Robotic surgery – does it justify the need and costs?

Published On: December 2017

Global Surgical Robots: Market Introduction

The surgical robotics is a new and exciting emerging technology that is taking the surgical profession by storm. According to marketresearchfuture.com, report “Surgical Robots Market Research Report - Global Forecast To 2023” the market for global surgical robots is expected to reach a staggering USD 21,225.0 million by 2023, growing at a double digit CAGR of greater than 20%. Robotic surgery is also claimed to inflict less post-operative pain, reduce blood loss, lower the need for blood transfusions, and a potentially faster recovery time. These robotic systems are also claimed to enhance dexterity in several ways such as instruments with increased degrees of freedom greatly enhance the surgeon’s ability to manipulate instruments. Some experts have however charged the surgical robots as unneeded superficialities and have drawn attention to the abhorrent costs involved in performing a robotic surgery. Some experts have also claimed that higher profit motive from companies and hospitals has driven the market, with patient needs and welfare being pushed under the carpet. Here we review the advantages and drawbacks of the robotic surgery and see if any base exists for the allegations against the surgical robots.

Market Drivers:

The primary advantage of surgical robots is definitely the microsurgical application due to the apparent technological advantages surgical robots provide to the surgeons. Microsurgery requires microscopic vision and fine tools for procedures such as micro sutures which are better performed by a surgical robot. However a careful analysis of the trends of surgical robots reveal a very different picture. For instance, with the help of Da Vinci system, a total of 563,000 procedures were performed in the U.S. in 2016, of which 44% were in gynecology, 33% were in general surgery, and 19% were in urology. The number of procedures performed outside the U.S. accounts for 190,000. Another aspect where surgical robots have gained an upper edge is real time imaging using Positron Emission Tomography (PET), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) etc. These allow the surgeons to operate with the surgical robots with a direct image of the condition.
Surgical robots have been claimed to have better hand-eye coordination resulting in excellent manoeuvrability and allow the physician to reach difficult anatomical positions with only a flick of controls due to the unparalleled precision of robotics control systems. This is claimed to result in better ergonomic position reducing the physical strain on the physician’s hands. However Some experts have charged this statement as completely baseless. In robotic surgery, the surgical robots mediate between the surgeon and patient which actually reduces coordination. Better ergonomics, manoeuvrability and positioning claims are also disputed. Some experts say that greater manoeuvrability of robotic systems is not what is important but the combined manoeuvrability of the human-robot system, which channels out to the end result that is patient. Better positioning the patient is a better alternative than to use robots. Increasing precision is also claimed to be an advantage of surgical robots with the robotic arm programmed to filter out any tremors in the physician's hands which increases the physician's range of motion. Some experts have however charged this claim to be a sign of exaggeration. In our analysis we found this claim only to be partially true, which is applicable to microsurgeries only.

Market Restraints:

Cost is the largest restraint of robotic surgery, which may increase by USD 1500 to USD 3000 as compared to the traditional surgery. Installation and operation of surgical robots requires a large operating space which involves additional costs. This coupled with the cost of making the robots is prohibitive. For example, for a robotic laparoscopic surgery, cost of a single robot may be about $2 million with disposable attachments may cost anywhere from $3,000 to $6,000 more than traditional laparoscopic surgery.

The surgical robots also have a steep learning curve, the situation which has been worsened by the lack of training surgeons receive. Medical colleges do not provide for the training due to low availability and volume of both surgical robots and robotic surgeries. The low availability of surgical robots coupled with low volume of robotic surgeries make mass training difficult. The robotic surgeries are also limited to certain fields of surgery such as Gynaecology, prostrate surgery etc. Thus, transfer to other surgery fields such as cardiac becomes difficult due to differential learning curve which is even steeper.
An advantage frequently raised by the supporters of the robotic surgery of risk reduction due to robotic surgery however falls flat on its face. Risks involved in robotic surgery are temporary pain and/or nerve injury resulting from positioning the surgical robot, from the use of air or gas in the procedure etc. Robotic surgeries also take longer operative time and time under anaesthesia. Robotic surgery involves the use of gases which may result in swelling of tissue, changes in heart rate and blood values due to absorption of the gas. Failure of surgical robots is a possibility which may have serious repercussions.
Most of present surgical robots have large size and footprint with numerous mechanical joints which increases friction. Thus, miniaturization of the system is of utmost priority and importance. The crowded nature of today’s operating room along with its traditional infrastructure also creates problems for the satisfactory installation and operation of surgical robots. This reduces the overall expenditure on infrastructure.
Robotic surgeries also require different instruments and equipment compatible with the robots. The situation is made more complex due to the need to develop compatible software’s and newer computer algorithms. Using these will also involve greater use of micro sensors so as to make the robot sense the equipment which increases the challenge. The lack of compatible instruments and equipment is also due to lack of standardisation. As robotic surgery is in its infant stage different systems use different standards of equipment and instruments thus increasing the cost of maintaining different accessories.

Future prospects of surgical robots

The miniaturization of the invasive surgical cameras, instrumentation and the robots themselves is likely to be the chief market driver for surgical robots. Another driver of the surgical robots would be the demand for minimally invasive surgeries so as to reduce the degree of the trauma, surgical foot print and others. The minimally invasive surgeries have the advantage of faster recovery period, less blood, reduced risk of infection, less scarring and thus reduced stay in the hospital.
Another important driver is the potential of remote surgeries. Remote surgery involves operating on a patient who is at a different location than the surgeon. Remote surgery has the potential advantages of reduced costs, reducing the transit time for surgeons who are scarce. Remote surgery has huge utility in battlefields where the surgeon cannot go due to safety concerns. The development of advanced computer controlled system has increased the propensity of remote surgery where the surgeon operates from a remote location. However Some experts were quick to charge this potential of belonging to the star wars and not present reality. Robotic surgery is very new and surgical robots themselves are in the early stage of development. Although technology is improving much needs to be done and more experience has to be gained. Technology improvements with high priority and need include haptics, processor speeds and more sophisticated software. Another requirement is the development of self-learning systems. Thus, attitude towards technology is an important determinant of the future of surgical robots. Attitude toward using technology and extrinsic motivation for users coupled with perceived utility of robotic surgery and its safety as well as efficacy and effectiveness remain strong deterrents for the surgical robots market. The costs and benefit analysis of surgical robots need to be analysed before their mass adoption by mainstream surgery. Thus, behavioural attitudes of surgeons and technological lag resulting from the difference between technology and human skills, will affect the rapid adoption of robotic surgery. This lag will be more severe in the market of the developing region. The U.S. is in a better position as the technological uptake is faster in the U.S. as compared to other regions. But this cannot be said of other regions of the world. However, we should also remember that each innovation has its challenges and surgical robots may be today, what microsurgery was some decades before. Thus development of surgical robots have a huge potential to a point of becoming a mainstay for surgical speciality, opening up new vistas!