Doug Pearman: Robotics in surgery

Robotic surgical theatre mock-up

I sat with my housemates Sam and Sabrina down in London over dinner one wintery night with Sabrina's lawyer father, and up came the conversation about robotics 'being the future', and the role of human surgeons being in gradual decline. Challenging! Could surgeons really be in one country while a robot operates in another, or could the blood-and-guts part of the profession become the realm of programmers? Something of a career risk as a trainee doctor considering surgery. How does the marketing hype about robotic surgeons hold up to the evidence?

Usage of robots in surgery:

The market-leading surgical robot manufacturer (Intuitive Surgical - the Da Vinci robot) report 600,000+ operations per year globally using robots in 2015. To put this in some context, there were 3.7 million surgical procedures in the UK in 2013/14

Intuitive surgical's marketing is supposedly excellent, and the limited US regulation of medical device advertising means that a market can be built for a product without there necessarily being a patient benefit. In a competitive hospital market, the prospect of robots to do your surgery is a differentiator for the patients. Bloomberg have a good article on this here

Conclusion:
Robot use is growing fast

Potential added value that robots can provide [LINK (2004)]
> Removing operator tremor
> Dexterity
> Technical solutions to microsurgery - operating on tiny blood vessels that might otherwise prove too challenging to reconnect (I find this particularly compelling)
> Ergonomic positioning of the surgeon
> 3D vision (better than on a typical laparoscopy screen)
> Decision support tools (i.e. an MRI overlay helping stereotactic needle placement)

> Automatic movement of instruments in synchrony with a beating heart

Conclusion:
The potential benefits to robot-assisted surgery are significant; but probably dependent on the extent to which the current practical limitations actually impact patient outcomes

Cost implication of robotic laparoscopy compared to conventional laparoscopy:
Per surgery additional cost:
+$200 per cholecystectomy (2014)
+$1,400-$2,200 per hysterectomy (2010)
+$2,500-$3,500 per nephrectomy/partial nephrectomy/pyeleoplasty (2011)
+$800 per radical prostatectomy (2011)

Individual outlay per robot

Net cost of DaVinci robot - $1.75 m, and when factored across their lifespan of use they have implications for the costs of each surgery performed.

Conclusion
Robot-assisted laparoscopy is currently more expensive than conventional laparoscopy.

History of surgical robot development: [LINK]

1983 - Arthrobot (holds limb during surgery)

1985 - PUMA560 (places needle for brain biopsy using CT)
2003 - Intuitive Surgical (DaVinci robot creator) merges with Computer Motion (Zeus/Aesop robot creators). Intuitive Surgical are now the leading robotic surgery technology company.

Conclusion:
Robots aren't a new thing in surgery - they've been around for 30+ years

Patient outcomes of robot use:
In general for surgery, robots are more expensive, have more complications, and outcomes are not improved over laparascopic surgery based on 4000 studies [LINK]. NHS England consider there to be no mortality gains but some quality of life gains in prostate surgery with robots [LINK]. Cancer Research UK consider there to be no advantages yet in prostate surgery with robots [LINK]

Conclusion:
The evidence doesn't currently suggest that there are consistent patient benefits from robotic surgery

General conclusion

Robot use in surgery use is on the rise, and the potential for robots to enhance the quality of surgery certainly sounds impressive. However, robots are expensive and currently of unproven benefit, so it's not yet time to be requesting your surgeon uses a robot rather than more traditional techniques.

Some videos of robots at work: