FASMBS

Maria Iliakova

The quality of a surgery is judged by many metrics, including patient outcome, efficiency, and cost. The introduction of new technology in surgery is subject to the same standards in comparison to existing tools and methods. The methods to perform general surgery and its subspecialties include two main categories: open and minimally invasive surgery. During minimally invasive surgery, small incisions are made to access a surgical field. Both laparoscopic and robotic surgery are considered minimally invasive forms of surgery. Though laparoscopic surgery is considered the mainstay of minimally invasive surgery, the first laparoscopic surgery in a human patient, performed in 1985, is a mere 13 years apart from the first robotic surgery in a human patient in 1998.    

Both patients and healthcare systems benefit from minimally invasive surgery. These benefits include smaller incisions, faster postoperative recovery, less pain, lower infection rates, faster operative time, improved surgical efficiency, and lower cost. The advent of minimally invasive surgery also heralded the introduction of evidence-based enhanced recovery after surgery (ERAS) protocols that focus on reducing narcotic use, decreased postoperative nausea, decreasing complication rates, and overall reducing recovery time following surgery.

Surgeons and medical systems experience benefits through minimally invasive surgery, such as improved access to challenging surgical fields including the foregut, pelvis, and retroperitoneum with improved ergonomics, as well as the ability to record and analyze cases for ongoing training and quality improvement. 

Robotic surgical systems (also termed robotically-assisted surgical device, RASD) enhance many of the advantages of minimally invasive surgery and offer others including enhanced visualization, surgical field access, tool articulation, surgeon control over all operative instruments and camera, case ergonomics, and further improve patient postoperative recovery. With volume in robotic surgery, even efficient laparoscopic surgeons experience decreasing operative times, lowered operative cost, and improvements in patient outcomes. However, cost is dependent on many factors, including acquisition and maintenance costs, robot utilization, case complexity, and proficiency of surgeon and surgical staff in robotic system usage.   

At this time, all robotic surgical systems used in the U.S. are fully surgeon-controlled with no autonomous function. Understanding why robotic surgery offers advantages over open and laparoscopic surgery begins by considering robotic surgery as an integrated tool and data platform rather than an individual surgical tool. The robotic surgical platforms currently being used are capable of recording cases, analyzing instrument and surgeon movement, detecting economy of motion, case annotation, detecting trends over time, and many other functions for use in education and for quality improvement purposes. 

"It is anticipated that as robotic surgical system adoption increases, their data features to assist in quality improvement such as artificial intelligence are on the horizon"

The difference between robotic surgery versus other surgical approaches begins upon access to a surgical site. After making minimally invasive incisions, ports are placed to allow robot docking, instrument placement and exchange. The torque generated by use of robotic instruments is generally lower than that of laparoscopic tools. Even this small difference leads to less patient pain and vastly improved intraoperative ergonomics. Further, the location of port sites can be better standardized across patients for improved reproducibility as robotic arms allow for greater degrees of motion and overall maneuverability of camera and surgical instruments. This maneuverability, including articulation of instruments, allows for improved access to regions such as the foregut, leading to improved visualization, surgical dissection, performance of fine tasks such as suturing, safety, and both short- and long-term patient outcomes, notable in complex colorectal, foregut, and bariatric surgery. In stark contrast to open or laparoscopic surgery, a surgeon is capable of controlling all instruments and camera throughout the duration of a case, which may result in less dependence on a surgical assistant. Despite these benefits, it is important to note that robotic surgery is not appropriate in all cases and is best used under appropriate surgeon discretion.

While robotic surgical systems have been FDA-approved and on the US market for decades, robotic surgery rates range widely from 15 percent for common general surgical procedures to over 85 percent for some procedures such as prostatectomies. Robotic-assisted surgery is now commonly performed in general, bariatric, colorectal, cardiothoracic, gynecologic, orthopedic, neurosurgery and even trauma surgery, with rising rates across surgical fields. Barriers to entry in using robotic surgical systems include up-front cost, surgeon and staff training, existing operating room facilities and lack of familiarity with these technologies as well as their advantages and disadvantages.

The robotic surgical market is primarily dominated by Intuitive Surgical, Inc., maker of the Da Vinci surgical system, which now accounts for approximately 80 percent of robotic surgical systems in use globally (BIS Research). Other robotic surgical systems with FDA approval include Asensus Surgical’s Senhance® Surgical System, Hominis® Surgical System, Intuitive’s Ion™ endoluminal system, Johnson & Johnson’s MONARCH™ robotic flexible endoscopy platform, and Stryker’s Mako SmartRobotics™. There are many robotic surgery systems undergoing further development and FDA evaluation, including some that are already in use outside of the US including Medtronic’s Hugo™ Robotic-Assisted Surgery device and the CMR Versius™ Surgical Robot. Johnson & Johnson has also recently announced their anticipated Surgical Robotics OTTAVA™ system, which demonstrates unique interaction with existing OR infrastructure.

As more robotic surgical systems enter the field, adoption of these different systems will largely depend on access and training. With the widespread use of the Intuitive Surgical Da Vinci robot, the vast majority of surgeons and residents in general surgery and its subspecialties are trained on this platform. The training of both physicians and surgical staff in varied robotic surgical systems will impact patient access to robotic surgery and hospital acquisition of these technologies and has yet to be standardized. It is anticipated that as robotic surgical system adoption increases, their data features to assist in quality improvement such as artificial intelligence are on the horizon.