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Sadagopan et al. Art Int Surg 2024;4:387-400 https://dx.doi.org/10.20517/ais.2024.34 Page 393

and better access to the surgical site without the need for the surgeon to contort themselves to maintain a
clear perspective. However, as conventional exoscopes like the Aesculap Aeos require manual or foot
joystick repositioning, groups have proposed designs for autonomous exoscope control, aiming to improve
ergonomics and reduce the surgeon’s physical and cognitive burden compared to joystick control. One
group has developed a markerless method that uses visual data from the operating field to control and
[26]
adjust the robotic arm of the exoscope in real time . Validation was conducted using a 7-DOF robotic
manipulator with a stereo camera in an eye-in-hand setup. The system achieved 89% accuracy in target
detection and tracking, enhanced efficiency with a significantly shorter operation time compared to that
required for foot-joystick control, and a lower overall time that the instrument spent out of the field of view
relative to joystick control.

Another promising system for autonomous neuro-registration is the 6 DOF parallel kinematic mechanism
(6D-PKM) robot, a 2018 stage 3 innovation developed by an Indian group . This system autonomously
[27]
navigates and measures fiducial marker coordinates in the patient’s real space, based on preoperative
imaging, eliminating the need for manual marker placement and reducing line-of-sight issues. Validation
experiments using various phantoms, including a PVC skull model and acrylic blocks, demonstrated
successful registration with a tracking error ranging from 0.50 ± 0.17 cm for low-speed movements to 1.38 ±
0.73 cm for high-speed movements. The proposed system also reduced overall registration time and
minimized the cognitive and physical load on surgeons. The system’s precision and repeatability were
confirmed through experiments that consistently demonstrated high accuracy, indicating substantial
potential benefits.

FDA-approved automated surgical systems
Current FDA-approved surgical systems predominantly fall between stages 0 and 2 proposed by Yang et al.,
providing mechanical assistance or improving pre- and intraoperative visualizations to streamline the
[17]
execution of procedural tasks . Nonetheless, their applications are wide-ranging and a testament to the
potential of integrating robotic innovation into treatment paradigms . We provide an overview of six
[28]
major approved systems and their performances in spine surgery [Table 3].

The da Vinci Surgical System (stage 0-1), developed by Intuitive Surgical, Inc., was first introduced for
formal clinical use in 2000 and cleared to assist with minimally invasive protocols spanning general
laparoscopic surgery. Now on its fifth iteration, the system consists of a surgeon console (with a high-
resolution patient imaging system and master controls), a patient-side cart holding both robotic arms and
EndoWrist instruments [with increased range of motion (ROM) and embedded force feedback], and a
vision system for monitoring of the surgical area. Albeit limited, applications in human spine surgery have
been very promising in controlled clinical settings. Molteni et al. noted the merits of the system in reaching
benign, anterior C1-C2 lesions, evasion of extensive cervical dissection, greater freedom of movement, and
more efficient oro/rhino-pharyngeal suturing . Perez-Cruet et al. employed an off-label, anterior approach
[29]
to the resection of paraspinal tumors presenting with intrathoracic extension in two patients with the da
[30]
Vinci . Additionally, Sadagopan et al. presented a resection of a sciatic notch lipoma with the da Vinci
Machine, demonstrating superior visualization and preservation of critical paraspinal and pelvic
structures .
[31]

The Mazor X Stealth Edition (stage 1) by Medtronic was cleared for spine surgery application in 2018 and
serves to streamline operative navigation. The system brings together preoperative and intraoperative 3D
visualization/implant trajectory tracking (MRI/CT guided) software, a linear optic camera, high-speed drill
systems (Midas Rex and Stealth-Midas), graft inserters (Catalyft PL Expandable Interbody System), and