There are three types of surgical robots: active, semiactive, and passive. An active robot system can complete an entire procedure without any surgeon input. A semiactive robot requires some surgeon input to carry out directed movements, while a passive robot is under complete control of the surgeon. Puma 560 was the first passive robotic surgical system. It was developed in 1985 with 6° of freedom, which allowed for increased precision of neurosurgical biopsies. A number of surgical robots have been introduced since then, but the only FDA approved system for Transoral Robotic Surgery (TORS) is the da Vinci Robot (Intuitive Surgical Inc., Sunnyvale, CA, USA) [13]. The origin of the da Vinci Surgical Robot stems from the National Aeronautics and Space Administration’s (NASA) need to offer surgical care for astronauts while away on space missions [14, 15]. Both the Stanford Research Institute and the US Army saw promise in this technology. The US Army needed a way to provide surgical care to a wounded soldier as soon as possible, without putting the surgeon in harm’s way. Intuitive Surgical Corporation was developed in 1995, 10 years after the introduction of the Puma system, to produce telerobotic systems for commercial public use [16]. In 2005, the first robot assisted otolaryngic procedure was described by Mac Leod and Melder who excised a vallecular cyst [17].

A review of the last 10 years of robotic surgery in pediatrics was published recently [18]. A total of 2,393 procedures in 1,840 patients were identified. Most cases were derived from the North American literature, with only 14 % of cases from Europe, 4 % from the Middle East, and 3 % from Asia. Genitourinary procedures were most commonly reported (n = 1,434) with pyeloplasty (n = 672) as the most commonly cited procedure. Gastrointestinal procedures accounted for 882 reported procedures and there were 77 reported pediatric thoracic cases. The authors note that the number of reported cases has increased dramatically since 2010 with six reports including over 100 cases each. Also of note, there are no randomized clinical trials of RAS in pediatrics to date.

There are both advantages and disadvantages to RAS. One of the biggest advantages of RAS when compared to traditional open techniques is the EndoWrist instruments have 90° of articulation and 7° of freedom. This translates into greater range of motion when compared to the human wrist, which allows for increased dexterity. Fatigue reduction is another advantage to RAS. During open head and neck procedures, most surgeons stand for the duration of the case. While using the robot, the surgeon is seated with his/her forearms resting on a pad and the head resting against the console, which results in less body fatigue. In addition, the surgeon avoids the need to physically twist and turn to move instruments and see the operative field. With improved comfort and view of the operative field, suturing is technically easier. Studies suggest that robotic surgery is less stressful for surgeons during complex tasks [19]. Furthermore, the robotic system’s 3-dimensional endoscopes with tenfold magnification improve visualization of the surgical field allowing for more precise dissection and suture placement.

When compared to endoscopic techniques, there are several advantages of RAS. First, the robotic system has the ability to eliminate tremor. Through hardware and software filters, a surgeon’s movements can be scaled down. Because of this ability, large hand movements are transformed into micromovements, which allows for more precision [1]. There is also improved hand eye coordination given that there is no fulcrum effect as is seen with endoscopic surgery [20].

Aside from the advantages compared to open and endoscopic techniques, there are several unique advantages of RAS. The robotic system provides a new vehicle for teaching. Trainees and surgeons can sit next to each other at different consoles and practice tissue holding and suturing techniques [21]. The daVinci Skill Simulator is a training tool made specifically for the robot. It can be attached to the console to allow virtual skills training using the same robotic interface [22]. There are currently no standardized residency curriculums that formally support the teaching of robotic surgical skills, but with the increase in RAS, this is likely to change.

Another unique advantage to RAS is the ability to perform telesurgery in which a surgeon performs a procedure on a patient from a remote location [23]. Marescaux and colleagues first described the feasibility and safety of a robot assisted telesurgery. They performed a laparoscopic cholecystectomy from a surgical console in New York on a patient in Strasbourg, France using a high-speed connection. They successfully completed the procedure in less than an hour with no complications.

There are some known disadvantages associated with RAS. As with any new technology, there is a learning curve for surgeons. The lack of haptic feedback can be a significant problem. Because of the lack of hands-on tissue manipulation, the early robotic surgeon can have issues with tearing tissue or suture. However, with time, evaluation of adjacent tissue can give the surgeon feedback about the amount of pressure being applied. Cost is also a downside to this technology with the average system costing $1.5–2.5 million. In addition, maintenance fees are $100,000 per year and instrument heads cost approximately $2,000 each and have limited life spans. The physical size of the unit also can be cumbersome with most hospitals requiring a dedicated robotic surgery room to accommodate the surgeon’s console, patient side cart, and instruments. The operating room staff also require additional training to become familiar with the instrumentation and to reduce surgical set-up time. Finally, as mentioned previously, there have not been any randomized controlled studies comparing RAS to endoscopic or open procedures to evaluate its effectiveness.

The 5 mm EndoWrist instruments are currently the smallest instruments available. All of the EndoWrist needle holders and tissue graspers can open their jaws from 0 to 30°. They differ in their intended application and the amount of force applied at their jaws. The 5 mm needle driver has medium jaw opening and closing force at its tip. There are no suture cut 5 mm needle drivers available. Round tip scissors have medium force during closing and opening. Curved scissors have low jaw closing force, but medium jaw opening force. The Schertel grasper is used for fine tissue handling and has low jaw opening and closing force. The Maryland dissector has similar tissue handling forces. DeBakey forceps have low jaw closing force, but medium jaw opening force. The needle driver and tissue graspers all have 20 uses per instrument, while the scissors have 12 uses.