Minimally invasive surgical techniques have significantly improved patient outcomes by reducing recovery times and post-operative risks. The advancement of robotic surgery, with cutting-edge devices like the da Vinci system and its Single-Port approach, marks a further step forward, delivering even more targeted and less invasive procedures.

“Big cut, great surgeon”. In the past, certainly not many decades ago, the skill and dexterity of a surgeon were judged by the length of the incision and the resulting scar on the patient.

It is precisely through dismantling what we can now call a “myth” that we find one of the clearest confirmations of how surgical techniques have evolved over the years, and how minimally invasive surgery has become a focal point for biomedical research and development.

Minimally invasive surgery, from laparoscopy to robotics, involves making smaller incisions compared to traditional open surgery. This approach offers various benefits for the patient, including shorter hospital stays, faster recovery times, smaller scars, and reduced risk of infections.


Robotic surgery represents a significant advancement in minimally invasive surgery, a field that has transitioned from large incisions to less invasive procedures. This shift not only improves patient experience and outcomes but also reduces hospital stay and recovery times, scarring, and the risk of infections.
Robotic surgery is becoming increasingly common in various medical specialities such as urology, gynaecology, and cardiothoracic surgery. However, not all surgeons are yet trained to use this technology, highlighting the importance of expanding training and access to these innovations. The spread of such systems to more hospitals and clinics could further democratise access to high-quality care and reduce healthcare costs due to the less invasive nature and better post-operative results.
The da Vinci systems are a cornerstone in robot-assisted surgery, offering advanced components such as the surgeon’s console with 3D stereoscopic vision and high-precision robotic arms. The recent development of the da Vinci SP system, with its Single-Port approach, marks a further step towards minimising surgical invasiveness. This new system allows procedures to be performed through a single access point, reducing the impact of incisions and promoting faster, less painful recovery for patients.

Minimally invasive surgery: the evolution of technologies

The fascination with “looking inside the human body” has ancient roots. Some scholars credit Hippocrates (460-377 BC) with the invention of endoscopic techniques, as he performed rectal examinations using a type of speculum.

However, the development of modern endoscopy is attributed to Philipp Bozzini, who invented the “Lichtleiter,” a light conductor that allowed for the inspection of the ear, urethra, rectum, female bladder, cervix, mouth, nasal cavity, and wounds, overcoming the challenge of poor illumination.

In 1853, Antonin Jean Desormeaux was the first to use Bozzini’s “Lichtleiter” on a patient. Further advancements, often occurring independently yet nearly simultaneously, led to significant developments in endoscopy and laparoscopy, laying the groundwork for the instruments used in modern operating theatres.

In 1901, Georg Kelling coined the term “coelioscope” to describe the use of a cystoscope to examine the abdominal cavity of dogs. In 1910, Swedish physician Hans Christian Jacobaeus introduced the term “laparothoracoscopy“.

In 1938, Hungarian internist János Veress developed a spring-loaded needle to drain ascites and evacuate fluids and air from the chest. Over the years, modifications have made the “Veress” needle ideal for achieving pneumoperitoneum during laparoscopic surgery.

In 1970, Harrith Hasson introduced a technique for performing laparoscopy through a small laparotomic incision. The advent of the first solid-state camera in 1982 ushered in the era of “video-laparoscopy.”

n 1981, Kurt Semm performed the first laparoscopic appendectomy, and within a year, all standard surgical procedures were being performed laparoscopically.

The evolution of surgery is not solely about techniques and instruments

The relationships between doctors and patients are equally important. The transformation of surgery and the changing dynamics between doctors and patients have been profoundly influenced by technological innovations and cultural shifts.

The introduction of laparoscopic cholecystectomy in the 1980s and 1990s marked a significant turning point, reflecting patients’ preference for less invasive procedures.

These new techniques were enthusiastically embraced by patients seeking options with shorter recovery times and less pain, and by surgeons who viewed these methods as a way to reduce risks without compromising outcomes. Minimally invasive surgery has become a symbol of a more patient-centred approach, contrasting with the more invasive practices of the past that often reflected a more authoritarian approach to care.

Yet, the desire of patients to influence their treatment is not a new phenomenon. The history of surgery shows that, as early as the 18th century, educated patients negotiated treatments with their doctors, maintaining a degree of decision-making power.

This power diminished in the 19th century with the rise of hospital medicine when doctors began to hold near-monopoly status over scientific expertise. Despite this, patients and their families have continued to play a crucial role in the surgical decision-making process.

The tension between medical authority and patient preferences has been a constant: a dichotomy reflected in historical controversies, where decisions had to balance emerging science with the needs and desires of patients.

Robotic surgery

The idea of employing surgical robots was first suggested in 1967, but it took nearly thirty years of collaboration between the United States Department of Defense, innovative startups, and established research agencies to develop the first fully functional multipurpose surgical robotThe initial prototypes of surgical robots were specialised for specific procedures, particularly remote surgeries on trauma patients in war zones.

The impetus for this innovation was the Department of Defense’s need to reduce battlefield casualties, with DARPA playing a pivotal role in high-risk research and development.

It is important to note that remote surgeries in the 1980s and 1990s were hampered by signal transmission inaccuracies. However, it was later discovered that robotic arms could be extremely useful in civilian contexts, significantly enhancing the precision and efficiency of a surgeon’s hands.

Over the years, both techniques and objectives have evolved: in the 1980s, Robodoc, the first image-guided orthopaedic system for hip replacement, was developed at Sutter General Hospital in Sacramento.

This was followed by PUMA 200, the first robot ever used in neurosurgery in 1985, and subsequently, other systems were developed in the fields of neurosurgery and otolaryngology.

Thus, the development of multipurpose teleoperated robotic systems has been a journey spanning over 40 years, leading to their current status as a standard of care.

How robotic surgery works

Essentially, robotic surgery is a form of minimally invasive surgery that utilises a system comprising one or more specialised robotic arms to manipulate surgical instruments and a camera.

The camera provides a magnified view of the surgical site on a screen, while the surgeon operates from a console. This system allows for more precise movements, which are crucial in delicate or complex operations. Surgeons control the robotic arms from a console, manoeuvring miniaturised instruments and a high-definition three-dimensional camera inside the patient’s body. This setup not only enhances the surgeon’s accuracy but also increases their range of motion and dexterity during procedures.

A key aspect of robotic surgery is that it is entirely controlled by the surgeon. The robotic system does not operate autonomously; it translates the surgeon’s manual movements into more precise actions executed by the robotic instruments.

This ensures that the surgeon maintains control of the operation while benefiting from the enhanced capabilities of the robotic system.

The use of robotics in surgery has been associated with fewer complications, reduced blood loss, and quicker recovery times for patients. Robotic surgery can be applied to a variety of medical conditions and is becoming increasingly common in fields such as urology, gynaecology, and thoracic cardiac surgery.

However, not all surgeons are trained to use robotic systems, and the safety and effectiveness of the technology significantly depend on the surgeon’s experience and the specific circumstances of each case.

Da Vinci: from four-armed robot to single port

Among the systems that have garnered significant recognition and adoption over the years in the field of robot-assisted surgery, the da Vinci robots stand out. Initially developed by Intuitive Surgical in California in 1995, these robots are based on the concept of surgical telepresence, originally conceived by Phil Green of SRI (formerly Stanford Research Institute). The da Vinci system comprises three main components:

  • the surgeon’s console, equipped with a binocular stereoscopic vision system that transmits 3D images of the surgical field, providing an immersive perception
  • the patient cart (Robot), that supports articulated arms with Endowrist joints that replicate human wrist movements with seven degrees of freedom, enhancing the precision of surgical instruments
  • the imaging system, that includes a light source, an insufflator, and a dual camera setup to transmit images to observers and personnel beside the patient

Originally designed for cardiovascular surgery, the da Vinci system has gradually found applications in various other fields such as gynaecology, urology, colorectal, and bariatric surgery. Its ease of manipulation and wide range of arm and instrument movements make it particularly effective in procedures requiring access to multiple quadrants of the abdomen.

Gaining approval from health authorities is a crucial step for the implementation of any new medical device. It is noteworthy that the da Vinci surgical system received FDA (Food and Drug Administration) approval in July 2000, paving the way for its use in the United States. In Europe, the system has been available since January 1999, having received CE certification, affirming its compliance with European medical device standards.

Recognition by these key health authorities has not only legitimised the use of the da Vinci system in medical practice but also paved the way for further innovations and developments in the field of robotic surgery. Notably, the introduction of a second console allows a novice surgeon to be guided by a mentor during operations, enhancing safety and facilitating the learning curve.

Immagine che ritrae il sistema da Vinci SP, il quale offre ai chirurghi una tecnologia robotica assistita, progettata per un accesso preciso ai tessuti del corpo con una tecnica mininvasiva e il vantaggio di ridurre dolore, cicatrici e tempi di recupero post-operatorio (Credit: ab medica).
The da Vinci SP system provides surgeons with robotic-assisted technology designed for precise access to body tissues using a minimally invasive technique, offering the benefits of reduced pain, minimal scarring, and shorter post-operative recovery times (Credits: ab medica).

Da Vinci SP: a further step towards minimally invasive surgery

The latest advancement in robotic surgery is represented by the da Vinci SP, a new device that completes the fourth generation of da Vinci robotic systems, joining the Multiport X and Xi models. The da Vinci SP provides surgeons with the capability to treat a greater number of patients by tailoring the surgery to the patient’s individual characteristics and minimising inflammation resulting from surgical incisions.

Equipped with a single robotic arm, the da Vinci SP enables surgeons to perform complex robot-assisted surgeries through a single point of access, utilising natural orifices to reach organs without incising the muscular wall.

The da Vinci SP integrates advanced robotic technology with a flexible endoscope that delivers high-definition 3D images, allowing visualisation above, below, and around anatomical structures during surgery. Additionally, the advanced instruments offer seven degrees of mobility, surpassing the flexibility and manoeuvrability of the human hand and enhancing surgical precision.

«With da Vinci SP – explains ab medica, which has been bringing da Vinci systems to Italy for 25 years – a single access point, a single 25-35 mm incision, brings the same number of surgical instruments inside the patient as a multi-arm system. There is a 30% reduction in invasiveness».

Advantages of single-port surgery and NOTES

Single-port surgery, performed through a single incision, and NOTES, which stands for Natural Orifice Translumenal Endoscopic Surgery, represent two major innovations in minimally invasive surgery.

Single-port surgery is a type of operation carried out through a single incision, often located at the navel or abdomen, using a robot specifically designed for this technique. This method was first clinically adopted in September 2018 and has since been widely utilised in many international medical centres for various types of procedures, particularly in the fields of urology and otolaryngology. The surgery is performed under general anaesthesia; the surgeon makes an incision through which the robot is inserted to complete the procedure.

The advantages of single-port surgery include less pain, the absence of a need for narcotics to manage pain, a rapid return to daily activities, and nearly invisible scars, thus also reducing post-operative complications common in traditional open and laparoscopic surgeries.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) is a technique that allows access to the peritoneal cavity through natural orifices (oral, rectal, vaginal, bladder) without passing through the anterior abdominal wall. With the NOTES technique, no incision of the abdominal wall is required.

Therefore, from a cosmetic perspective, the procedure is ideal, leaving no scars. It also eliminates common complications arising from abdominal wall incisions, such as hernias or wound infections.

The NOTES procedure is carried out in the same way as an endoscopic procedure using an upper endoscope or colonoscope. Once the endoscope is in the peritoneal cavity, any intervention that a surgeon could perform with a laparoscope or through open surgery can theoretically be executed. This methodology has seen rapid progress, particularly in animal models, while human trials are also advancing.

Robotic surgery in Italy

In Italy, the da Vinci surgical robots were introduced by ab medica, a company based near Milan with 40 years of history in the field of biomedical technologies and devices, which has chosen to pioneer the field of robotic surgery.

As CEO, Francesca Cerruti explains, «We were born and developed on the cornerstone of the minimal effective principle, that is, seeking treatments that cause the least possible damage to the patient’s quality of life while maintaining full efficacy against the disease».

Since 1999, when the first da Vinci system arrived in Italy, robotic surgery has undergone significant evolution. Today, Italy has 200 active systems in 168 hospitals, 130 of which are in the public system, and more than 300,000 patients have been treated.

Eighty percent of the procedures involve urologygeneral surgery, and gynaecology, while the remaining 20 percent covers thoracic surgerycardiac surgeryotolaryngology, and paediatric surgery.

«The Single-Port System – explain representatives from ab medica – allows for an expanded range of patients to be treated. In fact, it ensures a reduction in inflammatory processes associated with incisions and represents a further level of minimally invasive practice. It is no coincidence that among the applications of greatest interest is the surgical treatment of breast cancer. The single-port approach guarantees a completely minimally invasive access in breast surgery, with undoubtedly positive effects, including from a psychological perspective, for the patients».

Glimpses of Futures

In light of these premises, there are numerous observations to be made regarding the development of robotic surgery and its applications within our country. With the aim of anticipating possible future scenarios, let’s now try to outline – using the STEPS matrix – the impacts that these developments could have on multiple fronts.

S – SOCIAL: robotic surgery has a significant impact on society by improving surgical outcomes and reducing complications associated with procedures, which results in substantial economic benefits and cost savings due to the reduction in post-operative care and hospital stays. Globally, only a small fraction of surgical procedures are currently performed with robotic assistance. Therefore, it is essential to continue developing and implementing robotic systems in medical procedures to expand the scope of interventions, ensure broader access, democratise surgery, and ultimately reduce overall healthcare costs.

T – TECHNOLOGICAL: from a technical standpoint, research should focus on enhancing the experience for the surgeon and their team, as well as improving patient outcomes. Anticipated developments in this area include advancements in visualisation, such as better integration of pre-operative and intra-operative images (e.g., radiographs), sensor technology, and augmented reality interfaces. These advancements will make robot-assisted surgery more natural and intuitive, allowing surgeons to execute surgical plans with greater precision and efficiency. Additionally, improvements are expected in electronic components, particularly in terms of miniaturisation, integration, embedded intelligence, and communication. Similar advancements are also expected in the NOTES technique, which is currently primarily used in animal studies.

E – ECONOMIC: the economic sustainability of robotic surgery is directly linked to its usage. As explained by ab Medica: «From 1999 to today, 300,000 patients have been treated in Italy. We anticipate 50,000 procedures will be performed in 2024. This reflects the growth in the use of this technique, considering we have reached 200 systems installed nationwide. A Da Vinci system pays for itself with 200 procedures per year. Exceeding this threshold even results in savings. We can say that a system can be used for 400 clinical cases annually, and the Italian average already exceeds the usage threshold to be considered sustainable. Besides the undeniable clinical advantage, we can now also speak of economic sustainability, given that according to the Ministry of Health, a day of hospitalisation costs the state 800 euros».

P – POLITICAL: one of the key areas that requires further development is the recognition of robotic surgery in the pricing schedules of regional Health Services. «Germany has twice as many systems installed compared to Italy, and both France and England have more systems than we do – explains ab Medica – In Italy, Lombardy, Veneto, Tuscany, and Emilia Romagna are the regions that have invested the most in this field, incorporating and promoting robotic surgery in their pricing schedules. It is a trend that we need to continue fostering».

S – SUSTAINABILITY: from an environmental sustainability perspective, robotic surgery has a higher impact compared to traditional surgery. A study published in the British Journal of Surgery in 2022 reports significant increases in both greenhouse gas emissions and waste production. It remains to be evaluated whether this greater impact can be offset by the benefits observed in terms of the effectiveness of procedures and reduced hospital stays, or by the increased awareness of medical and healthcare staff due to greater practice in using the technique and tools.

Written by:

Maria Teresa Della Mura

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