May 10, 2023
The overall use of robotic surgery has grown significantly over the past 25 years.
Intuitive Surgical, once “the only game in town” and the current market leader in robotic surgery systems, reports that more than 12 million robotic surgery procedures have been performed and more than 60,000 surgeons around the world have been trained on its da Vinci Systems.1,2
Researchers in Michigan have noted an increase in robotic surgical procedures entered into the Michigan Surgical Quality Collaborative registry. From 2012 to 2018, the use of robotic surgery increased from 1.8% to 15.1%. Some specific procedures saw an even greater increase over that same time period. For example, use of robotic surgery for inguinal hernia repair grew 41-fold, from 0.7% to 28.8%.3
Growing acceptance of robotic surgery may be due largely to its apparent benefits to patients, surgeons, and hospital systems. Robotic surgery enables some procedures to be converted from open to laparoscopic, which often means less discomfort, less bleeding, less time in the hospital, and faster recovery periods for patients.
For surgeons, robotic surgery may help enhance performance and provide ergonomic benefits, such as enabling the surgeon to sit rather than stand during a long procedure. For hospital systems, robotic surgery can reduce costs through shorter hospital stays and fewer complications, and it may help offset the strains of the hospital workforce shortage.
An indicator of growth in this industry could be the number of companies now offering robotic surgery systems. Among Intuitive’s competitors are several large medical device manufacturers in the US, including Medtronic, Johnson & Johnson, and US Surgical, as well as overseas manufacturers such as CMR Surgical in England, SS Innovations in India, and Medicaroid Corp. in Japan.
“There is a quiet tsunami of robotic surgery headed our way,” said T. Sloane Guy, MD, MBA, FACS, FACC, director of minimally invasive and robotic cardiac surgery at the Georgia Heart Institute with the Northeast Georgia Physician Group in Gainesville.
Increased competition is expected to reduce prices and increase innovation. Advances are underway that make robotic surgery instruments smaller and more flexible, enabling them to navigate through blood vessels or natural orifices.
In addition, artificial intelligence (AI) and automation will allow surgical robots to guide and assess surgeons and even perform various surgical tasks such as placing sutures.
The idea of robotic surgery took off as part of the US military’s quest to create a “telepresence surgery system” that would enable surgeons to perform operations from a long distance.4
To provide immediate, expert surgical care to wounded servicemembers, the military collaborated with the Defense Advanced Research Projects Agency (DARPA) to find a way to virtually transport a surgeon to the front lines. When the Stanford Research Institute (SRI) developed a prototype of a surgeon-controlled robotic telepresence workstation and a remote surgical unit, DARPA and Stanford formed a research partnership to further develop the new tool.
Although the early robotics systems were developed for open surgery, it quickly became apparent that the robotic approach was particularly suitable for laparoscopy by helping surgeons operate in tight spaces. By seizing this idea, laparoscopic instrumentation pioneer Frederic Moll, MD, would become what Dr. Guy calls “the Steve Jobs of robotic surgery.”
“Dr. Moll thought robotic surgery would offer more degrees of freedom to open, close, or rotate the instrument than a straight, shafted laparoscopic instrument would,” Dr. Guy said.
In 1995, Dr. Moll and two partners formed Intuitive Surgical and negotiated to acquire SRI’s relevant intellectual property.5 Two years later, the first robotic-assisted operation—a cholecystectomy—was performed on a living patient using the Mona surgical robot.
In the early days, Intuitive competed with Computer Motion, which had funding from National Aeronautics and Space Administration's Jet Propulsion Laboratory (JPL). The JPL was interested in developing remote-controlled robots for astronaut training and remote operations. Computer Motion developed Zeus, a robotic system that combined a camera holder with laparoscopic instrumentation. In 2001, a transatlantic cholecystectomy was performed using Zeus.6
The two companies competed in the marketplace and battled in the courtroom for several years until Intuitive acquired Computer Motion in 2003.
“At this point, Intuitive essentially gained a monopoly on the robotic surgery industry that has lasted for years,” Dr. Guy explained.
Dr. Hadley Freeman, a general surgeon and chief resident at The University of Kansas in Wichita, performs a robotic surgery, with Dr. Kyle Vincent supervising.
As with many new technologies, there was initial resistance to robotic surgery. In addition to the natural struggle with change, some surgeons wanted more control over the operating field than what was offered by robotic surgery. Initially, the robotic approach to complex surgeries seemed more like a novelty than a new standard of care.
For example, cardiac cases were among the first to use robotic surgery based on the assumption that it would be easier to sew bypass grafts. But heart surgery often must contend with a heart-lung machine and a beating heart.
“A lot of surgeons tried robotic cardiac surgery and abandoned it early on,” Dr. Guy explained.
In addition, the goal of developing a remotely operated robotic system was stymied by latency time, which is the connectivity delay between sending and receiving information.
Another obstacle for remote robotic surgery is that many surgeons like to personally inspect and prepare the patient and operating field before going to the robot, said Stephanie G. Worrell, MD, FACS, section chief of thoracic surgery at the University of Arizona in Tucson.
Given these challenges and others, “it looked like robotic surgery might go away,” Dr. Guy reflected.
But robotic surgery began to build credibility when urologists and general surgeons regularly used it in a variety of procedures. For example, the robotic radical prostatectomy was the first procedure to gain wide acceptance in the US. Research began to show that compared to open procedures, the robotic-assisted approach decreased hospital stay and blood loss among prostatectomy patients.6
“The prostate saved robotics,” Dr. Guy said.
Robotic surgery became popular in procedures involving tight, cramped, and sometimes inaccessible areas because of the system’s 3-D camera and wristed instruments.
Now robotic surgery is used in many surgical specialties, including general surgery, especially for repairing abdominal wall hernias because this technology enables the surgeon to take a minimally invasive approach.6
As a general thoracic surgeon, Dr. Worrell finds that the robot makes some procedures easier to perform. For example, when operating on a mediastinal mass that sits on top of the heart, the surgeon has to operate “kind of upside down,” she said.
“Doing it traditionally is very difficult, but the robot, with its wristed instruments, makes it much, much easier,” Dr. Worrell added. She also uses the robot to perform all of her esophagectomies and lobectomies.
In 2022, Dr. Kyle Vincent performed more than 300 robotic surgery procedures.
More surgical training and experience also have led to greater acceptance of robotic surgery.
Early on, some surgeons would take a 1- or 2-day robotic surgery workshop, do a case, get a bad outcome, and get sued for malpractice, Dr. Guy said. The subsequent bad publicity deterred some surgeons from continuing to use the robotic approach. Today, most general surgery students receive robotics training, and there are fellowships available for additional robotics training, according to Dr. Worrell.
“Most hospitals require you to be proctored for a few cases,” she said. “So, there’s some good oversight in robotic surgery that is making it safer.”
Kyle B. Vincent, MD, FACS, the associate director for the residency program at The University of Kansas in Wichita, trains seven residents a year in open, laparoscopic, and robotic surgery.
“The next generation of surgeons are much more competent on the robot than they are laparoscopically for some of the more advanced procedures,” noted Dr. Vincent.
Surgeons also are gaining more experience in robotic surgery through wider access to robotic systems. Early on in her career, Dr. Worrell had access to the robotics system only about two or three times a month. Now, she performs approximately 100 robotic procedures per year out of a total of 250 cases.
More rural surgeons also have access to robotics systems. In 2021, the 60 critical access hospitals in the US that have robotic surgery systems each averaged about 106 robotic procedures, according to a presentation on “Robots in Rural Operating Rooms” at the 2022 ACS Clinical Congress.
A decade ago, Dr. Vincent performed approximately 30 to 40 robotic surgery procedures per year; last year, he completed 315 robotic surgery procedures.
Although access is much better overall, it remains an issue, Dr. Worrell said.
“I think a lot of us would do even more robotic surgery if we had a robot available every day of the week,” she shared.
Like many surgeons, Dr. Stephanie Worrell takes off her shoes during robotic procedures to allow for better control while operating the pedals of the system.
Surgeons today often choose the robotic approach if it appears to have benefits for the patient compared to the conventional approach.
Robotic surgery can help make an operation less invasive, and overall, the less invasive the operation is, the more quickly the patient recovers. As a cardiac surgeon, Dr. Guy performs a lot of mitral valve surgery with robots because he's able to make smaller incisions.
“I discharge a fairly significant number of patients on day 1 after open heart surgery, which is really unheard of,” Dr. Guy said.
Cardiac surgery data show robotic surgery leads to faster recovery and return to work for patients, as well as decreases in length of stay, intensive care unit time, time on the ventilator, and blood transfusion and pain, according to Dr. Guy.
Patient benefits from the less-invasive robotic approach also are evident in other types of procedures, especially if the alternative is open surgery.
“For me, converting an open procedure is the biggest benefit,” said Dr. Vincent. “If I can keep people in the hospital for less time, they have a quicker recovery, or they require less pain medication, then that’s the way to do it.”
Dr. Vincent typically uses the robotic approach to perform hernia repairs, colon surgery, and upper gastrointestinal procedures. But there also are procedures for which the robotic approach does not offer much benefit, he said.
For example, a gallbladder procedure takes about 30 minutes with a robot—the same as it takes with a conventional laparoscopic approach. And in either procedure, the patients usually go home the same day.
However, the costs associated with a robotic laparoscopy are higher than the conventional laparoscopy because it must be done at the hospital as opposed to a surgery center, he said.
“It’s hard to make a laparoscopic gallbladder procedure much better,” noted Dr. Vincent.
Dr. Worrell shared that studies using data from The Society of Thoracic Surgeons National Database found that robotic thoracic surgery patients lose less blood and have shorter hospital stays than those who have open surgery.
“But the results are mixed for laparoscopic versus robotic,” she said. “There are some studies that show robotic is better, while others show it’s equivalent.”
The robotic approach offers an opportunity for surgeons to sit in a chair rather than standing, bending, and twisting during a long conventional procedure, which can lead to orthopaedic injuries, according to Dr. Guy.
“It’s nice to be able to sit down in a chair, relaxed, to do an operation rather than stand up all day, hunched over,” he said.
For Dr. Worrell, long conventional surgeries can result in bursitis in her right shoulder and, when she was pregnant, edema in her legs.
“I think robotic surgery improves the longevity of surgeons because you have fewer joint issues, especially in your shoulders and back,” she said, adding that there are no studies to prove that robotic surgery extends the careers of surgeons because it is less physically demanding.
Even so, robotic surgery can be physically demanding. Some surgeons report back pain in different areas in addition to eye strain.
Dr. Vincent points out that he is often “just as sore” after a robotic procedure, though he agrees that there are “probably, over the long haul, ergonomic benefits to it.”
As noted earlier, compared to an open procedure, the robotic approach reduces costs for hospitals.
“In theory, hospitals save money on the back end with shorter lengths of stay and better outcomes,” said Dr. Worrell, who pointed out that some case-specific research shows robotics help hospitals lower costs.
In addition, fewer complications—especially if they lead to readmissions—can reduce costs.
In fact, hospitals that offer robotic surgery services may find it easier to attract new patients.
Although a significant obstacle for the widespread use of robotic surgery is the cost of equipment and training, growing competition is expected to drive down costs. At the same time, robotics training is becoming a more significant part of resident training.
The burden of acquiring new robotics systems also is being eased by creative financed leasing programs. For example, Intuitive has a program in which hospitals pay for robotics systems by how much they use them rather than spending millions of dollars upfront to buy a new system.
“As we increase our volume, the number of robots increases with it,” Dr. Guy said. “If a new robotics system comes out, we get it without having to finance it.”
As a result, even smaller, less financially viable hospitals have the opportunity to acquire robotics systems.
Greater competition will drive innovation, such as new instruments and new functions enhanced by advances in AI. These advances could include:
Resistance to robotic surgery may fade as some surgeons retire and the technology becomes more readily available, Dr. Guy said.
Meanwhile, robotics will thrive and continue to grow because it can make surgery easier and safer, he added.
Dr. Vincent predicts a “meteoric rise” in the number of robotic cases that are being done.
However, there are disagreements about the ultimate question: Will the robot ever be able to replace the surgeon?
“I think we’re a long way off from the robots being fully automated, but I believe we will get to that point,” Dr. Guy said.
Dr. Vincent doesn’t think there “will be a complete replacement ever,” as robotics systems are intended to augment human abilities and improve postoperative results.7
“Certain things can be automated, but I think a surgeon will always need to be involved,” Dr. Worrell agreed.
In any case, one thing is clear, Dr. Guy said. “Robotics are here to stay.”
Jim McCartney is a freelance writer.