The Surgical Robot Story

The surgical robot, in 2024, is used in more than 2 million operations worldwide each year, most of them prostatectomies and gynaecological procedures performed with the da Vinci Surgical System. The story of how a machine came to assist in the most delicate operation of all — cutting into a human body — is, in retrospect, a story of how the precision of industrial robotics was married to the dexterity of minimally invasive surgery, with a result that has changed the practice of surgery in less than 25 years.

The history of surgical robotics

The history of surgical robotics is, in many ways, a history of the marriage of two technologies: industrial robotics, which provided the precision and the dexterity, and minimally invasive surgery, which provided the clinical need. The first industrial robot, the Unimate, was installed at a General Motors plant in 1961, and the technology has since become ubiquitous in manufacturing. The first minimally invasive surgery, a laparoscopic cholecystectomy, was performed in 1985, and the technique has since become the standard of care for many abdominal and pelvic operations. The marriage of the two technologies — industrial robotics and minimally invasive surgery — was a natural step, and the first surgical robots appeared in the late 1980s and early 1990s.[1, 2, 9]

The first surgical robot, the ROBODOC, was developed at IBM Research in collaboration with the University of California, Davis, and was used for hip replacement surgery in 1992. The robot precisely milled the femur to receive the implant, with sub-millimetre accuracy, and the result was a better fit and a longer-lasting implant. The ROBODOC was followed by the AESOP (Automated Endoscopic System for Optimal Positioning), a voice-controlled robot that held the endoscope during laparoscopic surgery, freeing the surgeon’s assistant. The AESOP was followed by the Zeus robotic surgical system, developed by Computer Motion, which was the first to provide the surgeon with a console for teleoperation. The Zeus was used in the first transatlantic telesurgery, in 2001, when a surgeon in New York removed the gallbladder of a patient in Strasbourg, France.[1, 2, 9]

The dominant surgical robot, the da Vinci Surgical System, was developed at Intuitive Surgical in California, founded in 1995 by Frederic Moll, John Freund, and Rob Younge. The da Vinci was approved by the US FDA in 2000 for general laparoscopic surgery, and has since been upgraded through four generations (the S, Si, Xi, and SP systems). The da Vinci has more than 75 percent of the global surgical-robot market, and has been used in more than 10 million procedures worldwide. The system is dominant in prostatectomy (more than 85 percent of US radical prostatectomies are now performed with the da Vinci), and is widely used in hysterectomy, partial nephrectomy, and many other urological, gynaecological, and general surgical procedures.[1, 2, 9]

The da Vinci system: how it works

The da Vinci system has three components: a surgeon console, a patient cart, and an insight tower. The surgeon console is a workstation that the surgeon sits at during the operation. It contains a stereoscopic viewer (a pair of high-resolution displays, one for each eye, showing the image from the 3D endoscope), two hand controllers (which the surgeon manipulates with fingers and thumb, in a manner similar to holding a pen), and a set of foot pedals (which control the camera, the energy instruments, and the focus of the system). The patient cart is the robot itself: a set of four robotic arms mounted on a mobile base, positioned over the patient. Three of the arms hold surgical instruments; the fourth holds the 3D endoscope. The insight tower contains the light source, the image processor, the energy generator, and the other supporting equipment.[2, 3, 10]

The instruments are the most innovative part of the system. Each instrument is about 7 mm in diameter and 30 cm long, with a tool at the tip (a needle driver, a scissors, a forceps, an energy device, a clip applier) and a wrist joint near the tip that provides 7 degrees of freedom (compared to the 4 degrees of freedom of a conventional laparoscopic instrument). The wrist joint is critical: it allows the instrument to reach around corners and to perform fine movements in confined spaces. The instruments are disposable and are replaced after each use, at a cost of $2,000–$5,000 per instrument. The endoscope is a 12 mm tube that contains two high-definition cameras and a light source; it produces a stereoscopic 3D image that is magnified 10–15 times on the surgeon’s viewer.[2, 3, 10]

The system’s software provides several important features. Tremor filtering removes the surgeon’s physiological tremor (typically 8–12 Hz), allowing for smoother movements. Motion scaling allows the surgeon to set the ratio between the movement of the hand controllers and the movement of the instruments (a 3:1 ratio means that a 3 cm movement at the console becomes a 1 cm movement at the instrument tip). Instrument swap allows the surgeon to switch between instruments without removing the instruments from the patient. Safety features prevent the instruments from moving outside a defined workspace, and prevent two instruments from colliding. The combination of these features makes the da Vinci system a remarkably effective platform for minimally invasive surgery, and has been the dominant surgical robot for more than 20 years.[2, 3, 10]

The benefits and the limits of robotic surgery

The benefits of robotic surgery, compared to open surgery, are clear: smaller incisions, less blood loss, less pain, shorter hospital stays, and faster recovery. The benefits are most pronounced for procedures in confined spaces, where the robot’s small instruments and 3D vision are a significant advantage. The most common robotic procedure, radical prostatectomy, has been transformed by the da Vinci: the open procedure, which required a 15–20 cm incision, has been replaced by a robotic procedure with six 1 cm incisions, with comparable cancer control and better preservation of urinary and sexual function. Similar benefits have been demonstrated for many other urological, gynaecological, and general surgical procedures.[3, 4, 11]

The benefits of robotic surgery, compared to conventional laparoscopic surgery, are more modest. Several large randomised trials have shown that the da Vinci offers no clear benefit over conventional laparoscopy for many common procedures (hysterectomy for benign disease, cholecystectomy), except in the hands of a very experienced surgeon. The advantage of the da Vinci is most clear for the most complex procedures (radical prostatectomy, partial nephrectomy, rectal resection), where the 3D vision and the wristed instruments make a real difference. For simpler procedures, the da Vinci is a more expensive way to achieve a similar outcome. The cost is significant: a da Vinci system costs $1.5–$3 million, and the instruments and consumables add $1,000–$3,000 per operation. The cost-effectiveness, in many healthcare systems, is marginal.[3, 4, 11]

The other limitation is the lack of haptic feedback. The surgeon cannot feel the tissue through the instruments, which makes some tasks (e.g. suturing, knot-tying) more difficult, and increases the risk of inadvertent damage. Several companies (including Intuitive Surgical) are working on haptic feedback systems, but the technical challenge is significant: the instruments must measure the force at the tip, transmit the signal to the console, and apply the corresponding force to the hand controllers, all in real time and without instability. The lack of haptic feedback is, in 2024, the most significant limitation of the da Vinci system, and the most active area of research.[4, 5, 12]

The new competitors: Hugo, Ottava, and the Chinese market

The dominance of the da Vinci is, for the first time in 25 years, being challenged. The most serious competitor is Medtronic, the world’s largest medical device company, which received FDA approval for its Hugo robotic-assisted surgery (RAS) system in 2021. The Hugo system is similar in concept to the da Vinci (a master–slave teleoperation system with a console, a patient cart, and a set of instruments), but with a modular design (each robotic arm is a separate module, allowing the cart to be configured for different procedures) and a lower price (the system costs about $1 million, compared to $1.5–$3 million for the da Vinci). Medtronic has a large installed base of hospitals (its relationship with surgeons, built over decades of selling other devices) and is using this to drive adoption of the Hugo.[4, 5, 13]

The other major competitor is Johnson & Johnson, which acquired the Belgian surgical-robot company Moon Surgical and is developing its own system, called Ottava. The Ottava is designed around a single cart that can be folded away when not in use, freeing up operating room space. The system is in clinical trials, and FDA approval is expected in 2025–2026. The J&J system is likely to be the most serious threat to the da Vinci, because J&J has one of the largest medical device sales forces in the world, and a strong relationship with surgeons across all surgical specialities.[4, 5, 13]

China is also developing its own surgical robots. Touch Surgery (a subsidiary of Medivis) and Shurui Robot are developing systems for the Chinese market, and the Chinese government has made surgical robotics a priority of the Made in China 2025 plan. The Chinese systems are designed to be cheaper than the da Vinci (about $1 million), with a focus on the domestic market. The competition is likely to drive innovation and reduce prices, and the next decade of surgical robotics will be more competitive than the last.[4, 5, 13]

The future: autonomy, AI, and microsurgery

The dream of a fully autonomous surgical robot — one that can plan and execute a procedure without human intervention — has been a long-standing goal of the field. The most impressive demonstration, in 2022, was the Smart Tissue Autonomous Robot (STAR), developed at Johns Hopkins University, which performed a laparoscopic intestinal anastomosis in a pig without human assistance. The robot used a 3D endoscope, a structured-light scanner, and a deep learning model to plan and execute the suturing, with better consistency than a human surgeon. The result is, in 2024, a research milestone, not a clinical product. The regulatory, ethical, and legal framework for autonomous surgery is still being developed, and the first clinical applications are likely to be in well-defined, narrow tasks (e.g. suturing, bone cutting) rather than in full procedures. The long-term trajectory, however, is clear: more autonomy, more AI, and more use of the robot to do things that a human cannot do as well.[5, 6, 14]

The other frontier is in microsurgery. The Microsure robot, developed in the Netherlands, is designed for supermicrosurgery (surgical anastomosis of vessels less than 0.5 mm in diameter), which is at the limit of human dexterity. The Microsure robot scales down the surgeon’s movements by a factor of 10–20, and uses motion compensation to cancel out the surgeon’s tremor, allowing for more precise suturing. The first clinical use, in 2020, was for the treatment of lymphedema. The trend, in 2024, is toward more specialised robots, each optimised for a particular type of procedure, and toward the integration of AI to assist the surgeon in real time (e.g. identifying the optimal suture line, warning the surgeon of an impending collision, or suggesting the next step in a complex procedure).[5, 6, 14]

The surgical robot, in summary, is a remarkable technology: the most precise and the most dexterous surgical instrument ever developed, and the first to provide the surgeon with a level of control that is not possible with the human hand. It has transformed the practice of surgery in less than 25 years, and it continues to improve. The next decade will see more autonomy, more AI, and more specialisation, as the technology matures and the cost falls. The dream of a fully autonomous surgical robot is still a long way off, but the dream of a robot that can do things that a human cannot do is, in 2024, a reality.[6, 7, 15]

Comparison: leading surgical robots (2024)

System	Manufacturer	Headquarters	Approved	Console type	Approx. system cost	Approx. procedures worldwide (cumulative)
da Vinci (Xi, SP)	Intuitive Surgical	Sunnyvale, California	2000 (FDA)	Open, 3D HD	$1.5–$3 million	~10 million
Hugo RAS	Medtronic	Minneapolis, Minnesota	2021 (FDA)	Open, 3D 4K	~$1 million	~50,000 (early)
Ottava	Johnson & Johnson	New Brunswick, New Jersey	2025–2026 (expected)	Open, 3D 4K	~$1.5 million (est.)	In trials
Mako	Stryker	Kalamazoo, Michigan	2008 (FDA, orthopaedic)	Bone-cutting robot, orthopaedic	$1 million+	~1 million (orthopaedic)
Microsure	Microsure	Eindhoven, Netherlands	2020 (CE)	Microsurgery robot	~€1 million	~1,000 (early)
国产手术机器人 (various)	Shurui, Touch Surgery, others	China	Various	Various	~$1 million	Growing fast

Key numbers

• ~2 million: surgical robot-assisted procedures per year (2024).
• ~10 million: cumulative da Vinci procedures worldwide (2024).
• ~6,500: da Vinci systems installed worldwide (2024).
• ~$7 billion: global surgical robotics market (2024).
• ~$1.5–$3 million: cost of a da Vinci system.
• ~$2,000–$5,000: cost per use of da Vinci instruments.
• ~85 percent: share of US radical prostatectomies performed robotically (2024).
• ~75 percent: da Vinci share of the global surgical-robot market.
• 1992: year of the first surgical robot (ROBODOC).
• 2000: year of FDA approval for the da Vinci.

References

1. Wikipedia, “Surgical robot.” (Standard reference on surgical robots, with a section on the history.) https://en.wikipedia.org/wiki/Surgical_robot
2. Wikipedia, “Da Vinci Surgical System.” (Standard reference on the da Vinci, the dominant surgical robot.) https://en.wikipedia.org/wiki/Da_Vinci_Surgical_System
3. Wikipedia, “Intuitive Surgical.” (Standard reference on Intuitive Surgical, the maker of the da Vinci.) https://en.wikipedia.org/wiki/Intuitive_Surgical
4. Wikipedia, “Computer-assisted surgery.” (Standard reference on the broader field of computer-assisted surgery, of which surgical robotics is a part.) https://en.wikipedia.org/wiki/Computer-assisted_surgery
5. Wikipedia, “Teleoperation.” (Standard reference on teleoperation, the basis of all surgical robots.) https://en.wikipedia.org/wiki/Teleoperation
6. Wikipedia, “MAKO Surgical Corp.” (Standard reference on MAKO, the leading orthopaedic surgical robot.) https://en.wikipedia.org/wiki/MAKO_Surgical_Corp
7. Wikipedia, “Smart Tissue Autonomous Robot.” (Standard reference on STAR, the most advanced autonomous surgical robot.) https://en.wikipedia.org/wiki/Smart_Tissue_Autonomous_Robot
8. Wikipedia, “Robotic prostatectomy.” (Standard reference on robotic prostatectomy, the most common robotic procedure.) https://en.wikipedia.org/wiki/Robotic_prostatectomy
9. Wikipedia, “Unimate.” (Standard reference on the Unimate, the first industrial robot.) https://en.wikipedia.org/wiki/Unimate
10. Wikipedia, “Laparoscopic surgery.” (Standard reference on laparoscopic surgery, the clinical context of surgical robotics.) https://en.wikipedia.org/wiki/Laparoscopic_surgery
11. Wikipedia, “Randomized controlled trial.” (Standard reference on the RCT methodology used to evaluate surgical robots.) https://en.wikipedia.org/wiki/Randomized_controlled_trial
12. Wikipedia, “Haptic technology.” (Standard reference on haptic feedback, the missing feature in most surgical robots.) https://en.wikipedia.org/wiki/Haptic_technology
13. Wikipedia, “Medtronic.” (Standard reference on Medtronic, the maker of the Hugo RAS system.) https://en.wikipedia.org/wiki/Medtronic
14. Wikipedia, “Microsurgery.” (Standard reference on microsurgery, the surgical speciality driving the next generation of robots.) https://en.wikipedia.org/wiki/Microsurgery