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found that laparoscopic PD is associated with a signifi- cantly higher rate of pancreatic fistula. They conclude that laparoscopic PD should be limited to patients with a low risk of pancreatic fistula formation. A survey was sent to the members of six international hepatobiliary surgical societies [18]. A total of 435 sur- geons from 50 countries responded. Of these, 79% had performed laparoscopic DP and 29% had performed lap- aroscopic PD. The median personal experience was 20 cases of laparoscopic DP and 12 cases of laparoscopic PD. Respondents generally felt that laparoscopic DP is an important development but that laparoscopic PD needs further assessment. A lack of specific training was considered the major reason for not performing these procedures. Respondents would welcome an inter- national registry. These results represent important op- portunities for the future of laparoscopic and robotic pancreatic surgery. Minimally invasive PD is now offered as a viable op- tion in the care of patients with pancreatic malignancies in the guidelines of the National Cancer Control Net- work [19]. Further studies are needed to carefully evalu- ate long term outcomes. An international registry with standardized data collection would facilitate this. To date, available studies have not shown that outcomes are worse after laparoscopic PD, but they also have not shown any easily identified major advantages other than shorter hospital stay and decreased blood loss. While blood loss may be an important operative outcome, the need for transfusions may be of more clinical relevance, which has not been addressed to date. None of the stud- ies have mentioned a comparison of hospital costs or charges in comparing open and laparoscopic PD. Last, attention is needed to assure appropriate training in this advanced procedure. These issues also must be ad- dressed in the analysis of robotic PD, which is discussed extensively in the subsequent portion of this review. Robotic surgery The word robot was coined by the Czech playwright Karel Capek (1890 – 1938) in 1920 for his play “ Rossum ’ s Universal Robots ” , commonly known as R.U.R., which premiered in Prague in 1921. Since that time, robots have permeated people ’ s imaginations, literature and fac- tories. The word is derived from a Czech word which means “ forced labor ” . Robots are used in many facets of life, especially in manufacturing, greatly simplifying the production of many items, as well as allowing explor- ation of otherwise hazardous areas and other important applications. Robots are sure to play an even greater role in the future, largely made possible by rapid advances is sensing technology and computing on which the entire field of modern robotics is based. Given this, it is not surprising that the extensive use of robots in medicine was not possible until recent developments in micropro- cessor technology. Surgical robotics actually has a fairly long history that became widespread soon after the widespread adoption of laparoscopic cholecystectomy. Before that time, there were some highly specialized robots used. The robotic approach to surgery is a direct outgrowth of laparo- scopic surgery. The AESOP endoscope positioner was introduced in 1993, produced by Computer Motion Inc. (Santa Barbara CA), one of the first commercial entries in this field [20]. The DaVinci system was introduced in 1997 by Intuitive Surgical Inc. (Sunnyvale CA) and was cleared for use in the USA in 2000. The Zeus system was introduced by Computer Motion in 2001. Intuitive Surgical and Computer Motion subsequently merged. There are other robot systems in use and in develop- ment. At this time, the DaVinci system is the predomin- ant robot used in surgical practice today. It is noteworthy that there was considerable initial interest by the military to conduct tele-robotic surgery close to the battlefield. The DaVinci system is a master-slave system [21]. There are three main components including the patient cart, the surgeon ’ s console and the vision cart (Fig. 1). The instruments are inserted into the patient using simi- lar methods as laparoscopic surgery then attached to the arms of the robot on the patient cart (Fig. 2). The sur- geon sits at the surgeon ’ s console and manipulates the instruments using the robotic arms by moving controls at the console. The vision cart gives the same view to everyone in the operating room. Technically, this is robot-assisted surgery, since all motions are controlled by the surgeon ’ s hand. The tips of the instruments move in a manner determined by motion of the surgeon ’ s hands on the joysticks. The instruments move relative to the camera as the surgeon ’ s hands move relative to the eye. This enhances hand-eye coordination in robotic sur- gery. The system includes filtering of tremors, motion scaling and an internal articulated wrist. The DaVinci system costs approximately USD $2 M, as well as about $200,000 maintenance costs annually. There is a great deal of information available of various web sites for In- tuitive Surgical [22, 23]. The use of robots in surgery is a natural extension of lap- aroscopic surgery. Nearly all operations that have been re- ported to have been performed robotically had already been reported laparoscopically. There is a seemingly natural progression from conventional open surgery to laparo- scopic surgery and then to robotic surgery. The develop- ment of robotic surgery has been motivated by the related goals of overcoming the limitations associated with conven- tional laparoscopy as well as to further optimize outcomes [24]. Early in the development of surgical robots, the advan- tages of their use were clear [20]. Robot surgery provides Lefor BMC Biomedical Engineering (2019) 1:2 Page 5 of 15 JULY 2021 | The Surgical Technologist | 307