Teaching hospitals should be obliged to have multiple types of surgical robots: Agree?

Steve Bell on obligations of teaching hospitals and surgical robots

As of today the absolute market dominance of Intuitive, and number of active surgical robotic soft tissue systems out there... is overwhelmingly the da Vinci systems.

If we think there are just over 10,000 Intuitive systems out there (SP, Xi, ION) with the majority Xi / DV5 - and if we consider that between all the other manufacturers there may be 500 active systems out there today (either placed, leased or sold.)

Then we can estimate that like for like (Xi class) at about 9,000 working robots vs 500 from all the others - means about 95% of the world’s soft tissue robots are Intuitive (in that class). But (won’t do the naked maths here) about 99% of all robotic procedures are done with an Intuitive system today. THAT IS STAGGERING.

And so from a surgical education point of view - for me - that’s a big problem.

Why is this an issue for me?

And who the F am I anyway?

Most young surgeons (residents / registrars) if they touch a soft tissue surgical robot - the overwhelming odds say it will be a da Vinci system.

So what? Who cares?

Well the issue is that the first exposure to systems can have a major ingraining pattern on the user. The feel - the touch - the way it works - the comfort with it. The procedure steps - the architecture. It all gets ingrained into the young surgeon... and it is very very sticky. Often influencing theor future use patters. Especially if they have no exposure to alternatives.

Now it does not preclude that they can then go and try another robot post training - but the daVinci paradigm will be the predominant training that they are (most likely) to get. And it is that impact that will affect them going forwards. And don't think that is lost on Intuitive.

Oh and yes there are islands of Versius, Hugo RAS, Ssi Mantra and others… But statistically - the young surgeon is most likely to know the da Vinci and have used the da Vinci during their training.

I think we must also stop thinking in the current status of MAS (Minimal Access Surgery) - where there is still a lot (the majority) of surgeons that are skilled manual laparoscopy. As robots become more ubiquitous we will see the move to more and more robotic cases replacing manual lap. Soon (already in many institutions) the majority of procedures for MAS will be done robotically.

Interestingly the stats today are a bit weird and data is limited but here’s some stats I could find for the US.

Access & Participation

• About 96% of U.S. general surgery residents have access to a robotic system at their institution oakland.edu+10pmc.ncbi.nlm.nih.gov+10pmc.ncbi.nlm.nih.gov+10.

• Yet only around 63% have actually participated in a robotic case pmc.ncbi.nlm.nih.gov+1sages.org+1.

Console Time

• When residents do scrub in, only ~21% of robotic procedures have the resident actually at the console intuitive.com+15journalofsurgicalresearch.com+15pmc.ncbi.nlm.nih.gov+15.

• A multi-institution U.S. survey found 33% of residents logged any console time - most served as bedside assistant intuitive.com+3sages.org+3oakland.edu+3.

Summary Snapshot

Metric	Percentage
Institution has robot	96%
Residents participating	63%
Console participation	~21–33%

So we see that 96% of institutions with residents have a robot. And other data suggests that 85% of US teaching hospitals have a robot. That's high - very high.

And if the majority (vast majority) are da Vinci, then nearly all residents will be being exposed to a daVinci. It’s just stats. And the vast majority will ONLY be exposed to a da Vinci.

Now we can argue that only a third are getting to actually fly the robot so how much impact will that imporintinghave on them? But they are being exposed. Exposed to the brand, the architecture, the way it works. Bedside - they have confidence in the da Vinci system. And I'm sure most will have done some form of simulation with it.

So that mean the most likely course for them as they adopt robots in the future will be da Vinci. This is just the way it works. Exposure - Imprinting - familiarity - selection. "I trust therefore I am."

Well played Intuitive for basically owning the entire mind share of surgeons in training with regard to exposure to robotics. Smart - and strategic.

If you get the next generation of users to love your system - know your system or just have it as number 1 brand recall - you are on to a winner.

And an even bigger bonus is if you are in a teaching hopsital and see the educators "choosing" the da vinci over other systems week in week out. Then that is a powerrful statement. "The only system my educators want is the DV. The others are just to have a go on. Noted and noted well."

And that is my concern. There is such a vast dominance by Intuitive (and for good reasons) that it may be very hard for other companies to break into this education cycle. And I think that is a risk for surgery of the future.

The role of the teaching hospitals

If you leave it to industry - then of course each company is going to fight their corner. Say their architecture is best. Say that everyone should be exposed to their systems.

But the reality is that what you grow up on is usually the the first thing you think of. And as that new generation is exposed to more and more robotic (da Vinci) MAS vs manual MAS, their preference for systems that “mimic laparoscopy” will not be triggered. Why would it be. They don't do that much manual laparoscopy.

In fact, I fear they will not get that exposure at all; to fully understand why there may be potential benefits to open console systems, modular systems, mini systems etc etc. Systems that allow them to operate closer to their manual laparoscopic paradigm. (A reason amnay surgeons prefer other sysyems to da Vinci today.) In the next generation of surgeons that "desire" may not exist.

If those impressionable young minds are not exposed to the various systems - or are not manual lap minded - so searching out a system that helps them realign the feeling of lap… I fear we could be going down a dark tunnel where the only light is da Vinci.

(Hey not a bad light - I mean let’s look at the results.)

But I’m a firm believer in competition and choice. And I think most people are - even Intuitive. They might prefer if there is choice and people choose da Vinci - they reinforce their message… but that is still an aspect of choice.

So who is responsible to make sure that every resident knows there are alternatives? To make sure they know how to use an alternative - bedside or console side. To know there are different architectures from single booms, to modular, to lap 2.0, to mini systems, to various single ports.

To know there are a wide range of manufacturers.

Now it’s on Industry to make sure we deliver alternatives that are fit for purpose, deliver just as good an experience and results. So I’m taking that off the table.

But the older I get, the more I move through 35 years of seeing medical education… the more convinced (oh no surprise Steve) that this education of choice starts with a fair and open exposure to multiple systems at the major teaching institutions.

I feel that they need to be robotic teaching centres - not da Vinci teaching centres.

Obvious right?

No.

You see I have seen a lot of lip service to this - but so far I’ve seen few centres have a systematic implementation of this. Little imposed dividing up on case loads evenly across systems. In some major teaching centres - I’ve seen 16 daVinci Xis and 1 “other” system.

I see on a regular basis that 98% of case load is done on a da Vinci - and the odd “teaching case” is done on a.n.other system.

For me that is not being an open and inclusive teaching system. And it is certainly not being fair and balanced.

And when I’ve asked “why” to many surgeons I get a litany of excuses (many really good) but it self serves to never allow a fair chance to other systems. Which often becomes a loop.

DISCLAIMER: There are a few (and I mean a few) teaching hospitals around the world that have no da Vinci and another system. But this as rare as rocking horse…. Erm wheels. Please don’t say “I know a few centres that don’t have da Vinci” - YES. But let’s talk the majority not the corner cases.

The excuses why not

Now I’ve heard everything in the last few years, and to be fair some excuses are legit. And some are self fulfilling prophecies. Let me dig in. And see if any of these are familiar.

The other system doesn’t work as well:

Erm — yeah. Why did you think it would. There’s a 25 year lead. The question should be - in what cases does this work adequately. And what space can we give to this system to expose the residents to it?

If you are a teaching institution saying “There’s no stapler so we can’t use it.” I understand but have the bedside use a manual stapler. (A lot of teaching institutions even do this with da Vinci so don’t kick me) but if this type of features excuse means you do that vast majority of your cases on a da Vinci. Then you are depriving the oxygen to the other companies to get those feature sets on. You are contributing to the problem not helping it.

Find where they can be used, and use them in those procedures. Give the companies a chance to catch up. Give them fuel to keep pushing feature development. Help close the loop in a positive way.

We need to get on with cases and the learning curve slows us:

I’ve personally seen this a lot. And I see the catch 22. We don’t want to use the new system as we have a case load to do - and it is slower with the other system because we are not as used to it. So they don’t use it - so never get faster with it.

I think that loop needs to be broken by a commitment to use the system no matter what (patient outcomes and safety of course is not a negotiable.) Every new technology has a learning curve - but if you just use the system once a month for an odd case; but you are doing six cases a week on a DV. Then FFS of course it’s always going to be “slicker” on a DV.

Break the loop. The obligation must be exposure and use of systems. Force yourself up that learning curve through constant usage.

The data is clear in the literature, that once past the learning curve, other systems give the same clinical outcomes and the same procedure times. But it takes a commitment to get up the learning curve and get into regular usage. Other systems cannot be the reserve of the simple case - or the outlier case- or the case when we have a bit of extra time. There needs to be a strong commitment that you will divide up the case load between systems evenly. Or residents won’t get the exposure they deserve. And you will stay in that vicious circle. Da Vinci is the real robot and the other is a curiosity.

But we have a lot more da Vincis

"And I want to use that"... subtext Many hospitals have multiple da Vincis and 1 sole “let’s have another alternative.” And you then wonder why 95% plus of case loads is on da Vinci. It's a dog chasing its own tail.

I feel teaching hospitals have an utter obligation to have a diverse number of systems and spread the love across those systems. If you keep buying more da Vinci at a rate of 4:1 vs other systems - then … yeah…. that never changes.

I think it needs to be a policy of the teaching hospitals to ensure an equal spread of systems. Even if the users are all belly aching “I like my da Vinci. Let the other surgeon use the XXXX.”

If the institution and educators do not break this cycle we will continue to see a few other systems used sporadically... and the majority of the “work horse cases” done on the DV.

It’s just numbers. And that will give a massively distorted view to young surgeons.

But if we do not enforce this shift at the top level of education and the institutions - then here’s my  prediction. You are going to perpetuate a self fulfilling prophecy.

You will marginalise the other manufacturers - their systems will not be the first choice in teaching centres - the residents will learn to love da Vinci - and the cycle will continue. To the point where most manufacturers give up or fail because they can’t break the circle YOU have created. In twenty years we could be back to just one robotic system in all institutions.

I'm not joking.

You want that? Then keep going… have 14 da Vinci systems and 1 Hugo RAS.

The imbalance of publications and evidence

A secondary impact (besides direct education and exposure) results in an imbalance in clinical evidence, data and publications.

If the big name institutions are 95% da Vinci cases and are constant publishers... then there will be way more papers coming out with da Vinci systems and data. You just simply do more cases to collect data on and publish.

Of course we will get the RCTs of da Vinci vs system XXX

But come on. Is that a fair comparison? (And I’ve been witness to these trials). People that have done 10 years on an Xi and 4000 cases do an RCT vs a new system with 3 months of use and 35 cases - and they do a comparison. (I’m being unfair as many don’t do that.) But equally many do.

Now fortunately - some of those RCTs have shown non inferiority which has been good. But the volume of data - the comparison of cases - the volume of publications per annum is so far skewed to Intuitive (just by the volumes and access to system) that the data mass that is often used in purchasing decisions, and HTA (health technology assessments), and tenders is so skewed... it is untrue. But it is clear why it happens.

Again - I would hope that major teaching institutions would mandate research volumes to be equal across systems to redress this balance. Get more systems in - divide the work load evenly - and publish academically evenly. This is the ONLY way we are going to ensure an equal analysis - comparison and voice for other systems.

It is the big name institutions that must drive this as good scientists - good educators. I know there is always a “let’s try a new system - let’s give it a go - let’s do a publication or two and then move on.”

That to me is not science it’s “fad publishing.” Instead we need solid science and data to do fair and equal comparison. Show where these other systems have very practical usage.

And in the background 95% of cases will continue to be done on the da Vinci.

What I would love to see an academic group do, is go to a couple of big teaching hospitals and publish their % case loads across systems. Declare their grant spend per system for research, declare their number of publications per system. Declare flight time for residents by system. Let's see what the baseline is and let's set targets to redress the balance.

I’d like to see that the institutions we all look up to are giving a genuine and fair use of all the systems out there.

How many is too many?

But Steve - where’s the line? If there are 36 systems out there today - we have to choose right?

Well the answer to that is not 95% da Vinci and 5% others- that’s for sure.

Instead I think a pragmatic approach based upon segmented architectures / applications can be adopted. I’m not advocating that every single company must be used in very institution. But key architectures need exposing to residents so they are well equipped when they go out into the world to make an informed choice.

I would say at a minimum a boom system, a single port system, a modular system, a mini system or lap 2.0 system.

It should allow the equal exposure to various arm architectures, closed vs open console architectures, port placement differences, and appropriate use of systems for appropriate acuity of cases (clinical and economic considerations being looked at.)

Let’s imagine: St Elsewhere teaching hospital needs 6 surgical robots. A realistic division could be (just throwing names out) even if not approved yet - let me make the example.

Da Vinci Xi or DV5 or Toumai

HUGO RAS or Versius or Mantra

OTTAVA

Moon Surgical or Distal MotionVirtual incision

SP or other single port like Vicarious Surgical

This would give a more rounded education. The classic DV boom system architecture, modular system architecture, table mounted architecture. Lap 2.0 (robot and digital laparoscopy) - mini robotics and or single port.It would expose residents to how to dock vs non dock to ports and how different remote centres vs virtial pivot points work. Port placement education as each system allows different things . Arm dynamics and the differences. Exposure to different instruments and instrument loading / size / function. It would give them exposure to different company support and education systems, simulation and digital ecosystems. Open console robots - closed console robots - no console robots. Telesurgery non telesyurgery. Hand controllers vs foot pedals etc etc etc.

It would show them basic manual lap vs lap 2.0 digital assisted; and what that means.

It would expose to multiport vs single port use, applications and limitations.

How does that idea feel vs five daVinci Xis and 1 HUGO RAS that is used in a few cases a month. They are very very different education paradigms.

Surely educators want to expose their residents to the variety of systems and choices and the “why?” of various systems. And think of how much better the science would be in comparing the benefits and drawbacks of various systems - the right cases to use them in - the right economics associated - on and on and on.

And I can hear people saying “but who can have six systems.” - erm a LOT of teaching hospitals already have multiple systems. A lot. In fact (no naked maths here) the average number of robots in the USA in teaching hospitals is estimated at 6.2 (didn’t just pull that number out of my…) So this can be done if institutions put policy in place.

So it is possible. And yes there will be tons of internal self justification of “why I need a da Vinci…” but (in my mind)  there is an obligation at an institutional level - to move towards broader robotic education.

But surely standardisation is the key to better outcomes?

If we spread iot across many systems we will dilute cases, and standards and etc etc

Lots of evidence of course shows that standardising procedures - approaches - volumes etc has a positive impact on outcomes. But let’s not confuse that with this statement -

“Standardising everything on a da Vinci is key.”

These are two very different things. Of course you can introduce new systems and then standardise per system - per procedure. For example you might decide - that all prostates will be done in a standard way - either on a da Vinci (this way) or HUGO (this way) with slight modifications depending on system - but procedure steps are standardised. Care is standardised - just the scalpel is a bit different.

You might say - Inguinal hernia should be standardised (TAPP or TEPP) these key steps. And you might say... and we standardise on a Versius or Vicarious.

So we do all prostates on systems A&B - standardised

Hernia on C&D - standardised

Hysterectomy on E&F standardised.

So I think there can be procedural standardisation but the “tool” can be selected as the best tool for the job - or the right tool for the job - or the most pragmatic tool for the job.

As long as outcomes are equivalent - safety I not in discussion. I think we can standardise - ensure volume of cases per annum is high enough - but share that across systems. It can't just be 95% of cases in teaching institutes continue to be done on an Xi.

In fact - if the right institutional research is done - we could see published benefits on system A vs system C - if we standardise. We could see health economics benefits of system B vs D in these procedures when we standardise.

What I’m trying to say is this. Except for a few pockets across the world - and I do mean a few. I see little systematic education approach to “Robotic surgery” as a class. And still feel way too much weight towards training on a da Vinci. Too much exposure to da Vinci.

And I think educators are not only missing a trick but also setting up potential failure for all the other robots.

Summary

Maybe I’m in my own bubble and seeing this wrong - and a lot of teaching hospitals are going to scream that this is an outrage. Maybe most will say - we have a totally equal and open share of robotics in our institution. In fact we have three different types. (But how many sit in the corner?)

Maybe some will say - “The only good robot is da Vinci.” And then a whole list of excuses and reasons and “why” and “because.” But is it fact? Is it truth? Or is it convenience?

I want to fly the flag as to why teaching hospitals would best serve healthcare by being equally engaged in all systems. Having a fair spread of systems. Making it an institutional prerogative. And not just having three parked in the corner. I mean equal usage by mandate.

I’d like to see heads of departments - professors and hopsital C-suite ensure the next generation of surgeons have an equal exposure to the alternatives. A fair exposure.

Now if after all of that exposure they then say “da Vinci is the best by far” then so be it. That’s on industry to get their shit together. But at least there will have been a fair and open exposure to what’s out there.

If not, I fear we will see a brief blip of alternatives - but the “not fair shout in training” I believe, will mean it is a short... short lived blip. Industry can only do so much. Societies (another post for later) can do their part; and many are (ASIT being one, SRS another.), and education centres like ORSI and IRCAD are also doing their part.

But unless we see access and opportunity across the resident programs in teaching hospitals - across the world. We could end up with a very skewed perception of robotics as those young surgeons go out into the big wide world.

Agree? Disagree?

These are just thoughts and interpretations by the author for educational purposes and designed to stimulate debate.