**7. Conclusion**

*Latest Developments in Medical Robotics Systems*

**5. Ergonomics of robotic surgery**

**6. Future of robotic surgery**

platforms [1].

discrepancies between these studies, mainly due to different definitions of cost (console and robot; maintenance; instruments; stapling devices) and differences in healthcare and insurance regulations between countries [10]. A large-scale analysis of the NIS database showed that median costs of RATS were significantly higher than conventional VATS [74]. Similar findings were reported in an analysis of the Premier registry by Swanson et al. However, there is evidence to suggest that RATS is comparable or even less expensive than open surgery, mainly due to reduced operative times and shorter hospital LOS [75]. Furthermore, previous studies have shown that as programmes adopt and perform more robotic operations, the overall costs of hospitalisation will decrease [71]. These costs will likely decrease even more over time with the introduction of upcoming competitors' surgical robotic

In addition to the patient-related benefits of robotic surgery, these robotic platforms allow for a more ergonomic working environment for the surgeon [16]. Previous studies have already shown that work-related musculoskeletal disorders are frequently encountered among surgeons and surgical residents [76]. This is a result of several factors, such as frequent repetitive movements of the trunk and upper extremities and prolonged static body positioning [77]. When these work-related musculoskeletal disorders are not corrected early on, they can result in injuries such as carpal tunnel syndrome, wrist tendonitis, chronic back and knee pain, TOS, and the development of varicose veins [76, 78]. Several studies have compared conventional laparoscopic and robotic approaches and have found that surgeons using robotic surgery report less overall pain [79, 80]. In addition, data has shown that ergonomic training courses for surgeons can also significantly reduce pain [77]. However, more robust data from larger studies are necessary to measure the effect of robotic surgery on ergonomics,

and physical and mental fatigue compared to conventional approaches.

Since the introduction of robotic-assisted surgery, surgeons and medical engineers have continuously searched for new technologies and advancements across all surgical fields. Since its introduction approximately 20 years ago, the da Vinci robotic surgery system (Intuitive Surgical Inc., Sunnyvale, CA, USA) has been involved in over 5 million operations, making Intuitive Surgical the largest player in the surgical robotic market [81]. However, with the original da Vinci patents now expiring, many medical 'tech' companies are now setting their sights on joining this lucrative, growing market. New systems in the near future will likely aim to improve on the current robotic models by incorporating new technologies such as single-port instrumental arms, haptic feedback, eye-movement tracking, and virtual reality (VR) [82]. In addition to the technological aspects of the current robotic systems, there are also some important practical limitations that can be improved upon, such as the high operational costs, the size of the robotic systems, and its accessibility in lower-income countries. Several "large" robotic systems have become available in the last few years. Some examples are the Senhance console (TransEnterix, Morrisville, NC, USA), BITRACK system (Rob Surgical, Barcelona, Spain), and the Revo-i surgical robot (Meere Company, Seoul, South Korea). These systems each have some advantages over the da Vinci system, such as haptic feedback or eye-tracking, but are generally limited by their price and large size [81].

**68**

It is without a doubt that robotic surgery has changed the surgical world over the last decade. An increasingly large group of surgeons are incorporating robotic approaches in their daily practice as more and more data has shown the benefits of these approaches. In thoracic surgery, RATS has proven to be a valuable tool for many oncological and non-oncological indications, resulting in it being considered one of the standard treatment approaches in many centres. Similar, although less prominent, trends are being noted in the field of vascular surgery as well. However, despite these promising future perspectives, there is still a lack of well-powered, multi-centre randomised trials comparing robotic approaches to open surgery or conventional laparoscopy/thoracoscopy. Furthermore, more data regarding the cost and cost efficiency of robotic surgery are necessary in order to determine whether the benefits of robotic-assisted approaches outweigh its costs.
