Designs are needed to reduce the complexity and cost of robotic surgery.
by Michael Friedrich

Is widespread adoption of surgical robots around the corner? The question is certainly timely given the recent developments in the sector. To name a few, in mid-September, CMR announced it raised $243 million in a Series C round, while reaching unicorn status. Two weeks later, Medtronic was unveiling Hugo to investors, its long-awaited robotic surgery system. Meanwhile, Verb Surgical, the joint venture between Johnson & Johnson and Verily, took on a new CEO ahead of market launch. As the range of offerings continue to expand, should we expect to see surgical robots in every OR soon? The answer is not quite yet.

On one hand, a lot has happened since Intuitive Surgical came to existence and launched the da Vinci. Today more than five million patients have benefited from robotic surgery. On the other hand, it is evident that some of the limits of legacy technologies remain, while new problems have appeared. In fact, surgeons still call for a truly flexible and modular solution, while costs continue to be the elephant in the room. Ergonomics is also an issue still. Not to mention the much-discussed complexity and time-consuming efforts of running today’s surgical robots.

However, we need to look deeper to find one of the root causes of this situation. Robots in minimally invasive surgery today commonly use the DARPA-inspired setup formerly developed to facilitate battlefield surgery. The concept was to create a robot capable of performing the complete surgery and allowing the surgeon to control the robot remotely—potentially not even in the same building. In today’s operating rooms, however, this results in the surgeon being non-sterile at the console of the robot, and the robot at the patient in the sterile field. This approach, although helpful in military applications, does not reflect the realities of everyday surgery.

In fact, according to recent research from Cornell University, this set-up creates “cognitive and affective distance” within the surgical team (how the team collaborates and communicates) and feelings of emotional disconnectedness. This is a problematic situation in an environment where social dynamics in teams are critical. In open surgery, members of the operating team are highly in tune with each other’s moods and emotions—a necessity when performing intricate and high-stakes work, whereas surgeons using robots can feel isolated operating at the console apart from their team.

In the end, these factors make the whole thing complex, which drives costs up, thereby continuing to limit the widespread adoption of robotics in surgical procedures. One figure sums it all up: annually 9 million laparoscopic procedures still do not benefit from robotic surgery. It is a reality—robotic surgery is still not the standard of care in the vast majority of procedures. It is well adopted in prostatectomy, and it has good penetration in the hysterectomy niche, but that is about it outside these two areas.

Intuitive played a critical role in creating the market, and CMR provided a first answer to the much-needed democratization of robotic surgery by bringing some flexibility and portability to its robot. Moving forward, truly delivering on robotic surgery for patients, surgeons, hospitals, nurses, and the healthcare system requires building on this effort and focusing on a key point: reducing the complexity and costs of robotic surgery, by design.

I believe this starts by acknowledging that robotic surgery is not an “either-or situation.” The “original sin” of robotic surgery is perhaps to have thought about laparoscopy and robotics separately, creating new processes in the OR. In reality, integrating robotics into existing laparoscopy processes is the best way to keep things simple, while delivering several benefits such as keeping the surgeon sterile and allowing him or her to come back to the patient, operating in a seated or standing position.

For comparison purposes, Dexter allows surgeons to switch between robotics and laparoscopy in less than 20 seconds and to use the technique of choice for different tasks. Such versatility allows changing positions of instruments easily during surgery, giving full access to the operation site. In this setting, depending on the step, the surgeon can choose whether he or she prefers to defer to the robot or traditional laparoscopic steps. The robot can be used for long tasks, such as suturing or dissection, and the surgeon can be in control of short but complex steps, such as stapling, clipping, etc. In the end, this is also the best approach for getting robotic surgery costs in line with the costs of manual laparoscopic surgery.

I am convinced that this approach it is the path forward in robotic surgery. After bringing the much needed flexibility and mobility to surgical robots’ design, “unboxing” the surgeon is the natural next step. Right now, I believe the Palm, Blackberry, and other Ericsson equivalents dominate the market in robotic surgery, but once we break out of this “Robot Wars” phase, robotic surgery should soon be ripe for an “iPhone moment.”