Where’s the value in surgical robotics?

The first robot-assisted surgical procedure was performed in 1985. In the 35 years since, the field of surgical robotics has exploded, with both surgeons and patients demanding access to the technology. This boom has brought with it plenty of vocal advocates, and just as many critics, debating the risks and rewards of robotic technology over traditional open and laparoscopic techniques.

The main criticism of robot-assisted surgery comes down to the fact that, despite the lofty initial and recurring costs associated with robotic equipment, patient outcomes of robotic-assisted procedures seem to be no better than conventional laparoscopic procedures. Some may see this as evidence that investing in surgical robotics is nonsensical, but it is worth considering the future potential of the technologies. For while the tools and techniques used in conventional laparoscopy may see slow incremental improvements over coming decades, each new generation of surgical robots will likely continue to bring radical step-change improvements in procedural precision, patient safety and surgeon control and comfort.

Current benefits of robot-assisted surgery

The current generation of surgical robots offer a few significant advantages over traditional laparoscopy.

• Ergonomics & surgeon comfort: the ergonomics of laparoscopy are not ideal and can take a toll on a surgeon’s body. During robot-assisted procedures, the surgeon sits at a workstation and controls his surgical tools using ergonomic master controllers. If the surgeon needs to take a break at any point in time, they can let go of the controllers, and the robotic instruments will maintain their current positions.
• Precision: a robotic system translates the inputs from the surgeon’s controllers to output motion of the surgical instruments. This allows for motion scaling (for example, 3mm of movement by the surgeon results in only 1mm of movement of the surgical tool), providing unprecedented surgical precision.
• Stability: while providing some haptic feedback to the surgeon is desirable, a robotic system can handle all the stresses and loads associated with a procedure without translating them all back to the surgeon’s hands. Along with surgeon comfort, this allows for improved stability.
• Better visibility: the steerable robotic endoscopes provide a high-definition 3D visibility of the surgical site, allowing the surgeon to better see what they are doing, compared to 2D endoscopes used in laparoscopy.
• More hands: while we humans are tragically limited to typically having only two hands, robots are not subject to such limitations. The da Vinci Xi, for example, has four robotic arms. The surgeon toggles back and forth between controlling different combinations of these arms using foot petals.
• Fast learning curve: learning how to safely and effectively perform robot-assisted procedures tends to be faster than training to perform laparoscopic procedures.

Current limitations of robot-assisted surgery

Advocates of surgical robotic technologies tend to focus on the various benefits without mentioning some noteworthy risks and challenges:

• Setup time: nurses and surgical assistants often complain about the long time it takes to prepare a robotic system for a procedure, including wipe-downs, draping and loading of surgical tools.
• Lack of haptic feedback: current robotic systems provide very limited feedback of applied forces to the surgeon. Instead the surgeon is required to use the visual feedback from the 3D endoscope to judge what amount of force he is applying to patient tissue. Some studies suggest that surgeons apply significantly higher forces and stresses to tissue using robotic systems than using laparoscopic tools, potentially resulting in more damage to the tissue.
• High cost: a daVinci Xi system costs about $2M USD. Each da Vinci surgery may cost $3,000 USD more to the patient / insurance company than a traditional laparoscopic operation.

The future

Many of the criticisms above are valid and must be taken seriously. Effectiveness and safety of robotic technologies must continue to be proven, and limitations should be assessed and accounted for. However, these should be seen as criticisms of current robotic systems on the market today, not as criticisms of robotic surgery in general. If anything, these criticisms hint at where surgical robotics is headed next. While Intuitive Surgical continue to innovate, the field of players is also getting wider, with companies like Johnson & Johnson, Medtronic and Stryker investing billions into research and development. Future generations of robotic systems will bring a range of short-term and long-term improvements and will redefine what is possible in surgery.

Increased haptic feedback is expected to be a key feature in some future systems. This will allow the surgeon to truly feel the motions and gestures they are executing with the robotic instruments.

The cost of robotic systems and tools is expected to decrease as the volume of robotic systems and tools sold continues to grow and with increased competition, as new companies bring their robotic systems to market in the coming years.

There may be potential benefits in surgeons being able to carry out procedures remotely. Already today, the surgeon workstation does not necessarily have to be in the same room as the patient. Taking this to the next level, future systems may allow an expert cardiovascular surgeon to perform specialist surgeries all around the world from the comfort of his own office.
 

The Big Question

All of these features still depend on a human being (the surgeon) having control of every movement of the robot. The big question is: at what point will we be comfortable giving up some of this control to a robot? Crossing this line will increase the productivity of the scarcest of resources, highly trained surgeons, and start to significantly improve the cost-benefit equation for these systems.

Leveraging image recognition and artificial intelligence, it is fathomable that, in the quite near future, we could have a robotic system capable of making decisions and performing certain tasks independently. Especially with repetitive tasks like suturing, a robot could be trained to become increasingly efficient and effective.

However, as we’ve seen with self-driving cars, we humans have very little tolerance for injury and death caused by robotic systems. Despite worryingly high death tolls caused by inebriated and distracted drivers, it is not enough for new technology to reduce injury and death. Even a single death caused by a self-driving car convinces some that the technology is not ready. This may be the same psychological and regulatory hurdle that surgical robotics must overcome to realise its potential.