Robotics in cerebrovascular and endovascular neurosurgery

Current applications and prospective for the future

The use of the word 'robot' in any context, brings about the thought of something futuristic. The truth, however, is that we are already in the future. While it may not be stark, development in the field of robotics has crossed leaps and bounds, and surgical robotics specifically has seen tremendous progress.

The use of the robot in neurosurgery dates to even before the arrival of the more popularly known da Vinci system in use today. The first totally autonomous surgical robot to be used was the CyberKnife (Accuray) which was used in neuroradiosurgery and enabled image-guided targeting. This technique has found its use in several kinds of surgery including tumours, vascular malformations and movement and pain disorders.[¹]

The purpose of any machine has always been to accomplish tasks more easily, quickly and precisely than can be done manually. In the surgical context, this translates to operating with minimal invasion and maximal safety. It is apparent that robotic surgery aids in achieving smaller incisions, performing manoeuvers with enhanced dexterity and operative accuracy. Through superior spatial resolution and non-fatigability, robots have been developed to be able to perform a range of complex movements that are otherwise difficult, if not risk prone, for the manual surgeon in the operating field.[^2,3,4]

All these factors provide a very strong impetus for incorporating robotic surgery in vascular neurosurgery. Robots are already available and under further development for interventional neurovascular procedures such as robot-assisted angiography, neuronavigation and guided operative microscopes, coil insertion systems and endoscopic clipping devices. Many procedures can be successfully performed remotely, which may potentially be used in acute stroke intervention on patients in remote locations, with possibly improved functional outcomes.[^2,3,4]

Another highly positive prospect is the use of robots in surgical simulation and training. Practice of approaches with hand–eye coordination and without any risk to the patient, provides a very conducive environment for training and improvement, and also for pre-operative planning and rehearsal of complex surgeries. Robots are already available to virtually train for operations such as third ventriculostomy and transsphenoidal surgery.[^5,6]

The disadvantages to routinely performing robotic neurosurgery, include the steep learning curve and absence of proprioception. Although a survey on attitudes and adoption of robotics and neurosurgery has positively revealed that more than half of the study participants have had some training and have adopted at least one robotic system, available opportunities to train are expensive, and for trained surgeons, integrating robotics into the workflow is a process that few are keen to undertake due to the limited cost–benefit ratio, also in terms of acquisition and maintenance. This especially applies strongly to the Indian scenario. There is also still an obvious shortage of data on clinical outcome, which is the other pertinent point that explains its lack of implementation.[⁷]

On the whole, there is no denying that the possibilities in robotic neurosurgery are vast, especially if you compare against what robots have become capable of performing in other spheres. It would be trailblazing if research and development in this arena is undertaken in India, more so in the academic setting. Only if the current generation is exposed to it as a routine, which they must be encouraged towards, will it be possible for us as a neurosurgical fraternity to see robotics as part of the present.