![]() 29 The full set of decisions made by the surgeon before and during the operation lead them to stay within, or to venture outside of their comfort zone. 28 Leung et al propose a different categorisation, according to whether the influential factors are ‘’avowed’ (eg, first, do no harm), ‘unavowed’ (eg, rushing to finish a case on time to avoid cancellation of the next case), or ‘disavowed’ by the surgeon (eg, financial motives). Hendra et al propose a classification of these factors based on whether they are related to the patient, to the surgeon’s experience, or to external factors. ![]() Numerous factors can influence the decisions made by the surgeon during a procedure. 19 23 24 The latter type of event seems to decline with increasing operator experience, and when the robot is in routine use in the specialty. 27 Two main types of adverse events can be distinguished, according to whether they result from material malfunction or human error. ![]() 19 However, this number could be underestimated due to underreporting of complications and adverse incidents. In a retrospective study of the Food and Drug Administration data for the period from 2000 to 2013, Alemzadeh et al estimated the number of adverse events to be 83.4 injury and death events per 100 000 procedures. Conversely, the second point has more general applicability, and is of relevance for all surgeons who may, at one time or another, be called on to interact with a surgical robot. 19–27 The first of these two issues needs to be studied specifically in each specialty, and in each surgical indication. However, numerous controversies persist, mainly regarding two key points: (1) the efficacy of robotic surgical procedures vs the gold standard 12–18 (2) the safety and harmlessness of robotic surgical procedures. There has been growing interest in this topic among the scientific community over the last few years, and the number of scientific publications in this field has plateaued at around 2000 articles per year since 2016. The presence of surgical robots in the operating theatre is now well established. 10 In their annual report for 2019, the company claimed that they had 5582 devices in service around the world (of which 977 are in Europe), accounting for approximately 1 229 000 procedures performed in 2019. 6 The Da Vinci robot, commercialised by Intuitive Surgical, is the most widespread passive, teleoperated robot. When the surgeon is at a distance from the patient or operating theatre, and is following or performing the procedure from a console, then this is called a teleoperated robot. To complete this classification, a further parameter to consider is the location of the surgeon with regard to the operating field. These types of systems are mainly used in urological, gynaecological and digestive surgery. Finally, passive systems are subordinate to the surgeon’s action in real time. 8 9 They are mainly used in neurosurgery. Second, semiactive systems make it possible to position and guide the tools and the surgeon then performs the actual intervention. 5 6 First, active systems are capable of autonomously executing an operating procedure following a preplanned sequence input by the surgeon prior to the procedure. The different robotic surgery devices can be categorised into three groups according to the degree of surgeon involvement. Since this pioneering development, dozens of other surgical robots have been developed to assist surgeons in various ways during diagnostic and therapeutic procedures, 1 making them increasingly safe 2 and less invasive. Arthrobot, the world’s first surgical robot, was developed in Vancouver, Canada in 1983, 1 to manipulate and position the patient’s limb on voice commands from the surgeon during orthopaedic surgery.
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