Langenbeck's Archives of Surgery (2022) 407:1789–1795

https://doi.org/10.1007/s00423-022-02465-0

REVIEW ARTICLE

Robot‑assisted techniques in vascular and endovascular surgery

A. Püschel1 · C. Schafmayer1 · J. Groß1

Received: 11 August 2021 / Accepted: 9 February 2022 / Published online: 28 February 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
For thousands of years, robots have inspired the imagination of humans, but it was only about 35 years ago that a robot
was used for the first time in medicine. Since then, robot-assisted procedures have become increasingly popular in urology,
general surgical specialties, and gynecology. Robot-assisted vascular surgery was first introduced in 2002 and was thought
to overcome the limitations of laparoscopy. However, it did not gain widespread popularity, and its usage is still limited to a
few centers worldwide. Robot-assisted endovascular procedures, on the other hand, while still in its infancy, have become a
promising alternative to existing techniques. The improvements of the robotic systems promote better surgical performance
and reduce occupational hazards for vascular and endovascular surgeons. A comprehensive review of literature was performed
using the search terms “robotic,” “robot assisted,” “vascular surgery,” and “aortic” for surgical procedures or “robotic,”
“robot assisted,” and “endovascular” for endovascular procedures. Full text articles that were published between January
1990 and March 2021 were included. This review summarizes the development of the techniques for robot-assisted vascular
and endovascular surgery in recent years, its outcomes, advantages, disadvantages, and perspectives.

Keywords Robotic · Robotic-assisted · Vascular surgery · Endovascular · Intervention

The whole field of surgery is developing towards minimal Vinci system. It received its first FDA approval for general
invasiveness, and robotic surgery has become increasingly laparoscopic surgery in 2000. In 2003 Computer Motion
popular in many fields. and Intuitive Surgical merged, and the ZEUS and da Vinci
The first surgical application of robotic technology was systems were unified [2, 3].
used in 1985 by Kwoh et al. to undertake stereotactic brain Since then, the da Vinci system has been applied in
biopsy with the PUMA 560 [1]. Early active robotic sys- different specialties like urology, colorectal surgery, and
tems demonstrated the potential of mechanical devices to gynecology. In vascular surgery, it was first used in 2002 in
enhance surgical procedures. The driving force, however, for robot-assisted laparoscopic aorto-bifemoral bypass surgery
the development of the contemporary platforms was the con- [4]. Over the years, feasibility for robotic vascular surgery
cept of telepresence initially introduced by a collaboration has been demonstrated in a variety of laparoscopic vascular
between the NASA Ames Research Center and researchers reconstructions, mainly of the aortoiliac and visceral arter-
from Stanford with support by the US military. ies, and only recently, robot-assisted endovascular proce-
Further development of robotic systems was carried out dures have become a promising alternative to existing endo-
by Computer Motion with the introduction of the AESOP vascular techniques.
(automatic endoscopic system for optimal positioning) In 2020, approximately 1,243,000 robotic procedures
robotic platform. Modifications resulted in the ZEUS robotic were performed worldwide with Da Vinci Surgical Systems.
system that was FDA approved in 2001. Intuitive Surgical This is an increase to 2019 and 2018 with 1,229,000 and
released a robotic platform that was later to become the da 1,038,000 procedures, respectively, despite all difficulties
caused by the COVID-19 pandemic [5, 6].
The da Vinci system, as most surgical robots, is actually
* A. Püschel a telemanipulator as it lacks the autonomous elements of
[email protected] a robot and is entirely dependent on human activity. It is a
1
Universitätsmedizin Rostock, Klinik für Allgemein-,
master–slave system that consists of a patient side cart with
Viszeral-, Gefäß- Und Transplantationschirurgie, three to four interactive arms and the surgeon’s console for
Schillingallee 35, 18057 Rostock, Germany

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1790 Langenbeck's Archives of Surgery (2022) 407:1789–1795

remote manipulation. Compared with conventional laparos- However, only a small number of clinical studies have been
copy, there are several technological improvements such as published, even fewer series on laparoscopic abdominal
enhanced visualization due to the 3-dimensional interface, aortic aneurysm repair. It appears to be more difficult than
improved wrist motion freedom, motion scaling, tremor bypass surgery and competes against endovascular aneu-
filtration, and improved ergonomics. An interesting future rysm repair (EVAR) as a minimally invasive technique with
development is the creation of “virtual fixtures,” using soft- a low morbidity and mortality [12]. In light of the rapid
ware to create “no-go” areas and preventing robotic instru- development of endovascular procedures, laparoscopic aor-
ments from entering and damaging sensitive tissues, e.g., tic surgery did not gain widespread popularity, mainly due
blood vessels [7]. Additionally, this technology gives sur- to technical challenges, difficulty acquiring the necessary
geons the ability to perform telesurgery, the reason for its skills, especially for not laparoscopically experienced vas-
initial development [8]. cular surgeons, and hence a long operating time.
There are, however, some disadvantages to this innovative Robot-assisted (RA) laparoscopic surgery, on the other
robotic system. First, larger operating rooms to accommo- hand, is another possible alternative for minimally invasive
date the whole system are required. Additionally, staff needs vascular surgery. It overcomes the limitations of laparos-
to be trained, and there are no haptic sensors. Although copy and results in a higher level of precision and control in
robotic surgeons compensate for it by becoming more sus- confined spaces as well as in a shorter learning curve [14].
ceptible to visual cues, its lack of haptic feedback still may Laparoscopic or RA-(laparoscopic) surgery can be as less
lead to increased operating times and higher learning curve invasive alternative for aneurysm repair and for bypass sur-
and may cause tissue damage [9]. gery for aortoiliac occlusive disease (AIOD) or for second-
The main issue, however, are the higher costs when com- ary interventions after EVAR.
pared to conventional approaches. The costs for the system Robot-assisted laparoscopy was first introduced to vas-
are approximately $1.5 million for each unit, with annual cular surgery in 2003 by Wisselink et al. performing an
service costs of approximately $112.000 per year and extra aorto-bifemoral bypass [4]. From 2003 to 2016, a couple of
cost for disposable supply [10]. Cost comparisons between case series from few centers worldwide reported results of
conventional and robotic-assisted procedures vary from hos- robot-assisted laparoscopic surgery in the aortoiliac region.
pital to hospital and between the health systems. But with An overview over the largest ones with total robot-ssisted
increasing surgeons’ experience, costs may be reduced [11]. aortic anastomosis is summarized in Table 1.
For this review, a comprehensive search of literature was The conversion rate ranged from 1.3 to 25%, morbidity
performed on PubMed using the terms “robotic” OR “robot- rates from 0 to 20% and mortality rates from 0 to 3.5%.
assisted” AND “vascular surgery” OR “aortic” for surgical High-volume centers tend to have a better outcome.
procedures or “robotic” OR “robot-assisted” AND “endo- Stadler et al. reported an improvement of precision, con-
vascular” for endovascular procedures resulting in 884 and trol, and dexterity of the procedure with a high technical
330 results, respectively. The search timeline ranged from success rate. Aortoiliac anastomoses seem to be more accu-
January 1990 to March 2021. Only clinical studies reported rate and quicker than with conventional laparoscopic tech-
in English were included. Animal or ex vivo experimental niques [18, 19]. Contrary to that, other authors have found
studies were excluded. Additionally, PubMed listed articles no improvement of laparoscopic performance or shortening
from the authors’ personal archives were explored and the of the learning curve with robotic assistance [20, 21].
information included in this article. The total operating time, however, is longer in total robot-
assisted procedures, as shown by Lin et al. and Kolvenbach
et al., mainly due to the technical complexity of the robotic
Robot‑assisted (laparoscopic) vascular device [15, 18].
surgery Besides infrarenal aortic pathologies, robotic devices have
been used in other reconstructive arterial procedures such
Laparoscopic surgery leads to faster recovery by reduc- as renal and splenic artery aneurysm repair [22, 23]. Other
ing operative trauma. In vascular surgery, especially aortic pathologies that were treated were complications of endo-
repair, it combines minimally invasiveness with durable vascular procedures such as a persistent type II endoleak
results of conventional surgery [12]. The first laparoscopic after EVAR by robotic ligation of the inferior mesenteric
vascular surgery was performed in 1993 as a laparoscopi- artery and hybrid surgical debranching and endovascular
cally assisted aorto-bifemoral bypass [13]. Since then, an repair of thoraco-abdominal aortic aneurysms (TAAA), but
increasing number of patients was successfully treated, overall numbers were small [24, 25].
and new techniques and approaches have been developed. There are however conflicting results regarding the allo-
These include totally laparoscopic as well as laparoscopi- ver clinical benefits of robot-assisted laparoscopic pro-
cally assisted and laparoscopically hand-assisted techniques. cedures. Several publications have reported that robotic

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Table 1  Overview of case series of RA-aortoiliac procedures with RA-aortic anastomosis

Year Robotic system Patients Operation Conver- Operating time Clamping time Morbidity Mortality
(num- sion (num- (min) (min) (number) (number)
ber) ber)

Kolvenbach et 2003 Zeus 10 10 AAA​ 2 (20%) 242 ± 40.5 96 ± 21.6 1 (10%) 0

al. [15]
Desgranges et 2004 Da Vinci 5 5 AIOD* 1 (25%) 188 (mean) 75 ± 28 1 (20%) 0
al. [16]
Jongkind et al. 2011 5 Zeus 23 Da 28 28 AIOD 4 (14%) 350 (median) 70 (median) 4 (14%) 1 (3,5%)
[17] Vinci
Stadler et al. 2016 Da Vinci 285 61 AAA​ 8 (13%) 253 (median) 93 (median) 0 (0%) 1 (1,6%)
[14]
224 AIOD 2 (0,9%) 194 (median) 37 (median) 3 (1,33%) 0
Lin et al. [18] 2012 Da Vinci 3 3 AIOD 0 (0%) 494 ± 36 60 ± 21
9 AIOD** 0 (0%) 425 ± 94 102 ± 93 N.R. # 0
7 AAA** 1 (14%) 396 ± 146 87 ± 48

AAA, abdominal aortic aneurysm; AIOD, aorto-iliac occlusive disease. *Median-laparotomy in 3 patients; **a mini-incision was used
for clamping, #no detailed attribution to procedures

surgery equals or even improves outcomes by laparoscopic Robot‑assisted endovascular surgery

surgery in different specialties [26]. Surgeons worldwide
have proved its feasibility and safety for the performance Compared to open procedures for the treatment of aortoiliac
of many different robot-assisted surgeries and reported that occlusive disease, endovascular procedures have superior
it equals outcomes by laparoscopic surgery. short-term clinical and economic outcomes [32]. They are
For procedures in confined spaces such as colorectal minimally invasive, more suitable to high-risk patients,
and esophageal surgery, the robotic system has been shown and multiple procedures can be performed during the same
to be more beneficial [27, 28]. In bariatric surgery, how- operation.
ever, a meta-analysis comparing robotic and conventional Experience with robotic-controlled catheter systems was
laparoscopic gastric bypass did not find differences in initially obtained in cardiology for robotic cardiac ablation
mortality but increased operative times [29]. A Cochrane and mapping for arrhythmias [33, 34]. The first pilot study
database review from 2017 concluded that there is no of robotic-assisted percutaneous coronary intervention was
high-quality evidence for improved oncological outcomes, initially described by Beyar et al. [35].
postoperative complication rates, and postoperative pain Since then, the system has undergone multiple refine-
in RA-assisted prostatectomy compared to laparoscopic or ments, and robotic PCI has been shown to have comparable
open surgery [30]. A controlled randomized multicenter safety and efficacy to the manual approach [36].
study on RA-laparoscopic versus conventional laparo- One major benefit of remote vascular intervention is the
scopic surgery of rectal cancer reported similar results significant reduction of radiation and radiation-associated
[31]. occupational hazards such as cancer-related risks, cataract,
So far, good-quality data from randomized trials in vas- and atherosclerosis [37, 38]. In the PRECISE study, Weisz
cular surgery is missing as it is limited to individual case et al. demonstrated a median radiation reduction of 95.2%
studies from few centers worldwide. One reason for this may compared to traditional interventions [36].
be that the da Vinci system is not approved for this medical Two main types of endovascular interventional robots
field. An exception is the group of Stadler et al. with the big- have initially been used: an electromechanical-based, such
gest case series of 285 procedures an probably the broadest as the Sensei robotic navigation system (Hansen Medical),
experience in this regard. and the magnetically controlled systems, such as the Niobe
As mentioned before, robotic surgery has its pitfalls, magnetic navigation system (Stereotaxis St. Louis).
mainly in being more expensive than conventional proce- Later Hansen and Philipps developed the Magellan
dures, and there is still a learning curve, limiting its use Robotic system – the first purely vascular robot that received
to few centers worldwide. With the competition of a rising FDA approval in 2012. Its production, however, was stopped
endovascular field, robot-assisted laparoscopic procedures in 2016.
did not assert themselves in vascular surgery. However, they Corindus Vascular Robotics launched the CorPath200 in
can still add to the therapeutic options. 2012 for procedures in the whole cardiovascular system. It

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was first FDA-approved for percutaneous coronary interven- necessary, but with future technical progress and by combin-
tions (PCIs). Its successor, the CorPath GRX received FDA ing the robot with three-dimensional fusion imaging technol-
clearance for PCIs in 2016 and for peripheral artery disease ogy, these challenging procedures may be performed with
(PAD) in 2018. little radiation and contrast use, thus significantly improving
The CorPath is a two-component master and slave system patients’ safety as well as the surgeon’s radiation exposure.
consisting of a remote workspace and a table-side robotic In 2016, Mahmud et al. demonstrated for the first time
unit. The remote workspace is basically a radiation-shielded the feasibility and safety of a robotic-assisted peripheral
mobile workstation that allows independent manipulation vascular platform for femoropopliteal vessels. A total of 29
of guidewires and catheters, whereas the table-side robotic lesions in 20 patients with Rutherford category II–III and
unit consists of an articulating arm and a robotic drive that lesions mainly in the SFA (lesion length 33 mm ± 15,5 mm)
houses a single-use cassette which moves the guidewires and were successfully treated robot-assisted endovascular with
rapid exchange catheters. balloon angioplasty. The same group reported successful RA
This endovascular robotic platform enables control of all angioplasty in slightly longer lesions (49 mm ± 37,5 mm) in
three interventional devices, i.e., guidewire, catheter, and patients with Rutherford category III–IV [42, 44].
balloon/stent catheters, in ways that are not possible manu- The procedure times as well as fluoroscopy times were
ally. Rotations in 30 degree increments can be performed comparable to the conventional endovascular therapy. The
and the catheter can be advanced or retracted in 1-mm incre- success of below-the-knee revascularization has so far only
ments thus enabling exact steerability and precise position- been described by one author [53].
ing that helps to maintain the wire and catheter in the center Robotic assistance can be of great advantage in chal-
of the vessel lumen and avoids vessel trauma. However, as lenging anatomic conditions such as severely angulated
it is not compatible to all devices, intermittent manual inter- aortic arches and tortuous carotid arteries that may pose
vention might become necessary [39]. an increased risk for thromboembolism from catheter
Since its introduction, the endovascular robotic approach manipulation.
has been increasingly used for aortic, peripheral vascular, With endovascular robotic systems, catheters and wires
and neurovascular interventions. An overview of the largest can be kept in the center of the vessel lumen.
studies is summarized in Table 2. A study by Perera et al. found significantly less micro-
In 2009, an in vitro study evaluated the role of robotic embolization in intraoperative transcranial Doppler during
endovascular techniques in fenestrated grafts [49]. The first robotic catheter placement in the aortic arch compared to
robotic-assisted endovascular EVAR was successfully per- manual techniques [43].
formed by the same group in a 78-year-old patient [50]. The feasibility and safety of carotid artery stenting (CAS)
But up to date, in vivo experience in robotic-assisted have been demonstrated by several authors for patients with
endovascular aortic repair is limited to aortic arch catheter symptomatic [39] and asymptomatic carotid artery stenosis
placement during TEVAR [43], contralateral gate cannula- [45].
tion in EVAR [51], and cannulations of renal or mesenteric The first results of RA-endovascular procedures are
arteries during FEVAR [52]. Manual intervention is still very promising. However robotic endovascular navigation

Table 2  Overview of cases/case series of clinical applications of robotic endovascular procedures

Author Year Robotic system Patients/vessels Procedure

Bismuth et al. [40] 2013 Hansen 20 vessels Iliac artery and SFA cannulation
Cochennec et al. [41] 2015 Magellan 37 vessels Visceral and renal vessel cannulation during
FEVAR/BEVAR
Mahmud et al. [42] 2016 CorPath 200 20 patients Percutaneous angioplasty of the SFA
Perera et al. [43] 2017 Magellan 11 patients Catheter placement in aortic arch during TEVAR
Cheung et al 2020 Magellan 14 patients EVAR gate cannulation
Mahmud et al. [44] 2020 CorPath GRX 20 patients Percutaneous angioplasty of the SFA
Sajja et al. [45] 2020 CorPath GRX 7 patients Cerebral Angiography
3 patients Carotid artery angioplasty
Weinberg et al. [46] 2020 CorPath GRX 6 patients Carotid artery angioplasty
Nogueira et al. [39] 2020 CorPath GRX 4 patients Carotid artery angioplasty
Desai et al. [47] 2021 CorPath GRX 6 patients Cerebral Angiography
Jones et al. [48] 2021 Magellan 13 patients Carotid artery angioplasty

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has still some drawbacks. There is a setup time for the Conclusion
system before each procedure and additional staff training
is necessary. But as several in vitro experiments have dem- Robotic technology may enhance surgery by extending
onstrated, robotic endovascular surgery is much easier to human capabilities. With the help of a robotic system,
learn compared to conventional endovascular procedures surgeons’ movements can be scaled into micromotions,
[49, 54]. physical tremor is eliminated and, vision is improved, thus
As in RA- laparoscopic surgery, endovascular robotic sys- facilitating actions that are not possible in conventional
tems lack haptic control and thus might risk vascular injury. surgery.
At present, the endovascular robotic platforms are not com- Robotic surgery has been applied in a variety of lapa-
patible to all materials such as guidewires and some devices roscopic vascular reconstructions, such as iliac arteries,
need to be deployed manually [39, 45]. visceral arteries, and the abdominal aorta. But most of
The higher costs for the robotic system and for the dis- these procedures were performed solely at a few centers
posable cassette also need to be considered; however, the worldwide, and large series have only been published by
long-term health benefits for the staff and the patients’ safety the most active centers [14].
have to be taken into account. One of the reasons why it has not been widely adopted
Compared to conventional methods, the advantages of in the vascular community is the existence of a broad,
robotic endovascular surgery are shorter procedure time and well-established endovascular field. In cases where endo-
fluoroscopic exposure time, better stability of the catheter vascular treatment fails or in complex aortic disease treat-
tip, and improved control over catheter movements. After ment as hybrid procedures it may, however, still provide a
reaching the target site, the system is extremely stable to minimal-invasive surgical alternative.
make submillimeter movements [45]. In endovascular surgery, on the other hand, a transfor-
Further research will be needed to determine whether mation is underway. The utility of endovascular robot-
endovascular robotic systems truly improve patient out- ics has been proven in PAD, CAS, FEVAR, transfemoral
comes and to evaluate the cost-effectiveness and the safety renal, and mesenteric interventions even in challenging
in complex clinical cases. anatomic situations [41, 42, 44, 45, 48, 52, 53, 59].
Clinical trials have shown that robotic peripheral vascu-
lar interventions are feasible, safe, and reduce patient and
operator hazards, such as radiation time.
Telesurgery Further technological improvements are necessary to fully
integrate that promising new technology into the clinical set-
The initial goal of developing robotic surgical platforms was ting including advancements in steerability and haptic feed-
the possibility of performing remote surgical procedures. back as well as providing compatibility to existing devices.
This is especially imminent as the geographic distribution The future of this technology includes its use for remotely
of highly specialized healthcare limits medical access to a performed procedures such as stroke thrombectomies.
significant proportion of people. Yet, some limitations remain. To date, only a small
Telesurgery uses wireless networks and robotic tech- number of observational studies or case reports in a few
nology to connect surgeons and patients that are distantly centers worldwide have been published demonstrating the
located from another. The world’s first telesurgery, named feasibility and safety of robot-assisted endovascular pro-
“Operation Lindbergh,” was conducted in 2001 between a cedures. A valid evaluation of its long-term superiority to
team of French surgeons in New York, USA, and a female conventional endovascular techniques is not possible due
patient in Strasbourg, France, using a ZEUS robotic system to a lack of controlled randomized trials.
[55]. Further clinical studies have demonstrated its feasi- The main issue, however, is the costs. Robotic surgery
bility in interventional cardiology in vivo and in vitro in is more expensive than conventional therapies, but in end-
interventional vascular surgery so far [56–58]. ovascular robotics, higher costs come with considerable
Telerobotic procedures are presently, however, far from health benefits for staff and patients.
being fully operational and more experimental in character.
The major challenges are the latency time, delaying audi-
ble and visual signals, thus resulting in surgical inaccuracy Declarations
and a risk of the patient’s safety. A stable high-speed-data
connection is necessary throughout the procedure [56]. Fur- Conflict of interest The authors declare no competing interests.
thermore, financial and legal issues of remote surgical pro-
Ethics approval This article does not contain any studies with human
cedures between different medical centers have to be taken participants or animals performed by any of the authors.
into consideration.

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