IEEE Robotics & Automation Magazine - September 2023 - 149

O P I NI ON
Autonomous Robotic Surgical Systems
Needing Common Sense to Achieve Higher Levels of Autonomy
By Eleonora Tagliabue , Marco Bombieri , Paolo Fiorini , and Diego Dall'Alba
While executing a surgical procedure,
surgeons not only rely on their specific
medical knowledge but also on a set of
skills that are " obvious " to them and
allow for intuitively evaluating and
reacting to the intervention evolution.
Such skills belong to what is usually
called common sense, which is essential
to carry out an intervention. Although
general common sense refers to all the
basic concepts about the world and
belongs to all human beings (e.g., the
fact that a needle must be inserted from
tip to eye), we believe that field-specific
common sense is developed depending
on individual experiences within a field
of expertise. In surgery, field-specific
common sense is the " glue " knowledge
that is not explicitly described in surgical
manuals, but it is acquired during
lengthy surgical training. For example,
a textbook does not explicitly describe
how the needle should be held nor how
it should be inserted in the human body,
but this information is known by the
domain experts. Understanding how to
describe, represent, and learn this
knowledge is paramount to developing
robust and reliable autonomous robotic
surgical systems (ARSSs). Developing
ARSSs is a research trend of great interest
for which taxonomies and paradigms
have already been proposed. For
more details, the reader is referred to [1]
and [2]. The importance and challenges
of common sense have been discussed
in other fields [3], [4], but to the best of
Digital Object Identifier 10.1109/MRA.2023.3281269
Date of current version: 11 September 2023
our knowledge, this aspect has not yet
been addressed in robotic surgery.
COMMON SENSE AND SURGERY
Our research on ARSSs has shown that
automatic extraction of surgical procedures
from surgical textbooks is a feasible
task [5], but also that the result does
not include the large amount of implicit
knowledge that humans use during the
surgical task. In the following, we refer
to the granularity classification of surgical
procedures in phases, steps, actions,
and motions proposed by Lalys and Jannin
[6]. In this classification, a procedure
(e.g., partial nephrectomy) is composed
of a sequence of main events, called
phases, occurring in the procedure (e.g.,
tumor excision or final suture). Each
phase is then composed of a set of steps,
i.e., sequences of activities to achieve a
surgical objective (e.g., the main steps of
the final suture phase are the removal of
the trocar, extraction of the specimen,
and closure of the skin). Each activity is
then composed of a sequence of motions,
i.e., single-hand trajectories (e.g., pulling
the needle to close the suture using the
right arm). Based on the aforementioned
definitions and in-depth discussions with
surgeons, we propose a preliminary classification
of surgical knowledge into the
following four levels:
1) Procedural knowledge: Description of
the sequence of phases required to
perform a procedure, as can be learned
from surgical manuals. It does provide
general information about the specific
steps, but it does not specify the
parameters of each step, i.e., the physThis
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ical quantities that instantiate individual
actions and motions, such as
motion velocity or force to be applied.
2) Surgical common sense: This is a
field-specific common sense that
encompasses all the skills surgeons
acquire while experiencing (assisting
and performing) a specific procedure
multiple times. It allows defining
the sequence of elementary actions
needed to perform the surgical task
and intuitively setting their parameters.
It also includes the capability
to interpret surgical situations and
thoroughly understand correlations,
causes, and consequences of actions
and thus to select the best surgical
technique for each specific situation.
3) Medical common sense: This is
another subset of field-specific common
sense that is not specific to
a single surgical procedure and is
acquired during medical studies. For
example, it includes knowledge of
basic anatomical concepts (positions
and functions of organs), a highlevel
understanding of how surgical
actions impact anatomy, and evolution
of the patient's prognosis after
surgery and medications.
4) General common sense: The common
sense that surgeons have as
human beings. It represents the basic
knowledge of the world, is acquired
while experiencing everyday situations,
and helps infer the meaning
and behavior of things.
This classification is not always crisp
because it depends on the context. The
same concept can refer to one or to
SEPTEMBER 2023 IEEE ROBOTICS & AUTOMATION MAGAZINE
149
https://orcid.org/0000-0003-1536-2293 https://orcid.org/0000-0002-8607-8495 https://orcid.org/0000-0002-0711-8605 https://orcid.org/0000-0002-7300-5975 https://creativecommons.org/
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