User interfaces for actuated scope maneuvering in surgical systems: a scoping review.

The review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) guidelines [ 15 ]. An extensive search of scientific literature was conducted using PubMed and IEEE Xplore databases to identify articles describing user interfaces for robotic scope control in surgery. The search strategy for PubMed is given in Supplementary Content 1. Additional records were identified through thorough citation searches, websites, and patents. A total of 720 records were screened. Articles related to surgical systems using actuated scopes with user interfaces published between 1995 and 2022 were included. The records were screened using Rayyan app ( https://www.rayyan.ai/ ). Duplicate reports, non-robotic passive systems, soft robots, systems not related to endoscopic or laparoscopic visualization, and papers not in English were excluded. Data extracted from the records were categorized into user interfaces and types of robotic systems. Additional citations were also used (such as company websites) to provide references for the technical specifications of the robotic systems. In addition, papers comparing different user interfaces were also identified.

A total of 127 articles describing 67 different robot-assisted surgical platforms were included in the review after identifying and screening (Fig.  1 ). The platforms were grouped into: (a) 6 unique user interfaces to provide scope maneuvering commands (Fig.  2 ) and (b) 6 different categories based on the scope actuation mechanism (Fig.  3 ). Various characteristics of each robotic system, including (a) visualization type (stereo vision, high-definition, camera size, resolution), (b) degree(s) of freedom (DOF), (c) manipulation type (insertion, retraction, pan, tilt, rotate), (d) actuation method (motor, pneumatically driven), (e) control type (teleoperated, cooperative), (f) control interface, (g) development stage (commercial, research), (h) year, and (i) clinical application were also extracted. Fig. 1 Record identification and screening flowchart Fig. 2 Examples of interfaces to control scopes used in robot-assisted surgeries Fig. 3 Categories of robotic systems for visualization during surgery Record identification and screening flowchart Examples of interfaces to control scopes used in robot-assisted surgeries Categories of robotic systems for visualization during surgery Primary findings of the searches conducted are presented in the three subsequent sections. The first section describes the user interfaces for actuated scope control. The second section presents robot-assisted surgical platforms based on scope manipulation. A more detailed account of user interfaces used with different robot-assisted surgical platforms and in different surgeries is presented in the third section. Robotic systems increase the performance of camera scopes by filtering tremors and translating precise movements. Intuitive user interfaces have been developed for control of robotic systems. These can be categorized by mode of input, which includes control by foot, hand, voice, head, eyes, and image-based tracking of surgical tools, as illustrated in Fig.  2 . Foot pedals are often used as a clutch to activate scope control using handles such as finger loops or joystick [ 16 ]. The camera position is fixed unless the clutch is engaged. Foot pedals may also act as an independent control, such as the consoles developed by Yang et al. [ 17 ] and Huang et al. [ 16 ], where the novel foot interface controls the scope in four degrees of freedom (DOF). Foot control frees the hands for controlling surgical instruments. However, the buttons pressed by the foot may distract the surgeon’s attention, as they look down to differentiate the correct pedal from the ones used for operating an electric knife or other instruments [ 18 ]. The types of hand control devices that have been adopted by commercially available systems include joysticks, buttons, finger loops, touch pads, and trackballs. These allow operating surgeons to have independent control on the visualization without relying on human assistance. The application of this type of interfacing is limited because surgeons cannot simultaneously operate the scope and their instruments [ 16 ]. Surgical flow is interrupted as the operating surgeon switches between control of surgical instrument and camera scope. Additionally, pain in the fingers and thumb is commonly reported for robotic surgeries during prolonged use [ 9 ]. In systems controlled by voice, the surgeon speaks out commands such as “up”, “down”, “in”, “out” etc., to move camera scopes. Manipulating camera scopes using voice control mimics the default communication method used between operating surgeon and assistant, and there is no physical fatigue [ 19 ]. Noise in the background, however, can potentially affect voice recognition accuracy. Repetition of voice commands causing considerable delay in scope movement make it unfavorable for surgeons [ 20 ]. The typical task time for voice control is 2 s [ 21 ]. Head motion tracking provides a non-verbal intuitive control method using the surgeon’s head position as input data. Recognition of facial gestures [ 22 ] and use of head mounted displays [ 23 ] allows smooth scope control without discontinuing surgical tasks. However, it can be challenging to intuitively control the depth of the endoscope using head movements [ 24 ]. Eye tracking involves navigating the scope using eye gaze control by measuring reflections in the cornea. Although eye tracking methods free up hands for surgical instruments, they can be considered distracting. In a study [ 25 ] reporting surgeon’s opinion on interfaces, 3 out of 5 surgeons rated eye tracking unfavorably. Tool tracking uses image analysis that continuously detects the surgical instruments when activated and controls the scope position accordingly. Automatic view centering and zoom adaption is possible with the computer-based instrument tip tracking system. However, surgeons might have different priorities in terms of what they want to see while using instrument tracking [ 26 ]. This control can be challenging for tasks without surgical tools. This section presents the robot-assisted surgical platforms that utilize aforementioned user interfaces to visualize the operative field during surgery. As depicted in Fig.  3 , two main categories were used: (i) robotic surgical systems (grouped based on access to surgical site: multiple port, single port, and natural orifice), and (ii) robotic scope holders (grouped based on flexibility of scope used: rigid, articulated, and flexible endoscopes). As opposed to conventional laparoscopic surgery, robotic surgery provides enhanced visualization, dexterity, and ergonomics. Systems made for multiple-port surgeries utilize several incisions to gain access to the target area [ 27 ]. A surgeon console, either closed or open, with controllers is employed to teleoperate the robotic arm holding the camera scope. The surgeon may also switch ports over the course of the procedure. Robotic systems for multiple-port surgeries (Table 1 ), such as the da Vinci Xi (Intuitive Surgical Inc., USA) and Senhance (Asensus Surgical, USA), are utilized for a wide variety of clinical applications such as colorectal, general, gynecological, thoracic, and urological surgeries [ 28 – 30 ]. Table 1 Robotic surgical systems for visualization in multiple-port surgeries, by year Name Visualization type DOF a Manipulation type Actuation method Control type b & level of automation c Control interface Development stage Year Clinical application Camera Total ARTEMIS (Karlsruhe Research Center, Germany) d [ 31 ] Three-dimensional (3D) endoscopic vision system 4 6 Steerable & rotation of instruments 90° bending angle Electromotors Teleoperated Master–slave Open surgeon workstation—joystick control for endoscope, two master arms Research prototype (animal studies) (defunct) 1999 Surgery—minimally invasive Cardiac surgery ZEUS Robotic Surgical System (Computer Motion Inc., USA) e [ 32 ] 10 mm 3D laparoscope 4 6 One-way articulating tips Motor Teleoperated Master–slave Open surgeon console Voice-activated camera system Commercial (defunct) 2001 (FDA) Surgery—minimally invasive General surgery (gastrectomy, cholecystectomy) da Vinci Xi (Intuitive Surgical Inc., USA) [ 29 , 33 ] 3D high definition (HD) 8 mm 30° endoscope Fluorescence imaging – 7 Insertion, retraction Cable-driven Teleoperated Master–slave Closed surgeon console—hand controllers (finger loops), foot pedal (clutch) Commercial 2014 (FDA) Surgery—minimally invasive Cholecystectomy, prostatectomy, hysterectomy, colorectal cancer surgery, cardiothoracic surgery, head & neck surgery Micro Hand S (Tianjin University, China) [ 34 ] 3D camera – 7 360° rotation Cable-driven Teleoperated Master–slave Open surgeon console—hand control Commercial 2014 (China) Surgery—minimally invasive General & colorectal surgery (total mesorectal excision, sigmoidectomy) Senhance Surgical System (Asensus Surgical USA, Inc.) f [ 35 – 37 ] 3D HD vision, fluorescence visualization – 7 Insertion, retraction, pan, zoom Electrical motor Teleoperated Master–slave Open surgeon console—track pad & handles 3D glasses, eye-tracking Commercial 2017 (FDA) Surgery–minimally invasive Colorectal, gynecological, general, urological, thoracic Revo-i (meerecompany, South Korea) [ 37 – 39 ] 3D HD – 7 Zoom, rotate Electrical motor Teleoperated Master–slave Closed surgeon console–precision grip finger controls & foot pedal (clutch) Commercial 2017 (Korea) Surgery—minimally invasive Urology, general, obstetrics & gynecology Bitrack (Rob Surgical, Spain) [ 29 , 40 ] 3D HD – 7 – – Teleoperated Master–slave Open surgeon console with hand controls 3D glasses Haptic feedback Research prototype (animal studies) 2018 Surgery—minimally invasive General, urology, colon & rectal, gynecology, thoracic, renal & hepatic avatera (avateramedical, Germany) [ 41 , 42 ] 3D HD vision – 7 – – Teleoperated Master–slave Closed control unit with slender eyepiece, handle, footswitch Commercial 2019 (CE) Surgery—minimally invasive Urology (removal of prostate & kidney tumors), gynecology Versius (CMR Surgical, UK) [ 43 ] 3D HD camera system – 7 – Electrical motor Teleoperated Master–slave Open operator console with joystick controllers 3D glasses Commercial 2019 (CE) Surgery—minimally invasive Gynecologic, colorectal, renal, head & neck, upper gastrointestinal hinotori™ (Medicaroid Corporation, Japan) [ 44 , 45 ] 3D vision 4 8 – – Teleoperated Master–slave Semi-open surgeon cockpit—3D viewer, hand control, foot pedal (clutch) Commercial 2020 (Japan) Surgery—minimally invasive Prostatectomy Dexter (Distalmotion, Switzerland) [ 46 , 47 ] – – 7 In/outward, up/downward, left/right, rotational, pitch, yaw, open/close Cable-driven Teleoperated Master–slave Open surgeon console with handle grip Commercial 2020 (CE) Surgery—minimally invasive Gynecology surgery (hysterectomy) Jo, Kim [ 48 ] (Seoul National University, South Korea) [ 48 ] 3D endoscope 4 – Up/down, right/left, roll Cable-driven Teleoperated Master–slave VR headset Head tracking Research 2020 Surgery—minimally invasive Laparoscopic surgery Toumai Endoscopic Surgical System (MicroPort MedBot, China) [ 49 ] 3D view – 7 – – Teleoperated Master–slave Closed surgeon console with hand controls, foot pedal (clutch) Commercial 2021 (China) Surgery—minimally invasive Urology (prostatectomy, nephrectomy) SHURUI (Beijing Surgerii Technology Co. Ltd., China) [ 27 , 50 , 51 ] 3D stereo vision 10 mm diameter 60 fps 1280 × 720 6 – Tip deflection Cable-driven Teleoperated Master–slave Open surgeon console—hand controllers (customized Geomagic TouchX devices) Research prototype (human clinical trials) 2021 Surgery—minimally invasive Radical resection of sigmoid colon cancer, gynecologic surgeries (radical nephrectomy, partial bladder resection, thoracoscopic mediastinal lymph node dissection in porcine models) Hugo RAS system (Medtronic, USA) g [ 52 – 54 ] 3D visualization – 7 – Cable-driven Teleoperated Master–slave Open surgeon console 3D HD vision Hand grip controllers Foot pedal (clutch) Commercial 2021 (CE) Surgery—minimally invasive Urologic (prostatectomy) and gynecologic procedures SSI Mantra (SS innovations, India) [ 55 ] 3D HD chip-on-tip articulating scope 4 – Four-way articulation – Teleoperated Master–slave Open surgeon console with hand control (mini joystick), foot pedal (clutch) Commercial 2022 (India) Surgery—minimally invasive Urology, general surgery, gynecology, thoracic, cardiac, head & neck a DOF refers to degree(s) of freedom b Control type: Teleoperated, cooperative, autonomous c Level of automation: Master-slave, semi-autonomous, autonomous d ARTEMIS used FIPS robotic scope holder. It was not developed further e ZEUS used AESOP robotic scope holder. Computer Motion was acquired by Intuitive Surgical f Senhance was formerly known as Telelap Alf-X. Asensus Surgical US, Inc. was previously known as TransEnterix, Inc. g Hugo RAS incorporates MiroSurge (German Aerospace Center DLR, Germany) Robotic surgical systems for visualization in multiple-port surgeries, by year Steerable & rotation of instruments 90° bending angle Teleoperated Master–slave Surgery—minimally invasive Cardiac surgery Teleoperated Master–slave Open surgeon console Voice-activated camera system Commercial (defunct) Surgery—minimally invasive General surgery (gastrectomy, cholecystectomy) 3D high definition (HD) 8 mm 30° endoscope Fluorescence imaging Teleoperated Master–slave Surgery—minimally invasive Cholecystectomy, prostatectomy, hysterectomy, colorectal cancer surgery, cardiothoracic surgery, head & neck surgery Teleoperated Master–slave Surgery—minimally invasive General & colorectal surgery (total mesorectal excision, sigmoidectomy) Teleoperated Master–slave Open surgeon console—track pad & handles 3D glasses, eye-tracking Surgery–minimally invasive Colorectal, gynecological, general, urological, thoracic Teleoperated Master–slave Surgery—minimally invasive Urology, general, obstetrics & gynecology Teleoperated Master–slave Open surgeon console with hand controls 3D glasses Haptic feedback Surgery—minimally invasive General, urology, colon & rectal, gynecology, thoracic, renal & hepatic Teleoperated Master–slave Surgery—minimally invasive Urology (removal of prostate & kidney tumors), gynecology Teleoperated Master–slave Open operator console with joystick controllers 3D glasses Surgery—minimally invasive Gynecologic, colorectal, renal, head & neck, upper gastrointestinal Teleoperated Master–slave Surgery—minimally invasive Prostatectomy Teleoperated Master–slave Surgery—minimally invasive Gynecology surgery (hysterectomy) Teleoperated Master–slave VR headset Head tracking Surgery—minimally invasive Laparoscopic surgery Teleoperated Master–slave Surgery—minimally invasive Urology (prostatectomy, nephrectomy) 3D stereo vision 10 mm diameter 60 fps 1280 × 720 Teleoperated Master–slave Open surgeon console—hand controllers (customized Geomagic TouchX devices) Surgery—minimally invasive Radical resection of sigmoid colon cancer, gynecologic surgeries (radical nephrectomy, partial bladder resection, thoracoscopic mediastinal lymph node dissection in porcine models) Teleoperated Master–slave Open surgeon console 3D HD vision Hand grip controllers Foot pedal (clutch) Surgery—minimally invasive Urologic (prostatectomy) and gynecologic procedures Teleoperated Master–slave Surgery—minimally invasive Urology, general surgery, gynecology, thoracic, cardiac, head & neck a DOF refers to degree(s) of freedom b Control type: Teleoperated, cooperative, autonomous c Level of automation: Master-slave, semi-autonomous, autonomous d ARTEMIS used FIPS robotic scope holder. It was not developed further e ZEUS used AESOP robotic scope holder. Computer Motion was acquired by Intuitive Surgical f Senhance was formerly known as Telelap Alf-X. Asensus Surgical US, Inc. was previously known as TransEnterix, Inc. g Hugo RAS incorporates MiroSurge (German Aerospace Center DLR, Germany) Compared to multiple-port procedures, single-port surgeries reduce invasiveness and significantly benefit patients with less scarring, low recovery time and reduced postoperative pain [ 56 ]. Robotic systems developed for single-incision laparoscopic surgeries, as detailed in Table 2 , usually have a single arm with multiple instruments and a scope for visualization that extends outwards. The incision may be of different sizes depending on the system used and the procedure. Single-port surgery may prove challenging for the surgeon due to poor ergonomics. To avoid collision, distally actuated arms that achieve triangulation of the instruments around the target organ are often required [ 57 ]. Much like the ones for multiple-port surgeries, these systems utilize either closed or open surgeon console with controllers to manipulate the robotic arm. The da Vinci SP (Intuitive Surgical Inc., USA) has US Food and Drug Administration (FDA) approval for urologic and transoral otolaryngology procedures. Other platforms under development target gynecological and general surgery applications. Table 2 Robotic surgical systems for visualization in single-port surgeries, by year Name Visualization type DOF Manipulation type Actuation method Control type & level of automation Control interface Development stage Year Clinical application Camera Total da Vinci SP Surgical System (Intuitive Surgical Inc., USA) [ 36 , 58 ] 12 × 10 mm articulating camera – 7 Double articulating (wrist & elbow) endoscope 360° rotation Cable-driven Teleoperated Master–slave Closed surgeon console—hand controllers (finger loops), foot pedal Commercial 2014 (FDA) Surgery—minimally invasive Urologic (prostatectomy, cystectomy, nephrectomy, pyeloplasty), transoral otolaryngology surgeries, transanal total mesorectal excision in human cadaveric model SurgiBot, (TransEnterix, Inc., USA) a [ 30 ] 3D HD visualization – 6 Retraction – Teleoperated Master–slave Patient-side hand controller with knobs Research prototype (towards commercialization) 2015 Surgery—minimally invasive Abdominal surgery General and urology procedures SJTU unfoldable robotic System (SURS) (Shanghai Jiao Tong University, China) [ 59 ] 3D vision unit 640 × 480 3 6 Bending & translation Motor-driven actuation rods Teleoperated Master–slave Hand control (Phantom Omni devices) Research prototype (lab studies) 2015 Surgery—minimally invasive Single-port laparoscopic procedures Vicarious surgical system (USA) [ 60 , 61 ] Two cameras 3D HD 360° visibility, panoramic view 2 9 Pan, tilt 180° swivel Cable-driven Teleoperated Master–slave Open surgeon console with head mounted display Research prototype (under development) 2017 Surgery—minimally invasive Ventral hernia repair SPAS robotic system (National University of Singapore, Singapore) [ 62 , 63 ] 5.5 mm diameter 1280 × 720 resolution 2 5 – Tendon-sheath mechanism Teleoperated Master–slave Hand control (two geomagic touch haptic devices) Research prototype (design concept) 2019 Surgery—minimally invasive Appendectomy, nephrectomy Oncology—treatment of giant cell tumor Enos Surgical System (Titan Medical Inc., Canada) b [ 28 , 37 , 64 , 65 ] 2D & 3D HD – 6 Elevate, tilt, pan Electrical motor Teleoperated Master–slave Open surgeon console—hand controllers & foot pedal (clutch) Research prototype (animal & human cadaver studies) 2020 Surgery—minimally invasive Cholecystectomy, fundoplication, future gynecologic application MIRA (Virtual Incision, USA) [ 66 ] Full HD (1080p /60 Hz) – 7 Articulating flex tip – Teleoperated Master–slave Open surgeon console—hand controllers, foot pedals, touchscreen Haptic feedback Research prototype (FDA clinical trials) 2022 (FDA IDE) Surgery—minimally invasive Bowel resection procedures a SurgiBot was built on Single Port Instrument Delivery Extended Research (SPIDER). SurgiBot assets were later sold to Great Belief International Limited (GBIL), China for commercialization. TransEnterix, Inc. is currently known as Asensus Surgical US, Inc. b Enos was previously known as Single Port Orifice Robotic Technology (SPORT) Robotic surgical systems for visualization in single-port surgeries, by year Double articulating (wrist & elbow) endoscope 360° rotation Teleoperated Master–slave Surgery—minimally invasive Urologic (prostatectomy, cystectomy, nephrectomy, pyeloplasty), transoral otolaryngology surgeries, transanal total mesorectal excision in human cadaveric model Teleoperated Master–slave Surgery—minimally invasive Abdominal surgery General and urology procedures 3D vision unit 640 × 480 Teleoperated Master–slave Surgery—minimally invasive Single-port laparoscopic procedures Two cameras 3D HD 360° visibility, panoramic view Pan, tilt 180° swivel Teleoperated Master–slave Surgery—minimally invasive Ventral hernia repair 5.5 mm diameter 1280 × 720 resolution Teleoperated Master–slave Surgery—minimally invasive Appendectomy, nephrectomy Oncology—treatment of giant cell tumor Teleoperated Master–slave Surgery—minimally invasive Cholecystectomy, fundoplication, future gynecologic application Teleoperated Master–slave Open surgeon console—hand controllers, foot pedals, touchscreen Haptic feedback Surgery—minimally invasive Bowel resection procedures a SurgiBot was built on Single Port Instrument Delivery Extended Research (SPIDER). SurgiBot assets were later sold to Great Belief International Limited (GBIL), China for commercialization. TransEnterix, Inc. is currently known as Asensus Surgical US, Inc. b Enos was previously known as Single Port Orifice Robotic Technology (SPORT) Further minimizing surgical aggressiveness, robotic systems for natural orifice procedures approach the site of interest through the natural openings in the body such as the mouth or anus [ 67 ]. This is especially beneficial when the patient has a compromised immune system. The robot consists of a highly flexible and dextrous arm that can be steered towards intricate structures. An open surgeon console or a bed-side controller is used to manipulate the arm, and correspondingly the camera. Table 3 describes robotic systems used for transoral applications such as vocal cord lesion resection and bronchoscopy, as well as colorectal surgeries. Systems aimed for endoscopic submucosal dissection (ESD) in the gastrointestinal tract and ear, nose, throat (ENT) surgeries are under development. Table 3 Robotic surgical systems for visualization in natural orifice procedures, by year Name Visualization type DOF Manipulation type Actuation method Control type & level of automation Control interface Development stage Year Clinical application Camera Total Flex system (Medrobotics Corp., USA) [ 29 , 68 , 69 ] 3D HD Dual 1920 × 1080 pixel 80° field of view – – 180° articulation, horizontal, vertical, rotation, zoom Cable-driven Teleoperated Master–slave Open console Single-port control joystick Commercial 2015 (FDA) Surgery—minimally invasive Transoral surgery (oropharyngeal, hypopharyngeal, laryngeal procedures) Obstetric/gynecologic applications MONARCH platform (Auris Health, Inc., USA) a [ 14 , 70 – 73 ] 660p x central airways & periphery vision 10 – Insertion, retraction, articulation 180° in all direction Cable-driven Teleoperated Master–slave Hand-held controller (joysticks & buttons) Commercial 2018 (FDA) Investigational procedure Robotic bronchoscopy for peripheral pulmonary lesion biopsy Surgery—minimally invasive Urology—percutaneous nephrolithotomy STRAS (ICube b ) [ 13 , 16 ] – 2 10 Rotation, deflection, translation Motor (tendon-driven) Teleoperated Master–slave Handle shaft on L-shaped bracket, two small four-way finger joysticks to operate endoscope Research prototype (animal studies) 2018 Surgery—minimally invasive Treatment of tumor in rectum and sigmoid colon Gastrointestinal tract surgery Endoscopic submucosal dissection (ESD) in animal model i 2 Snake (Hamlyn Centre, UK) [ 74 ] 3 mm 640 × 480 pixels – 7 – Tendon driven actuated by EC motors Teleoperated Master–slave Hand-held gripper Foot pedal for switching modes Research prototype (lab studies) 2018 Surgery—minimally invasive Transoral surgery Tumor resection, sleep-apnea surgery Ion endoluminal system (Intuitive Surgical Inc., USA) [ 75 – 77 ] Removable vision probe 90° field of view 0° direction of view – – 180° in all direction (pitch & yaw) Electromechanically (servo/stepper motors & software) Teleoperated Master–slave Hand control (trackball & scroll wheel) Commercial 2019 (FDA) Investigational procedure Minimally invasive peripheral lung biopsy (bronchoscopy) Endoscopic Therapeutic Robot System (ETRS) (Kyushu Institute of Technology, Japan) c [ 78 ] 120° field of view 4 – Up/down & left/right angulation, insertion/retraction, rotation Motor Teleoperated Master–slave Hand controls (Geomagic Touch) Research prototype (animal studies) 2019 Surgery—minimally invasive Endoscopic submucosal dissection (ESD) in porcine model K-FLEX (EasyEndo Surgical, Korea) [ 79 ] High definition 4 14 Deflection, translation, rotation Wire cable & motor Teleoperated Master–slave Hand interface switched by foot clutch Research prototype (ex vivo porcine study) 2020 Surgery—minimally invasive Possible application for gastrointestinal tract, ENT surgeries Three-Limb Robotic System (Nanyang Technological University, Singapore) d [ 16 , 80 , 81 ] 120° field of view 0° forward viewing 4 13 Up/down, left/right, in/out, rotation Tendon-sheath mechanism & motors Teleoperated Master–slave Open master console Two hand interfaces One foot interface to control endoscope Research prototype (ex vivo porcine study) 2021 Surgery—minimally invasive Transoral robotic surgery Gastrointestinal tract surgery Endoscopic resection Endoluminal Surgical System (EndoQuest Robotics, USA) e [ 82 , 83 ] 3.7 mm HD robotic camera – 7 Advanced flexibility & dexterity – Teleoperated Master–slave Open surgeon console—hand controllers & foot pedal (clutch) Research prototype (clinical trial) 2021 Surgery—minimally invasive Transanal endoluminal procedures; colorectal endoscopic submucosal dissection (ESD) a Auris Health previously acquired Hansen Medical, manufacturer of Magellan & Sensei robotic systems. Auris Health was later acquired by Johnson & Johnson, which plans to build Ottava. b STRAS is a robotic version of Anubiscope (IRCAD & KARL STORZ Endoskope) c The endoscope is controlled by endoscopic operation robot (EOR) d Nanyang Technological University has also produced the robotic system EndoMaster (EndoMaster Pte Ltd., Singapore). However, it requires manual operation of the endoscope e Endoluminal Surgical System was previously known as ColubrisMX ELS System Robotic surgical systems for visualization in natural orifice procedures, by year 3D HD Dual 1920 × 1080 pixel 80° field of view Teleoperated Master–slave Open console Single-port control joystick Surgery—minimally invasive Transoral surgery (oropharyngeal, hypopharyngeal, laryngeal procedures) Obstetric/gynecologic applications Insertion, retraction, articulation 180° in all direction Teleoperated Master–slave Investigational procedure Robotic bronchoscopy for peripheral pulmonary lesion biopsy Surgery—minimally invasive Urology—percutaneous nephrolithotomy Teleoperated Master–slave Surgery—minimally invasive Treatment of tumor in rectum and sigmoid colon Gastrointestinal tract surgery Endoscopic submucosal dissection (ESD) in animal model 3 mm 640 × 480 pixels Teleoperated Master–slave Hand-held gripper Foot pedal for switching modes Surgery—minimally invasive Transoral surgery Tumor resection, sleep-apnea surgery Removable vision probe 90° field of view 0° direction of view 180° in all direction (pitch & yaw) Teleoperated Master–slave Investigational procedure Minimally invasive peripheral lung biopsy (bronchoscopy) Teleoperated Master–slave Surgery—minimally invasive Endoscopic submucosal dissection (ESD) in porcine model Teleoperated Master–slave Surgery—minimally invasive Possible application for gastrointestinal tract, ENT surgeries 120° field of view 0° forward viewing Teleoperated Master–slave Open master console Two hand interfaces One foot interface to control endoscope Surgery—minimally invasive Transoral robotic surgery Gastrointestinal tract surgery Endoscopic resection Teleoperated Master–slave Surgery—minimally invasive Transanal endoluminal procedures; colorectal endoscopic submucosal dissection (ESD) a Auris Health previously acquired Hansen Medical, manufacturer of Magellan & Sensei robotic systems. Auris Health was later acquired by Johnson & Johnson, which plans to build Ottava. b STRAS is a robotic version of Anubiscope (IRCAD & KARL STORZ Endoskope) c The endoscope is controlled by endoscopic operation robot (EOR) d Nanyang Technological University has also produced the robotic system EndoMaster (EndoMaster Pte Ltd., Singapore). However, it requires manual operation of the endoscope e Endoluminal Surgical System was previously known as ColubrisMX ELS System Minimally invasive surgeries employ rigid scopes for visualization that is either zero-degree which is forward-viewing or angulated that provides a wide range of view. Robotically actuated scope holders, which are used to hold and maneuver rigid scopes, provide a tremor-free stable view that is directly controlled by the operating surgeon. It eliminates the need to communicate desired scope position changes to an assistant [ 84 ]. Several holders have been developed for rigid scopes, with AESOP (Computer Motion, USA) being one of the earliest robotic scope holders using hand, foot, and voice control. As described in Table 4 , they are used extensively in general, urology, gynecology, and colorectal surgeries. SOLOASSIST II (AKTORmed, Germany) has applications in transoral thyroid surgeries as well. Table 4 Robotic scope holders for rigid scopes, by year Name DOF Manipulation type Actuation method Control type & level of automation Control interface Development stage Year Clinical application AESOP (Computer Motion Inc., USA) a [ 85 ] 4 Three rotations and insertion depth Motor Teleoperated Master–slave Hand control joystick, voice commands, foot pedal control Commercial (defunct) 1994 (FDA) Surgery—minimally invasive Thoracic surgery FIPS (Karlsruhe Research Center, Germany) [ 86 , 87 ] 4 3 revolute & 1 prismatic joint Up/down, left/right, in/out, rotate Motor Teleoperated Master–slave Finger-ring joystick Voice control Research prototype (animal studies) (defunct) 1999 Surgery—minimally invasive Cholecystectomy FAce MOUSe (Osaka University, Japan) [ 22 ] 3 Up/down, left/right, insertion/retraction Motor Teleoperated Master–slave Facial motion (image-based system), voice commands Research prototype (ex vivo & in vivo trial) 2003 Surgery—minimally invasive Cholecystectomy LapMan (Medsys, Belgium) [ 88 – 90 ] 3 In/out, right/left, up/down Motor Teleoperated Master–slave Hand control joystick & remote-controlled keypad Commercial 2003 (FDA) Surgery—minimally invasive Gynecology surgery Naviot (Hitachi, Japan) [ 91 ] – Zoom, vertical and horizontal directions Motor Teleoperated Master–slave Hand controller with two buttons Commercial 2008 (Japan) Surgery—minimally invasive Thoracoscopic surgery (anatomical pulmonary resection) Cholecystectomy ViKY (EndoControl, France) [ 92 – 95 ] 3 Up-down, left–right, forward–backward Motor Teleoperated & cooperative, master–slave & semi-autonomous (detection & tracking of instrument using image analysis) Voice control, instrument tracking Commercial 2008 (FDA) Surgery—minimally invasive Radical prostatectomy, gynecology, abdominal, thoracoscopic surgery FreeHand (FreeHand Surgical, UK) b [ 86 , 96 ] 3 Pan, tilt, zoom Motor Teleoperated Master–slave Headset with footswitch (to engage movement) Commercial 2009 (FDA) Surgery—minimally invasive General, gynecology, urology, thoracic surgeries EVOLAP (Université catholique de Louvain, Belgium) [ 97 , 98 ] 2 – Motor Teleoperated Master–slave Miniature hand joystick Research prototype (in vivo trial) 2013 Surgery—minimally invasive Gynecology (salpingectomy) RoboLens (Sina Robotics & Medical Innovators Co., Ltd., Iran) [ 20 , 99 – 101 ] 4 Up/down, left/right, in/out, rotation Motor Teleoperated & Cooperative Master–slave & Semi-autonomous (Tracking surgical instruments) Six-button foot pedal Touch screen keypad Voice commands Surgical instruments tracking (image processing) Commercial 2015 (Iran) Surgery—minimally invasive Cholecystectomy Ovarian cystectomy AutoLap (MST Medical Surgery Technologies, Israel) c [ 8 , 86 , 102 , 103 ] – Up/down, left/right, zoom in/out Tracking designated tool Motor Teleoperated & Cooperative Master–slave & Semi-autonomous (Automatic view centering, zoom adaption, camera horizon correction) Joystick (Image analysis and computer-based instrument recognition) Commercial 2016 (FDA) Surgery—minimally invasive General, gynecology, urology procedures EMARO (Riverfield Inc., Japan) [ 86 , 104 – 106 ] 4 Pan, tilt, zoom, roll Pneumatically driven Teleoperated Master–slave Head sensor, foot pedal (clutch) Commercial 2015 (Japan) Surgery—minimally invasive Inguinal hernia repair MTG-H100 (HIWIN Technologies Corp., Taiwan) [ 23 , 107 , 108 ] 3 Zoom in/out, upward/downward, right/left Motor Teleoperated Master–slave Controller with foot pedals Head mounted display & speech controller proposed Commercial 2017 Surgery—minimally invasive General, urology, gynecology, colon & rectal surgeries Cirq (Medineering, Germany) d [ 109 ] 7 Forward/backward, left/right, up/down, pivot point rotation Motor Teleoperated Master–slave Foot pedal controller with joystick Commercial 2017 (CE) Surgery—minimally invasive Transnasal sinus and skull base surgery EinsteinVision 3.0 (Aesculap AG, Germany) [ 110 , 111 ] – – Motor Teleoperated Master–slave Remote hand control button interface Commercial 2017 Surgery—minimally invasive Abdominal surgery (upper gastrointestinal procedure) Gynecology surgery SOLOASSIST II (AKTORmed GmbH, Germany) [ 112 – 115 ] 3 Up/down, left/right Zoom in/out Electrical motor e Teleoperated Master–slave Voice control, joystick Commercial 2018 (FDA) Surgery—minimally invasive General, urology, gynecology, thoracic, cardiac surgeries Transoral endoscopic thyroid surgery ROSA ONE Brain (Zimmer Biomet, USA) [ 116 ] 6 – – Cooperative & semi-autonomous (force torque sensor, preoperative or intraoperative planning values) Touchscreen Foot pedal (for activation) Haptic technology Commercial 2019 (FDA) Investigational procedure Ventricular endoscopy Transnasal endoscopy Surgery—minimally invasive Neurosurgery (brain and spine) De Pauw, Kalmar [ 117 ] (Ghent University, Belgium) – Zoom in/out Electromotor Master–slave Single-hand control (thumb lever) Research prototype (cadaveric trial) 2020 Surgery—minimally invasive Colorectal surgery (single-port rectopexy) Yang, Udatha [ 17 ] (Monash University, Australia) 4 Left/right Forward/backward Insertion/withdrawal Rotation – Teleoperated Master–slave Foot interface Research prototype (lab studies) 2020 Surgery—minimally invasive Laparoscopy FREEDOM (The Chinese University of Hong Kong) [ 118 , 119 ] 3 Horizontal/vertical, pitch/yaw, translation Motor Teleoperated Master–slave Foot control Research prototype (clinical trials) 2020 Surgery—minimally invasive Endoscopic sinus surgery Avellino, Bailly [ 120 ] (Sorbonne Université, France) – Left/right Cable-driven Teleoperated & Cooperative Master–slave & Semi-autonomous Hand manipulation, joystick, tool tracking, posture/head tracking Research prototype (lab studies) 2020 Surgery—minimally invasive Urology, gynecology surgery Bed-side robotic surgery a AESOP is no longer commercialized. Computer Motion was taken over by Intuitive Surgical b FreeHand (previously Prosurgics, UK) replaced EndoAssist / EndoSista (Armstrong Healthcare, UK) c TransEnterix Inc. previously acquired MST Medical Surgery Technologies. AutoLap assets were later sold to Great Belief International Limited (GBIL), China [ 51 ] d Medineering was acquired by Brainlab, Germany e Previous generation of the system (SOLOASSIST) was fluid actuated Robotic scope holders for rigid scopes, by year Teleoperated Master–slave Surgery—minimally invasive Thoracic surgery 3 revolute & 1 prismatic joint Up/down, left/right, in/out, rotate Teleoperated Master–slave Finger-ring joystick Voice control Surgery—minimally invasive Cholecystectomy Teleoperated Master–slave Surgery—minimally invasive Cholecystectomy Teleoperated Master–slave Surgery—minimally invasive Gynecology surgery Teleoperated Master–slave Surgery—minimally invasive Thoracoscopic surgery (anatomical pulmonary resection) Cholecystectomy Surgery—minimally invasive Radical prostatectomy, gynecology, abdominal, thoracoscopic surgery Teleoperated Master–slave Surgery—minimally invasive General, gynecology, urology, thoracic surgeries Teleoperated Master–slave Surgery—minimally invasive Gynecology (salpingectomy) Teleoperated & Cooperative Master–slave & Semi-autonomous (Tracking surgical instruments) Six-button foot pedal Touch screen keypad Voice commands Surgical instruments tracking (image processing) Surgery—minimally invasive Cholecystectomy Ovarian cystectomy Up/down, left/right, zoom in/out Tracking designated tool Teleoperated & Cooperative Master–slave & Semi-autonomous (Automatic view centering, zoom adaption, camera horizon correction) Joystick (Image analysis and computer-based instrument recognition) Surgery—minimally invasive General, gynecology, urology procedures Teleoperated Master–slave Surgery—minimally invasive Inguinal hernia repair Teleoperated Master–slave Controller with foot pedals Head mounted display & speech controller proposed Surgery—minimally invasive General, urology, gynecology, colon & rectal surgeries Teleoperated Master–slave Surgery—minimally invasive Transnasal sinus and skull base surgery Teleoperated Master–slave Surgery—minimally invasive Abdominal surgery (upper gastrointestinal procedure) Gynecology surgery Up/down, left/right Zoom in/out Teleoperated Master–slave Surgery—minimally invasive General, urology, gynecology, thoracic, cardiac surgeries Transoral endoscopic thyroid surgery Touchscreen Foot pedal (for activation) Haptic technology Investigational procedure Ventricular endoscopy Transnasal endoscopy Surgery—minimally invasive Neurosurgery (brain and spine) Surgery—minimally invasive Colorectal surgery (single-port rectopexy) Left/right Forward/backward Insertion/withdrawal Rotation Teleoperated Master–slave Surgery—minimally invasive Laparoscopy Teleoperated Master–slave Surgery—minimally invasive Endoscopic sinus surgery Teleoperated & Cooperative Master–slave & Semi-autonomous Surgery—minimally invasive Urology, gynecology surgery Bed-side robotic surgery a AESOP is no longer commercialized. Computer Motion was taken over by Intuitive Surgical b FreeHand (previously Prosurgics, UK) replaced EndoAssist / EndoSista (Armstrong Healthcare, UK) c TransEnterix Inc. previously acquired MST Medical Surgery Technologies. AutoLap assets were later sold to Great Belief International Limited (GBIL), China [ 51 ] d Medineering was acquired by Brainlab, Germany e Previous generation of the system (SOLOASSIST) was fluid actuated Articulated scopes have a flexible distal end that improves visualization around complex anatomy. Such scopes reduce the chance of interference with surgical instruments inserted through the same port. Research prototypes of scope holders described by Li et al. [ 121 ] and Huang et al. [ 26 ] aim towards thoracic surgery applications (Table 5 ). These research prototypes tend to use a variety of different control interfaces for scope manipulation. Table 5 Robotic scope holders for articulated scopes, by year Name DOF Manipulation type Actuation method Control type & level of automation Control interface Development stage Year Clinical application Cardioscope (The Chinese University of Hong Kong, China) [ 121 , 122 ] – 180° bending with controllable length Wire-driven flexible mechanism Cooperative Master–slave Control body with handle and actuation module Research prototype (ex vivo & in vivo tests) 2016 Surgery—minimally invasive Cardiac surgery (single hole) Omori, Arai [ 123 ] (Chuo University, Japan) [ 123 , 124 ] 3 Pan-tilt, pitch-yaw, zoom in/out – Teleoperated Master–slave Head-mounted interface detecting jaw movements Research prototype (lab studies) 2021 Surgery—minimally invasive Cholecystectomy PliENT (Robotics, Automation and Mechatronics Group, Belgium) [ 125 ] 6 Distal end steering Bend up to 93° Pneumatic Teleoperated Master–slave Single-handed button interface (Adafruit keypad) Research prototype (concept design) 2022 Surgery—minimally invasive Endoscopic maxillary sinus surgery Augmented Reality Visualizing Robotic Stereo Flexible Endoscope (ARSFE) (The Chinese University of Hong Kong, China) [ 26 , 126 ] 6 Rotation, depth, view centering Cable-driven Autonomous Fully autonomous (Image moment-based visual servoing method) Tracking surgical instrument or surgeon’s head (Foot pedal to activate different modes) Research prototype (lab & animal studies) 2022 Surgery—minimally invasive Thoracic surgery Robotic scope holders for articulated scopes, by year Cooperative Master–slave Surgery—minimally invasive Cardiac surgery (single hole) Teleoperated Master–slave Surgery—minimally invasive Cholecystectomy Distal end steering Bend up to 93° Teleoperated Master–slave Autonomous Fully autonomous (Image moment-based visual servoing method) Tracking surgical instrument or surgeon’s head (Foot pedal to activate different modes) Surgery—minimally invasive Thoracic surgery Flexible endoscopes are highly dexterous and heavily used in gastroscopy and colonoscopy procedures. Complex movements are required when compared to rigid scopes [ 127 ]. Few robotic scope holders have been developed for forward-viewing flexible endoscopes (Table 6 ). Certain motions, such as rotation, are still controlled manually in some of these systems. Majority of the scope holders are exclusively used for colonoscopy and gastroscopy. The Avicenna Roboflex (ELMED Medical Systems, Türkiye) has applications in urology as well. Table 6 Robotic scope holders used for flexible endoscopes, by year Name DOF Manipulation type Actuation method Control type & level of automation Control interface Development stage Year Clinical application NeoGuide endoscopy system (NeoGuide Systems Inc., USA) a [ 128 – 131 ] – Steering with natural loop maintained Electromechanical motor Teleoperated Semi-autonomous Open console system with joystick (Computer console shapes according to natural loops of colon) Commercial (defunct) 2007 (FDA) Investigational procedure Colonoscopy Endotics endoscopy System (Era Endoscopy SRL, Italy) [ 130 , 132 , 133 ] – Steering Pneumatic Teleoperated Semi-autonomous (Self-propelling) Workstation with hand-held console Commercial 2009 (CE) Investigational procedure Colonoscopy Endodrive (ECE Medical systems, Germany) [ 84 , 134 , 135 ] – Shaft insertion, retraction Electro-mechanical Teleoperated Master–slave Foot pedal Commercial 2010 Investigational procedure Colonoscopy, biopsy Surgery—minimally invasive Polypectomy Avicenna Roboflex (ELMED Medical Systems, Türkiye) [ 136 , 137 ] – Forward/backward, insertion/retraction, rotation, deflection Motor Teleoperated Master–slave Console with touchscreen and hand manipulator controls (wheel & joystick) Commercial 2013 (CE) Investigational procedure Flexible ureterorenoscopy Surgery—minimally invasive Urology (retrograde intrarenal surgery) Teleflex (University of Twente, Netherlands) [ 10 , 138 ] 4 Distal tip actuation (up/down, left/right) Shaft translation, rotation Motor Teleoperated Master–slave Hand control Head movements Research prototype (lab studies) 2013 Surgery—minimally invasive Transoral gastrointestinal procedures Aer-O-Scope (GI View, Israel) [ 139 – 141 ] – Steering Pneumatic Teleoperated Semi-autonomous (Self-navigation) Open workstation with full joystick control (Computer algorithm adjusts pressure) Commercial 2016 (FDA) Investigational procedure Colonoscopy invendoscopy E200 System (invendo medical, Germany) b [ 29 , 142 , 143 ] – 180° tip deflection Tip steering, shaft translation Electromechanical motor Teleoperated Master–slave Open invendo ScopeController with hand-held joystick Commercial 2016 (FDA) Surgery—minimally invasive Colonoscopy Polypectomies Gastroscope intervention mechanism (GIM) (Chinese Academy of Sciences, China) [ 144 ] 2 Push-pulling, rotating Pneumatic pressure Teleoperated Master–slave Hand control joystick Research prototype (in vivo live animal studies) 2017 Investigational procedure Gastroscopy Endoscopic operation robot (EOR) (Kyushu Institute of Technology, Japan) [ 145 , 146 ] 4 Up/down & left/right angulation, insertion/retraction, rotation Motor Teleoperated Master–slave Hand control mini-joystick & knobs Research prototype (lab studies) 2018 Investigational procedure Colonoscopy Surgery—minimally invasive Endoscopic submucosal dissection (ESD) in porcine model Robotic-assisted flexible endoscope (RAFE) (Kyushu University, Japan) [ 127 ] 4 Up-down, right-left, back–forth, twisting Motor Teleoperated Master–slave One-handle master controller Research prototype (porcine model) 2018 Surgery—minimally invasive Endoscopic submucosal dissection (ESD) Sivananthan, Kogkas [ 147 ] (NHS & Imperial College London, UK) – Steering, advancement, withdrawal, retroflexion Motor Teleoperated Master–slave Eye gaze tracking glasses, head control, joystick (insertion/withdrawal) Research prototype (lab studies) 2021 Surgery—minimally invasive Endoscopic submucosal dissection (ESD) a NeoGuide was acquired by Intuitive Surgical Inc., US b Invendo medical was acquired by Ambu, Denmark Robotic scope holders used for flexible endoscopes, by year Electromechanical motor Teleoperated Semi-autonomous Open console system with joystick (Computer console shapes according to natural loops of colon) Investigational procedure Colonoscopy Teleoperated Semi-autonomous (Self-propelling) Investigational procedure Colonoscopy Teleoperated Master–slave Investigational procedure Colonoscopy, biopsy Surgery—minimally invasive Polypectomy Teleoperated Master–slave Investigational procedure Flexible ureterorenoscopy Surgery—minimally invasive Urology (retrograde intrarenal surgery) Distal tip actuation (up/down, left/right) Shaft translation, rotation Teleoperated Master–slave Hand control Head movements Surgery—minimally invasive Transoral gastrointestinal procedures Teleoperated Semi-autonomous (Self-navigation) Open workstation with full joystick control (Computer algorithm adjusts pressure) Investigational procedure Colonoscopy 180° tip deflection Tip steering, shaft translation Teleoperated Master–slave Surgery—minimally invasive Colonoscopy Polypectomies Teleoperated Master–slave Investigational procedure Gastroscopy Teleoperated Master–slave Investigational procedure Colonoscopy Surgery—minimally invasive Endoscopic submucosal dissection (ESD) in porcine model Teleoperated Master–slave Surgery—minimally invasive Endoscopic submucosal dissection (ESD) Teleoperated Master–slave Surgery—minimally invasive Endoscopic submucosal dissection (ESD) a NeoGuide was acquired by Intuitive Surgical Inc., US b Invendo medical was acquired by Ambu, Denmark Robot-assisted surgical platforms presented above utilize different user interfaces for scope manipulation. Overall, the results presented in Fig.  4 a and Table 7 suggest that robotic surgical systems predominantly use hand control interfaces, whereas robotic scope holders tend to utilize and experiment with a variety of different interfaces, including tool tracking. In robotic surgical systems for multiple port, single port, and natural orifice, the design of closed consoles requires the surgeon to place their head on the stereo viewer. This limits the surgeon’s range of movement, making hand controllers appropriate for scope control. Most commercially available robotic scope holders offer a hand control interface due to its familiarity and intuitiveness which is necessary while performing surgical procedures. Advantages such as user-friendliness, easy hand–eye coordination, and lower cognitive load make hand control popular. Fig. 4 Mapping of user interfaces with robotic systems and surgeries Table 7 Mapping of actuated scopes with common user interfaces used Interface System type Robotic surgical systems Robotic scope holders Multiple port Single port Natural orifice Rigid scopes Articulated scopes Endoscopes Foot Commercial AESOP [ 85 ] Cirq [ 109 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] RoboLens [ 20 , 99 – 101 ] Endodrive [ 84 , 134 , 135 ] Research Three-Limb Robotic System [ 16 , 80 , 81 ] FREEDOM [ 118 , 119 ] Yang, Udatha [ 17 ] Hand Commercial avatera [ 41 , 42 ] da Vinci Xi [ 29 , 33 ] Dexter [ 46 , 47 ] hinotori [ 44 , 45 ] Hugo RAS system [ 52 – 54 ] Micro hand S [ 34 ] Revo-i [ 37 – 39 ] Senhance [ 35 – 37 ] SSI mantra [ 55 ] Toumai [ 49 ] Versius [ 43 ] da Vinci SP [ 36 , 58 ] Flex system [ 29 , 68 , 69 ] Ion endoluminal system [ 75 – 77 ] MONARCH platform [ 14 , 70 – 73 ] AESOP [ 85 ] AutoLap [ 8 , 86 , 102 , 103 ] EinsteinVision 3.0 [ 110 , 111 ] LapMan [ 88 – 90 ] Naviot [ 91 ] RoboLens [ 20 , 99 – 101 ] ROSA ONE brain [ 116 ] SOLOASSIST II [ 112 – 115 ] Aer-O-Scope [ 139 – 141 ] Avicenna Roboflex [ 136 , 137 ] Endotics [ 130 , 132 , 133 ] invendoscopy E200 System [ 29 , 142 , 143 ] NeoGuide [ 128 – 131 ] Research ARTEMIS [ 31 ] Bitrack [ 29 , 40 ] SHURUI [ 27 , 50 , 51 ] Enos [ 28 , 37 , 64 , 65 ] MIRA [ 66 ] SPAS robotic system [ 62 , 63 ] SurgiBot [ 30 ] SURS [ 59 ] ETRS [ 78 ] i 2 Snake [ 74 ] K-FLEX [ 79 ] STRAS [ 13 , 16 ] Three-Limb Robotic System [ 16 , 80 , 81 ] Endoluminal surgical system [ 82 , 83 ] Avellino, Bailly [ 120 ] De Pauw, Kalmar [ 117 ] EVOLAP [ 97 , 98 ] FIPS [ 86 , 87 ] Cardioscope [ 121 , 122 ] PliENT [ 125 ] EOR [ 145 , 146 ] GIM [ 144 ] RAFE [ 127 ] Sivananthan, Kogkas [ 147 ] Teleflex [ 10 , 138 ] Voice Commercial ZEUS [ 32 ] AESOP [ 85 ] RoboLens [ 20 , 99 – 101 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] Research FAce MOUSe [ 22 ] FIPS [ 86 , 87 ] HIWIN MTG-H100 a [ 23 , 107 , 108 ] Head Commercial EMARO [ 86 , 104 – 106 ] FreeHand [ 86 , 96 ] Research Jo, Kim [ 48 ] Vicarious [ 60 , 61 ] Avellino, Bailly [ 120 ] FAce MOUSe [ 22 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] ARSFE [ 26 , 126 ] Omori, Arai [ 123 ] Sivananthan, Kogkas [ 147 ] Teleflex [ 10 , 138 ] Eye Commercial Senhance [ 35 – 37 ] Research Sivananthan, Kogkas [ 147 ] Tool Tracking Commercial AutoLap [ 8 , 86 , 102 , 103 ] Avellino, Bailly [ 120 ] RoboLens [ 20 , 99 – 101 ] ViKY [ 92 – 95 ] Research ARSFE [ 26 , 126 ] a Voice and head control are not present in the commercially available HIWIN MTG-H100 system Mapping of user interfaces with robotic systems and surgeries Mapping of actuated scopes with common user interfaces used AESOP [ 85 ] Cirq [ 109 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] RoboLens [ 20 , 99 – 101 ] FREEDOM [ 118 , 119 ] Yang, Udatha [ 17 ] avatera [ 41 , 42 ] da Vinci Xi [ 29 , 33 ] Dexter [ 46 , 47 ] hinotori [ 44 , 45 ] Hugo RAS system [ 52 – 54 ] Micro hand S [ 34 ] Revo-i [ 37 – 39 ] Senhance [ 35 – 37 ] SSI mantra [ 55 ] Toumai [ 49 ] Versius [ 43 ] Flex system [ 29 , 68 , 69 ] Ion endoluminal system [ 75 – 77 ] MONARCH platform [ 14 , 70 – 73 ] AESOP [ 85 ] AutoLap [ 8 , 86 , 102 , 103 ] EinsteinVision 3.0 [ 110 , 111 ] LapMan [ 88 – 90 ] Naviot [ 91 ] RoboLens [ 20 , 99 – 101 ] ROSA ONE brain [ 116 ] SOLOASSIST II [ 112 – 115 ] Aer-O-Scope [ 139 – 141 ] Avicenna Roboflex [ 136 , 137 ] Endotics [ 130 , 132 , 133 ] invendoscopy E200 System [ 29 , 142 , 143 ] NeoGuide [ 128 – 131 ] ARTEMIS [ 31 ] Bitrack [ 29 , 40 ] SHURUI [ 27 , 50 , 51 ] Enos [ 28 , 37 , 64 , 65 ] MIRA [ 66 ] SPAS robotic system [ 62 , 63 ] SurgiBot [ 30 ] SURS [ 59 ] ETRS [ 78 ] i 2 Snake [ 74 ] K-FLEX [ 79 ] STRAS [ 13 , 16 ] Three-Limb Robotic System [ 16 , 80 , 81 ] Endoluminal surgical system [ 82 , 83 ] Avellino, Bailly [ 120 ] De Pauw, Kalmar [ 117 ] EVOLAP [ 97 , 98 ] FIPS [ 86 , 87 ] Cardioscope [ 121 , 122 ] PliENT [ 125 ] EOR [ 145 , 146 ] GIM [ 144 ] RAFE [ 127 ] Sivananthan, Kogkas [ 147 ] Teleflex [ 10 , 138 ] AESOP [ 85 ] RoboLens [ 20 , 99 – 101 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] FAce MOUSe [ 22 ] FIPS [ 86 , 87 ] HIWIN MTG-H100 a [ 23 , 107 , 108 ] EMARO [ 86 , 104 – 106 ] FreeHand [ 86 , 96 ] Avellino, Bailly [ 120 ] FAce MOUSe [ 22 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] ARSFE [ 26 , 126 ] Omori, Arai [ 123 ] Sivananthan, Kogkas [ 147 ] Teleflex [ 10 , 138 ] Tool Tracking AutoLap [ 8 , 86 , 102 , 103 ] Avellino, Bailly [ 120 ] RoboLens [ 20 , 99 – 101 ] ViKY [ 92 – 95 ] a Voice and head control are not present in the commercially available HIWIN MTG-H100 system As shown in Fig.  4 b and Table 8 , all categories of interfaces are used in general, urology, and gynecology surgeries. Otolaryngology, which focuses on ears, nose, and throat, predominantly utilizes hand control, and has the least variety of interfaces applied. Figure  5 illustrates the key surgical applications of the robotic systems, and the entry port sites. About 85% of prostatectomies in the USA are performed using robot assistance [ 148 ]. Complexity of the procedure and surgeon’s prior experience with related technology both affect the learning curve in robotic surgery [ 25 ]. Table 8 Common areas of surgical specialties and the interfaces used for robotic scope control Surgical specialty System type User interface for robotic scope control Foot Hand Voice Head Eye Tool Cardiothoracic surgery Coronary artery bypass grafting (CABG) Lung cancer surgery Mitral valve repair Commercial da Vinci Xi [ 29 , 33 ] Naviot [ 91 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] FreeHand [ 86 , 96 ] Senhance [ 35 – 37 ] ViKY [ 92 – 95 ] Research Cardioscope [ 121 , 122 ] ARSFE [ 26 , 126 ] ARSFE [ 26 , 126 ] Colorectal surgery Colon resection Rectal resection Rectopexy Commercial Endodrive [ 84 , 134 , 135 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Aer-O-Scope [ 139 – 141 ] da Vinci Xi [ 29 , 33 ] Endotics [ 130 , 132 , 133 ] Invendoscopy E200 System [ 29 , 142 , 143 ] Micro hand S [ 34 ] Senhance [ 35 – 37 ] Versius [ 43 ] Senhance [ 35 – 37 ] Research De Pauw, Kalmar [ 117 ] EOR [ 145 , 146 ] MIRA [ 66 ] SHURUI [ 27 , 50 , 51 ] STRAS [ 13 , 16 ] Endoluminal surgical system [ 82 , 83 ] HIWIN MTG-H100 a [ 23 , 107 , 108 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] General surgery Acid reflux disease surgery Bariatric surgery Cholecystectomy Endocrine surgery Hernia repair Liver surgery Pancreas surgery Small bowel surgery Commercial HIWIN MTG-H100 [ 23 , 107 , 108 ] RoboLens [ 20 , 99 – 101 ] AutoLap [ 8 , 86 , 102 , 103 ] da Vinci Xi [ 29 , 33 ] EinsteinVision 3.0 [ 110 , 111 ] Micro Hand S [ 34 ] Naviot [ 91 ] Revo-i [ 37 – 39 ] RoboLens [ 20 , 99 – 101 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Versius [ 43 ] RoboLens [ 20 , 99 – 101 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] EMARO [ 86 , 104 – 106 ] FreeHand [ 86 , 96 ] Senhance [ 35 – 37 ] AutoLap [ 8 , 86 , 102 , 103 ] RoboLens [ 20 , 99 – 101 ] ViKY [ 92 – 95 ] Research Three-limb robotic system [ 16 , 80 , 81 ] Bitrack [ 29 , 40 ] Enos [ 28 , 37 , 64 , 65 ] EOR [ 145 , 146 ] ETRS [ 78 ] GIM [ 144 ] K-FLEX [ 79 ] RAFE [ 127 ] Sivananthan, Kogkas [ 147 ] SurgiBot [ 30 ] Teleflex [ 10 , 138 ] Three-Limb Robotic System [ 16 , 80 , 81 ] FAce MOUSe [ 22 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] FAce MOUSe [ 22 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Omori, Arai [ 123 ] Sivananthan, Kogkas [ 147 ] Teleflex [ 10 , 138 ] Vicarious [ 60 , 61 ] Sivananthan, Kogkas [ 147 ] Gynecology Endometriosis resection Hysterectomy Myomectomy Ovarian cystectomy Pelvic organ prolapse surgery Commercial HIWIN MTG-H100 [ 23 , 107 , 108 ] RoboLens [ 20 , 99 – 101 ] AutoLap [ 8 , 86 , 102 , 103 ] avatera [ 41 , 42 ] Avicenna Roboflex [ 136 , 137 ] da Vinci Xi [ 29 , 33 ] Dexter [ 46 , 47 ] Flex System [ 29 , 68 , 69 ] Hugo RAS system [ 52 – 54 ] LapMan [ 88 – 90 ] Revo-i [ 37 – 39 ] RoboLens [ 20 , 99 – 101 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Versius [ 43 ] RoboLens [ 20 , 99 – 101 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] FreeHand [ 86 , 96 ] Senhance [ 35 – 37 ] AutoLap [ 8 , 86 , 102 , 103 ] Avellino, Bailly [ 120 ] RoboLens [ 20 , 99 – 101 ] ViKY [ 92 – 95 ] Research Avellino, Bailly [ 120 ] Bitrack [ 29 , 40 ] Enos [ 28 , 37 , 64 , 65 ] EVOLAP [ 97 , 98 ] SHURUI [ 27 , 50 , 51 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Avellino, Bailly [ 120 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Otolaryngology Sinus surgery Surgery for tumors in mouth and throat Tongue base resection Commercial Cirq [ 109 ] da Vinci SP [ 36 , 58 ] da Vinci Xi [ 29 , 33 ] Flex System [ 29 , 68 , 69 ] ROSA ONE Brain [ 116 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Versius [ 43 ] SOLOASSIST II [ 112 – 115 ] Research FREEDOM [ 118 , 119 ] i 2 Snake [ 74 ] K-FLEX [ 79 ] PliENT [ 125 ] Urology Bladder surgery Cyst removal Kidney surgery Prostate surgery Pyeloplasty Ureteral implantation Commercial HIWIN MTG-H100 [ 23 , 107 , 108 ] AutoLap [ 8 , 86 , 102 , 103 ] avatera [ 41 , 42 ] da Vinci SP [ 36 , 58 ] da Vinci Xi [ 29 , 33 ] hinotori [ 44 , 45 ] Hugo RAS System [ 52 – 54 ] Revo-i [ 37 – 39 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Toumai [ 49 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] FreeHand [ 86 , 96 ] Senhance [ 35 – 37 ] AutoLap [ 8 , 86 , 102 , 103 ] Avellino, Bailly [ 120 ] ViKY [ 92 – 95 ] Research Avellino, Bailly [ 120 ] Bitrack [ 29 , 40 ] SHURUI [ 27 , 50 , 51 ] SPAS Robotic System [ 62 , 63 ] SurgiBot [ 30 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Avellino, Bailly [ 120 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] a Voice and head control are not present in the commercially available HIWIN MTG-H100 system. Fig. 5 Surgical applications and entry port sites of various robotic systems Common areas of surgical specialties and the interfaces used for robotic scope control Cardiothoracic surgery Coronary artery bypass grafting (CABG) Lung cancer surgery Mitral valve repair Naviot [ 91 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] Colorectal surgery Colon resection Rectal resection Rectopexy Endodrive [ 84 , 134 , 135 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Aer-O-Scope [ 139 – 141 ] da Vinci Xi [ 29 , 33 ] Endotics [ 130 , 132 , 133 ] Invendoscopy E200 System [ 29 , 142 , 143 ] Micro hand S [ 34 ] Senhance [ 35 – 37 ] Versius [ 43 ] De Pauw, Kalmar [ 117 ] EOR [ 145 , 146 ] MIRA [ 66 ] SHURUI [ 27 , 50 , 51 ] STRAS [ 13 , 16 ] Endoluminal surgical system [ 82 , 83 ] General surgery Acid reflux disease surgery Bariatric surgery Cholecystectomy Endocrine surgery Hernia repair Liver surgery Pancreas surgery Small bowel surgery HIWIN MTG-H100 [ 23 , 107 , 108 ] RoboLens [ 20 , 99 – 101 ] AutoLap [ 8 , 86 , 102 , 103 ] da Vinci Xi [ 29 , 33 ] EinsteinVision 3.0 [ 110 , 111 ] Micro Hand S [ 34 ] Naviot [ 91 ] Revo-i [ 37 – 39 ] RoboLens [ 20 , 99 – 101 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Versius [ 43 ] RoboLens [ 20 , 99 – 101 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] EMARO [ 86 , 104 – 106 ] FreeHand [ 86 , 96 ] AutoLap [ 8 , 86 , 102 , 103 ] RoboLens [ 20 , 99 – 101 ] ViKY [ 92 – 95 ] Bitrack [ 29 , 40 ] Enos [ 28 , 37 , 64 , 65 ] EOR [ 145 , 146 ] ETRS [ 78 ] GIM [ 144 ] K-FLEX [ 79 ] RAFE [ 127 ] Sivananthan, Kogkas [ 147 ] SurgiBot [ 30 ] Teleflex [ 10 , 138 ] Three-Limb Robotic System [ 16 , 80 , 81 ] FAce MOUSe [ 22 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] FAce MOUSe [ 22 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Omori, Arai [ 123 ] Sivananthan, Kogkas [ 147 ] Teleflex [ 10 , 138 ] Vicarious [ 60 , 61 ] Gynecology Endometriosis resection Hysterectomy Myomectomy Ovarian cystectomy Pelvic organ prolapse surgery HIWIN MTG-H100 [ 23 , 107 , 108 ] RoboLens [ 20 , 99 – 101 ] AutoLap [ 8 , 86 , 102 , 103 ] avatera [ 41 , 42 ] Avicenna Roboflex [ 136 , 137 ] da Vinci Xi [ 29 , 33 ] Dexter [ 46 , 47 ] Flex System [ 29 , 68 , 69 ] Hugo RAS system [ 52 – 54 ] LapMan [ 88 – 90 ] Revo-i [ 37 – 39 ] RoboLens [ 20 , 99 – 101 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Versius [ 43 ] RoboLens [ 20 , 99 – 101 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] AutoLap [ 8 , 86 , 102 , 103 ] Avellino, Bailly [ 120 ] RoboLens [ 20 , 99 – 101 ] ViKY [ 92 – 95 ] Avellino, Bailly [ 120 ] Bitrack [ 29 , 40 ] Enos [ 28 , 37 , 64 , 65 ] EVOLAP [ 97 , 98 ] SHURUI [ 27 , 50 , 51 ] Avellino, Bailly [ 120 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] Otolaryngology Sinus surgery Surgery for tumors in mouth and throat Tongue base resection da Vinci SP [ 36 , 58 ] da Vinci Xi [ 29 , 33 ] Flex System [ 29 , 68 , 69 ] ROSA ONE Brain [ 116 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Versius [ 43 ] i 2 Snake [ 74 ] K-FLEX [ 79 ] Urology Bladder surgery Cyst removal Kidney surgery Prostate surgery Pyeloplasty Ureteral implantation AutoLap [ 8 , 86 , 102 , 103 ] avatera [ 41 , 42 ] da Vinci SP [ 36 , 58 ] da Vinci Xi [ 29 , 33 ] hinotori [ 44 , 45 ] Hugo RAS System [ 52 – 54 ] Revo-i [ 37 – 39 ] Senhance [ 35 – 37 ] SOLOASSIST II [ 112 – 115 ] SSI Mantra [ 55 ] Toumai [ 49 ] SOLOASSIST II [ 112 – 115 ] ViKY [ 92 – 95 ] AutoLap [ 8 , 86 , 102 , 103 ] Avellino, Bailly [ 120 ] ViKY [ 92 – 95 ] Avellino, Bailly [ 120 ] Bitrack [ 29 , 40 ] SHURUI [ 27 , 50 , 51 ] SPAS Robotic System [ 62 , 63 ] SurgiBot [ 30 ] Avellino, Bailly [ 120 ] HIWIN MTG-H100 [ 23 , 107 , 108 ] a Voice and head control are not present in the commercially available HIWIN MTG-H100 system. Surgical applications and entry port sites of various robotic systems

Use of robot assistance in surgeries has increased in the past decade. Early appearances of user interfaces in research and commercial robotic systems are illustrated in Fig.  6 . In the period of 1990–2010, commercial systems were chiefly controlled using foot, hand, voice, and head interfaces, while the period of 2010–2020 has witnessed the emergence of eye-gaze and tool tracking scope control interfaces. AESOP and ZEUS systems (Computer Motion Inc., USA) developed during the mid to late 1990s both utilized voice commands as input [ 32 ], mimicking the default communication between surgeon and assistant. Computer Motion Inc. was acquired by Intuitive Surgical which uses hand interfaces for their da Vinci systems. Intuitive Surgical has been the market leader since early 2000s [ 149 ]. Head motion for rigid scope control was first used in EndoSista (Armstrong Healthcare, UK) during the mid-1990s [ 150 ]. It was later commercialized by FreeHand Surgical, UK in 2008. Tool tracking, as implemented in the AutoLap system (MST Medical Surgery Technologies, Israel) in 2016, has received more attention recently. Fig. 6 Early appearances of different user interfaces in research and commercial robotic systems Early appearances of different user interfaces in research and commercial robotic systems There has been a limited number of studies comparing different user interfaces. These studies focus on robotic scope holders for rigid scopes. A summary of these studies is presented in Table 9 , which illustrates that surgeons increasingly prefer scope control interfaces that free their hands to control surgical instruments and do not interrupt surgical tasks. Voice control was favored due to its reduced length of operating time and improved concentration [ 151 ]. However, foot control was preferred in multiple studies. In studies [ 19 – 21 ] comparing foot and voice controls that keep surgeon’s hands free, foot control was preferred, as voice commands had a higher chance of misinterpretation. In addition to task completion time, Allaf, Jackman [ 19 ] measured operator-interface failures, which was defined as occasions where the surgeon had to focus attention on the interface rather than the surgical field. The protocol was also repeated to assess the percentage of improvement retained after two weeks, where foot control was found easier to learn. While comparing AESOP and ViKY systems [ 21 ], it was found that voice commands had to be repeated due to speech recognition failures. Voice control was found to be affected by pronunciation while evaluating the RoboLens [ 20 ]. The system was assessed based on time for procedure completion, need for cleaning, image stability, and procedure field centering during several laparoscopic cholecystectomies. A significant lag between voice command and scope movement was observed. Although foot control is preferred over voice, eye–foot coordination might not be ideal, and surgeons often looked down to choose the right pedal from multiple ones [ 151 ]. Tool tracking is increasingly preferred as there is no interruption to surgery to control the scope. In a study by Avellino et al. [ 120 ] comparing joystick controlled by hand, body posture tracking and tool tracking, surgeons evaluated the interfaces based on a defined set of tasks. Joystick received good ratings and was ranked behind tool tracking, while posture tracking was found suitable for tasks requiring short distance movements. Despite raising concerns for tasks that do not involve surgical instruments, tool tracking was well-regarded. Table 9 Comparison of different interfaces for scope control, by year Study & year Interfaces Robotic system Comparators Observation Allaf, Jackman [ 19 ] (1998) Voice & foot AESOP 2000 Mean task completion time, operator-interface failure per trial, & durability of learning experience retained over two weeks Foot control was preferred over voice Voice commands were misinterpreted, whereas foot control was quick & easier to learn ( p  < 0.002) Mettler, Ibrahim [ 151 ] (1998) Feet, hand & voice AESOP 2000 Operating time length Voice control was favored over foot & hand controls Foot pedal was preferred over hand control as it freed surgeon’s arms Berkelman, Cinquin [ 18 ] (2005) Voice & hand ViKY Surgeon’s evaluation of user commands Voice command was preferred over keypad mounted on scope Gumbs, Crovari [ 21 ] (2007) Voice & foot ViKY & AESOP 3000 Average setup time, repetition of commands, occurrence of errant commands Foot pedal was preferred over voice by surgeons Voice commands were likely to be misheard, while there was no chance for misinterpreted commands with foot pedals. Better setup and removal time was observed for ViKY ( p  < 0.001) Mirbagheri, Farahmand [ 20 ] (2011) Voice & foot RoboLens Procedure completion time, need for cleaning, image stability, procedure field centering, surgeon’s evaluation of interface Foot control was preferred over voice by surgeons Voice recognition was affected by pronunciation, and significant lag was observed between voice command and scope movement Kranzfelder, Schneider [ 152 ] (2014) Feet, voice & eye – Surgeon’s evaluation As an addition to hand control, foot pedal was preferred over speech and eye tracking by surgeons & gastroenterologists (56%). More specialists preferred foot control than generalists Avellino, Bailly [ 120 ] (2020) Hand (joystick), body posture & tool tracking – Surgeon’s evaluation of stability, precision, cognitive load, and intuitiveness as criteria Tool tracking was preferred Posture tracking may be considered for tasks that require short distance movement Comparison of different interfaces for scope control, by year Foot control was preferred over voice Voice commands were misinterpreted, whereas foot control was quick & easier to learn ( p  < 0.002) Voice control was favored over foot & hand controls Foot pedal was preferred over hand control as it freed surgeon’s arms Foot pedal was preferred over voice by surgeons Voice commands were likely to be misheard, while there was no chance for misinterpreted commands with foot pedals. Better setup and removal time was observed for ViKY ( p  < 0.001) Foot control was preferred over voice by surgeons Voice recognition was affected by pronunciation, and significant lag was observed between voice command and scope movement Tool tracking was preferred Posture tracking may be considered for tasks that require short distance movement Overall, actuated scopes utilize a variety of user interfaces such as foot, hand, voice, head, eyes, and tool tracking to provide stable views and smooth control during minimally invasive surgeries. Hand control is the most popular interface across all categories of surgical systems as it is familiar, intuitive and requires less mental load. However, various other interfaces are being investigated to address the interruption to surgical workflow caused by hand control. Head tracking interfaces are being explored in research prototypes such as the multiple-port system by Jo et al. [ 48 ]. This helps address the issue of interruption to surgical procedure caused by hand interfaces when switching control between surgical instrument and scope. Breaks in surgical workflow can result in longer operating time and increased risk of patient injury [ 48 ]. Having an easy-to-use and intuitive single-person interface is considered important for scope control by surgeons and gastroenterologists [ 152 ]. In teleoperated systems, where the surgeon is away from the patient, there is a preference for an open surgeon console. In an open console design, the surgeon views the video feedback through a head-up display, as opposed to an enclosed stereo viewer. Compared to a closed console, an open platform offers increased situational awareness, enables the expert surgeon to effectively mentor interns, and improve team communication [ 153 , 154 ]. Preference for working position, either sitting or standing, varies among surgeons [ 152 ]. Majority of the systems utilizing hand controllers (such as da Vinci—Intuitive Surgical, Revo-i—Revo Surgical Solutions, and Enos—Titan Medical) or head-motion-based controllers (such as FreeHand system and MTG-H100–HIWIN) requires a foot pedal to activate the scope control mechanism. In these multimodal user interfaces, the foot pedal has two functionalities. First, it acts as an on–off switch that triggers the motion of the scope. In case of hand controllers, it enables the operator to switch the control from surgical instruments motion (to operate on the tissue) to scope maneuvering (to navigate the operative field). In case of head-motion-based controllers, it activates the scope motion only when the foot pedal is pressed and thus allows the surgeons to freely move the head during the rest of the procedure [ 155 , 156 ]. Second, the foot pedal acts as a clutch and facilitates ergonomic repositioning of the hand controllers or head position [ 157 ]. Another example of a multimodal user interface for scope control is head-mounted display (HMD) devices. HMDs have been used in the operating room for surgical navigation and planning [ 158 , 159 ]. In case of actuated scope maneuvering, the operative field view is rendered by HMD devices in a virtual reality or a mixed reality environment, whereas head motions detected by the device’s sensors are used to maneuver the scope [ 160 – 162 ]. In contrast to visualizing the operative field on a physical screen, the usage of HMD devices offers the surgeon the flexibility to ergonomically place the virtual view of the operative field in the operating room [ 5 , 163 , 164 ]. It decreases the surgeon’s shift of focus from the screen to the operating site [ 165 , 166 ] and thus may assist in reducing the prolonged strains (in the neck and lower back) due to bad monitor positioning [ 167 , 168 ]. Further end-user clinical studies would be required to assess the potential of HMD devices as a multimodal user interface (i.e., to immerse the operator with the information pertaining to the operating field and evaluate the control of the robotic system [ 169 , 170 ]). Limitations of this review include removal of non-English literature. The exclusion may have prevented a broad representation and insight. Methodological quality of the included studies was also not assessed. Additionally, there are no studies comparing all the different user interfaces with the same surgical task and scenario, which would have provided an equal assessment. In conclusion, the observations in this review indicate that integration of multiple control interfaces for camera control would be ideal, especially for scope holders used in bed-side procedures. As each interface has its own benefits, merging different control types enables the surgeon to benefit specifically from each interface in various surgical steps [ 120 ]. The surgeon would be free to choose the appropriate control type throughout different stages of the surgical procedure. Integration of head tracking, which is efficient for 3D navigation, or tool tracking, which lowers cognitive load, would be advantageous. Nevertheless, merging several controls may result in limitations such as redundancy. It may also pose a challenge for the surgeon to achieve seamless transition while changing interfaces. It would be helpful to further explore the impact of different user interfaces on surgical outcomes in future studies.

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