Robotic surgery

The next generation of robotic surgery is emerging: but is it better than a human?

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High financial costs and limited evidence restrict the adoption of robotic surgery, but new uses for robots and attempts to assess efficacy could widen access.

Seated in a high-back, cushioned chair, Varun Bathani resembles a video gamer more than a surgeon. He places his forearms on rests and uses hand controls to manipulate robotic arms fitted with surgical grabbers and clippers. Watching a high-resolution screen, Bathani, who is at St. Paul’s Hospital in Saskatoon, Canada, guides the tools to perform minimally invasive surgery for prostate cancer. “The visualization is incredible,” Bathani says. “That 3D view that you get makes surgery that much better, that much more precise.” Operating from outside the theatre also allows him to sit in a comfortable position, instead of being hunched over the patient.

Robotic surgery looks futuristic, but surgeons first used robotic arms in the mid-1980s1. The momentum really increased in the late 1990s, when California-based Intuitive Surgical’s da Vinci surgical system came on the scene2. Today, the da Vinci system commands 80% of the market. Although Intuitive Surgical dominates the field, other companies — including CMR Surgical, Johnson & Johnson and Medtronic — offer platforms for robotic surgery. “This has helped to foster innovation in the field, for example, with the creation of modular, open-console robots,” says Ara Darzi, an expert in minimal-access surgery at Imperial College London.

Robotic surgery can be carried out at a console while others watch on a monitor.

In 2000, Darzi participated in the first robotic surgery procedure in the UK, a gallbladder removal performed at St Mary’s Hospital. “Now there are more than 100 of these systems actively being used across the country,” Darzi says. “Unlike laparoscopy, which is one of the mainstays of minimally invasive surgery, the robotic system offers better visualization with stereoscopic views and improved ergonomics.”

After several decades of applications and improvements, though, a lingering question remains: is robotic surgery better surgery?

Robots cost money and time

Some experts believe that certain procedures benefit from using a robot. As Darzi says, “Robots are regularly being used in urology, gynecology, general surgery, and ear, nose and throat, where surgeons work in a narrow field, and where visualization is often sub-optimal.”

Still, it’s not clear to everyone in healthcare that robotic platforms are an improvement. “We still don’t actually have a lot of proof that they’re better than old-fashioned surgeons — at least old-fashioned surgeons doing minimally invasive surgery,” says Peter McCulloch, professor of surgery at the University of Oxford in the UK. Plus, adding a robot to surgery takes more than just installing it. “You’ve got to change your entire way of doing surgery,” McCulloch says. As one example, he notes that putting the surgeon behind a robot console “disrupts the traditional communication and teamwork within the surgical team.” This requires surgical teams to adjust to a different dynamic.

Money and time are also key considerations. Robotic surgery is expensive, with an average platform costing about €1.4 million, according to one market survey. “Then you need to factor in the cost of disposables, which can be a few hundred thousand pounds a year, and maintenance,” Darzi says. “This initial outlay can often preclude centers getting a robot, and only makes it viable if costs can be recouped across multiple fiscal cycles.”

In terms of time, several of the experts interviewed by Nature Medicine note that it takes longer to set up robotic surgery than a manual approach. “Some studies have demonstrated that median operating time is significantly longer for robotic compared to either laparoscopic or open procedures,” Darzi says. “This varies [depending] on the type of procedure being performed, the surgeon and the familiarity of the theatre team.”

Unclear benefits

Time in surgery, however, is not the only temporal metric that matters. As reported by Katherine Fay, a fellow in minimally invasive surgery at Emory University School of Medicine, and Ankit Patel, chief of surgery at Emory Saint Joseph’s Hospital, both in Atlanta: “Studies have shown that, across multiple specialties — including general surgery and surgical oncology — patients who undergo robotic-assisted surgery have… shorter postoperative length of stay than patients who undergo laparoscopic surgery”3.

Even with improved ergonomics and better visualization, today’s robots come with some limitations. As Fay and Patel noted: “One major shortcoming of the robotic platform compared to laparoscopy is the lack of tactile feedback.”

Robotic surgery comes with pros and cons, with some experts unclear about its impact. “How do we scientifically test robotic surgery?” McCulloch asks. “It’s much harder to test surgery than it is to test medicines.” In surgery, even the same procedure varies from one surgeon to the next, which is the case with or without a robot. By contrast, he says, “the drug is the drug.”

Making such a scientific assessment of robotic surgery also comes under the pressure of progress. “In the early days, there were a lot of efforts to do high-quality evaluations of robots,” McCulloch explains. “Frankly, they were kind of brushed aside by the stampede to start using robots, and surprisingly, after nearly 20 years, there’s a very small amount of evidence that robots are better than a human surgeon.” McCulloch does grant that robotic surgery could be a bit better in some operations, such as prostate surgeries.

McCulloch argues that more scientific tests of robotic surgery are needed. “If you’re going to spend all that money and change the direction, let’s make sure it’s the right thing,” he says. “Let’s have the scientists prove it.”

Competing with the human hand

Neurosurgery could be a final frontier for robots. Zimmer Biomet has developed the ROSA robotic arm for stereotactic neurosurgery. This robot can be used in various brain-related procedures, including implanting electrodes to treat epilepsy. Many more robotic options are available for neurosurgeons.

“In the past five years, we’ve had an explosion of robots for spine surgery,” says Peter Konrad, chair of neurosurgery at West Virginia University Health Sciences. As a neurosurgeon who also earned a PhD in biomedical engineering, he is concerned about the value of robots for neurosurgery but sees the benefits of using them in spine surgery. “That is a really good use of a robotic arm for the placement of screws and hardware into the spine,” he says. “It’s much more error-prone to do that by hand.”

For neurosurgery, Konrad only sees the value of robots for repetitive and standardized steps — so far. “The complexity of the [neurosurgery] cases we do at the large medical centers is so varied, and this is where robotics fails to help,” he says.

Beyond placing hardware in a patient’s spine, Konrad says, “The real advantages will be if we can get robots to do something we cannot physically do.” As an example, he mentions reconnecting axons to repair nerves. At just a few micrometers in diameter — sometimes even fractions of a micrometer — stitching axons together one by one is impossible for now. “That’s where the robotic development people should go,” he argues, “doing stuff that we can’t do.”

Robots struggle to compete with the dexterity of the human hand, says Konrad: “This is by far the most sensitive instrument we have, because your vision and your sense of touch make an incredible tool that is hard to improve on.”

Still, experts will keep trying to find niches for robotic surgery. Pierre Dupont, an expert in mechanical and biomedical engineering at Boston Children’s Hospital, and his colleagues are developing a two-armed endoscopic robot to help neurosurgeons work in tight spaces4. “The point is you’re doing two things: you’re bringing your imaging and your arms right down to a surgical site, like a tumor in a brain’s ventricular space,” Dupont explains. With this device, a neurosurgeon could work with two tools, controlled by joysticks.

Dupont and his colleagues developed a set of skill tests modeled after removing a brain tumor. When comparing surgeons completing these tests with and without a robot, Dupont says, “Using the robot was pretty consistently faster — even in the hands of the same clinician.” Plus, with the robot’s two “hands,” Dupont explained, “you can sort of walk down the edge of the tumor to separate it from the surrounding brain.”

Global inequities

Robotic surgery raises ethical issues because it is not available to everyone. More than 60% of the 7,544 da Vinci platforms around the world in 2022 were in the USA, and only about 2% were in Latin America, according to data from Intuitive presented by Nam Jin Kim at the 2023 Latin American Forum on Quality and Safety in Health. Kim, who is medical director of the surgical network of the Hospital Israelita Albert Einstein in São Paulo, Brazil, hopes to change that.

Since 2008, more than 14,000 robotic surgeries have been performed at Einstein, with a 72% increase between 2021 and 2022. “Robotic surgery is good for the patient — smaller incisions, reduced pain and discomfort, shorter hospital stays, faster recovery, less infection and better outcomes,” Kim says. He also points out the ergonomic benefits to surgeons.

Of the 150 da Vinci platforms in Latin America in 2022, 10 were at the Hospital Israelita Albert Einstein. “Many hospitals in Latin America are struggling to buy their first robotic platform,” Kim says. “It’s a shame [when] surgeons and patients still don’t have access to this technology.”

Once robotic platforms are acquired, surgeons must be trained to deliver consistent outcomes. In 2019, Einstein became an official Intuitive Training Centre, and part of the agreement included a da Vinci platform. At the time of writing, this center, which now has four da Vinci platforms, has trained more than 1,500 surgeons from 16 countries.

Outside the operating room

Robots might perform other clinical duties beyond surgery. Núria Vallès-Peris and Miquel Domènech of the Universitat Autònoma de Barcelona, in Spain, reviewed the use of robots in patient care5. These robots could be used in many ways, including feeding patients with severe mobility issues.

Progressing from idea to application with care robots is complicated. “Technical limitations remain very important, and, outside the laboratory or highly controlled robotic experiences, these applications do not always work as expected,” Vallès-Peris says. “Right now, talking about the benefits of such robots is more a matter of speculation than something we can verify empirically.”

Robots might also be used in rehabilitation6. José Lucas Oliveira de Sena, an occupational therapist at the Rehabilitation Center of the Hospital Israelita Albert Einstein, uses the ArmeoSpring robotic arm to help patients improve upper-limb motor skills damaged from a traumatic brain injury, such as that from a car accident, Parkinson’s disease, stroke or other neurological condition. As Sena says, “The robotic therapy complements conventional treatment protocols, enabling a virtual environment in which patients can hone the skills essential for occupational performance.”

The ArmeoSpring robotic arm serves as an exoskeleton that, Sena says, “is a powerful resource in rehabilitating the upper limbs of patients grappling with neurological disorders.” Combining this robot with games based on virtual reality helps patients “practice the repetitive movements that mirror daily routines,” Sena explains.

Much like care robots, however, Sena emphasizes: “While technological advancements and robotic devices herald new horizons for therapeutic interventions, we must tread with clarity.” In particular, he notes, “It’s essential to establish clear clinical guidelines for deploying these novel tools to ensure we retain and potentially enhance the effectiveness of treatments.”

AI-powered autonomous robots

Artificial intelligence (AI) promises to expand the capabilities of tomorrow’s surgical robots. As McCulloch says, “AI plus a robot does give you a kind of science fiction future possibility, and I don’t think it’s actually that far off.” That future could include autonomous robots that perform some procedures on their own. “I think the potential for autonomous robots in the future is very high, whether we want them or we don’t want them,” McCulloch says. “That’s a society issue.”

Some robotic devices being developed for surgery already use AI. For instance, Ron Alterovitz, professor of computer science at the University of North Carolina at Chapel Hill, says, “By leveraging the power of robotics and AI, I am developing new robots capable of autonomously moving through the patient’s anatomy to complete procedures with unprecedented accuracy and safety.” As one example, Alterovitz and his colleagues recently described a robot that can autonomously steer a needle through a patient7. “It’s akin to a self-driving car, but it navigates through lung tissue, avoiding obstacles like significant blood vessels as it travels to its destination,” Alterovitz explains.

Although Alterovitz points out that “medical procedures are an especially challenging domain for autonomous robots,” he believes that “autonomous medical robots have the potential to improve the accuracy, precision and safety of medical procedures and enable entirely new procedures not possible by instruments limited by human dexterity.”

Robotic Surgery Is Safer and Improves Patient Recovery Time

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Summary: Robotic surgery for bladder removal decreased recovery time and hospital stay duration for patients, researchers report.

Source: UCL

Robot-assisted surgery used to perform bladder cancer removal enables patients to recover far more quickly and spend significantly (20 per cent) less time in hospital, concludes a first-of-its kind clinical trial led by scientists at UCL and the University of Sheffield.

The study, published in JAMA and funded by The Urology Foundation with a grant from the Champniss Foundation, also found robotic surgery reduced the chance of readmission by half (52 percent), and revealed a “striking” four-fold (77 percent) reduction in prevalence of blood clots (deep vein thrombus & pulmonary emboli) – a significant cause of health decline and morbidity – when compared to patients who had open surgery.

Patients’ physical activity – assessed by daily steps tracked on a wearable smart sensor – stamina and quality of life also increased.

Unlike open surgery, where a surgeon works directly on a patient and involves large incisions in the skin and muscle, robot-assisted surgery allows surgeons to guide minimally invasive instruments remotely using a console and aided by 3D view. It is currently only available in a small number of UK hospitals.

Researchers say the findings provide the strongest evidence so far of the patient benefit of robot-assisted surgery and are now urging National Institute of Clinical Excellence (NICE) to make it available as a clinical option across the UK for all major abdominal surgeries including colorectal, gastro-intestinal, and gynecological.

Co-Chief Investigator, Professor John Kelly, Professor of Uro-Oncology at UCL’s Division of Surgery & Interventional Science and consultant surgeon at University College London Hospitals, said: “Despite robot-assisted surgery becoming more widely available, there has been no significant clinical evaluation of its overall benefit to patients’ recovery.

“In this study we wanted to establish if robot-assisted surgery, when compared to open surgery, reduced time spent in hospital, reduced readmissions, and led to better levels of fitness and quality of life; on all counts this was shown.

“An unexpected finding was the striking reduction in blood clots in patients receiving robotic surgery; this indicates a safe surgery with patients benefiting from far fewer complications, early mobilisation and a quicker return to normal life.”

Co-Chief Investigator Professor James Catto, Professor of Urological Surgery at the Department of Oncology and Metabolism, University of Sheffield, said: “This is an important finding. Time in hospital is reduced and recovery is faster when using this advanced surgery.

“Ultimately, this will reduce bed pressures on the NHS and allow patients to return home more quickly. We see fewer complications from the improved mobility and less time spent in bed.

“The study also points to future trends in healthcare. Soon, we may be able to monitor recovery after discharge, to find those developing problems. It is possible that tracking walking levels would highlight those who need a district nurse visit or perhaps a check-up sooner in the hospital.”

“Previous trials of robotic surgery have focused on longer term outcomes. They have shown similar cancer cure rates and similar levels of long term recovery after surgery. None have looked at differences in the immediate days and weeks after surgery.”

Open surgery remains the NICE “gold standard” recommendation for highly complex surgeries, though the research team hope this could change.  

Professor Kelly added: “In light of the positive findings, the perception of open surgery as the gold standard for major surgeries is now being challenged for the first time.

“We hope that all eligible patients needing major abdominal operations can now be offered the option of having robotic surgery.”

Rebecca Porta, CEO of The Urology Foundation said: “The Urology Foundation’s mission is simple – to save lives and reduce the suffering caused by urological cancers and diseases. We do this through investing in cutting-edge research, leading education and supporting training of health care professionals to ensure that fewer lives will be devastated.

“We are proud to have been at the heart of the step change in the treatment and care for urology patients since our inception 27 years ago, and the outcomes of this trial will improve bladder cancer patients’ treatment and care.”

Bladder cancer is where a growth of abnormal tissue, known as a tumour, develops in the bladder lining. In some cases, the tumour spreads into the bladder muscle and can lead to secondary cancer in other parts of the body. About 10,000 people are diagnosed with bladder cancer in the UK every year and over 3,000 bladder removals and reconstructions are performed. It is one of the most expensive cancers to manage.

Trial findings

Across nine UK hospitals, 338 patients with non-metastatic bladder cancer were randomised into two groups: 169 patients had robot-assisted radical cystectomy (bladder removal) with intracorporeal reconstruction (process of taking section of bowel to make new bladder), and 169 patients had open radical cystectomy.

The trial’s primary end-point was length of stay in hospital post-surgery. On average, the robot-assisted group stayed eight days in hospital, compared to 10 days for the open surgery group – so a 20% reduction.  Readmittance to hospital within 90 days of surgery was also significantly reduced – 21% for the robot-assisted group vs 32% for open.

A further 20 secondary outcomes were assessed at 90 days, six- and 12-months post-surgery. These included blood clot prevalence, wound complications, quality of life, disability, stamina, activity levels, and survival (morbidity). All secondary outcomes were improved by robot-assisted surgery or, if not improved, almost equal to open surgery. 

This shows a person undergoing robotic surgery
Patients’ physical activity – assessed by daily steps tracked on a wearable smart sensor – stamina and quality of life also increased. Credit: UCL

This study, and previous studies, show both robot-assisted and open surgery are equally as effective in regards cancer recurrence and length of survival.

Next steps

The research team is conducting a health economic analysis to establish the quality-adjusted life year (QALY), which incorporates the impact on both the quantity and quality of life.

Patient case studies

John Hammond, retired, age 75, from Doncaster, said: “I left my symptoms too long, and found out that I had a tumour in the bladder. I was lucky to see Professor Catto and after being given options, I chose the operation to have my bladder removed and a stoma in place. 

“I had the operation in August 2019 and was aware that it was robotic surgery in a trial and was keen to take part; in fact I was pleased to be in a position to help anybody else in the future with this type of surgery. The operation was successful, and the whole team was hugely supportive. 

“Amazingly, I was walking the next day and progressed excellently, improving my walking each day. I was in no pain and just had to adjust to the stoma bag. I have fully recovered from the operation and throughout I knew I was in professional hands. I was home about five days after surgery and am grateful to Professor Catto and his team that I did not have to stay in hospital for longer than necessary.”

Frances Christensen Essendon, from Hertfordshire, said: “I was diagnosed with bladder cancer and after a course of chemotherapy it was suggested that I have my bladder removed. Under Professor John Kelly I underwent robotic surgery to remove my native bladder which was replaced with a new bladder made out of bowel.

“The operation was a success, and I was up and walking soon after surgery. Having had the operation in April I was back to work and the gym in the middle of June. I have gone on to lead a normal active life and am eternally grateful to Prof Kelly and his team for their care and support.”

The trial took place from March 2017 to March 2020 and involved 29 surgeons at nine UK hospital trusts namely; University College London Hospitals NHS Foundation Trust, Sheffield Teaching Hospitals NHS Foundation Trust, Guys and St Thomas’ NHS Foundation Trust, NHS Greater Glasgow and Clyde, Royal Berkshire NHS Foundation Trust, St James University Hospital Leeds, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Royal Devon and Exeter NHS Trust, and North Bristol NHS Trust.

Abstract

Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial

Importance  

Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer.

Objectives  

To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy.

Design, Setting, and Participants  

Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021.

Interventions  

Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169).

Main Outcomes and Measures  

The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center.

Results  

Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%).

The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, –6.5% [95% CI, –11.4% to –1.4%]) and wound complications (5.6% vs 16.0%; difference, –11.7% [95% CI, –18.6% to –4.6%]) were less common with robotic surgery than open surgery.

Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, –0.07 [95% CI, –0.11 to –0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks.

There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1).

Conclusions and Relevance  

Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain.

Robotic Surgery in Oncology Gaining Traction

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At the 2021 virtual American College of Surgeons Clinical Congress, a panel of experts discussed the benefits of robotic surgery in oncology. All panelists said more research was needed in comparing robotic approaches with open approaches.

Abhineet Uppal, MD, an assistant professor at The University of Texas MD Anderson Cancer Center, in Houston, pointed out that 86% of patients are operated on at hospitals that don’t have robots. He said surgical complications for colorectal diseases are low regardless of the surgical approach that is used: open, laparoscopic or robotic. “Robotic surgery offers ergonomic and visualization advantages in confined spaces,” Dr. Uppal said. The learning curve for robotic surgery is significant, especially for surgeons without laparoscopic experience, he added.

Dr. Uppal said randomized data on the advantages of robotic surgery in colorectal diseases are limited. The results of a meta-analysis revealed that robotic-assisted ventral mesh rectopexy is effective and feasible in the treatment of rectal prolapse (Int J Colorectal Dis 2021;36[8]:1685-1694). A few studies have examined robotics for total proctocolectomy, and found longer operation times, shorter hospital stays and nonsignificant trends for fewer complications with robotic surgery (J Colorectal Dis 2021;36[7]:1345-1356; Dis Colon Rectum 2016;59:201-207). Studies have shown that oncologic outcomes are similar between robotic and laparoscopic total mesorectal excision (Int J Colorectal Dis 2019;34[6]:983-991). “As the footprint of robots decreases, ease of use will increase,” Dr. Uppal said.

Vivian Strong, MD, an attending surgeon at Memorial Sloan Kettering Cancer Center, and a professor of surgery at Weill Cornell Medical College, both in New York City, spoke about the role of robotics for gastric cancer. She said oncologic outcomes were equivalent with robotic and open approaches and there were advantages with a minimally invasive approach. In fact, robotic approaches have distinct advantages for selected patients, she noted. She said not all cases are appropriate for robotic approaches, and surgeons should use caution with diffuse-type tumors where margins are not well visualized and for large/bulky tumors. However, neoadjuvant chemotherapy is not a contraindication if margins can be visualized.

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Adam Yopp, MD, the Occidental Chemical Chair in Cancer Research and chief of the Division of Surgical Oncology at UT Southwestern Medical Center, in Dallas, spoke about the role of robotic surgery in metastatic colorectal cancer. He said robotic-assisted partial hepatectomy for colorectal liver metastases is safe and oncologically sound in limited series. “Concomitant robotic-assisted colectomy and hepatectomy is efficacious and can avoid second surgical procedures,” he said. Robotic-assisted insertion of a hepatic artery infusion pump in high-volume robotic hepato-pancreato-biliary centers is feasible, with similar complication rates as seen in open procedures (HPB 2017;19[5]:429-435; J Surg Oncol 2016;114[3]:342-347). “Further registry trials capturing prospective data on robotic-assisted liver surgery [are] needed.”

Karim Halazun, MD, an associate professor of surgery with the liver transplantation, hepatobiliary and pancreatic surgery program at Weill Cornell Medicine, in New York City, spoke about robotic surgery for hepatocellular carcinoma (HCC). “Robotic surgery for HCC is safe. Robotic surgery for HCC is oncologically feasible and at least equivalent to open and laparoscopic surgery. There is limited literature specifically examining HCC outcomes, and therefore more data is required,” Dr. Halazun said. He noted that robotic surgery has some technical advantages over laparoscopic surgery, and better transection technology is required. He said the advantages of robotic surgery were visualization with bifocal 3D vision and Firefly; articulating instruments that improve fine hilar dissection; and easier dissection of hepatic veins due to visualization and instrumentation. Disadvantages of robotic surgery, said Dr. Halazun, included no Cavitron ultrasonic surgical aspirator, a variable setup that impedes the learning curve, and operating at a distance from the patient can induce anxiety.

According to Melissa Hogg, MD, MS, a surgeon with Northshore University HealthSystem, in Evanston, Ill., surgery has a learning curve, and this concept is revisited with each technique, including robotics. She said formal robotic training can diminish the learning curve for robotic-assisted surgery. In addition, she said, surgeons with laparoscopic experience may be able to overcome the robotic learning curve faster.

New Surgical Robots May Get a Boost in Operating Rooms

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Da Vinci robotic system from Intuitive Surgical Inc. at the Rikshospitalet University Hospital Oslo, Norway 

Even though many doctors see need for improvement, surgical robots are poised for big gains in operating rooms around the world.

Within five years, one in three U.S. surgeries – more than double current levels – is expected to be performed with robotic systems, with surgeons sitting at computer consoles guiding mechanical arms. Companies developing new robots also plan to expand their use in India, China and other emerging markets.

Robotic surgery has been long dominated by pioneer Intuitive Surgical Inc, which has more than 3,600 of its da Vinci machines in hospitals worldwide and said last week the number of procedures that used them jumped by 16 percent in the second quarter compared to a year earlier.

The anticipated future growth – and perceived weaknesses of the current generation of robots – is attracting deep-pocketed rivals, including Medtronic Inc and a startup backed by Johnson & Johnson and Google. Developers of the next wave aim to make the robots less expensive, more nimble and capable of performing more types of procedures, company executives and surgeons told Reuters.

Although surgical robots run an average of $1.5 million and entail ongoing maintenance expenses, insurers pay no more for surgeries that utilize the systems than for other types of minimally-invasive procedures, such as laparoscopy.

Still, most top U.S. hospitals for cancer treatment, urology, gynecology and gastroenterology have made the investment. The robots are featured prominently in hospital marketing campaigns aimed at attracting patients, and new doctors are routinely trained in their use.

Surgical robots are used in hernia repair, bariatric surgery, hysterectomies and the vast majority of prostate removals in the United States, according to Intuitive Surgical data.

Doctors say they reduce fatigue and give them greater precision.

But robot-assisted surgery can take more of the surgeon’s time than traditional procedures, reducing the number of operations doctors can perform. That’s turned off some like Dr. Helmuth Billy.

Billy was an early adopter of Intuitive’s da Vinci system 15 years ago. But equipping its arms with instruments slowed him down. He rarely uses it now.

“I like to do five operations a day,” Billy said. “If I have to constantly dock and undock da Vinci, it becomes cumbersome.”

SURGEONS’ WISH LIST

To gain an edge, new robots will need to outperform laparoscopic surgery, said Dr. Dmitry Oleynikov, who heads a robotics task force for the Society of American Gastrointestinal and Endoscopic Surgeons.

Surgeons told Reuters they want robots to provide a way to feel the body’s tissue remotely, called haptic sensing, and better camera image quality.

New systems also will need to be priced low enough to entice hospitals and outpatient surgical centers that have not yet invested in a da Vinci, as well as convince those with established robotic programs to consider a second vendor or switching suppliers altogether.

“That is where competitors can differentiate,” said Vik Srinivasan of the Advisory Board Co, a research and consulting firm that advises hospitals.

Developers say they are paying attention. Verb Surgical, the J&J-Google venture that is investing about $250 million in its project, said creating a faster and easier-to-use system is a priority.

Verb also envisions a system that is “always there, always on,” enabling the surgeon to use the robot for parts of a procedure as needed, said Chief Executive Scott Huennekens.

Intuitive said it too is looking to improve technology at a reasonable cost, but newcomers will face the same challenges.

“As competitors come in, they are going to have to work within that same framework,” CEO Gary Guthart said in an interview.

Device maker Medtronic has said it expects to launch its surgical robot before mid-2018 and will start in India. Others developing surgical robots include TransEnterix Inc and Canada’s Titan Medical Inc.

An RBC Capital Markets survey found that U.S. surgeons expect about 35 percent of operations will involve robots in five years, up from 15 percent today.

J&J, which hopes to be second to market with a product from Verb, has said it sees robotics as a multibillion-dollar market opportunity. Huennekens said Verb’s surgical robot will differ from another Google robotics effort, the driverless car, in one important aspect.

“There will always be a surgeon there,” he said.

Robotic Surgery and Computer Navigation in Orthopaedics

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  • The term “Robot” is derived from the Polish word, “robota”, which means, “forced labour” and is used to describe a machine that carries out multiple tasks automatically or with a minimum of external impulse, especially one that is programmable
  • Two systems for Robotic Surgery exist: 1)Autonomous 2) Haptic (Tactile) System
  • Haptic systems allow the surgeon to drive, or use the robot to perform the operation
  • Constant input of the surgeon is mandatory for efficient functioning of the system
  • In autonomous systems, the surgeon performs the approach, sets up the machine and then engages the robot to complete the surgery without the surgeons help

Proposed advantages of Robotic Surgery include:-

  1. Ability to perform MIS
  2. Improved accuracy of implant placement
  3. Improved radiological alignment of extremities

HAPTIC ROBOTIC SYSTEMS

  • Commercially available tactile systems for Unicondylar knee replacement: Robotic Arm Interactive Orthopaedic System (RIO, Mako Surgical Corp.)
  • Uses preoperative CT scans to generate 3D computer model of the knee
  • Helps for preoperative planning
  • Surgeon will intraoperatively mark the bony surfaces of the femur and tibia allowing the preoperative model to be merged into the active anatomy of the knee
  • The knee is taken through a full range of motion, the flexion-extension gaps assessed, component size and implant placement finalized and a cutting zone is created for the robot
  • The system’s algorithm is wholly based on the preoperative planning and templating
  • While manipulating the burr, for resection of bone, the surgeon can view the 3D model on the monitor
  • Resection of bone is confined to the predefined cutting space on the forced controlled tip of the rotating burr
  • In any case if the surgeons goes beyond the cutting zone, the safety system automatically stops the burr

Robot assisted Unicondylar Knee Replacement(UKR) Systems

  • In 2010 Roche et al..described the use in 43 cases, where he measured 344 radiological parameters. There were only 3 abnormal parameters.
  • Roche proposed advantages like smaller incisions, short recovery and rehabilitation time, hence can be performed as an out-patient procedure

 Acrobot Systems

  • Cobb et al..used Acrobot systems (UK), and compared Robot assisted UKR versus Conventional UKR
  • They found that in patients who underwent Robot assisted UKR, there were better AKS scores(American Knee Society) , increased operating time,  tibiofemoral alignment and implant positioning within 2 degree of preoperative plan in all patients
  • In the conventional UKR group, only 40% of patients achieved tibiofemoral alignment within 2 degree of the preplanned position

AUTONOMOUS ROBOTIC SYSTEMS

  • Autonomous robotic systems complete the surgery without assistance of a surgeon
  • Though the robot operated independently, the surgeon is in control of an emergency shut-off switched
  • ROBODOC was such a system that was developed in the 1980s and was introduced into surgical practice in 1992(Curexo Technology, California)
  • ROBODOC was very popular in Germany with many trials conducted in THA demonstrating good component positioning, but soon fell into disrepute amidst safety concerns
  • A hybrid system has been developed in Carnegie Mellon University, Pittsburgh, Pennsylvania
  • In this system the Mini Bone Attached Robotic System(MBARS), mounts on to the femur and completes the bony resection in TKR
  • Praxiteles (Praxim, France) is another similar robotic system developed in France.

ROBOTIC Surgery: Pitfalls

  • The setup required for performing robotic surgery is expensive. Also contant software upgradations and calibrations will add to the cost. It may still be cost efficient in high volume institutions
  • Though proposed advantages like short hospital stay, less blood loss, greater accuracy are present, long term outcomes studies are necessary to demonstrate superiority and cost efficiency of Robotic surgery in routine practice
  • Robots, can identify bony anatomy well. But the nuances of soft tissue dissection are not still identified by a robot.
  • The autonomous robotic system, the ROBODOC fell into disrepute because it was associated with increased risk of infection, blood loss, neurological damage and perhaps an increased rate of litigation
  • Currently, high quality level I studies including Randomised Control Trials are not available for the use of Robotic Surgery in Clinical Practice.

 

  • The navigation systems have several cameras to track surgical instrumentation, boney geometry and alignment
  • The cameras communicate with instruments and boney landmarks through light-emitting diodes(LEDs)
  • The surgeon always has the option to override the information given by the computer
  • The surgeon is not limited to “predefined cutting zones”, as in robotic surgery
  • It is useful for surgeons in the early learning curve
  • Many authors have reported superior alignment of the femoral and tibial components, tibial slope and the mechanical axis  using passive surgery systems
  • Accuracy in restoring rotational alignment has been questioned while using computer navigation in TKA

Ref:

  1. Banks SA. Haptic robotics enable a systems approach to design of a minimally invasive modular knee arthroplasty. Am J Orthop (Belle Mead NJ) 2009;38(Suppl):23–27.
  2. Roche MW, Augustin D, Conditt MA. Accuracy of robotically assisted UKA. J Bone Joint Surg [Br] 2010;92-B(Suppl):127.
  3. Bargar WL. Robots in orthopaedic surgery: past, present, and future. Clin Orthop 2007;463:31–36
  4. Wolf A, Jaramaz B, Lisien B, DiGioia AM. MBARS: mini bone-attached robotic system for joint arthroplasty. Int J Med Robot 2005;1:101–121.
  5. Plaskos C, Cinquin P, Lavallee S, Hodgson AJ. Praxiteles: a miniature bonemounted robot for minimal access total knee arthroplasty. Int J Med Robot 2005;1:67–79.
  6. Park SE, Lee CT. Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty 2007;22:1054–1059.
  7. Jenny JY, Clemens U, Kohler S, et al. Consistency of implantation of a total knee arthroplasty with a non-image-based navigation system: a case-control study of 235 cases compared with 235 conventionally implanted prostheses. J Arthroplasty 2005;20:832–839.
  8. Cobb J, Henckel J, Gomes P, et al. Hands-on robotic unicompartmental knee replacement: a prospective, randomised controlled study of the acrobot system. J Bone Joint Surg [Br] 2006;88-B:188–197.

New approaches to thyroidectomy prompt discussion.

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During an academic debate held here, two presenters focused on the pros and cons of conventional vs. minimally invasive approaches to thyroidectomy.

In the process, some of the concerns that patients now harbor, particularly in terms of cosmetic effects, came to the forefront.

“The frontiers of thyroidectomy today focus on minimizing pain and maximizing cosmesis and preventing long hospital stays,” Carmen C. Solorzano, MD, professor of surgery and director of the Vanderbilt Endocrine Surgery Center, said during a presentation at the American Thyroid Association 82nd Annual Meeting.

‘Gold standard‘

Conventional thyroidectomy consists of a Kocher incision and requires elevation of large flaps, often with the use of a surgical drain, to allow complete exposure of the thyroid gland, according to Solorzano, whereas a minimally invasive approach involves an incision in the cervical area that is small and requires less extensive dissection. These approaches include minimally invasive video-assisted thyroidectomy (MIVAT), minimal incision and endoscopic minimally invasive thyroidectomy, but not remote approaches to the thyroid gland, such as the robotic facelift thyroidectomy.

Solorzano, who spoke in favor of the conventional approach, noted that a meta-analysis showed that the rate of recurrent nerve palsy between the two approaches was the same, although cosmetic satisfaction and pain scores were better in the minimally invasive thyroidectomy group. The conventional approach, however, was associated with shorter operative times, lower cost and wider applicability, she said. Additionally, conventional thyroidectomy remains the standard approach for Graves’ disease, which usually involves very large glands, and bulky cancer, as these would be difficult to remove through small incisions.

“The fact remains that one of the drawbacks to the minimally invasive approach is that it is only appropriate in about 5% to 30% of cases,” Solorzano said. “Major limitations are thyroid size, thyroiditis or toxic glands and cancer or adenopathy.”

Nevertheless, patients can still experience the benefits associated with minimally invasive surgery, according to Solorzano, as long as surgeons adapt by considering cosmesis with smaller incisions in the skin crease, using magnification and lighting, and paying attention to the edges of the wound.

“The conventional thyroidectomy remains the gold standard approach to removing the thyroid gland,” Solorzano said. “The minimally invasive approach remains an option but is limited by thyroid size and pathology.”

For select patients

Although not appropriate for all, according to Maisie L. Shindo, MD, FACS, patients and physicians may benefit from the MIVAT approach, which is similar to a laparoscopic procedure in which a high definition camera is used that allows the surgeon to dissect using a monitor.

“An advantage of the high definition camera is you can really see the nerve in magnified view and then just take out the thyroid,” Shindo, who is director of thyroid and parathyroid surgery at Oregon Health & Science University, said.

She also cited data from several studies suggesting that patients who underwent MIVAT experienced somewhat better outcomes vs. those who underwent conventional thyroidectomy. In a 2002 prospective study comparing post-operative pain at 24 and 48 hours after the procedure, for instance, indicated that post-operative pain was better in the MIVAT group. Similarly, a 2004 study showed that patients in the MIVAT group experienced better cosmetic and pain results than those in the conventional approach group.

Additionally, a study comparing minimally invasive thyroidectomy without video with mini-incision revealed that pain was significantly lower among patients who underwent surgery with the minimally invasive approach, according to Shindo.

She expressed concern, however, about the use of MIVAT in patients with thyroid cancer where the surgeon would likely be performing a total thyroidectomy and potentially removing lymph nodes as well, and noted that becoming skilled in using MIVAT requires time.

“My argument is that MIVAT is safe with the appropriate patient selection,” Shindo said. “It does provide a small incision and less pain, but there is a learning curve like with any other laparoscopic procedure. You have to be very experienced because there can be anatomic variations, so you have to be aware of that.”

Perspective

 

David J. Terris

  • I thought both of the speakers made very balanced and informed presentations. It’s always a challenge assessing new technology and new procedures, and I thought they both did a great job of presenting fair arguments about the procedures.

Much of the discussion was about minimally invasive techniques, but there was mention of robotic surgery, and it was clear that neither speaker was necessarily supportive of that approach. I think they drew an important distinction between minimally invasive surgery and robotic remote access surgery conventional techniques because sometimes the lines get blurred by the uninformed who may think that robotic surgery must be minimally invasive. For other procedures, such as robotic prostatectomy, it is. In many respects, it is minimally invasive, but when we refer to thyroid surgery and remote locations like the armpit or behind the ear, there’s more dissection involved just to get to where the thyroid gland is. The reason the robot is so valuable in those cases is because you’re working down a long tunnel and you can use these very minitaturized instruments to a) provide tremendous 3-D visualiation and b) the maneuverability of the instruments in that small space is so superior that if you’re going to do remote access surgery, it’s much easier if you use the robot. But the overall technique itself, the remote access techniques, is more invasive, but I was pleased to see that each of the speakers kind of emphasized that point.

Source: Endocrine Today.