During the last decade and a half, robotic-assisted surgery has led to smaller scars, less pain, and faster recoveries for patients. Concurrently, surgeons using this technology have benefited from being able to perform surgeries in a more comfortable position, while also experiencing greater visualization and enhanced precision. With all of these benefits, robotic-assisted surgeries are becoming increasingly common worldwide, particularly in the United States, where more than 67 percent of all of Intuitive Surgical‘s da Vinci robots are installed. Moreover, just yesterday we covered the FDA clearance of the Senhance surgical robotic system from TransEnterix, the first true competitor to the da Vinci. (Note: The photos of the robotic system in this article are of the Senhance, and are courtesy of TransEnterix.)
However, as with any disruptive technology, it faces some skepticism and challenges. We at Medgadget were at the MIS WEEK in San Francisco earlier this month and sat down with Dr. Mona Orady, Minimally Invasive Gynecologic Surgeon, Director of Robotic Surgery Services, St. Francis Memorial Hospital, Dignity Health Medical Group, to talk more about the obstacles facing robotic-assisted surgery and its future.
Medgadget, Kenan Raddawi, M.D: Before we get started, tell us a little more about your career in robotic-assisted surgery and why you decided to go into this field.
Dr. Mona Orady: I have been doing robotic surgery since the end of 2007, just two years after the FDA approved the use of robotic assisted surgery in gynecological surgery.
I remember the first patient I had when I was starting to incorporate robotic-assisted surgery into my minimally invasive surgery tool kit. She was a single mother of six children, with three jobs, and a humongous uterus due to fibroids. My first question to her was why did you wait so long to seek treatment? Why didn’t you have the surgery earlier? She replied, “Nobody told me that I could have the surgery done without taking six or more weeks off work. If I take six weeks off work, I am going to lose my job and then my house, and my kids will be on the street.” That patient is one of those who made me become a robotic surgeon, because I could see that robotic surgery could push the limits of laparoscopy and minimally invasive surgery to include patients who otherwise would not have a minimally invasive option.
In robotic surgery, you have increased vision, more precision, and increased dexterity. Therefore, I saw the potential to do more complicated surgeries using a robot. At that time, I didn’t know the degree that those limits could be pushed, but now, more than a thousand complex surgeries later, I have found that almost all patients, no matter how complex, could have a minimally invasive surgical option.
Medgadget: What do you think are the main obstacles and challenges facing the adoption of robotic-assisted surgery?
Dr. Orady: The biggest obstacles to the adoption of robotic-assisted surgery have been two things: first, the cost, and second, the training. You are talking to someone who has been very involved with residency education and training. I helped develop the curriculum for residents training at the Cleveland Clinic. I implemented it, and I helped train the residents in the program in minimally invasive surgery using a combination of didactic teaching, laboratory simulation, and hands on training.
The issue with robotic-assisted surgery training is that there is really a dichotomy. You don’t only have to learn how to use the instrument, but you also need to learn how to perform the surgery. When we train during residency, and almost in all of the training centers, everybody focuses on manual dexterity and getting to learn the tool. However, just as important, and even more important, is the understanding of surgery as an art. If you are teaching someone how to paint, you don’t give him a brush and tell him how to use the paint and what colors to dip in. You have to teach him the concept of 3D depth perception, what lies underneath the surface, the lighting, shadows, etcetera. It is the same way with surgery. We should teach the principles of hemostasis, dissection techniques, and how to avoid traumatizing tissue, etc. It is an unfortunate reality that in most Obstetrics and Gynecology residencies, there is so much to learn in four years – obstetrics, gynecology, primary care, office procedures, robotic surgery – and often, one of the things that get neglected is surgical techniques. This is the reason that the advent and demand for Minimally Invasive Surgical Fellowships is increasing, and the need for the specialty to split as so many others have done, is becoming more apparent.
Medgadget: What are some of the technical/logistic factors that restrict the performance of robotic-assisted surgery?
Dr. Orady: Let’s first talk about what some people working in the field of robotic surgery usually point out as missing or restricting factors, and then, talk about what I personally want when I perform a robotic-assisted surgery. A lot of surgeons point out the fact that in robotic assisted surgery, you don’t have haptic feedback. You lose the sense of touch. To me, that has never been a big issue because once you have done so many cases, it become very easy to obtain the ability to feel through an alternate sense of vision, so called “visual hepatics”, so I don’t consider that as an issue. The issue of the size of the robot and trying to dock it has been improved with newer models. Some of the newer surgical robots that are being developed are smaller, slimmer, and equipped with longer arms to reach the surgery site while allowing the staff to access the patient in an easier way. In terms of energy, I believe all robotic companies need to focus on their energy application. I helped write an article about the future of energy, and in my opinion, while sticking to just traditional monopolar and bipolar energy is okay. But, robotic companies really need to get into the advanced bipolar energy, I am not talking about the sealing, cutting techniques, but I am talking about advanced impedance detection, with a pulsed waveform, and adjusting the type and output of energy to the tissue reaction. We have seen that Intuitive Surgical had the PK energy in their Si system and took it off their new Xi system. I believe that is a mistake, as we should never go backwards and should always try to move towards using more advanced energy for our patients.
Medgadget: What is the one thing you wish you had every time you sit down at your da Vinci console?
Dr. Orady: Without question I wish for smaller instruments. Eight millimeters is still pretty big, especially since I perform Microlaparoscopical and Minilaparoscopical surgery. I use 3 millimeters instruments in traditional laparoscopic procedures. Jumping from 3 millimeters – almost a scarless incision – to 8 millimeters incision is what sometimes steers me more down the laparoscopy route rather than the robotic-assisted route. The second thing that I wish I had is a dedicated and trained team. A dedicated robotic team is one of the most important things for efficiency in a robotic-assisted procedure. The robot is different than other traditional surgical procedures. It’s a computer-based product, there is a lot of troubleshooting going on, and you have to be able to work through and fix error messages efficiently. Therefore, to optimize the function of the robot, you need someone who is really savvy in adjusting things perfectly and quickly.
Medgadget: Intuitive Surgical has had virtually no competitors for the last decade. Do you think this will change anytime soon?
Dr. Orady: It definitely will change. It cannot stay like that forever. The da Vinci robot has been around since 1999, so almost 20 years. New robotic companies have been working on their robots for maybe 10 years or more; although, none of them have been FDA approved yet but some are very close. [Note: this interview was conducted prior to the FDA clearance of Senhance from TransEnterix] In fact, an alternate system is currently being used in Europe and may be FDA approved within the next few weeks to months. The question is, will they catch up? Maybe, and most likely, probably. Intuitive Surgical hasn’t really innovated that much in the last 10 years. They almost kept everything the same, and even as I mentioned before, have gone backwards in some instances, like taking away advanced bipolar energy from their new Xi system. Also, Intuitive Surgical is focusing more on moving towards single port surgery instead of focusing on smaller instruments. In my opinion, this may not necessarily be to right direction, since with single port surgery, you end up with a bigger, more painful incision, and studies have shown that. I believe future robotic companies that will focus on smaller incisions, while maintaining the precision and vision, are the ones that will succeed in the future.
Medgadget: What is the future of robotic surgery? Do you think Artificial Intelligence (AI) can play a role in robotic-assisted surgery? Are we moving towards more automation during these types of surgeries?
Dr. Orady: I believe tissue is very dynamic. There are too many variables – the strength of the tissue, the texture, and how it stretches and reacts to tension and energy is extremely variable patient to patient. It’s too much data to input at the moment to believe that AI can completely take over. Artificial intelligence will definitely help guide our hands and eyes while we are performing the procedure using overlapped imaging or other detection methods.
I believe that in very specific procedures, like placing stents or in valvuloplasty, where it is a fairly straightforward procedure with minimal steps, we might see more automation utilizing artificial intelligence. However, in terms of intra-abdominal pelvic surgery, the variability and dynamic variation in anatomy make these types of surgical procedures really complicated to be able to automate. It is difficult enough to teach human brains how to adjust to variables in anatomy and the dynamic aspects of tissue reaction and to adjust and vary technique for each individual case as the case progresses. Thus, outside of using AI to help locate anatomy or teach people how to adjust to the dynamic movement of the tissue, it would be difficult to rely on it to actually perform the procedures. I am never going to say never, but I believe the amount of investment you have to put in will far exceed the cost of investing in training good surgeons and teaching them how to use the information that we can obtain using advanced imaging and advanced energy to simply perform better, more accurate, and less invasive surgery.
Also, I believe what will happen in the future in surgery is consolidation. We can’t teach a hundred thousand physicians to perform hundreds of procedures. I think every person is going to be really good at a few things and just repeat those procedures. Repetition is key. If you take surgeons and make them repeat the same surgery over and over again, they are going to get better. If you do a hysterectomy once a month versus ten a month, the improvement rate will be exponential. It is similar to a pianist who practices a piece of music daily versus once a month.
Yes, robots will become more automated in doing certain things, like real-time imaging. But, will a surgery be performed completely by AI without a surgeon? I think right now we are too far away from this.