Why bother having a Surgical Robot?
- Steve Bell
- Jan 23, 2024
- 15 min read
Updated: Jul 30
Why would anyone on earth want a soft tissue surgical robot? Surely a skilled laparoscopist has no need for such a thing... It is debatable if they bring "any" clinical benefits verses standard lap surgery? The evidence is clear in Urology... but not so clear anywhere else... right? They are just money pits that sit in the corner and do 3 or 4 surgical procedures a week. They just don't bring value.... They are never going to take off... right?
Heard all this before? Have you even said this? Or you still saying this?
Well let me give you 10 reasons (in no particular order) why surgical robotics will become the gold standard in the next 20 years (at least why I think so). And then let me dive into each one.
They will extend surgical careers
They will accelerate "better surgery" in younger surgeons
Data will be king and you will be measured on your data
Automation & Help will start to come and reduce errors
No fly zones will start to reduce errors (early career errors)
No robot? No future in your career if you're a young surgeon.
No robot? No surgeons are coming to you as a Hopsital
They will compress the bell curve of skills
They will be the place where innovation expands (vision and instruments)
They will ultimately save money for the Hopsital
1: They will extend surgical careers
Data shows that surgeons are making their best patient led and surgical decisions when they are at 55 plus. They have gained the right experience to make the best judgement calls and so get better outcomes. But unfortunately the boom in laparoscopic surgery since the 90's has created an entire raft of surgeons that have been in suboptimal ergonomic poses for years. Many now suffer with shoulder pain, neck problems, back problems. For years this has been ignored by the employers (the hospitals): but that tide tide is turning. More and more superbly skilled surgeons (at the peak of their careers) are retiring through long term sustained posture injuries. They just can't do the big long lap cases anymore. And many of them are now looking for compensation (as would any employee!)
Enter the robot. When you have a master slave robot (be careful not all robots are cerated equal) - the surgeon gets to sit in a better ergonomic position and operate from a much more comfortable position. It no longer matters your size and reach as a surgeon (this is important for small surgeons or some female surgeons who are disadvantaged in lap surgery just by their physical stature.). With the master slave robot - that all now goes away. (I'm not saying it might not cause other issues) but the damaging ergonomics of laparoscopy are no longer the big issue.
This will firstly impact the older surgeons at the end of their career - by allowing them to continue to perform multiple complex cases much later into their careers. This is essential for all healthcare systems across the world. Essential !! Not a nice to have. Next it will impact the new generation of surgeons - allowing them to avoid those injuries in the first place! So again allowing another generation of surgeons to have prolonged careers - and hopefully reduce the impact of injury during their carers. It cannot be stressed enough how important it is to retain a healthy and productive surgical work force as long as possible - especially as they hit their prime.
2: Surgical robots will accelerate "better surgery" in younger surgeons
As working hours have been highly regulated, and the learning time of "on the job" surgical training has been reduced; Junior surgeons need to get to proficiency faster and with less exposure hours to surgery. The robot allows this on many fronts. First much of the training for a robot can be simulated (and simulated well). The lack of haptics makes the simulation much closer to the actual use of the real robot vs haptic less lap simulators. We should not underestimate how this change to proficiency based simulation will massively increase the speed at which junior surgeons can get to proficiency of surgical manoeuvres such as laparoscopic suturing. Add to that the natural movements allowed by the robot - where the learning through a fulcrum goes away (thanks to the robot doing that heavy lifting) (again not all systems are equal) - where up is up, down is down, left is left and right is right. And where your natural wrist movements are translated into movements of a wristed instrument. And well... it is just way easier and faster to learn to do complex laparoscopic movements on a robot.
Next (and just a few years away) the combined knowledge and wisdom of the "hive" will become available to all surgeons "on the fly" - where the robot will start to advise (based on common agreed knowledge) what the best next steps are. Sort of like "phone a friend" or having the best mentors in the world right at your side. It is way way closer than people think. And when it arrives in practice it will help young surgeons (or maybe also... bad surgeons) to get better outcomes through error reduction or following known steps that work in a sequence that works better.
All of this will ensure that better surgery with less errors will be performed earlier in the career of surgeons. And it will all be driven by clear metrics and data so everyone can get onto the same comparable playing field. The robot's digital systems will be able to look at the movements of the novice - and guide them in a personalised way in how to improve. This is here and now! In laparoscopy - with no computer between the surgeon and the patient, all of that data for the last three decades has just been thrown away. Putting a smart robot between the surgeon the patient will quickly, easily and (importantly) automatically measure it all. Now there is no excuse - even today - to not measure the entire training pathway of a junior, and their early case progression through the learning curve. Multiple robots can deliver that TODAY! What will be the excuse for "not doing it?" Very soon it will be very hard for surgeons not to be mandated to have digital logbooks of their training progression. For laparoscopy it "could" be done manually - but the robot just makes it so much easier and the data so much richer.
Intuitive DaVinci skills simulator
3: Data will be king and you will be measured on your data
Building on that - the data will not just be for the novice junior in their learning curve. Data, video records, and telemetric data is starting to creep in to many institutions and even healthcare systems. Audits, post error investigations... quality reviews.... more and more the data will become mandatory, and the robots already throw off that data in a rich format that can lead to better insights. Some may see it as "big brother" but the next generation see it in a much more constructive way - the Strava generation. The data will be able to help you simply complete your annual audit reports, congress abstract preparation, clinical paper preparation... etc. The data will all be at the fingertips of the surgeons, the institution and the insurers - so they can all see progress, and quality. Many will fear this at first - but will they be the under performing surgeons? And if that data is used in the right way - all stakeholders will be alerted early on, before things become a problem. "Hey Doc - you could do with a few hours of suturing to improve you left hand position!" - "Hey doc your cases are starting to take a lot longer than normal... is all okay?" etc etc. Non threatening advice from the robot and accompanying app - not colleagues. Useful help that will keep people on track and get people back on track before serious problems creep in.
It's going to become a standard in the near future - and many surgeons are benefiting from this today by already doing critical self analysis and improving from the insights.
The data will do so much more when it is rolled up from major groups, and major trends are analysed in almost real time - then recommendations pushed out to the fleet of robots - that can - almost in real time give insights to better outcomes via their apps. It's already happening.
4: Automation & help will start to come and reduce errors
Imagine now that all those insights can be baked into the kinematic software of the robot. Better scaling for rotation to help suturing and tremor reduction are already here - guided movements where the system correct for minor errors are already creeping in. On the way will be automatic dissection, electrosurgery application, knot tying and more - these are already in the labs - they will slowly come on to the systems in the commercial setting. It's like the creep from automatic gears, to parking sensors, to cruise control, ABS .... automatic braking in emergencies: have all been the slow walk to self driving in cars. It is on its way in robots and will happen in a step wise fashion - and in the next decade error reduction will help to get better outcomes (and ultimately save money in healthcare.) One small example that is here today is that the robot controls the pivot point in 3D space. You can't put hard lateral forces on the ports like in manual lap. That is already an error that can be removed from every patient... today. Hard lateral forces that can cause damage and pain. Instead the robots measure those forces thousands of times a second, and alarms and stops when forces are too high. It's here... now. And the more that robots get "smart" the less excuses there will be to maintain doing manual lap. No one is going back from their current car with lane assist to a horse and buggy... (right?)
5: No fly zones will start to reduce errors (early career errors)
The human eye is pretty limited - and you combine that with poor anatomical knowledge - perhaps in junior surgeons. Well things can get difficult pretty fast. So instead give assisted vision - seeing beyond the human eye's limited spectrum combined with anatomical boundary knowledge, a pinch of AI, and the robot can start to create target zones (were there are tumors) - and critically - no fly zones. Beyond Human vision is already here - with magnification - better colour rendition and flourescence. But already the robots (where the innovation investment is happening) are getting better and better stable (that is key) vision systems with amazing capability such a fluorescence markers, high contrast profiles and hyperspectral imaging.
You then add in the immense computing power of the robot and you can create restricted target zones and blocked no fly zones. "But couldn't we just see that in manual lap?" - YES. But the robot gives one massive difference - Intervention. Already today - because the surgeon is not physically connected to the instrument - the robot is intervening. Certain movements just can't be done - no matter how hard a surgeons moves the hand controllers. Because the arm becomes disconnected from the hand controller by the safety software. That capability will be used more and more in no fly zones. The subtle difference between a warning in lap and the disconnect in a robot creates a gulf in safety. Why? When the surgeons gets that warning in lap, they can simply continue and ignore the warning. With a robot - there will need to be a physical act of "Overriding" the warning and safety system. Taking physical action to say "ignore and re-engage and continue." That physical act alone will reduce error rates - as it will give a moment of pause. This "intervention" ability will be an essential feature; and in some robots... it is very close for no fly zones, but already happening on excessive forces. The robot can also know you have a scissor and not a grasper in that area - so the software will act differently depending on the end effector. It will know if you are pulling too hard on sutures, it will know if you are about to activate electrosurgery out of vision. And it can stop you and ask "Sure you want to continue doc?"
Getting that safety system right - so surgeons don't get warning overload - will be the tricky part. Also, I believe, being able to dial it up and down depending on surgeon skill will be needed to stop the frustration of skilled surgeons. But being able to dial it right up on an inexperienced trainee could be very useful indeed.
6: No robot? No future in your career if you're a young surgeon.
I saw this back in the early 90s with the adoption of lap vs open. I saw bright young surgeons avoid going to hospitals that refused to adopt laparoscopy. That is valid today with robots. I have spoken with so many clinical directors and even C-suite managers at hospitals that have said "we'd like a robot because we can't recruit surgeons into posts." The next generation of surgeons will all expect robotic flight time - period. I predict that the opposite will also become true. If a surgeon has no robotic experience - their curriculum will have a glaring hole in it. It will soon become career limiting to turn up to an interview and not have robotic experience. It may also become "patient" limiting - as more and more patients will expect their surgeon to be doing "the latest and greatest." And they will be asking for the robot - and shop around for it if that surgeon does not offer it. It is already happening in some areas, but will come widespread as more hospitals adopt robotics.
Ten years ago - virtually no junior surgeon was fixated on the robot. Today 2024 - it's nearly 100% that want to be on the robot.
7: No robot? No surgeons are coming to you as a Hopsital
Hopsital administrators have already understood that not having a robot is limiting to attracting the top talent and the next generation of junior surgeons. It is unlikely there will be a single teaching hospital within five years that does not have a robotic program. If they don't - they will be considered out of touch. Having at least one robot in any teaching hospital is now table stakes - with many of them now adopting multiple systems from differing manufacturers. They cannot be seen as a single style robot centre. From a teaching point of view and an academic publication point of view.
I have personally seen hospitals struggle to retain surgeons and gain surgeons due to a lack of a robot. The economic damage - or even loss of critical cancer services has been utterly destructive to many hospitals. I've seen hospital after hospital lose cancer status just because they had no urology robot. You can't do prostatic cancer surgery in 2024 if you don't have a robot. Beyond 2025 that will become thoracic and 2026 - colorectal surgery.
8: Surgical robots will compress the bell curve of skills
Often the thinking is that a great laparoscopic surgeon will get little to no benefit from converting to a robot. And that may be true - in fact in "golden hands" RCTs between robot and lap - there have been few advantages realised. But real world - there is a bell curve of surgical skill with a tail leading to the "danger" range - which relates to a lot of the complications and errors. The robot is not aimed at making the best 2% better. It is about making the lower 50% better. A bad surgeon that cannot work out how to suture laparoscopically, has challenges with the fulcrum motion and hand eye coordination will be suddenly as good as the rest with a robot. Why? Because it is way easier to use than lap instruments - movements are translated for you by the robot. So those less skilled laparoscopic surgeons get a performance boost.
Let's not forget that a fool with a tool is still a fool... But what it covertly does is put in a hard filter. To get on the robot you need to get trained and proctored - and that's a big gate. Also the robot is now "watching you" and your data. So? The really bad surgeons will just either not join the robot group (Darwinism) or they will try and won't reach the proficiency they imagined in their head they would. They probably should never have been operating anyway... but getting robotic certified will act as a pretty hard filter. Surgeons with lower skills will be trained harder, assisted more through the process, proctored longer, and the robot "process" will raise their game - and feed that all back through data. This has already been seen.
So yes - much of the data shows that in open vs lap prostate - the robot is clearly better. Of course it is. But much of the other data in RCTs done by the best laparoscopists - show little to no advantage in the robot group. Yeah... why would the robot make a skilled expert more skilled and expert? It shouldn't. But what real world evidence will start to show is that as robots improve training, make surgery "easier" ( I mean difficult surgical manoeuvres), allow even the most difficult cases to be done (low in the pelvis let's say), data improves, technology on the robot improves - the overall impact on the health system will become massive. If we can cut off that left tail of the bellcurve and nudge more surgeons a little bit to raise the average and the curve gets narrower and taller - that is the big win. Less errors, less complications, better outcomes - more cost saving.
And the final whammy - the robot will be the enabler to get more open cases done as lap cases (where the massive patient benefits come in.) Think about it. The robot with its better vision, and wristed instruments may allow even the most complex cases to be done lap. Cases that some surgeons would have felt more comfortable doing open. That means if we could move just another 15% of global cases to lap (in all comers hands - not just the top flight surgeons) then that will be a massive benefit and cost saving to healthcare.
It is here en-mass that the economics of savings will out weight the initial cost of the robot and higher in-case costs. It will reach a tipping point (and in fact in may institutions it is already past that tipping point.) Even some healthcare systems like the NHS have already understood it.
9: They will be the place where innovation expands (vision and instruments)
Follow the money. Investment and advances in healthcare in the next 20 years will be focused on robots, digital health and AI. Period. In the next years if you want the best vision system, the most advanced hyper spectral imaging, the next gen of staplers, advanced energy, trocars and multi functional smart instruments. They will be hanging off the robot first and foremost. Connected data, connected training and VR training will all be centred around the robots. If you want early access to the next breakthrough technologies in surgery... get a robot. The innovation $$ are being pumped into robots - not lap hand instruments. This is where the big companies can build massive firewalls to keep "cheap Chinese" hand held product out. Why - because the robot is a system with electromechanical and software. You can't put your stapler on my robot if I don't allow my software to talk to it. A huge barrier !!!
So they are going to ram all their R&D into products that can be protected by IP, but more so by the fact the company chooses what hangs on the robot. And they will choose the end effectors that make them the most money. They will block all other end effectors - and regulatory barriers will enforce that. You haven't seen any cheap generic instruments for DaVinci have you!
If you want the latest and greatest in the next years - get a robot today.
10: They will ultimately save money for the Hopsital
It's quite hard to see this now when robots cost a million $ to buy, then more to service and even more for the consumables. How could they ever save money?
I said it above. This is not a cost of procedure analysis. This is going to be the savings of better healthcare, less complications and faster return to productive work for the patients. The savings will be hard to measure directly - but as robots come in - the % of Minimal Access Surgery just goes up (Open surgery goes down). FACT. Go look at any of the graphs. If MAS goes up - patients and healthcare systems (and society) get financial benefits.
But in every institution where a robot is applied, the % of MAS goes up - combined Lap and robotic. And the critical thing for the economics of healthcare is that the % of unnecessary open cases goes down. In some specialities it is very dramatic.
Like laparoscopic surgery from open. It took a generation to see the massive benefits proven out. But the data is becoming clear. The same will be true of robotics.
Summary:
Folks - the train has left the station. If you are not on the robotic train yet... it's time to get on. Because it is not going to stop. People can try hard to justify why "they think the robot is a stupid waste of money" and interestingly - many of them will have been the laparoscopists of the 90s, when their bosses said "laparoscopy is a stupid waste of money." It's generational for some. But Darwinian for all.
As technology baked into the robots accelerates - there will be a point (and we are almost at it) where it will just not be acceptable to operate without a robot where it is indicated. It will be an overwhelming set of safety features and monitoring data combined with class leading vision and instruments. We are close to having people ask "Why are you not using a surgical robot?". The next five and then ten years will be very interesting.
The author has worked in laparoscopy since 1990, and been involved with surgical robotics since 1998. If you would like more insights from Steve then head to www.howtostartupinmedtech.com
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