Roger Smith, PhD, CTO, Florida Hospital Nicholson Center
Robots entered the operating room around 2000 in the USA following several successful research projects sponsored by DARPA. Since that time, Intuitive Surgical’s da Vinci machine has become the dominant player in robotic surgery with over 4,000 of these multi-million-dollar devices placed in hospitals around the world. In 2018, surgeons will use these robots to perform nearly one million procedures. However, da Vinci is far from the only robotic platform in the OR. Patients will find the Mazor X performing spinal procedures, the Stryker Mako and the Globus Excelsius performing hip and knee replacement, the Stereotaxis Niobe ablating nerves in the heart, and the TransEnterix SenHance and handheld Endocontrol Jaimy assisting with laparoscopic abdominal cases. Robotic assistance of complex surgical procedures has become a very active growth industry that is impacting both the delivery of care to patients and the management of internal resources within the hospital. There are currently nearly two dozen robotic assistance devices approved in the USA and EU and another two dozen that have been announced in the final phases of R&D or regulatory approval.
"The future of healthcare will have more humans and more robots working together throughout the continuum of care for our aging population"
All these robots aid human surgical teams in performing procedures for which earlier, more manual tools are not well designed. The kind of mechanical and electrical assistance that can be provided with robots was unimaginable just a few decades ago when surgeons and engineers created the current toolbox of surgical instruments. But the success of Intuitive and the companies listed above has shown the power of reimagining surgical tools to allow the latest technologies to extend the skills of the surgeon in performing more precise actions within the human body. This trend is just a couple of decades old, but it points to a future in which almost every surgical procedure and instrument is redesigned to take advantage of advanced materials, mechanical capabilities, electronic and computer controls, integration with healthcare IT infrastructures, and eventually intelligent advice from cloud-based AI.
The robotic systems that exist today deliver both advantages and challenges in the delivery of patient care. The improved control, dexterity, and reach of these devices makes it possible to perform procedures with both higher fidelity and improved accuracy. Procedures can be less invasive for the patient by reducing or eliminating external incisions to access the surgical site. Some devices also reduce workplace injuries to surgeons and OR teams by allowing them to perform the procedure from outside of the X-ray energy field. This energy contributes to early onset cancer and the lead vest creates musculoskeletal injuries in the back, neck, and shoulders. When robots are appropriately integrated into surgical processes and facilities, they can improve OR efficiency and the throughput of patients receiving care. This list of advantages is so prevalent that countries like South Korea and China are actively investing national resources to position their domestic companies as leaders in the field, just as they previously supported the electronic, cell phone, and automobile industries. Surgical robotics is an important technology for the future of all industrial countries.
These machines also come with challenges that must be balanced against the improvements they offer. Chief among these is the high cost of the core robotic system itself. The large units typically run from $1.5 to $2 million each. Investing this kind of capital requires a hospital to analyze its surgical volume to determine whether an ROI case can be made for the purchase. Once purchased many of these machines require significant floor space to install and operate. In a few cases, the OR must be custom configured and dedicated to a single robot. Each robot also requires its own unique surgical instruments. These may be reusable, single-use, or multi-use disposables. The disposable items can increase the cost per case of a procedure by $200 per instrument or more, another case for re-calculating profit margins. Then there is the cost of training staff at all levels to work with the new robot and its instruments. This begins with the surgeons but extends to the nurses and assistants who work side-by-side with the machine, and even to the sterile processing staff who must clean and store these unique instruments following the surgery.
Though the challenges are not trivial, the advantages continue to attract healthcare systems to adopt these devices and investors to fund companies with clever ideas for new robots. Today’s robots have a very small footprint with the IT infrastructure of a hospital since they are generally closed systems which, at most, use hospital networks only to exchange system diagnostic data with the manufacturers. But as future systems become smarter they will become a more integrated and demanding part of the healthcare IT ecosystem. This may include integration with the hospital EHR systems and imagery databases, and connections to external cloud-based AI services which are able to provide surgeon guidance and advice in real-time. Each of these connections will raise new questions about access to patient data and exposure of internal hospital information to vendor computers.
Today, surgical robots sound futuristic to most people, even though they have been in active use for almost two decades. The future holds more robotic devices that can provide better assistance to human surgical teams by extending and enhancing both the physical and the mental capabilities of clinicians. The future of healthcare will have more humans and more robots working together throughout the continuum of care for our aging population.
Hesham Abboud, MD, PhD, Director of the Multiple Sclerosis and Neuroimmunology Program and staff neurologist at the Parkinson’s and Movement Disorder Center at University Hospitals of Cleveland, Case Western Reserve University School of Medicine