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Medical robots – the future of surgery?

by Arabel Luscombe Published on 20th Nov 2015

by Arabel Luscombe Published on 20th November 2015

For some people the idea of being operated on by a robot might sound horrifying, particularly if there isn't even a doctor in the room to check that everything is running smoothly. Surgery is in any case a risky business that few would undertake willingly if it wasn't absolutely necessary, and it seems unlikely that the spectacle of an enormous machine with mechanical arms attached to surgical scalpels would reassure anyone about having to undergo an operation. However, the use of robotic surgery has spread rapidly in recent years and for some types of operations it is becoming the standard. While there is a lot of controversy surrounding the topic, many doctors see surgical robots as a vital tool to provide better medical care and lower the risks associated with surgery.

History of robotic surgery

The roots of robotic surgery go back to the mid-1980s, when a robotic surgical arm was first used to perform a neurosurgical biopsy. Two years later, the first robot-assisted laparoscopic (i.e. keyhole) operation was conducted, a cholecystectomy. The following years saw continued advances in the area of robotic surgery, which was used for a growing range of surgical procedures. One of the earliest robotic surgical systems to enter into general use was the ROBODOC system, which came on the market in the early 1990s and allowed surgeons conducting hip replacements to mill the femur with more precision that would have been conventionally possible.

A major driver of robotic surgery research in this period was the interest that NASA and the US Army had in the concept of remote surgery, i.e. when a surgeon performs an operation on a patient without being physically present. This idea was very appealing to the military, as it has the potential to reduce wartime mortality by enabling rapid provision of medical care to injured soldiers without deploying medical staff to dangerous conflict situations. One of the ideas currently being developed by the US Army is that of “Trauma Pods”, unstaffed treatment centres where wounded soldiers could be attended to on the battlefield by surgeons working from removed locations.

As of yet there remain a number of unsolved issues in relation to remote surgery – for example the fact that the surgeon cannot physically feel the patient, and the need to avoid the occurrence of time-lapses between the movement of the surgeon and the response of the robot – but massive advances have been made. 2001 saw the first transatlantic remote surgical procedure, in which doctors in New York performed a cholecystectomy on a patient in France.

The da Vinci robot

In terms of everyday civilian healthcare, one of the most important developments in the field of robotic surgery has been the da Vinci robot, which was approved by the FDA for general laparoscopic surgery in 2000 and has contributed to a massive increase in the use of robot-assisted surgery in routine healthcare. This is a complete robotic surgical system that includes both surgical instruments and visual aids. It consists of several mechanical arms attached to surgical instruments, as well as an additional arm with a camera on it.  Rather than standing directly next to the operating table, the surgeon sits at a computer console from which she/he controls the machine's arms, guided by a magnified, high-resolution and three-dimensional image of the surgical area.

Since its introduction, use of the da Vinci robot has spread rapidly. At least three million operations have been conducted with the system since it was brought onto the market, and already in mid-2014 more than 3,000 of the systems were in operation worldwide. Primarily they are used for minimally invasive keyhole surgery, in particular for prostatectomies and hysterectomies (together these accounted for more than half of the 570,000 robot-assisted operations performed worldwide in 2014). Already in 2009, 86% of prostate cancer operations in the US were robot-assisted.

However, the extent to which hospitals make use of robotic surgery equipment varies significantly. Among other things, medical training and the availability of the expensive equipment play a role in determining what type of surgery will be performed. Last year the Royal College of Surgeons published a report in which they criticised the UK's National Health Service (NHS) for reacting too slowly to surgical innovation and failing to take advantage of robotic surgery. While the first robotic  procedures were offered by the NHS in 2004, it has been reluctant to finance their widespread use.
According to the report from the Royal College of Surgeons, robotic surgery can have a number of advantages over conventional surgery. Looking in particular at Robotically Assisted Radical Prostatectomy, it refers to several improved patient outcomes, including faster recovery, better maintenance of continence and sexual function, less blood loss and more effective cancer control.

In general, proponents of robot-assisted surgery argue that it allows for much more precision and control, meaning that surgeons can perform delicate procedures – such as removing cancerous tissues from hard-to-reach areas – that would otherwise have been impossible, or at least very difficult. Improved precision and control is viewed as being particularly important when operating in sensitive areas (e.g. near the spinal cord). Furthermore, robotic systems may allow the use of keyhole surgery in situations where conventional methods would require open surgery, which is associated with longer recovery times and more post-surgical complications.

Controversy

On the other hand, robot-assisted surgery also has its critics. Some surgeons have called into question its efficacy, particularly in view of the fact that it costs so much more than conventional surgery. Evidence for the superiority of robotic surgery is not clear-cut – for example, a study published in 2013 by researchers from Columbia University found that robotically assisted adnexal surgery is actually associated with a slightly higher risk of complications than conventional laparoscopic surgery. At the same time, the costs are very high – the initial investment in a da Vinci robot costs around two million dollars, with additional costs arising from the use of disposable surgical tools. It has been estimated that robotically assisted gallbladder removal operations cost around three times more than conventional procedures. Critics of robot-assisted surgery stress that new is not necessarily better and urge people not to get carried away by its supposed benefits.

It seems that one key point toward making effective use of robotic surgery is to ensure that the surgeons using the robotic equipment have received sufficient training. Studies have found that the rates of complications and readmissions, as well as the length of a patient’s stay in hospital , tend to be very dependent on the amount of experience that the surgeon has had with robotic surgery. The ECRI Institute included robotic surgery as one of its Top 10 Health Technology Hazards for 2015, explaining that: 'If surgeons, the rest of the surgical team, and associated staff are not sufficiently trained on how to use the robotic surgical system and how to perform a surgery under these unique conditions, adverse events can result'.

Furthermore, it is important that surgical robots are only applied in situations where there is actual evidence of a genuine clinical benefit – while robotic surgery may in some cases be superior to conventional methods, it is not appropriate for all types of surgical procedures. According to Dr. Terry Loftus, who conducted a study of robotic surgery outcomes at the Banner Health hospital network in Arizona, “I saw some things I couldn’t believe... Some physicians were doing a range of procedures, such as biopsies and diagnostic laparoscopies, using the robot, which is clearly an inappropriate use of the technology. Certain cases should not be done robotically because there is no evidence to support it and it’s not cost-effective” (quoted in General Surgery News).

Besides questions relating to the superiority of robotic surgery over conventional methods, other issues have also been raised. In particular, there are concerns about the vulnerability of these systems to hacking. This was displayed very clearly earlier this year when researchers at the University of Washington conducted an experiment on a novel remote surgical system. They found that they were able to hijack the system, disrupting its functions and overriding command inputs.

While non-remote robotic systems are less prone to this type of attack, security issues remain. A security audit conducted last year by Essentia Health (which runs a chain of hospitals and clinics in the American Midwest) found that their medical equipment was severely vulnerable to abuse, partly due to software security holes, but also relating to the use of weak passwords and ineffective firewalls. Among other things, the audit found that it was possible to alter medical records, as well as manipulate CT scanners and infusion pumps to change the dose of radiation or drugs that patients receive. They were also capable of breaking down the firewalls protecting the surgical robots.

Artificial intelligence

Concerns about robotic surgery become even more pronounced in regard to one of the most recent developments in the field, namely systems that make use of artificial intelligence. Google, for example, is currently teaming up with Johnson&Johnson to develop semi-autonomous robotic surgical assistants. Research being conducted by NASA goes even further – due to the huge distances involved in space travel, remote surgery will not always be possible, and the organisation is therefore exploring the possibility of developing robots capable of performing operations without the guiding hand of a surgeon on Earth. However, it is difficult to imagine this type of technology being introduced into everyday healthcare any time soon, if at all. Surgery entails a huge amount of potential for unexpected occurrences, and completely removing doctors from the picture would generate all sorts of risks. It is also unclear whether the idea could find public acceptance.

Whether or not fully-automated surgery ever becomes a realistic proposition, however, robots will surely play an ever larger role in medical practice. Research is ongoing to solve the current flaws of robotic surgery, for example by finding better ways to replace the tactile feedback that a surgeon conventionally gets from touching a patient with their hands. Moreover, laparoscopic surgery is by no means the only area of medicine to make use of robots. Robotic exoskeletons for people recovering from strokes, miniature robots that perform biopsies in the human colon and robotic maggots that remove cancerous brain tissue are just a few of the ideas currently being worked on.