Surgical Robotics: May the Force be with you
- Steve Bell
- Mar 25, 2025
- 14 min read
When the daVinci 5 launched last year - there was some, but not a huge amount, of noise about the new features they added. The tower, the menus, the workflow, the console, and oh yes - Force Feedback. But it didn’t get a huge amount of hype. Why? Well because millions of procedures had been done without force feedback to date… and quite well, so it seems.
And many die hard da Vinci users felt - “Well I just don’t need it…”
And finally there was not much evidence that it actually helps clinically (let me come back to that)
Oh and it comes with about a 28% premium on price for those force feedback instruments. Yikes.
But is Force feedback mis-understood, and do some recent studies demonstrate that force feedback may actually have some value - all be it not always directly clinical . And as da Vinci 5 is the first and only system with force feedback… WAIT what? No it isn’t. In fact it was not even the second or third or fourth or sixth or tenth. What?!?!
The da Vinci 5 is actually the 8th commercial system to get force feedback - yes NUMBER 8
And in terms of systems that have that capability (including some non launched) it is number 12. Yep 12 and almost 20 years late to the party.
Let me go deeper here because this may surprise you...
So who are the others robotic systems with Force feedback?
I will forsake Sensei (but it gets an honourable mention) as it’s not a laparoscopic robot - but it is a catheter robot. But it was one of the first commercial robots with force feedback.
So First: Let’s talk about the commercial lap systems.
The first system out there that had commercially available force feedback was actually the original Alf X - from Sofar… which later became the Transenterix system - which later became Asensus’s Senhance (all just name changes.)
ALF - X (Advanced Laparoscopic through Force Refection) erm the clue was in the name if anyone had bothered to ask what ALF-X stood for - was launched in 2015 nearly a full decade before Intuitive introduced force feedback on their da Vinci systems. Yes 10 years before. I’ll come back later as to why many of these systems didn’t get the recognition they deserve for force feedback.
SINA Surgical 2015 launched at almost the same time as ALF X but on account that it was being developed in Iran - it didn’t seem to get the press it also deserved. And this was quite interesting as they has a very future thinking “force gage” that would display on the heads up display. Quite innovative. But as an “odd ball” robot it largely went unnoticed.
Microhand is a Chinese system that came out with force feedback… but then for reasons known to them (probably cost) removed it for the later MicroHand S versions. They had it. Now they don't have it.
Next is SAROA 2023 - by Riverfield in Japan, which had clearance in Japan in May 2023 with pneumatic haptics (recent journal nature). This took a different approach to the mechanical systems and that allows for some interesting capabilities through its pneumatics. This is very interesting as we start now to discuss force feedback vs Haptics - which I’ll get into. But by measuring the pressures in their pneumatic system they are capable of actually feeling “grip” forces on the tissue - which is a little different to some others. It is still force feedback but starting to become haptic like.
December 2023
13(1)
Almost at the same time Mantra by SSI in 2023 that also had force feedback capability. But it was limited. That has been massively improved for Mantra 3 where a better force feedback can be given back to the surgeons. They claim improved precision and control when using the force feedback. But I've not actually seen it yet. And of course that only applies to the no floating haptics on their console version.
Toumai - Microport - 2023 in China took a different approach: and their force feedback is monitored through the trocar port - not directly by the instruments. And this is important as it allows every instrument to have a degree of force feedback. Now is that as good as a DV5? We’ll get into what’s good and what’s not in a minute. But Toumai’s approach make it very interesting as you get force feedback as standard. Especially as you combine that force feedback with telesurgery… hmmmm that starts to get interesting but is for another day. Now, they do also have a force indicator as well as force through feedback, which can indicate the forces being applied as a bonus visual meter.
So as i started... very late to the party is da Vinci 5 by Intuitive. But as they say “better late than never…” Or is it? I mean with all these systems out there with force feedback are we really seeing a clamouring desire for it? Do people demand it?
(I’ve also listed the other developmental systems out there… but you can google them at your pleasure. Also not for today.)
What’s the difference between Force feedback and Haptics
Let me try and help a little here on force feedback vs. haptics in surgical robots because they’re related, but not identical. Let me put it like this: (and remeber I have another deep dive post on Haptics here >>) https://www.howtostartupinmedtech.com/post/force-feedback-haptics-in-surgical-robotics
Force Feedback (aka Kinesthetic Feedback)
What it is: Provides resistance or force information back to the surgeon's hands as they interact with tissues.
Example sensation: You feel how much pressure you're applying through the robot — like a tug, resistance, or tension.
Mechanism: Typically via motors, sensors, or pneumatic actuators that simulate physical pushback.
Pros: Helps prevent over-compression, tearing, or excessive force on delicate tissues.
Real-world use:
Saroa – Pneumatic real-time force feedback
MiroSurge – 6-DOF torque/force feedback (experimantal)
ALF-X / Senhance – Haptics via actual resistance to movement
Toumai (HapticSense®) – Proprietary tech mimicking tactile response
Mantra 3 – Claims of improved haptic feedback (recent)
Haptics (Broader Term)
What it is: Includes both force feedback and tactile feedback (surface texture, vibration, pressure, temperature). Sort of touchy feely.
Think of it as the umbrella term.
Most surgical robots so far focus on force feedback, not full-on tactile feedback — texture, for instance, is still rare. But several companies are working on this to try and mimic the sensations of open surgery.
What Most Surgical Robots Actually Use:
System | Force Feedback | Tactile Feedback | Type | Notes |
Saroa | ✅ Yes | ❌ No | Pneumatic | Unique real-time feedback via air pressure |
Senhance (ALF-X) | ✅ Yes | ❌ No | Motorized | Commercially proven haptic interface |
da Vinci 5 | ✅ Yes (new) | ❌ No | Electric motrized | First da Vinci to include force feedback |
Toumai | ✅ Yes (HapticSense) | ❌ No | Proprietary Trocar based | Newer tech, claims haptic perception |
MicroHand S | ❌ No | ❌ No | Visual only | Earlier version lacked feedback entirely |
Sina | ⚠️ Visual-only | ❌ No | Partial using on screen | Feedback via visual haptic interface |
SSi Mantra 3 | ⚠️ Claimed | ❌ Not verified | Unknown | No strong technical publication yet |
MiroSurge | ✅ Yes | ❌ No | Research | High-res force sensors for telesurgery |
SOFIE | ✅ Yes | ❌ No | Research | Force feedback for laparoscopic tools |
Force Feedback vs. Visual Feedback
Force Feedback = You feel it
Visual Feedback = You see it (a warning or indicator when pressure is high)
Some systems (like Sina) only give visual cues, not physical resistance.
So what's the bottom line on surgical robotics Force Feedback
If the system physically pushes back against your hand = True Force Feedback If it alerts you visually or vibrates = Partial / Visual Haptics Full tactile (touch) sensation? Still a bit sci-fi in surgical robotics, but believe me… it’s coming. So if you look at the table above you can see that in reality.. today they all have force feedback as their “Haptics.” Some via mechanical, some via instruments, some via pneumatics.
So does force feedback give better clinical outcomes?
Well that’s a multi million dollar question isn't it. But even Intuitive when they announced it on the DV5 were extremely cautious to say “time will tell.” And they are looking at studies for how much force the DV applied with the force feedback on vs off. And well early on that can say clearly that users (even experts with the Xi) put less force on the tissues.
But that so far has they have no hard clinical evidence that it matters… yet.
A paper released yesterday (as of me writing this) suggests that force feedback greatly lowers the forces applied to tissue, and the implication will be less tissue damage, which “should” result in better clinical outcomes.
Nakashima, H., Ueda, Y., Miyanari, Y. et al. In vivo evaluation of tissue damage from varying grasping forces using the Saroa surgical system. Sci Rep 15, 10043 (2025). https://doi.org/10.1038/s41598-025-95310-5
"Abstract
Robot-assisted surgery can help to reduce patient burden and operator stress by enabling precise manipulations with multiple joint motions, but may also cause complications due to the lack of tactile sensation. The Saroa surgical system was developed with a haptic feedback function, and allows operators to adjust grasping forces as desired. In this study, we investigated tissue damage from varying grasping forces using the Saroa surgical system, and assessed the utility of this system. The grasping forceps of the Saroa system were used to grasp the lungs, esophagus, aorta, liver, spleen, small intestine, and large intestine of six beagle dogs with forces of 1, 2, and 3 N for durations of 1, 2, and 4 min. The effects of different grasping forces and durations on tissue damage were histologically evaluated. Histological evaluations showed that grasping force caused tissue damage in the lung and liver, but not the other organs. These results showed the lung and liver were more vulnerable to grasping forces, and exhibited more severe tissue damage at higher forces. These findings suggest that the haptic feedback function of the Saroa system could help to reduce intraoperative organ damage, especially in the fields of lung and liver surgery."
And interestingly this is the Saroa system in Japan - NOT the DV5. So other comapnies are on this, and doing research.
And there are other studies out there, so I did a quick GPT analysis of what’s out there…“Clinical studies have explored the impact of force feedback (FFB) in robotic-assisted surgery (RAS), focusing on its potential to enhance surgical precision and patient outcomes. Key findings include:
Reduction in Tissue Trauma: Integrating FFB into robotic systems has been shown to significantly reduce the forces exerted on tissues during surgical tasks, potentially decreasing tissue trauma and blood loss. This effect was observed across all levels of surgical experience. - Carolina Digital Repository
Improved Performance in Novice Surgeons: Visual force feedback (VFF) has been found to benefit novice robotic surgeons by reducing suture breakage and force inconsistencies. However, experienced surgeons did not exhibit significant changes in these metrics with VFF, suggesting that the benefits of force feedback may be more pronounced during the initial stages of surgical training. - ScienceDirect
Enhanced Suturing Efficiency: A study demonstrated that novice surgeons using FFB-enabled instruments completed suturing tasks with less force, fewer errors, and in less time, indicating that FFB can improve efficiency and reduce tissue trauma during robotic-assisted suturing. Carolina Digital Repository - SpringerLink
Accurate Force Application: The use of contact-force feedback enabled surgeons to apply specified forces more accurately to tissues, with junior surgeons showing a more pronounced improvement. This suggests that FFB can aid in the precise manipulation of delicate tissues, potentially reducing the risk of injury. Wiley Online Library -SpringerLink -
These studies collectively suggest that force feedback in robotic surgery can enhance surgical performance, particularly for less experienced surgeons, and may lead to better patient outcomes by minimising tissue damage. However, further research is needed to fully understand the long-term clinical benefits and to optimize the implementation of force feedback technologies in surgical practice.”
Now, one thing keeps jumping out at me here when I look at such studies - and it jives with my own personal feeling. I think that “master roboticists” have managed to tune their visual haptics to such a degree that they don’t cause lots of tissue trauma. They also have created that inbuilt visual haptics so they are as fast as laparoscopy. The lack of touch is no longer a barrier to them. The robot has almost become an extension of them.
But for novice surgeons, trainees, or certain surgeons that can’t cope with that visual haptic experience. The data seems to indicate that they will be the biggest beneficiaries of force feedback. Especially during that initial learning curve. And it is interesting, but we may start to see that the more they use the system the more they dial down the force feedback.
That may seem counter intuitive - but let me explain (beyond just the fact on a DV5 force feedback instruments are more expensive.) I think it will be more than a cost cutting exercise - it will be all about fidelity. Because on all of these systems it is not an exact "feel" as you would get if you were directly connected to the instruments like in manual laparoscopy.
The challenge of force feedback.
By now nearly every one of you will have used force feedback - in fact nearly every day. No not on surgical robotics but in your car. You may think your steering wheel and brakes are directly connected the steering and brakes - but in most cases now they are not. In fact most steering is a simulated feedback via motors and most brakes are now brake by wire.
And as many of you may have also sensed if you’ve switched cars. “That steering feels horrible.” “Those brakes feel dead.” And in some cars they feel great.
You are getting a (not quite) sensation like with bad force feedback. And now imagine if the brakes actually start to break a half second after your put your foot them. Or worse the steering of the car reacts about a half second after you steer., That lag would feel weird and horrible and you would say - I’d rather have no feedback. Beacsue the feedback sensation would be disconnected to what your eyes see. The car would act differently to what you believe.
So one of the challenges of robotic systems is how real the force feedback feels - and how laggy it is.
I don’t want to put Senhance down… but all the feedback I’ve ever had (and I’ve also tried it) is that their particular force feedback was too laggy and felt “off.”
The risks to that is that if you don’t get the reality right, you could end up either over representing the forces or under representing them.
Both could be worse than no force feedback at all. Why?
Well if you think you are putting light pressure on tissue because the feedback tells you that - but in reality you are putting 2X force … then that’s bad. The feedback must represent reality or we have a problem.
Part of this whole issue is motion scaling - and the filters that go into robotic arms to make them tremor free. All things that messes up with the 1:1 direct force translation. So it comes down to just how good your software team is in translating the forces being felt in the patient by the robot arms - and creating a high fidelity real time feedback that gets pushed up the console arms to "realistically" mimic what is happening in the abdomen.
I’ve tried all force feedback systems, and to be fair no one has it right yet in my mind. Toumai and DV5 are “getting there” but for me they still feel “dull” and not 100% how I think it feels in a laparoscopic instrument. It feels a tiny bit laggy, and the relationship is not quite on point. Not bad but not perfect.
Now for me as a novice hack - if it feels like that - then imagine for a high end robotic surgeons that now has a “woolly” feeling between them and the patient vs their inherent visual haptics system - that to them is spot on. Well it may for a while give a disconnect. It may take time to adjust. But by then that 28% premium feels redundant and an expense you don't need.
You can dial the amount of force feedback up and down to try and find a level that suits - but for many surgeons that have no issue with haptics, force feedback I fear will be a faff.
For robotic newbies - I think it will be a reassuring safety blanket. It will give some anchoring to what they see on screen and knowing “something” is connecting. They will have “trainer wheels” for the first cases; and I am sure that will be super helpful and compress learning curves a lot. But I also predict they will turn it down over time unless two things happen.
The fidelity of the system gets to 1:1 perfection and in real time.
We add “Haptics” touch - such as heat, surface texture etc etc
If these happen (and they will) then that shifts the whole game. Because it is no longer just about mimicking gross forces - it will be about a return to sensation. This is subtly different but important.
I do wonder if some big users will hold out with the force feedback and persist and then get to a combined visual haptics and force feedback.... and make a leap? I for one am insisting every time I sit on a demo to have FF turned on so I can get better at interpreting it. Maybe it suddenly clicks.
DV5 late to the game… but
I fully understand why Intuitive have waited for the DV5 to implement phase one of force feedback. The underlying system of motors and sensor etc is modern and has a higher fidelity. They also have some advances in materials technology that allows their instruments to transmit forces in a much better way) - see my Old post HERE
Remember: In one month Intuitive will have done more force feedback cases than every other company combined have done in history. And this is a data game. Feedback - data - reiterate - feedback data. And with their already massive DV5 installed base - plus years of Xi kinematic data - they will be analysing this to death. Combining with user feedback and tweaking the software as we speak. And their vast data inputs will give them a huge advantage over all the other systems.
Also they do know instruments - they really do. And all of that combined data with the knowhow of instruments will give them a huge edge verses everyone else.
And they have massive reach and marketing power. For many of you it will have been a surprise they were number 12 in the race. Right? Because many will never have heard that the other systems had it. And many will think that this new innovation came from Intuitive. Well nope. But the victor writes history as they say. And with just their power on social media alone you will all be thinking they are the first. More power to them.
To me they are like Apple in how they do product launches and product development. They - like Apple - are not often the first, but usually have the best implementation of it - technically and business model wise - when they eventually come. They don’t launch crap.
And when they do launch such an innovation... They are cautious and reserved - like Apple. And they will put their vast R&D budgets to work to improve it after launch. And prove its value.
They may be late, but I guarantee you they will be one of, if not the best at implementing it and monetising it. Giving reason to upgrade to established users. And making it easier for new users to enter the robotic world. This is how they might bring even more users across to the robot.
What I will say - is now that THEY have it - then everyone else MUST have it. HUGO, OTTAVA and all the others will need to have it, as Intuitive and several others have that tick box on the tender documents and RFPs tech sheets.
Will everyone actually use it? — no.
Will everyone that wants to ensure they get a DV tick that box? - hell yes. It will kick competition to the side for those wanting to scupper their chance of hospital management buying a competing system. "I demand force feedback!"
Will Intuitive eventually fine tune it, add to it, make it a must have? I think they can. The data is clear that tissue damage is less when its on. That just needs to convert (over time with data) to better outcomes and it will become a mandatory.
Will others get better - yes. Toumai and others are fast iterators - so they will improve it day by day - and a lot of this is in software. So it’s fast.
As I started out — “Use the Force Feedback Luke…” as it is definitely the direction of travel.
These are just comments and thoughts of the author for educational purposes only. "Never rely on an idiot."
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