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Around 20 years ago, few had been able to imagine the future of surgery. Scientific progress and potentiality are amazing, and the next century will proceed in a radical new approach towards the practice of medicine. It will be based on information technology, defined as the devices that acquire information; those that process, transmit, and distribute information, and those that use information to provide therapy. Although conventional surgery will continue to have a presence, there will be radically different surgical approaches and technologies that may become the predominant form of surgery [1]. The field of surgery is entering a time of great change, spurred on by remarkable recent advances in surgical and computer technology. Surgical robotics is on the cusp of revolutionizing evolution of the new technologies. The last decades have seen robots appearing in the operative room worldwide. Thanks to its advancement, robot technology is now regularly used in endoscopic surgery and, in general terms, in minimally invasive surgery. It is still hard to believe that the future of robotics surgery is now. The use of robots has assumed a principle role in main surgical procedures in chief medical referral centers in Western countries. It is used widely for many minimally invasive procedures including Nissen fundopli-cation for treatment of gastroesophageal reflux disease, radical prostatectomy, hysterectomy, donor nephrec-tomy for kidney transplant, and reconstruction of the kidney and ureter, producing safe and notable results with benefit for patients: smaller incisions, less injury to surrounding tissues, lower risk for wound infection, shorter hospitalizations, and quicker recoveries [2-4].

One reason surgical applications are progressing quickly is the large technology base that has been developed in robotics research in the past three decades [5]. Results in mechanical design, kinematics, control algorithms, and programming that were developed for industrial robots are directly applicable to many surgical applications. Robotics researchers have also worked to enhance robotic capabilities through adaptability (the use of sensory information to respond to changing conditions) and autonomy (the ability to carry out tasks without human supervision). The resulting sensing and interpretation techniques that are proving useful in surgery include methods for image processing, spatial reasoning and planning, and real-time sensing and control [6]. In surgery, the robotics system enhances the surgeon's precision and capabilities in laparoscopic procedures, which are performed through tiny incisions with pencil-thin instruments and cameras. The robot moves high-speed cutting tools to perform precise incisions and safe dissection, and the system provides the surgeon a three-dimensional imaging of the operating field, giving intuitive hand movement, resulting in significant improvements over standard laparoscopic surgery. We must not forget that traditional laparoscopic surgery has two-dimensional imaging, and the movement of instruments is "counterintuitive", i.e., similar to doing surgery while looking into a mirror [7].

Robotic surgical systems provide the surgeon with nearly all of the natural movements of the human wrist. They also eliminate natural hand tremors and improve dexterity to enable surgeons to do ever-finer surgery in a more controlled manner [8].

However, humans still are superior at integrating diverse sources of information, using qualitative information and exercising judgment. Humans have unexcelled dexterity and hand-eye coordination, as well as a finely developed sense of touch. Unlike interaction with robots, interaction with human members of a surgical team for instruction and explanation is straightforward. These differences in capabilities mean that current robots are restricted to simple procedures, and humans must provide detailed commands, using preoperative planning systems or by providing explicit move-by-move instructions. Even in the most sophisticated systems, robots are specialized to specific tasks within procedures; humans must prepare the patient, make many of the incisions and sutures, and perform many other functions. Robotic systems are best described as "extending human capabilities" rather than "replacing human surgeons".

In fact, what we today call robot is in reality an effector, a material performer, a transducer of a commands that are directly imparted by the human being that checks and directs closely the sensibility, the move ment, and in practice therefore the action. Nevertheless, in the common imaginary the robot replaces the human being in the working assignments not as ungrateful persons, perfectly adherent to the etymology of the Czech term robota, or "servitude" or "forced labor". Therefore, the trick to imagining the future of surgery is really to think of robots as animated, i.e., an operator and worker endowed with artificial intelligence and founded on the development of complex neural networks to the service of human beings through a truth and height remote control.

Medicine of the future and progresses in new technologies applied to surgery is not only concept of robotics systems and their application in operating room of the future, but also diffusion of knowledge, sharing of ideas, standardization of the procedures, scientific competences of sectors, standardization of the therapies, professional and formative education that, translated in different terms, produce qualitative improvement of healthcare systems worldwide. The scenario of the world of surgery is already changing, passing from the structural organizations to reach the arena of the teaching and the future of new generations of the surgeons.

The introduction on minimally invasive surgery has demonstrated the need for training surgical skills outside the operating room, using animal model or simulators. As laparoscopic surgery involves displaying images on a screen, virtual reality simulation of surgical task is feasible. Different types of simulators have become available. All simulators aim at training psy-chomotor skills, and some simulators also allow training in decision making and anatomical orientation. In the near future virtual reality simulators may become a tool for training and validation of surgical skills and monitoring the training progress [9].

Another field of application of the complex world of advancement in scientific technical progress is the access and the fruition of communication. Widely present in the normal daily life of everyone—especially in Western countries—the new means and modalities of communication and information technologies have significantly revolutionized access to surgical education. The introduction of the Internet information highway into mainstream clinical practice as an information-sharing medium offers a wide range of opportunities to healthcare professional. An amazing example of a world virtual university is WebSurg.com, dedicated to minimally invasive surgery laparoscopic surgery updating and professional education, assuring contributions to the worldwide diffusion of scientific information in an easy and user-friendly way. [10].

The exponential growth in information technology is resulting in a rapid increase in the ability to develop useful applications on the Internet. It is becoming difficult for surgeons to reach their full potential unless they exploit Internet-based activities. This is because the ability to rapidly capture information of quality is an essential ingredient in a reflective approach to surgical problems. More futuristic is the prospect of using computer-based technology to operate on patients from a distance, as proposed by telesurgery. With the advent of laparoscopic surgery, a method characterized by a surgeon's lack of direct contact with the patient's organs and tissue and the availability of magnified video images, it has become possible to incorporate computer and robotic technologies into surgical procedures. Computer technology has the ability to enhance, compress, and transmit video signals and other information over long distances. These technical advances have had a profound effect on surgical procedures and on the surgeons themselves because they are changing the way surgery is taught [11].

Finally, a mention of telementoring. It is used when an experienced surgeon assists or directs another less experienced surgeon who is operating at a distance. Two- and three-dimensional, video-based laparoscopic procedures are an ideal platform for real-time transmission and thus for applying telementoring to surgery. The images viewed by the operating surgeon can easily be transmitted to a central "telesurgical mentor" and permit intraoperative interaction. Several studies have demonstrated the practicality, effectiveness, and safety of surgical telementoring. The goal of this application of telemedicine is to improve surgical education and training, expand patient care, and improve healthcare delivery by allowing access to surgical specialists. Eventually, surgical telementoring could assist in the provision of surgical care to underserved areas, and potentially facilitate the teaching of advanced surgical skills worldwide [12].

What future awaits us? Will surgeons be able to follow the entire and complex world of scientific progresses? Are surgeon of tomorrow ready to be abreast of the increase of knowledge and request of quality of assistance? Modern surgery is relatively young, and despite this it has a history noble, and illustrious sort of audacity, rush and grandiose, and perspective vision of the future. The exponential growth of unknown affairs is still intimately tied to the nature of man and the drive to attain knowledge. The future requires preparation and attention to understanding of the knowledge necessary in the exclusive direction of the interest of humanity, improving performances, increasing quality solutions, providing availability of the scientific competences of sector, standardizing procedures, and providing worldwide formative education.

References

1. Satava RM, Jones SB (1998) Laparoscopic surgery: transition to the future. Urol Clin North Am 25:93-102

2. Horgan S, Vanuno D (2001) Robots in laparoscopic surgery. J Laparoendosc Adv Surg Tech A 11:415-419

3. Hazey JW, Melvin WS (2004) Robot-assisted general surgery. Semin Laparosc Surg 11:107-112

4. Cuschieri A, Buess G, Perissat J (1992) Operative manual of endoscopic surgery. Springer, Berlin Heidelberg New York

5. Khatib O (ed) (1992) Robotics review 2. MIT Press, Cambridge, Massachusetts

6. Craig JJ (1989) Introduction to robotics: mechanics and control, 2nd edn. Addison-Wesley, Reading, Massachusetts

7. Hubens G, Coveliers H, Balliu L, Ruppert M, Vaneerdeweg W (2003) A performance study comparing manual and ro-botically assisted laparoscopic surgery using the da Vinci. Surg Endosc 17:1595-1599

8. Gerhardus D (2005) Robot-assisted surgery: the future is here. J Healthc Manag 48:242-251

9. Korndorffer JR Jr, Dunne JB, Sierra R, Stefanidis D, Touchard CL, Scott DJ (2005) Simulator training for lapa-roscopic suturing using performance goals translates to the operating room. J Am Coll Surg 201:23-29

10. Lunca S, Maisonneuve H, Marescaux J (2004) WebSurg and the Virtual University. Rev Med Chir Soc Med Nat Iasi 108:230-233. Review

11. Marescaux J, Rubino F (2003) Telesurgery, telementoring, virtual surgery, and telerobotics. Curr Urol Rep 4:109-113. Review

12. Rosser JC Jr, Herman B, Giammaria LE (2003) Tele-mentoring. Semin Laparosc Surg 10:209-217. Review

Economics of New Surgical Technologies

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