INVITED

PAPER

A Perspective on
Medical Robotics
Robots are reducing surgeon hand-tremor, assisting in spine and joint-replacement,
positioning surgical needle guides, and coordinating medical imaging
with surgical procedures.
By Russell H. Taylor, Fellow IEEE

ABSTRACT | This paper provides an overview of medical influence on our society. Applications include such fields
robotics, from the perspective of a researcher who has been as industrial production, inspection and quality control,
actively involved in the field for 17 years. Like all robot systems, laboratory automation, exploration, field service, rescue,
medical robots fundamentally couple information to physical surveillance, and (as discussed below) medicine and health
action to significantly enhance humans’ ability to perform care. Historically, robots have often been first introduced
important tasksVin this case surgical interventions, rehabili- to automate or improve discrete processes, such as
tation, or simply helping handicapped people in daily living painting a car or placing test probes on electronic circuits,
tasks. Research areas include modeling and analysis of but their greatest economic influence has often come
anatomy and task environments, interface technology between indirectly as essential enablers of computer-integration of
the Bdata world[ and the physical world, and study of how entire production or service processes.
complex systems are put together. This paper will discuss these As this paper will argue, medical robots have a similar
research areas and illustrate their interrelationship with potential to fundamentally change interventional medicine
application examples. Although the main focus will be on as enabling components in much broader computer-
robotic systems for surgery, it will also discuss the relationship integrated systems that include diagnosis, preoperative
of these research areas to rehabilitation and assistance robots. planning, perioperative and postoperative care, hospital
Finally, it will include some thoughts on the factors driving the logistics and scheduling, and long-term follow-up and
acceptance of medical robotics and of how research can be quality control. Within this context, surgical robots and
most effectively organized. robotic systems may be thought of as Bsmart[ surgical tools
that enable human surgeons to treat individual patients
KEYWORDS | Computer-integrated surgery; human–machine with improved efficacy, greater safety, and less morbidity
cooperative systems; medical robotics; rehabilitation robotics; than would otherwise be possible. Further, the consistency
robotic assistive systems; surgical assistants; telerobotics; and information infrastructure associated with medical
telesurgery robotic and computer-assisted surgery systems has the
potential to make Bcomputer-integrated surgery[ as
important to health care as computer-integrated manufac-
I. INTRODUCTION turing is to industrial production.
The ability of robotic systems to couple information to This paper is not intended to be a survey, in the
physical action in complex ways has had a profound traditional sense. Other papers in this special issue provide
a comprehensive overview of major technology themes in
medical robotics, as well as related work on robotic sys-
Manuscript received September 26, 2005; revised February 7, 2006. This work tems for rehabilitation and human assistance. Other sur-
was supported in part by the National Science Foundation under Cooperative
Agreement EEC9731478 and other NSF Grants, in part by other U.S. Government
veys may be found in a recent IEEE TRANSACTIONS ON
agencies and private foundations, including the National Institutes of Health ROBOTICS special issue on medical robotics [1], [2] and
and the National Institute of Science and Technology and the Whitaker Foundation,
in part by industry, including IBM, Siemens Corporation, General Electric,
elsewhere (e.g., [1], [3]–[5]).
Northern Digital, Intuitive Surgical Systems, and Integrated Surgical Systems, Instead, the goal is to provide a perspective on how
and in part by Johns Hopkins University.
The author is with the Department of Computer Science, Johns Hopkins University,
surgical, rehabilitation, and assistive robots relate to
Baltimore, MD 21218 USA (e-mail: [email protected]). broader themes of computation, interface technology, and
Digital Object Identifier: 10.1109/JPROC.2006.880669 systems. This perspective is informed, first, by the

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2006 IEEE
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 Taylor: A Perspective on Medical Robotics

Table 1 Complementary Strengths and Limitations of Robots and such as Bno fly zones[ preventing robots from moving tools
Humans [4]
into dangerous proximity to delicate anatomical structures.
A third advantage is the inherent ability of medical
robots and CIS systems to promote consistency while
capturing detailed online information for every procedure.
This Bflight data recorder[ information can be invaluable in
mortality and morbidity assessments of serious incidents,
but the true potential is much more far-reaching. Poten-
tially, statistical analysis comparing outcome measures to
procedure variables may produce both better understand-
ing of what is most important to control and, ultimately, to
safer and more effective interventions. This data can also be
a valuable tool for training, skill assessment, and certifi-
cation for surgeons.
Similarly, robotic systems for rehabilitation or for
assistance in daily living must offer real advantages if they
are to be adopted. Once again, acceptance will come from
exploiting the complementary abilities of humans (who may
have disabilities) and machines to accomplish tasks that
might not otherwise be feasible or practical for unassisted
humans. Typical benefits may include more efficient or
consistent performance of exercise following injury or
surgery; partial restoration of function through Bintelligent[
prostheses, either for long-term use or during recovery; and
discussion and experience reported in many workshops cooperative aids for our aging population. Acceptance in
over the past fifteen years (e.g., [6]–[10]); and, second, by these areas will also be crucially dependent on economic
my own experiences at IBM Research and at Johns and social factors such as cost, ruggedness, ease of use, and
Hopkins University (JHU). My primary focus will be on human–machine communication capabilities.
medical robotics and computer-integrated surgery (CIS)
systems, which have been the major focus of my own re- B. Surgical CAD/CAM
search over the past 17 years. However, there are impor- The basic information flow of CIS systems is illustrated
tant synergies between robotics for CIS and for such fields in Fig. 1. Preoperative planning typically starts with two-
as rehabilitation and assistance for elderly or handicapped dimensional (2-D) or three-dimensional (3-D) medical
people, and I will touch on these related areas as well. images, together with information about the patient. These
images can be combined with general information about
human anatomy and variability to produce a computer
II . BAS IC S YS T EM CONCEPT S: M EDI CAL model of the individual patient, which is then used in
ROBOTICS IN COMPUTER-INTEGRATED surgical planning. In the operating room, this information
SURGERY AND REHABILITATION

A. Factors Driving Acceptance of Medical Robotics

Just as with manufacturing robots, medical robots and
CIS systems must provide real advantages if they are to be
accepted and widely deployed.
First, and perhaps most obvious, is the ability of
computer-integrated systems to significantly improve sur-
geons’ technical capability, either by making existing pro-
cedures more accurate, faster, or less invasive or by making
it possible to perform otherwise infeasible interventions. In
these cases, the advantages often come from exploiting the
complementary strengths of humans and robotic devices, as
summarized in Table 1. A second, closely related, advantage
is the potential of computer-integrated systems to promote
surgical safety by: 1) improved technical performance of
difficult procedures; 2) on-line monitoring and informa-
tion supports for surgical procedures; and 3) active assists Fig. 1. The information flow of CIS systems.

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 Taylor: A Perspective on Medical Robotics

is registered to the actual patient using intraoperative The second variety, auxiliary surgical supports, generally
sensing, which typically involves the use of a 3-D work side-by-side with the surgeon and perform such func-
localization, x-ray or ultrasound images, or the use of the tions as endoscope holding or retraction. These systems
robot itself. If necessary, the surgical plan can be updated, typically provide one or more direct control interfaces such
and then one or more key steps in the procedure are as joysticks, head trackers, voice control, or the like. How-
carried out with the help of the robot. Additional images or ever, there have been some efforts to make these systems
sensing can be used to verify that the surgical plan is Bsmarter[ so as to require less of the surgeon’s attention
successfully executed and to assist in postsurgical follow- during use, for example by using computer vision to keep
up. The coupling of imaging, patient-specific models, and the endoscope aimed at an anatomic target or to track a
computer-controlled delivery devices can significantly surgical instrument. Their value is assessed using the same
improve both the consistency of therapy delivery and the measures as for surgeon extenders, though often with
data available for patient follow-up and statistical studies greater emphasis on surgical efficiency.
required to develop and validate new therapies.
We refer to the process of building a model of the D. Rehabilitation and Assistive Systems
patient, planning, registration, execution, and follow-up as As our population ages, robotic systems for rehabilita-
surgical CAD/CAM, stressing the analogy with computer- tion and for helping deal with physical and cognitive
integrated manufacturing. Typical examples of robotic disabilities will become more and more important [7].
surgical CAD/CAM are discussed in Section IV. The ad- Broadly, we can identify four areas of great promise:
vantages provided by robotic execution in surgical CAD/ 1) systems assisting with physical therapy following in-
CAM depend somewhat on the individual application, juries or surgery; 2) Bsmart[ prosthetic devices; 3) systems
but include: 1) accurate registration to medical images; designed to help disabled people in daily living activities;
2) consistency; 3) the ability to work in imaging envi- and 4) systems designed to help prevent or ameliorate
ronments that are not friendly to human surgeons; and cognitive and emotional decline.
4) the ability to quickly and accurately reposition instru-
ments through complex trajectories or onto multiple targets.
In addition to the technical issues inherent in cons- I II . THE S TRUCTURE AND T ECHNOLOGY
tructing systems that can provide these advantages, one of OF MEDICAL ROBOTIC SYSTEMS
biggest challenges is finding ways to reduce the setup Fig. 2 shows the block diagram of a typical CIS system.
overhead associated with robotic interventions. A second These systems work cooperatively with humans (surgeons
challenge is to provide a modular family of low-cost robots and other medical personnel) to couple information with
and therapy delivery devices that can be quickly configured action in the physical world to perform tasks. Broadly,
into fully integrated and optimized interventional systems research supporting these systems comprises three areas:
for use with appropriate interventional imaging devices for computer-based modeling and analysis of images, patient
a broad spectrum of clinical conditions with convenience anatomy, and surgical plans; interface technology relating
comparable to current outpatient diagnostic procedures. the Bvirtual reality[ of computer models to the Bactual
reality[ of the patient, operating room, and surgical staff;
C. Surgical Assistants
Surgery is a highly interactive process and many sur-
gical decisions are made in the operating room. The goal of
surgical robotics is not to replace the surgeon with a robot,
but to provide the surgeon with a new set of very versatile
tools that extend his or her ability to treat patients. We thus
often speak of medical robot systems as surgical assistants
that work cooperatively with surgeons. A special subclass of
these systems are often used for remote surgery.
Currently, there are two main varieties of surgical
assistant robot. The first variety, surgeon extenders, are
operated directly by the surgeon and augment or supple-
ment the surgeon’s ability to manipulate surgical instru-
ments in surgery. The promise of these systems, broadly, is
that they can give even average surgeons superhuman
capabilities such as elimination of hand tremor or ability to
perform dexterous operations inside the patient’s body. The
value is measured in: 1) ability to treat otherwise
untreatable conditions; 2) reduced morbidity or error
rates; and 3) shortened operative times. Fig. 2. Block diagram of typical CIS system.

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 Taylor: A Perspective on Medical Robotics

• real-time data fusion for such purposes as updating

models from intraoperative images;
• methods for human–machine communication,
including real-time visualization of data models
and natural language understanding, gesture rec-
ognition, etc.;
• methods for characterizing uncertainties in data,
models, and systems and for using this informa-
tion in developing robust planning and control
methods.
Of course, these themes are highly interrelated and
mutually supportive. For example, modern medical image
segmentation methods are intimately associated with
registration methods.
Statistical methods have long been important in
Fig. 3. The daVinci surgical robot uses mechanically constrained
medical robotics, and their importance is increasing.
remote-center-of-motion arms manipulate modular tools
under surgeon teleoperator control. The tools use cable drives
Examples include the following.
to provide high-dexterity manipulation inside the body. • Construction of statistical Batlases[ characterizing
(Photo: Intuitive Surgical Systems). anatomic variation over large populations of
individuals. Such atlases provide a natural frame-
work for consolidating a wide variety of informa-
tion about disease states, biomechanical modeling
and systems science and analysis permitting these compo- results, surgical plans, outcomes, etc.
nents to be combined in a modular and robust way with • Methods for Bdeformably[ registering atlases to
safe and predictable performance. individual patient images to produce Bmost pro-
bable[ patient models, based on available informa-
A. Modeling and Analysis tion. Such models also naturally incorporate prior
As medical robotic systems evolve, computational information about possible treatment plans, bio-
modeling and analysis will become more and more im- mechanical simulations, expected outcomes, etc.
portant. There is a robust and diverse research community • Methods for correlating information about treat-
spanning an equally broad range of research topics and ment plans and actual procedure execution with
techniques. outcome variation, in order to identify key factors
The core challenge is to develop computationally ef- affecting outcomes and safety.
ficient methods for constructing models of individual Fig. 4 shows one typical example of the use of these tech-
patients and populations of patients from a variety of data niques for brain tumor treatment planning. Other exam-
sources and for using these models to help perform useful ples include statistical modeling of the location of prostate
tasks. A related challenge is modeling the tasks themselves cancer based on histology specimens, followed by deform-
and the environment in which the tasks are performedV able registration of this atlas to ultrasound or MRI images to
whether the operating room, intensive care facility, clinic,
or home. Some common themes include:
• medical image segmentation and image fusion to
construct and update patient-specific anatomic
models;
• biomechanical modeling for analyzing and pre-
dicting tissue deformations and functional fac-
tors affecting surgical planning, control, and
rehabilitation;
• optimization methods for treatment planning and
interactive control of systems;
• methods for registering the Bvirtual reality[ of
images and computational models to the Bphysical
reality[ of an actual patient;
• methods for characterizing treatment plans and indi-
vidual task steps such as suturing, needle insertion, Fig. 4. Patient-specific model of a brain tumor patient based on
or limb manipulation for purposes of planning, a deformable registration to a statistical atlas incorporating
monitoring, control, and intelligent assistance; finite-element simulations and functional data [99], [100].

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 Taylor: A Perspective on Medical Robotics

create optimized patient-specific biopsy plans [11], [12], the

use of statistical atlases to create 3-D bone models from 2-D
x-ray images [13]–[15], and statistical analysis of procedure
variability in hip arthroplasty [16], [17].
Although the use of patient-specific models for reha-
bilitation planning has so far been relatively limited, the
potential for applying similar atlas-based techniques
incorporating biomechanical simulations has great future
potential.
Fig. 5. Autonomous motion inside the body. Left: CMU HeartLander
B. Interface Technology [44]. Right: S. Supiore Sant’Anna endoluminal robot [101].
Robotic systems inherently involve interfaces between
the data world of computers and the physical world. One
consequence of this is that robotics has always been a 2) Teleoperation and Hands-On Control: Many surgical
highly interdisciplinary field involving many branches of robots (e.g., [24], [25], [31], [35]) are teleoperated. Two
engineering research. For medical robotics, the core potential drawbacks of this approach are that more
challenge is to fundamentally extend the sensory, motor, equipment (i.e., a Bmaster[ control station) is needed,
and human-adaptation abilities of robotic systems in an and the surgeon is often somewhat removed from the
unusually demanding and constrained environment. operating table, thus necessitating significant changes in
surgical work flow. Early experiences with ROBODOC
1) Specialized Mechanism Design: Early medical robots [21] and other surgical robots (e.g., [50], [51]) showed that
(e.g., [18]–[23]) frequently employed conventional indus- surgeons found a form of Bhands-on[ admittance control,
trial manipulators, usually with modifications for safety in which the robot moved in response to forces exerted by
and sterility. Although this approach had many advantages the surgeon directly on the surgical end-effector, to be very
and is still frequently taken for laboratory use or rapid convenient and natural for surgical tasks. Subsequently, a
prototyping, surgery and rehabilitation applications im- number of groups have exploited this idea for precise
pose special requirements for workspace, dexterity, surgical tasks, notably the JHU BSteady Hand[ microsur-
compactness, and work environment. Consequently, the gical robot [52] and the Imperial College Acrobot
trend has been more and more toward specialized designs. orthopedic system [53]. These systems (Fig. 8) provide
For example, laparoscopic surgery and percutaneous very high stiffness and precision and eliminate physiolog-
needle placement procedures typically involve passage or ical tremor while still permitting the surgeon to exploit his
manipulation of instruments about a common entry point or her natural kinesthetic sense and eye-hand coordina-
into the patient’s body. In response, two basic designs have tion. Other groups have developed completely freehand
been widely used. The first, adopted by the Aesop and Zeus instruments that sense and actively cancel physiological
robots [24], [25], uses a passive wrist to allow the
instrument to pivot about the insertion point. The second,
adopted by a variety of groups, using a variety of design
approaches (e.g., [26]–[33]), mechanically constrains the
motion of the surgical tool to rotate about a Bremote center
of motion (RCM)[ distal to the robot’s structure.
A second problem is the need to provide high degrees
of dexterity in very constrained spaces inside the patient’s
body, and at smaller and smaller scales. Typically, the
response has been to develop cable actuated wrists (e.g.,
[34], [35]. However, the difficulties of scaling these
designs to very small dimensions have led some groups to
investigate bending structural elements (e.g., [36]–[39]),
shape memory alloys [40], microhydraulics [41] or other
approaches (see Fig. 6). The problem of providing access to
surgical sites inside the body has led several groups to
develop semiautonomously moving robots for epicardial or
endoluminal applications (e.g., [2], [42]–[44], Fig. 5).
The necessity of providing robots that conform to
Fig. 6. Dexterity inside the body. (A) daVinci wrist. (B) Waseda
human biomechanics and physical constraints has similarly dual-arm end effector for MIS flexible endoscopy [102].
led researchers to develop specialized designs for rehabil- (C) JHU bendable Bsnake[ robot [36]–[39]. (D) Five degrees of
itation or assistive applications (e.g., [45]–[49], Fig. 7). freedom, 3-mm-diameter microcatheter robot [103], [104].

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 Taylor: A Perspective on Medical Robotics

Both teleoperation and hands-on control are likewise

used in human–machine cooperative systems for rehabilita-
tion and disabilities assistance systems. Constrained hands-
on systems offer special importance for rehabilitation
applications and for helping people with movement dis-
orders. Similarly, teleoperation and Bintelligent[ task follow-
ing and control is likely to be vital for further advances in
assistive systems for people with severe physical disabilities.

4) Augmented Reality Interfaces: Once a surgical pro-

cedure has begun, a surgeon’s attention is necessarily fo-
cused on the patient’s anatomy. Traditionally, surgeons
have relied on their natural hand–eye coordination, either
Fig. 7. Typical rehabilitation robots. Left: Rehab. Institute of Chicago
Manipulandum [49]. Right: Tsukuba Gaitmaster 2 [49]. with direct visualization or (more recently) using endo-
scopic video images. Additional information, such as medi-
cal image data, has traditionally been posted on a light box
somewhere in the operating room. The ability of the
tremor (e.g., [54], [55]). Still other groups have developed computer to coregister and visualize images, models, and
passive or semiactive mechanisms for assisting surgeons other task-specific data provides an opportunity to signif-
manipulate tools or body parts (e.g.,[56]–[59]). icantly improve the surgeon’s ability to assimilate and use
all this information. Accordingly, there has been significant
3) Human–Machine Cooperative Systems: Although one interest in creating Baugmented reality[ information dis-
goal of both teleoperation and hands-on control is often plays and in using interactive means such as laser pointers
Btransparency,[ i.e., the ability to move an instrument in surgical assistant systems (Fig. 9). Similar interfaces
freely and dexterously, the fact that a computer is actually have also been exploited in rehabilitation systems, for
controlling the robot’s motion creates many more possi- example, in directing a patient’s motions for exercise.
bilities. The simplest is a safety barrier or Bno-fly zone,[ in
which the robot’s tool is constrained from entering certain C. Systems Science
portions of its workspace. More sophisticated versions Medical robots are complex systems that necessarily
include virtual springs, dampers, or complex kinematic involve many interacting subsystems, including computa-
constraints that help a surgeon align a tool, maintain a tional processes, sensors, mechanisms, and human–machine
desired force, or perform similar tasks. The Acrobot system interfaces. As such, they share the same underlying needs for
shown in Fig. 8 represents a successful clinical application good system design and engineering practice: modularity,
of the concept, which has many names, of which Bvirtual well-defined interfaces, etc. However, the fact that they are
fixtures[ seems to be the most popular (e.g., [60]–[64]). A to be used in clinical applications or otherwise directly
number of groups (e.g., [65]–[67]) are exploring exten- interact with people imposes some unusual requirements.
sions of the concept to active cooperative control, in which The most obvious of these is safety. Although there may be
the surgeon and robot share or trade off control of the multiple valid approaches to robot safety in specific
robot during a surgical task or subtask. As the ability of circumstances, a few principles are common [68], [69].
computers to model and Bfollow along[ surgical tasks The most important of these is redundancy: no single point of
improves, these modes will become more and more failure should cause a medical robot to go out of control or
important in surgical assistant applications.

Fig. 9. Typical augmented reality interfaces for CIS. Left: CMU image
Fig. 8. Cooperatively controlled surgical robots. Left: The JHU BSteady overlay system [106]. Right: Osaka/Tokyo laser guidance
Hand[ robot [105]. Right: the Acrobot orthopedic robot [53]. system [107]. See also Figs. 12 (upper left) and 13.

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 Taylor: A Perspective on Medical Robotics

endanger a patient. A second, and often equally important, easy to image in CT and x-ray fluoroscopy. These factors
principle is that the computer’s model of the task environ- have made orthopedics an important application domain in
ment must correspond accurately to the actual environment. the development of Surgical CAD/CAM.
This is especially important for robotic systems that execute One of the first successful surgical CAD/CAM robots
plans based on preoperative images. With careful design and was the ROBODOC system [21], [70], [71] for joint
implementation, it is possible to practically eliminate the replacement surgery, which was developed clinically by
possibility that the robot will somehow Brun away[ or make Integrated Surgical Systems from a prototype developed at
an inappropriate motion. But this does little good if the IBM Research in the late 1980s. Since this system has a
image, robot, and physical patient coordinate systems are not number of features found in other surgical CAD/CAM
correctly registered to each other. Similarly, it is vital to robots, we will discuss it in some detail.
ensure that the procedure is planned correctly and appro- In ROBODOC joint replacement surgery, the surgeon
priately. Surgical robots are not surgeons. They are surgical selects an implant model and size based on an analysis of
tools that must be used correctly by surgeons. Consequently, preoperative CT images and interactively specifies the
it is vital that the surgeon have a clear understanding of the desired position of each component relative to CT
capabilities and limitations of the robotic system. coordinates. In the operating room, surgery proceeds
It is important to realize that surgical robots can often normally up to the point where the patient’s bones are to
enhance patient safety. First, the robot can provide better be prepared to receive the implant. The robot is moved up
control over process parameters (force, precision, etc.) to the operating table, the patient’s bones are attached
that can affect outcomes. Second, the robot typically does rigidly to the robot’s base through a specially designed
not suffer from momentary lapses of attention, although fixation device, and the transformation between robot and
(of course) the human operator may. Third, a robotic CT coordinates is determined either by touching multiple
system can be programmed to include Bvirtual barriers[ points on the surface of the patient’s bones or by touching
preventing the surgical tool from entering a forbidden preimplanted fiducial markers whose CT coordinates have
region unless the surgeon explicitly overrides the barrier. been determined by image processing.
Achieving these advantages requires careful design and The surgeon hand guides the robot to an approximate
validation, as well as rigorous testing and validation. initial position using a force sensor mounted between the
Another safety-related issue of special concern to regu- robot’s tool holder and the surgical cutter held by the tool
latory bodies is careful documentation and rigorous proce- holder. The robot then cuts the desired shape while moni-
dures in development, testing, and maintenance of toring cutting forces, bone motion, and other safety
medical robots. Sterility and biocompatibility are of sensors. The surgeon also monitors progress and can inter-
specific concern for surgical robots; these considerations rupt the robot at any time. If the procedure is paused for any
can impose unusual design constraints, especially in choice reason, there are a number of error recovery procedures
of materials. available to permit the procedure to be resumed or re-
Other systems considerations are of practical interest started at one of several defined checkpoints. Once the
mainly for researchers and developers. The most impor- desired shape has been cut, surgery proceeds manually in
tant of these is the vital importance of integration testbeds. the normal manner.
Medical systems, especially those involving image guid-
ance, are extremely difficult to develop without access to
all the pieces needed to do complete experiments.

IV. EXAMPLES OF MEDICAL

ROB OTI CS SY S TE MS

A. Robotic Orthopedic Surgery

Geometric precision is often an important consideration
in orthopedic surgery. For example, orthopedic implants
used in joint replacement surgery must fit properly and
must be accurately positioned relative to each other and to
the patient’s bones. Osteotomies (procedures involving cut-
ting and reassembly of bones) require that the cuts be made
accurately and that bone fragments be repositioned ac-
curately before they are refastened together. Spine surgery
often requires screws and other hardware to be places into Fig. 10. The ROBODOC system for hip and knee surgery was one
vertebrae in close proximity to the spinal cord, nerves, and of the first successful applications of robotics to surgical
important blood vessels. Further, bone is rigid and relatively CAD/CAM [21], [70], [71].

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 Taylor: A Perspective on Medical Robotics

delivering the therapy through a series of percutaneous

access steps, assessing what was done, and using this
feedback to control therapy at several time scales. The
ultimate goal of current research is to develop systems that
execute this process with robotic assistance under a variety
of widely available and deployable image modalities,
including ultrasound, x-ray fluoroscopy, and conventional
MRI and CT scanners.
Current work at JHU and related work at Georgetown
University is typical of this activity. This approach has
emphasized the use of Bremote center-of-motion[ (RCM)
manipulators to position needle guides under real-time
image feedback. This work has led to development of a
modular family of very compact robotic subsystems
Fig. 11. Parallel link robots that attach directly to the patient’s [79]–[83] optimized for use in a variety of imaging en-
bone. The left system [108] is used for hip surgery and the vironments, as well as a simple image overlay device for
right system [109] is intended for spine surgery. use in CT environments (Fig. 12). These devices have been
used clinically at JHU and have been evaluated for spine
applications at Georgetown [84], [119]. Many other groups
have also investigated the use of robotic devices with real-
After preclinical testing demonstrated an order-of- time x-ray and CT guidance, including [85]–[87].
magnitude improvement in precision over manual surgery, A number of groups have developed robotic devices for
the system was applied clinically in 1992 for the femoral use with ultrasound-guided (e.g., [88]–[90]) and MRI-
implant component in primary total hip replacement guided (e.g., [91]–[94] needle placement. In-MRI systems
(THR) surgery. Subsequently, it has been applied success- represent both an unusual challenge and an unusual
fully to both primary and revision THR surgery, as well as opportunity for medical robotics. On the one hand, the
knee surgery [72]–[74]. strong magnetic fields and very stringent electrical noise
A number of other robotic systems for use in joint requirements of MRI significantly limit design flexibility.
replacement surgery were subsequently proposed, includ- On the other hand, MRI imaging offers unprecedented
ing the CASPAR system [75], which was very similar to tissue discrimination and imaging flexibility that can be
ROBODOC, and the cooperatively guided Acrobot [53] exploited by compact robots operating inside the scanner
(Fig. 8, right). More recently, several groups have environment.
proposed small parallel-link robots attaching directly to
the patient’s bones (Fig. 11). Similarly, there has been
extensive progress in so-called surgical navigation for
orthopedics (e.g., [8], [76], [77]), in which the surgeon
manipulates tools freehand while a computer generates
corresponding displays based on 2-D or 3-D images.
One significant consequence of the ability of medical
robots and navigation systems to help surgeons carry out
plans accurately is that the planning itself becomes more
valuable. In turn, this has increased the potential
importance of 3-D modeling of bone from 2-D and 3-D
images, finite-element biomechanical analysis, and meth-
ods for image-based real-time registration of bone models
to x-ray and ultrasound images.

B. Robotically Assisted Percutaneous Therapy

One of the first uses of robots in surgery was posi-
tioning of needle guides in stereotactic neurosurgery
[18], [20], [78]. This is a natural application, since the
skull provides rigid frame-of-reference. However, the
potential application of localized therapy is much broader. Fig. 12. Needle placement under image guidance. Top left: in-CT
freehand placement with image overlay device [110]. Top right: x-ray
Percutaneous therapy fits naturally within the broader guided nephrostomy needle placement [81]–[83]. Bottom: in-CT
paradigm of Surgical CAD/CAM systems. The basic pro- kidney biopsy with fiducial structure on needle driver to assist
cess involves planning a patient-specific therapy pattern, robot-to-scanner registration [111], [112].

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 Taylor: A Perspective on Medical Robotics

have great potential in rehabilitation and in providing

more general assistance in daily living activities for the
infirm or disables. Although this area is not strongly tied to
my own expertise and experience, I will discuss these
applications briefly here. An excellent survey and detailed
discussion of the relevant research problems may be found
in a recent of the International Advanced Robotics
Program workshop reporton medical robots [7].
Interactive systems for physical therapy and rehabilita-
tion share many of the characteristics of surgical assistance.
Exercise robots such as those in Fig. 7 usually must come in
contact with the patient, and often must constrain the
patient as well. This raises obvious safety and ergonomic
challenges, which may also be viewed as research oppor-
tunities. The potential of these systems to customize indi-
vidual treatment plans based on patient-specific
biomechanical simulations and real-time monitoring of
Fig. 13. Some surgical assistant systems. Clockwise from upper left: patient performance represents a significant opportunity.
visual servoing of laparoscopic instrument relative to organ [113]; Another, longer term, opportunity is the possibility of
stereo video overlay of visually tracked laparoscopic ultrasound image
in daVinci robot [114]; image feedback controlled laparoscopic
combining the capabilities of surgical systems with reha-
ultrasound robot [115]; and laboratory setting for Bskill acquisition[ bilitation robots. In this scenario, a patient might present
for suturing and similar tasks [116]–[118]. with symptoms such as pain or mobility difficulties and
would receive suitable diagnostic tests and imaging to
permit a patient-specific model to be developed. An ap-
propriate therapy plan would be developed from this
C. Minimally Invasive Robotic Surgery model. If the plan includes surgery, the procedure would be
Teleoperated robots have been used for close to 15 years carried out with the assistance of appropriate technology,
to assist surgeons in minimally invasive procedures, such as robots or navigation aids. A customized and updated
first, to hold endoscopes or retractors (e.g., [24], [50], rehabilitation plan would then be executed, taking account
[95], [96]) and, later, to manipulate surgical instruments of any unexpected events in surgery. Patient progress
(e.g., [24], [25], [31], [35]). Although there have been would be monitored both to promote optimal recovery and
some spectacular long-distance demonstrations (e.g., [31], to provide statistical data correlating procedural variables
[32], [97], [98]) most uses still occur within a local (plan, patient anatomy, execution variability) with out-
operating room environment. Currently, practical clinical comes for the purposes of improving overall care.
use is more or less limited to surgeon extender uses, in One of the most rewarding things for any engineer is to
which the robot mimic the surgeon’s hand motions, and develop technology and systems that directly help people.
the surgeon relies on visual information from endoscopic Surgical and rehabilitation robots clearly fulfill this crite-
cameras for feedback. rion. But systems helping individuals with severe disabi-
However, sufficient progress in modeling and analysis lities, such as the assistive robot in Fig. 14 (left) are in a
has now been made so that medical robots with special category. These systems pose many of the same
characteristics of true surgical assistants. Some examples human–machine research challenges as surgical assistants,
are shown in Fig. 13. Research challenges associated with
the development of more capable assistants include:
1) interactive fusion of preoperative models with real-time
images and manipulator feedback, especially for deforming
organs; 2) development of ways to describe surgical tasks
and task steps that can be related in real time to these
models; 3) development of effective menus of assistive
capabilities that can be adapted to these models in real
time; and 4) development of ways for the computer to
Bfollow-along[ the progress of the procedure so as to offer
exactly the most appropriate assistance at any given time.

D. Rehabilitation and Assistance in Daily Living

Although this paper has focused on robotic systems for Fig. 14. Robots for assistance in daily living. Left: exact dynamics
surgery and other direct medical interventions, robots also assistive robot manipulator [49]. Right: CMU Nursebot [49].

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 Taylor: A Perspective on Medical Robotics

such as modeling tasks and work environments, under- world[ to the physical world of patients and clinicians, and
standing human intentions, providing meaningful assis- to the system science that makes it possible to put every-
tance and feedback without being unduly intrusive, etc. thing together safely, robustly, and efficiently. Progress in
There are some obvious differences, as well. In particular, these areas will most fruitfully be made within the context
better means must be found to develop patient-specific of well-defined applications or families of application.
human–machine interface, while at the same time finding Careful attention must also be paid to the advantages that
common elements that can be standardized on. Over time, the robotic subsystem will provide, at least potentially,
research on methods of direct coupling of systems to brain within the larger context of the application and hospital,
and nerve signals to robots and sensors will enable a new, clinic, or home environment in which it will be deployed.
more capable generation of prostheses and assistive de- Academic researchers, such as the author of this paper,
vices. Interestingly, fitting of such devices to individual can contribute to progress in these areas, but we cannot do
patients may be enabled by more precise and delicate it alone. To an even greater extent than in other subspe-
surgical robots. cialties of robotics, industry has unique expertise that is
As our population ages, we will all become more absolutely essential for successful development and deploy-
susceptible to the physical and mental frailties that come ment of medical robot systems. Also, the surgeons who will
with growing older. This will inevitably pose enormous use these systems have unique insights into the problems to
challenges for our working population. Nursing and daily be solved and into what will and will not be accepted in the
living care personnel will be stretched thinner and thinner, operating room. All groups must work together for progress
and old people may become increasingly isolated. Robotic to be made, and they must work together practically from
systems such as the BNursebot[ in Fig. 14 (right) have the very beginning. Our experience has been that building a
significant potential to help improve both the ability of strong researcher/surgeon/industry team is one of the most
human care givers to help other people and of people challenging, but also one of the most rewarding aspects of
needing help to sustain independent lives. Progress is likely medical robotics research. The only greater satisfaction is
to be incremental, as general robotic capabilities improve. the knowledge that the results of such teamwork can have a
Conversely, as these systems become more important eco- very direct impact on patients’ health. Medical robotics
nomically, they are likely to serve as testbeds for developing research is very hard work, but it is worth it. h
a broad range of multiuse robotic capabilities.

Acknowledgment
V. PERS PECTIVES: WHITHER ARE Although this paper is intended as a personal perspec-
WE TENDING AND HOW CAN tive on the field of medical robotics, this perspective has
WE GET THERE? necessarily been shaped by my experiences in working with
In less than two decades, medical robotics has developed others. I am grateful to all of these many colleagues and
from a subject of late-night comedy routines into a growing collaborators. Similarly, one notable trend over the past
field engaging the attention of hundreds of active several years has been the explosion of excellent work in
researchers around the world. If work on related technical the field. It is no longer possible to produce a truly inclusive
areas such as medical image analysis is included, there are survey. I am acutely conscious that much excellent work
thousands of researchers involved. has gone uncited. To those who have been passed over,
This research is challenging, interdisciplinary, and sy- please accept my apologies. Finally, I must express
nergistic. Progress is needed across the board in the model- appreciation to the many government and industry
ing and analysis required for medical robotic applications, partners who have partially funded some of the work
for the interface technologies required to relate the Bdata reported here.

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ABOUT THE AUTHOR

Russell H. Taylor (Fellow, IEEE) received the history of research in computer-integrated surgery and related fields. In
B.E.S. degree from Johns Hopkins University, 1988–1989, he led the team that developed the first prototype for the
Baltimore, MD, in 1970 and the Ph.D. degree in ROBODOC system for robotic hip replacement surgery and is currently on
computer science from Stanford University, Stan- the Scientific Advisory Board of Integrated Surgical Systems. At IBM he
ford, CA, in 1976. subsequently developed novel systems for computer-assisted craniofa-
He joined IBM Research in 1976, where he cial surgery and robotically augmented endoscopic surgery. At Johns
developed the AML robot language. Following a Hopkins, he has worked on all aspects of CIS systems, including
two-year assignment in Boca Raton, FL, he man- modeling, registration, and robotics in areas including percutaneous
aged robotics and automation technology re- local therapy, microsurgery, and computer-assisted bone cancer surgery.
search activities at IBM Research from 1982 until Dr. Taylor is Editor Emeritus of the IEEE TRANSACTIONS ON ROBOTICS AND
returning to full-time technical work in late 1988. From March 1990 to AUTOMATION, a Fellow of the American Institute for Medical and Biological
September 1995, he was manager of Computer Assisted Surgery. In Engineering (AIMBE), and a member of various honorary societies,
September 1995, he moved to Johns Hopkins University as a Professor of panels, editorial boards, and program committees. Dr. Taylor is a
Computer Science, with joint appointments in Radiology and Mechanical member of the scientific advisory board for Integrated Surgical Systems.
Engineering. He is also Director of the NSF Engineering Research Center In February 2000, he received the Maurice Müller award for excellence in
for Computer-Integrated Surgical Systems and Technology. He has a long computer-assisted orthopedic surgery.

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