notion of artificial intelligence rivaling that of humans, the fear is real, and not too distant. No other medical professional is faced with the industrialization of his labors. According to Butter (2008), there are no robotic systems being designed to take the role of other medical professionals, such as dentists, cardiologists, pediatrics, or general practitioners. This is not to imply, though, that surgeons have a simpler task, or that they are frankly more replaceable than other doctors. The issue lies in the well-defined nature of surgery, unlike the more abstract family practitioner, oncologist, or even researcher. Surgeons have a clear-cut, singular goal in a procedure. A diagnosis has been made, a previously-established and proven successful plan of action is designed, and it is up to the surgeon to execute the plan. The human surgeon's main advantage is in forward thinking in the event of an unplanned complication. Because the subject

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is a living being, and unpredictable like the surgeon himself, many things may not go according to plan during surgery. According to Priestley (1957), it is up to the surgeon's common sense, ingenuity, and dexterity of mind to devise a backup scheme in such a situation. Even this progressive thinking, considered fundamentally human, is being investigated and modeled to implement in free-standing autonomous robotic surgeons. Another uniquely human aspect of surgery is the notion of post-operative responsibility and liability. Long before taking his scalpel between his adept fingers, the surgeon acknowledges the risks he is taking in the name of his patient. More significant, though, is his post-operative liability. To err is human, and in any procedure there are decisions made that could lead to patient mortality. The unpredictability of the human body, however, does not limit error to only human surgeons. Regarding accidental injuries in surgery, Purtilo (1998) notes, “Sometimes the injury is a random unavoidable event that occurs due to the slings and arrows of fate that fly to remind each of us of our mortality” (p. 311). An autonomous robotic surgeon, regardless of improved precision and efficiency, will still make judgment calls with ill outcomes due to the unpredictability of the human subject (Purtilo, 1998). In these cases, who will be held liable? The robot cannot be interrogated about why it made an artificially intelligent 'decision' during surgery or mistook one vital duct for another. A robotic surgeon also could not be held legally liable or financially responsible for mistakes during surgery. Where does blame fall here? To the software designers? To the mechanical engineers? To the remaining surgical team assistants present in the OR? Artificially-intelligent robots—the future of robotic surgical technology—will replace human surgeons in the future. His role in the operating room and society will change, as well as

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the relationship between patient and surgeon. Robots, regardless of the advances in artificial intelligence, are incapable of empathy and human consideration and are thus not prepared for the responsibility unique to the surgical profession since the beginning of its history. For now, the human surgeon remains in control of the robotic arm, playing a central role in the OR. Once power shifts away from human hands into robotic, the definition of surgery will no longer remain the same. Caution must be taken in diminishing the human component of surgery and cheapening the concept of healing. Predictions for the Future of Robotic Surgery In a field where the notion of “traditional methods” are constantly updated, debated, and revised, and the distinction between contemporary and future technology is blurred by constant research and experimental data, it is difficult to define the latest state of development. Several thousand surgeon-controlled robotic surgery systems are in use across the United States, with much more advanced, autonomous artificially-intelligent robots developed and in late experimental stages (Akasie, 2008). Excitement for the vast possibilities in the future of robotic surgery is countered by wariness of new technology, and yet undeliberated implications that further advances will have for surgeons of the future. The future of robotic surgery will minimize the surgeon and maximize statistical success rates as NASA and the US military's 1980s fantasies are approached. Breakthrough projects integrate novel imaging techniques with microscopic tools to provide the least invasive techniques possible. Several research universities are funding development teams to design advanced hardware and software to aid in operating rooms worldwide. According to Akasie (2008), Duke University biological engineers are in the final stages

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of developing an autonomous robotic surgeon for use in minimally invasive surgery and biopsies. Engineers are integrating ultrasound technology—to create real-time three-dimensional images—with artificial intelligence software to design robots capable of remote telesurgery without human control. Three-dimensional image technology has greatly improved upon the last medical technological breakthroughs in endoscopic surgery, where light-image cameras are inserted into the patient, relying on miniature flashlights to illuminate internal spaces. The robot has successfully executed pre-programmed, hypothetical surgical schemes with an experimental subject, maneuvering needle tips within a simulated tumor with error as little as two millimeters. Akasie claims that surgical robotic uses are limited to human surgeon-directed procedures, but Duke University engineer's developments include expanding the use of robots to involve autonomic tumor biopsies, sampling and assessing tumor tissues. Major proponents of this new robotic technology include the US government's Medical Research Command, interested in utilizing autonomous, artificially-intelligent robot surgeons on the battlefield. The team is conducting more research to improve the robot's precision and swiftness in surgery (Akasie, 2008). The United States military's original goal of developing robot surgeons for the battlefield is still a force driving technological developments in this era. The replacement of thousands of jobs in the military alone will result when such a system is designed and implemented. Before complete replacement, though, will be a stepwise transition—that is already apparent—where the revered surgeon is reduced to only a technician for robotic systems. Next will be an era of both human and robotic surgeons practicing,undoubtedly triggering controversy as the public becomes

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aware of the displacement. Wider applications will arise for autonomous medical professionals, and the detriment to surgeons in the United States will spread to doctors worldwide.

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