In the late 1980s, DARPA, the American military technology agency, began a project to allow soldiers on the front lines to be operated on remotely by surgeons in the United States or at allied bases. Although it did not reach that point, the project initiated the creation of surgical robots. Even before the manufacturer Intuitive became the reference in the global market, Computer Motion developed the AESOP 1000 robotic arm, associated with a command center (ZEUS). This first robotic system was used for transcontinental surgery, where surgeon Michel Gagner (in New York) operated on a patient in Strasbourg, France, assisted by French surgeon Jacques Marescaux. A major breakthrough was made by the need for the US Armed Forces to perform remote surgeries in the 1990s, with the expectation of having robotic arms in hospitals close to the front lines, while in the US or elsewhere in the world, the main surgeon, operating a joystick, would perform the procedure. However, the project did not go ahead due to limitations in data transmission speed and the impossibility of operating on the battlefield without someone handling the robot on site. However, this project was continued by the company Intuitive Surgical (Sunnyvale, CA, USA), and, in fact, robotic surgery, as we know it today, began in 1999 with the creation of the Da Vinci® robot. In 2000, the Da Vinci was approved by the FDA (Food and Drug Administration) for use in patients.

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DaVinci Si

On March 30, 2008, the first surgery in Brazil was performed using the Da Vinci robot. The surgery was a urological prostatectomy at the Sírio Libanês Hospital (SP). The Albert Einstein and Nove de Julho hospitals, both also in São Paulo, subsequently purchased the equipment. In 2011, the first year of the survey, a modest 450 surgeries had been performed. On August 9, 2013, the Hospital de Clínicas de Porto Alegre was the first hospital to offer this surgery through the Unified Health System. By 2014, there were already 13 systems of this type in Brazil, accounting for one third of the 36 robots sold to Latin America. Meanwhile, in the United States, the number reached approximately 1,800 devices. In addition to the hospitals already mentioned, Oswaldo Cruz, AC Camargo, the São Paulo State Cancer Institute (ICESP), in São Paulo, and the National Cancer Institute (INCA) and Hospital Samaritano, both in Rio, had surgical robots. In the last 5 years, large hospital groups such as Amil (now UHG) and Rede D'Or have boosted the market to such an extent that Brazil is the country that performs the most robotic surgeries in Latin America, currently having 57 platforms spread across all regions, having performed more than 8 thousand procedures throughout the country.

DaVinci Xi

DaVinci SinglePort

Robots are considered the third generation of surgery (surgery 3.0), after open surgeries (surgery 1.0) - which require large incisions - and laparoscopic surgeries (surgery 2.0), a modality considered minimally invasive. The technology cannot be applied to every case, but it has already made a big difference in areas such as urology, gynecology, general surgery and digestive system, chest and head and neck surgeries. The main feature is precision, allowing the robot to perform 7 degrees of movement, while laparoscopy only allows 4 degrees. In other words, the technology allows the surgeon to perform movements that were previously impossible through laparoscopy and even in open surgery.

Console used by the surgeon to control the movements of the robotic arms and the camera

Console do DaVinci 5

The robot analyzes human movement approximately 1,500 times per second, correcting any imperfections. It gets so close that it is possible to see the nerves without burning them; each cut is tenths of a millimeter; the image is produced in HD and in 3D, and can be magnified 10 to 15 times; it allows the visualization of nerves and structures that are not possible using any other method. The ergonomics that favor the surgeon allow him to perform long surgeries without the physical fatigue caused by other approaches. For patients, the advantages are: shorter hospital stay; lower risk of hospital infection; improvements in blood loss; reduced doses of medication in the postoperative period and faster return to work activities. There are cases of resection (removal) of a pharyngeal tumor, for example, in which the average surgery time decreases from ten hours to one and a half hours, the hospital stay drops from ten days to one or two days and the patient returns to normal speech within nine to ten days, compared to the usual time period of one month. There are very few cases of blood transfusions and even fewer cases of hospital infection.

The growth in interventions using technology is being hindered by costs, government machinery and professional training. Robotic surgery is still expensive, but the benefits of recovery are gaining notoriety among doctors and patients, and five public hospitals now have this platform; only São Paulo, Rio de Janeiro and Rio Grande do Sul have managed to make the surgery available in public

hospitals, and it is necessary to define criteria for choosing who will undergo robotic surgery. Generally, the choice depends on the type of surgery, the experience of the doctors in the area and the contribution that the operation can represent in terms of accumulated knowledge for the institution. The additional cost is covered by the government. Another obstacle to people's access to the procedure is that health insurance plans do not cover the surgery. The National Health Agency (ANS) defines what is mandatory coverage by the plans and the robot is not yet included in the ANS list of procedures. And finally, the training of professionals has become a new problem. From the implementation of robotic surgery until 2019, Brazilian doctors who were interested in training for robotic surgery had to obtain certification outside of Brazil. The country still did not offer training, with the closest training centers being in Colombia and the United States. In addition to a theoretical-practical course, it is necessary to perform the first 10-20 surgeries accompanied by a tutor/preceptor. In addition to these certification steps, the physician's qualification is only complete after he or she has actively participated in numerous robotic surgeries. One of the best ways to achieve this level of training is for the physician to complete a 12-month full-time fellowship. There are few vacancies available for this type of training in Brazil, with only 1 vacancy per year in Minas Gerais, at the Felício Rocho Hospital in Belo Horizonte. The first physician to occupy this position and complete this training, having participated in approximately 240 robotic surgeries, was Dr. Rodrigo Lolli.