Key Takeaways
- Cutting-edge software and hardware in robotic keyhole surgery have revolutionized minimally invasive surgery.
- Expiration of core patents is set to increase competition within robotic treatment devices.
- Artificial intelligence and enhanced visualization technologies are the next frontiers in robotic surgery.
The treatment device known as the surgical robot has reshaped how we perform surgeries and has changed the standard training practices for many surgical subspecialties. Given its popularity and widespread use, patients now know to ask for it by name.
It’s been a long road for robotic surgery; however, it’s worth delving into to understand how we got here and where we’re headed.
Robotic Surgery, Explained
Robotic surgery is a progression of minimally invasive surgery that attempts to overcome the existing limitations of traditional laparoscopy (keyhole surgery).
Robotic surgical platforms consist of electronically controlled arms that wield a variety of surgical instruments. These arms are controlled by a surgeon sitting at a console across the room. This type of surgery promises shorter recovery times, reduces surgical blood loss, and improves surgeon ergonomics.
Where It All Began
The origins of robotic surgery can be traced to the late 1980s when surgical platforms such as ROBODOC and PROBOT were introduced for hip replacements and prostate surgery, respectively. In the following decades, multiple iterations of robotic systems were developed both by the private sector for commercial use and by the U.S. government for use in battlefield hospitals. Research and development led to the introduction of the da Vinci system by Intuitive Surgical (Sunnyvale, CA) and the Zeus system by Computer Motion (Gelota, CA) in the early 2000s.
Computer Motion and Intuitive Surgical merged in 2003. Under one roof, the technologies developed by both companies culminated in the da Vinci S, Si, Xi, and SP systems, which became the most widely used platforms worldwide.
To put it into perspective: Intuitive Surgical Inc. revolutionized surgery with the da Vinci robot the way Apple revolutionized mobile phones with the iPhone.
The Da Vinci Robot
Robotic platforms are broadly categorized into three types of systems:
- Active systems work autonomously on pre-programmed tasks under the supervision of the operating surgeon.
- Semi-active systems augment the actions of the surgeon with computer guidance.
- Master-slave systems cannot perform any pre-programmed tasks or autonomous actions. Their actions are completely controlled by the surgeon’s hand movements.
The da Vinci surgical robot is an example of a “master-slave” system.
The da Vinci surgical robot consists of a surgeon console, a patient tower with robotic arms, and a “vision cart” that coordinates communication between system components. The enclosed surgeon console houses a high-definition display and two electronic hand controllers. Every movement of the surgeon’s hands is translated into the movement of surgical instruments in real-time.
Specs
The system utilizes an endoscope with a dual-lens camera representing our left and right eyes. This camera provides the surgeon with stereoscopic depth perception and image magnification up to 15 times what we can see with our naked eye. The improved visualization allows surgeons to perform their operations with increased precision and accuracy. Robot control of the camera also frees the bedside surgical assistant from holding the camera and allows the surgeon to move the camera to the area they are working on.
The patient tower contains four robotic arms controlled by electric motors. Each arm has multiple pivoting joints that mimic human arms and help position the instruments in the optimal orientation for the chosen operation. The arms are compatible with an extensive catalog of instruments commonly used in surgery, including scissors, forceps, needle drivers, an endoscope, and specialty instruments needed for specific situations.
The EndoWrist technology embedded in the instruments has a distinct advantage over traditional laparoscopic instruments: a robotic wrist that can articulate with 7 degrees of freedom. EndoWrist instruments closely imitate and often supersede the natural range of motion of the human hand. The system checks and correlates the movements of the “master” and “slave” 1,500 times per second, enabling precise control of the instruments while eliminating surgeon hand tremors.
The Benefits of Robotic Surgery
Unparalleled visualization, precise instrument control, small surgical incisions, and ergonomic surgeon interface made the robotic platform extremely popular and well-suited for operating in small spaces like the pelvis.
The degree to which the da Vinci robotic surgical platform has permeated operating rooms is best seen in Urology, where nearly 90% of prostatectomies, a surgery to remove a walnut-size gland between the bladder and rectum, is performed with the Intuitive Surgical platform in the U.S.
The use of the robot has become so ubiquitous that urology trainees today receive little training in open and traditional laparoscopic prostatectomy. Nonetheless, the increased utilization of the da Vinci robot is not without its shortcomings.
The Cost of Robotic Surgery
With a price tag of over $2.5 million and annual service contracts costing nearly $200,000 per device, the cost is the most cited problem with the da Vinci platform.
Intuitive Surgical Inc. used a combination of clever marketing, effective surgeon training programs, and strategic patenting to establish a monopoly over the global surgical robot market. The US-based technology giant has sold over 6,500 surgical platforms worldwide and has been used to perform 10 million surgeries. It is a lucrative market estimated to be worth $6.8 billion in 2018 and is projected to reach $17 billion by 2025.
Research on the efficacy of using robotic treatment devices, however, has thrown into question their true value. For instance, in the treatment of certain cancers, outcomes were the same with robot-assisted surgery versus open. Yet, the popularity and permanence of robotic platforms in operating rooms are unlikely to change. Both patients and surgeons have grown accustomed to the availability of robotic assistance and the smoother recovery process after surgery.
Competition In Robotic Surgery
The 20-year dominance of the da Vinci platforms may soon be challenged as some of the U.S. patents for Intuitive’s core technologies have expired. Companies in the U.S., Europe, and Asia have begun the development of systems set to compete with the da Vinci surgical platform.
In December 2022, U.S.-based treatment device manufacturer Medtronic, with annual sales totaling 4.5 times that of Intuitive Surgical, started enrolling patients in a clinical trial for its robotic surgery platform Hugo.
Johnson and Johnson, an American multinational conglomerate and a major player in the healthcare industry, announced the development of a six-arm surgical robot named Ottava.
Several smaller companies worldwide have announced similar ventures. The entrance of novel surgical platforms should increase competition in the space, decrease the cost associated with robotic surgery, and stimulate innovation.
Comparison: da Vinci, Hugo and Ottava
The current design of the da Vinci platforms requires the surgeon to view the surgical field through a high-definition display enclosed within the surgical console. Microphones and speakers on the console enable communication between the surgical team members.
In contrast, two advantages of the Hugo and Ottava platforms are the open surgeon consoles and modular design without enclosures. Surgeon vision is enabled by 3D goggles viewing a large, high-definition digital display. The open design allows the surgeon to communicate with the rest of the surgical team directly, without encumbrances. The surgeon also has better oversight over the patient during surgery through their peripheral vision.
All four robotic arms of the da Vinci systems are located on a single tower, creating a large physical footprint. The platform’s footprint cannot be reduced for surgeries that do not require all four arms. Hospitals that perform high-volume robotic surgery are often limited by the availability of operating rooms large enough to accommodate the surgical robot.
Medtronic’s Hugo platform is modular, with each robotic arm on individual towers. This design reduces the platform’s footprint and allows it to be tailored to specific operations. As a result, Hugo can be used in smaller operating rooms that could not accommodate the da Vinci robot.
In addition, Hugo’s modular design will improve its usability for operations that involve a large area of the body. While the da Vinci robot is used in a variety of surgeries, it excels in gynecologic and urologic surgery because the arms of the da Vinci system are well suited for working in a small, confined space with a single target area. Hugo’s modular towers can be individually positioned for different areas of the body, thus expanding its target area.
Future Advancements in Robotic Surgery
So much has happened already in the robotic arena, and much is yet to come.
First, the race to develop new surgical robots will help reduce the enormous costs of robotic surgery and potentially usher in a new era of active and semi-active robotic platforms.
AI Integration
Artificial intelligence (AI) powered by deep-learning models (DLM) and artificial neural networks (ANN) is rapidly becoming a facet of daily life. The lessons we learn from popular AI chatbots like ChatGPT can be applied to an intelligent surgical robot that recognizes organs, soft tissue, instruments, and surgical steps. Akin to the computer in an autonomous vehicle, the computer within surgical robots can capture an enormous amount of surgical data through endoscopic video input and various sensors that monitor the patient during surgery.
Data Analysis & Data-driven Assistance During Surgery
DLM and ANN can be deployed to analyze the data and learn much faster than the human brain. Even more, the DLM can access a repository of surgical videos from around the world, including those from surgeons with niche expertise. An intelligent surgical robot armed with lessons from thousands of surgeries can be configured to help surgeons prevent and remedy potential complications. The computer may recognize subtle differences in tissue quality and guide the placement of surgical instruments during surgery.
This kind of technological advancement can make the difference between a surgery that leaves a patient cancer-free versus one that leaves a part of the tumor behind.
Telesurgery
DLMs and ANNs may eventually reach a level of complexity and reliability to perform routine portions of an operation with little to no surgeon input. Furthermore, low-latency connectivity of 5G networks will enable telesurgery in which an expert surgeon performs operations remotely with a few surgical assistants at the bedside.
These technologies can increase patient access to specialty surgical services in rural areas suffering from healthcare scarcity.
Enhanced Decision Making For Patient Care
Other uses of AI are noted in advancements by Intuitive Surgical, which recently introduced the IRIS 1.0 system that uses patient radiographic studies to create 3D anatomical models of the surgical site. The surgeon can manipulate the models while operating to provide a surgical roadmap and aid with real-time decision-making.
Verb Surgical Inc., now part of Johnson & Johnson, developed a surgical platform capable of low-latency connectivity, advanced data analytics, simulation, and machine learning.
These are two examples of emerging technologies that will enhance surgical outcomes and improve patient safety.
Improved Visualization Technology
Another frontier of robotic surgery is immunofluorescence, a technique that allows surgeons to see components of a specific cell type during live surgery. Intuitive Surgical incorporated the Firefly® technology into the da Vinci robot in 2011, which uses a near-infrared imaging system to identify an immunofluorescent agent Indocyanine Green (ICG), a dye that binds to protein molecules in the bloodstream and lymphatic system. Certain body structures, such as the colon and ureter, a tube that carries urine from the kidneys to the bladder, light up bright green on the surgeon’s video feed when Firefly® is activated. Surgeons frequently use this technology to identify and avoid injury to vital structures.
Recent advances in molecular biology have allowed us to “tag” specific components of cancer cells with pharmaceutical agents. For instance, Lu177-PSMA-617 (Pluvicto) is a radiopharmaceutical that received FDA approval to treat some adults with metastatic prostate cancer. Pluvicto tags a component of prostate cells with radioactive particles that kill prostate cancer cells. The same concept can create an agent capable of tagging cancer cells with an immunofluorescent dye that will light up on the surgeon’s video feed. This technology will be a giant leap for cancer surgery, helping the surgeon completely remove cancer invisible to the naked eye.
Final Thoughts
The da Vinci surgical robot treatment device has revolutionized how surgeries are performed, how a generation of surgeons has been trained, and the expectations patients have for their road to recovery after major surgery.
After 20 years of market dominance by Intuitive Surgical Inc., many new players are entering the surgical robot market with innovative technologies that are set to transform surgery once again.
Zhan Wu, MD
Dr. Wu is a Urology resident at Geisinger Health System who received his medical degree from SUNY Downstate Health Sciences University. He is passionate about integrating new technologies into all facets of Urology to improve patient care for those with genitourinary disease. From early in his medical training, Dr. Wu took an interest in robot-assisted keyhole surgery and recognized the immense potential for innovations such as artificial intelligence to revolutionize care delivery. He also contributes to the urologic community by presenting research at national meetings and publishing in peer-reviewed journals. Driven by his interest in using technology to tackle unique challenges, Dr. Wu aspires to become a urologist who focuses on the reconstruction of the genitourinary tract.
Mark Ferreti MD, MBA
Dr. Mark Ferretti is a fellowship-trained, board-certified urologic surgeon with robotic and minimally invasive surgery expertise. He currently practices in Pennsylvania and New Jersey, where he is involved in instructing medical students and residents. His research interests include robotic and minimally invasive surgery for urologic conditions, including cancer and stone disease. He co-founded Bryant Bionics, a company focused on creating novel technology for surgical and interventional procedures.
