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Page 2 of 5 Gagner. Mini-invasive Surg 2021;5:12 I http://dx.doi.org/10.20517/2574-1225.2021.23

interested in the technology for future cardiac applications. I had worked previously with Dr. Gilles Soulez
back at the Hotel-Dieu de Montreal, an interventional radiologist, on a percutaneous guided mammary-
coronary anastomosis, under thoracoscopic guidance, and had experimented with thoracoscopic coronary
[4]
anastomosis in the swine before 1995 . This led to animal and clinical trials at the Cleveland clinic with
[5-7]
small calibre anastomosis like the coronary anastomosis and fallopian tube reconstruction . I then moved
to Mount Sinai School of Medicine in New York in 1998, leading the laparoscopic and bariatric surgery
section, and convinced Larry Hollier, the new chairman of the surgery, to get a lease on ZEUS. After also
convincing Jacques Marescaux from IRCAD to acquire the same model ZEUS, as he did not want initially,
so we could perform using the same system, a surgery between New York and Strasbourg, rather than the
incompatible DaVinci at the time, to perform the first transatlantic robotic assisted surgery . ZEUS had
[8]
been used first for human coronary and cardiac applications, and gynecological applications, but DaVinci
got there first in human general surgical applications [9-11] . Both had their strengths and weaknesses, and
for the next 5 years, conferences were presenting clinical work from those 2 systems. Thus, after the
collapse of Computer Motion due to losing a major key patent lawsuit with Intuitive Surgical, and their
merger in 2003, my development efforts with robotic surgery were halted. The lack of competition for the
next 15 years, led Intuitive to occupy the field alone, and frankly with slow improvements on the existing
system of the 1990’S. For me, it didn’t make sense to perform large suture surgeries (2-0 and 3-0) with
those systems, as we demonstrated already in 1996, the equivalence of laparoscopic surgery, at much lower
[12]
costs . We even did a comparison with the 2 existing robotic systems ZEUS vs. DaVinci, and laparoscopic
surgery, showing no real differences and advantages . One difficulty in comparing laparoscopic surgery
[13]
and robotic surgery is the added 3D vision with robotic surgery, and one had to wonder if we are really
comparing surgical systems or visual systems, as comparison between 2D and 3D systems in laparoscopic
surgery has shown an advantage for non-experience or poorer proficient surgeons [14,15] . It seems to me that
this is what is captured in the comparison of robotic vs. laparoscopic surgery using the existing system,
mostly a 3D effect.

Both the Zeus system and the DaVinci system are not a true robotic system, but rather a “master-slave”
manipulator as used in the nuclear research facilities. Hence, whatever you do with the manipulator, it
is reproduced with fidelity and filtered at the end of the “slave” instrument, or “garbage in, garbage out”.
Hence, if the surgical gesture is excellent, the surgery will be excellent; if it is bad, the surgery will not be
corrected into a good one, due to the lack of artificial intelligence. Also, as Dr. Harvey Cushing, one of
Harvard’s great neurosurgeons, once remarked, “There is no such thing as minor surgery, but there are
[16]
a lot of minor surgeons.”, and robotic assisted surgery still requires skilled hands . Therefore, from that
perspective, what people call “robotic surgery”, is actually laparoscopic surgery with surgical human hands,
period. I continued in the early 2000’s at Mount Sinai School of medicine to dabble with the DaVinci robot
looking for general surgical applications, especially in bariatric surgery, because it was there in the corner
accumulating dust [17,18] . I did not find it useful, and it was slower for me, taking more time to set up the
operating room, and not providing any clinical benefit to patients.

After several clinical series have been published on the matter of robotic-assisted surgery for general
surgery, HPB surgery, thoracic surgery, urology, gynaecology and now other surgical fields, RCT
(Randomized Controlled Trial) data followed this period comparing robotic surgery to laparoscopy, but
also later between robotic surgery and open surgery. Most trials have shown no difference clinically,
between laparoscopic surgery and robotic surgery [19-28] . Why then robotic-assisted surgery vs. open surgery?
Because if you cannot demonstrate a clinical benefit with laparoscopic surgery, then those who sell the
system, will use arguments that it does have benefits over open surgery. However, we already demonstrated
this in the 1990s, where laparoscopic was demonstrated to be superior in decreasing length of stay, pain,
morbidity and mortality, as well as costs. So why repeat it? Perhaps because it is the only argument left,
trying to confirm to the users and patients that robotic surgery is giving benefits on its own. The robotic