The Robots Aren’t Coming; They’re Already Here.

The fast pace of technology is revolutionizing health care. The internet has made the adoption of mobile health (mHealth) and remote patient monitoring possible. Tablets and mobile devices are perfect for adopting structured synoptic reporting for clinics looking to reduce transcription costs and improve report accuracy. And now, robots are taking over the operating room.

To be fair, the inclusion of robots in the OR isn’t actually a new phenomenon. Robot Assisted Surgery Devices (RASDs) have been around since at least 1985. Back then, the PUMA 560 robot surgical arm assisted with a neurosurgical biopsy [1], but it wasn’t until the early 2000s that RASDs started to become significantly more commonplace. Robot-assisted surgery has been increasing in cardiac surgery, gynecology, orthopedic surgery and many other surgical domains [2, 3]. But are RASDs actually a beneficial addition to the OR?

Fast-Growing Market

There are many possible reasons why robot-assisted surgery is taking off; RASDs are expensive (some costing over a million dollars) and healthcare providers may feel the need to make sure they use their expensive new equipment. Surgeons may be becoming more comfortable with the technology, and patients may even be asking for them, preferring robot-assisted surgery over traditional surgery procedures.

Regardless of the reason, the robotic revolution in the OR shows no signs of slowing down. The market for RASDs is expected to grow to $6 billion by 2020 [4], and the FDA recently announced approval of a new device, and the first serious challenger to Intuitive’s DaVinci, the Senhance. With competition heating up and patient and physician demand growing, the role of RASDs in delivering important healthcare and surgery assistance is poised to grow even more.

The Good

Despite their enormous price-tag, RASDs do provide some distinct advantages. In addition to making transcontinental remote telesurgery possible, which can help with the provision of surgical services for rare or difficult operations in areas where such expertise isn’t readily available [5], RASDs can provide for improved range of movement and tool manipulation that may not be available in non-robot assisted surgery [6]. And while these advantages do not always translate into time and cost savings or improved overall outcomes, they may create additional benefits in specific surgeries, such as reduced intraoperative blood loss during partial nephrectomies [7]. High definition 3-D optics, camera-control autonomy, ergonomic considerations and improvements in the wrist mechanisms of these devices have also made more precise surgical motions possible [8]. Advantages such as these are difficult to quantify in scientific literature [8], but may be contributing to the growing adoption RASDs.

The Bad

However, while there might be benefits to using RASDs in specific procedures, using robotic assistants doesn’t necessarily lead to better outcomes. A recent study out of the Stanford University Medical Centre shows that robot-assisted surgeries may not be as useful as once thought. In fact, robot assisted kidney laparoscopies boosted average hospital cost by almost $3,000, likely due to high robot-maintenance costs and additional operating room time, as robot assisted surgeries were also almost twice as likely to take over four hours to complete [9]. Similarly, robot-assisted surgeries performed on rectal cancer patients didn’t create an improvement in complication rates or postoperative quality of life compared to traditional techniques, but boosted the average cost of the procedure by over $1,000 and added an average of 37 minutes to the operation time [9].

Given their dramatic rise and continuing demand, it’s unlikely robot-assisted surgery is going anywhere anytime soon, but there are choppy waters ahead, particularly in Canada, where the Ontario Health Technology Advisory Committee recently advised against funding robot-assisted prostatectomies [10], a recommendation that could have repercussions across Canada as OHTC recommendations can strongly influence other provinces’ committee recommendation. It remains to be seen if the individual benefits of using RASDs in specific sets of procedures justify the higher-costs associated with RASDs while seemingly not providing a reduction in postoperative complications, recovery or overall outcomes.

References:

[1] Samaldi, D. History and the Future of Robotic Surgeryhttp://www.roboticoncology.com/history-of-robotic-surgery/

[2] Holloway, R., Patel, S.D., Ahmad, S. Robotic Surgery in Gynecology. Scandinavian Journal of Surgery (2009); 98(2): 96-109

[3] Corcione, F., Esposito, C., Cuccurullo, D. et al. Advantages and limits of robot-assisted laparoscopic surgery: Preliminary ExperienceSurgical Endoscopy and Techniques (2005); 19(1): 117

[4] Surgical Robotics Market by Component (Systems, Accessories, Services) and Surgery Type (Gynecology , Urology, Neurosurgery, Orthopedic, General) – Global Opportunity Analysis and Industry Forecast, 2014 – 2020. Allied Market Research.

[5] Marescaux, J., Leroy, J., Rubino, F., et al. Transcontinental Robot-Assisted Remote Telesurgery: Feasibility and Potential ApplicationsAnnals of Surgery. 2002;235(4):487-492.

[6] Ruiz M.R., Kalfa N., Allal H. Advantages of robot-assisted surgery in anorectal malformations: Report of a caseJournal of Minimal Access Surgery. 2016;12(2):176-178.

[7] Benway, B.M., Bhayani, S.B., Rogers, C.G., et al. Robot Assisted Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Tumors: A Multi-Institutional Analysis of Perioperative OutcomesThe Journal of Urology. 2009;182(3):866-873.

[8] Madueke-Laveaux, O.S.Advincula, A.P. Robot-assisted laparoscopy in benign gynecology: Advantageous device or controversial gimmick? Clinical Obstetrics & Gynaecology. 2017.

[9] Jeong, I.G., Khandwala, Y.S., Kim, J.H., et al. Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015Journal of the American Medical Association2017;318(16):1561-1568.

[10] Grant, K. How Ontario put the future of operating-room robots in question. The Globe and Mail. August 17, 2017.