Flexible robotic platforms for surgical applications in microgravity environments: a comprehensive systematic review of minimally invasive mechatronic systems and the impact of artificial intelligence on behalf of the Center for Space Systems (C-SET) & TROGSS-The Robotic Global Surgical Society.

The advent of minimally invasive surgery (MIS) in the 1990s marked a transformative shift in surgical practice, leveraging advanced robotic-assisted systems (RAS) for enhanced precision, dexterity, and improved patient outcomes. Over the past two decades, the surgical field has expanded from a handful of platforms to over 20 commercially available systems, some of them with artificial intelligence (AI) capabilities to varying degrees. While these advancements have redefined conventional surgical care, the unique challenges of space exploration, including microgravity, necessitate the adaptation of flexible robotic systems with AI. As the demand for long-duration space missions grows, addressing the surgical needs of astronauts becomes increasingly critical for human space exploration. A systematic review of the literature was conducted across PubMed/MEDLINE, Scopus, Embase, and Google Scholar. Search terms included "flexible robotic system," "endoscopic system," "robotic surgery in space," "microgravity environment," "artificial intelligence," and "space surgery." Studies were included based on their relevance to flexible robotic systems, microgravity surgical challenges, and the pathophysiology of space-induced conditions necessitating surgical interventions. Information on relevant space missions was sourced from the NASA databases. Of 69 studies reviewed, 21 MIS platforms were analyzed, with a focus on single-port and flexible robotic designs. Globally, RAS has revolutionized minimally invasive procedures, with over 12 million operations performed in 70 countries. Leading platforms, some of them with AI capabilities to assist with surgical decision-making, including da Vinci, and Hugo RAS, demonstrate potential for adaptation to microgravity. NASA's Integrated Medical Model (IMM) identifies 27 surgical conditions that may arise during space missions, emphasizing the need for compact, precise systems. Challenges, such as altered fluid dynamics, hemostasis, patient stabilization, and equipment ergonomics, are amplified in microgravity. Emerging innovations in actuators, sensors, and thermal management, alongside the compact and versatile designs of flexible robotic platforms with AI show significant promise in addressing these hurdles. Flexible robotic systems with AI offer transformative potential for surgical care in space, paving the way for safe and effective interventions in microgravity. Continued research, cross-disciplinary collaboration, and technological advancements are essential to overcome microgravity-specific challenges and ensure astronaut health during prolonged space exploration. This review underscores the necessity of adaptable robotic platforms with AI to support the future of space medicine.