Sept. 26, 2023 – On her flight to Atlanta, Robin Pollack nibbled gummy bears and sipped a cranberry juice cocktail. It had been a week since she’d gotten robotic surgery to remove a cancerous stomach tumor at MD Anderson Cancer Center in Houston, and she was heading home – feeling surprisingly good.
The surgery required five small cuts. “I now have four little dots and a 2-inch slit that he superglued shut,” Pollack said. “After surgery, I woke up hungry.”
She was out of bed and walking in a day, and out and about town with her husband within a week, enjoying crème brûlée and eggs Florentine.
“I have not had one bit of pain since,” she said 2 weeks after surgery. “I have not taken pain medication, not even one Tylenol. I walked 2 miles yesterday.”
A better post-operative quality of life is one perk of robotic surgery, said surgical oncologist Naruhiko Ikoma, MD, who performed Pollack’s procedure.
There are pluses for the surgeon, as well. “I feel more precise in terms of dissection and in suturing,” said Ikoma. “In conventional open operations, surgeons use instruments. … In robotic surgery, surgeons feel like they’re operating with their own fingers with precise tips.”
Robotic surgery, or robot-assisted surgery, is more than 20 years old, but experts believe it is now poised for growth. Propelling the technology forward are the very advantages that Pollack and Ikoma describe: improved accuracy, shorter recovery times, and less pain.
About 644,000 robotic surgeries were performed in the United States in 2021, and that figure is expected to approach 1 million by 2028. Millions more have taken place worldwide. The global market hit $6.3 billion in 2022 and is projected to reach $26.8 billion in 10 years.
Robot-assisted devices are FDA-cleared across many specialties. For prostate removals and hysterectomies, the use of surgical robots is now more common than not. It’s also rapidly growing in bariatric surgery and hernia repair, and has increased steadily in hip and knee replacements. Several surgical teams have pioneered robot-assisted kidney transplants, and recently the Washington University School of Medicine in St. Louis reported the first robotic liver transplant in the U.S.
The most widely used robotic system in the U.S. is Intuitive Surgical’s da Vinci. The FDA first approved a da Vinci in 2000 and has cleared newer models since then. Today, more than 7,500 da Vinci surgical systems are in use in 69 countries across six continents.
Dozens of other companies have entered the game. Advances in materials science are driving soft, flexible designs that can navigate winding pathways or operate on some of the body’s most delicate tissues.
Auris Health’s Monarch, a flexible robotic endoscopic system, enters through the mouth into the trachea and bronchial passages to examine potentially cancerous tissue in the lungs. The platform recently earned a urological clearance for kidney stone removal. Other flexible robots enter the rectum and travel through intestines, as for colonoscopy. Still others snake through the nose to reach the brain, or the thigh’s femoral vein to get to the heart.
An upgrade of Stryker’s Mako robot, currently used for hip and knee replacements, will enable its use in spine and shoulder surgery and could launch as early as next year. (The doctors interviewed for this article are not promoting or endorsing any products mentioned.)
Meanwhile, artificial intelligence, or AI, is letting researchers and developers make robots more autonomous, capable of performing surgical subtasks or even entire surgical procedures.
“It is an exciting time,” said Michael Yip, PhD, an associate professor of electrical and computer engineering, and director of the Advanced Robotics and Controls Laboratory, at the University of California San Diego. “The diversity of robotic technologies is really widening exponentially.”
Benefits for Patients
Data shows that robotic surgery can help reduce bleeding, scarring, and recovery time, and it allows for shorter hospital stays, compared to traditional surgery.
One of the most striking benefits: Many patients, like Pollack, do not need opioids – or any painkillers, for that matter. That’s remarkable when you consider the norm.
For kidney transplant, “it’s 100% narcotic use after an open transplant,” said Thomas Pshak, MD, a robotic kidney and liver transplant surgeon at UCHealth University of Colorado Hospital. Open surgery patients go home with as much as a week’s supply of opioids, and sometimes need morphine or oxycodone in an IV after surgery.
Robotic surgery patients heal much faster, returning to work and normal activities within a few weeks, vs. the recommended 8 weeks after open kidney transplant.
“A painless kidney transplant seems like science fiction, but here we are,” Pshak said.
He uses a da Vinci surgical robot system with four slender arms, each about the size of a pencil, that hold surgical instruments and a high-definition camera. During surgery, he sits at a computer console a few feet away, looking through binoculars that provide a highly magnified 3D view of the operation site. With both hands on joystick-type controls, he guides the arms into the cuts to perform “delicate, precise movements,” such as suturing the new kidney to blood vessels. Foot pedals engage and disengage the robot arms.
Pshak performed UCHealth’s first robotic kidney transplant in 2021 and has done more than a dozen since then, and even more donor kidney removals, using the robot. With robotic kidney transplant, “the biggest incision is about 2 inches, near the bellybutton,” he said. For context, a traditional open kidney transplant involves a 10- to 12-inch cut.
Robotics may improve access to surgery as well. One-third of patients waiting for a donated kidney have body mass indexes over 35. The higher BMI can mean longer, deeper cuts, increasing the risk of complications and negative outcomes. The less invasive robotic procedure could make kidney transplant possible for these patients.
Benefits for Doctors
In a sense, robotics give surgeons superhuman skills. The robot can correct for any tremor in the surgeon’s hand and lets a surgeon view hard-to-see creases, moving the camera and small tools into places the human hand can’t reach.
“I can set the [robot] arm movements to move at one-tenth of my normal hand movement,” Pshak said. “That just allows for some insane accuracy.”
In spinal surgery, robotics minimize the misplacement of a screw. That means “a lower revision rate – having to go back and remove and replace a misplaced screw,” said Mohamad Bydon, MD, a neurosurgeon and clinician-scientist at the Mayo Clinic in Rochester, MN, where they’ve been performing robotic neurosurgeries since 2018.
Bydon was the lead author of a study in Mayo Clinic Proceedings that reported that out of 402 screws placed in 77 patients who had robot-assisted spinal surgery, none had to be redone after surgery.
Other advantages, Bydon noted, include the ability to map out the surgery in advance, and sub-millimeter accuracy around a patient’s nerves and spinal cord. “It preserves muscles, tendons, and ligaments,” he said.
Corey Walker, MD, is a neurosurgeon at Cedars-Sinai in Los Angeles who performed minimally invasive robotic back surgery on a high school football player last year after the player fractured his spine in three spots. The robots collect data that is fed back into AI algorithms to improve planning and accuracy. “The robot is not just giving us a technical advantage,” Walker noted, “but also a data advantage.”
After surgery, the football player was back to normal activities and training again within weeks instead of the usual 6 months.
With younger patients, Walker said, it’s important to preserve their longevity and avoid injury to the muscles surrounding the spine. Robotic procedures “leave as little of a footprint on the structure of the spine as possible.”
Robotic Surgery: What Patients and Doctors Should Know
In the United States, academic medical institutions and hospitals have developed their own credentialing paths. Many robotic surgeons train in conventional surgical techniques and later move into robotic procedures, taking web-based and in-person courses with equipment manufacturers, practicing on sample tissues, in virtual reality simulations, and on inanimate objects (like picking up small items or peeling tape from a surface).
Some surgeons and medical centers offer robotic training for those outside their institution. At the Ohio State University College of Medicine, interested surgeons from around the world can visit, observing existing and emerging robotic procedures for $500 a day.
“The biggest challenge with robotics is that it is so automated, it sometimes takes away from the residents’ ability to learn the anatomy,” Walker said. “Our challenge is to still be able to teach residents the anatomy and to not become reliant on the technology.”
Patients should look into a hospital’s history with robotics and ask how many procedures their institution and surgeon have performed, as Pollack did before her surgery. Not all surgeries are suitable for robotics; patients and surgeons should discuss pros and cons.
Challenges
Robotic surgery is not without controversy. A 2021 review of 50 randomized trials comparing robot-assisted surgeries with laparoscopy and/or open surgery for belly or pelvic surgery found little difference in outcomes.
Some older studies suggest risks or potentially worse outcomes for some procedures. In 2018, a New England Journal of Medicine multicenter study led by MD Anderson Cancer Center researchers reported that, in women with early cervical cancer, laparoscopic or robotic minimally invasive radical hysterectomy was linked to lower rates of disease-free survival and overall survival, when compared to open abdominal radical hysterectomy. And in 2021, the FDA cautioned against robotically assisted surgical device use for mastectomy.
Still, scores of other recent studies back up robot-assisted surgery’s benefits.
One drawback: It’s not available everywhere. “You have to be at a place that is willing to invest in it and that believes in it as a technology,” Walker said.
For certain specialties, the high cost (the da Vinci’s price tag is reported to be $2 million) may not outweigh the return on investment, Yip said , stalling growth.
According to Francis Sutter, DO, chief of cardiac surgery at Lankenau Medical Center, part of Main Line Health, and a longtime robotic surgeon, the number of robotic heart surgeries has fallen in the past 10 years.
“There’s not a market for it,” he said. “I hope there will be more interest from cardiac surgeons in the years ahead.”
What’s Next?
Semi-autonomous devices that perform surgical tasks – like holding a clamp in place or removing damaged tissues – could start to emerge clinically in the next 10 years, Yip said.
Like a self-driving car, they use sensors to localize with respect to anatomy and map the environment.
Someday, we may see fully autonomous robots capable of performing an entire procedure. At Johns Hopkins last year, surgeons tested a new robotic technology called Smart Tissue Autonomous Robot (STAR) that visualizes and plans its next surgical move almost in real time. They successfully practiced with it in four experiments, sewing together pig intestines, tissue that’s soft, pliable, and difficult to operate on.
For hemorrhage control, Yip said, “the computer recognizes blood and will immediately try to suck up the blood, find the source, and clamp it.” Such robots could be airdropped during, say, natural disasters to stabilize injured people. The technology could also open the door to remote “telesurgery.”
Still, fears that robots will replace surgeons altogether are inflated, experts say. For the foreseeable future, robots will enhance the work of the surgeon, not replace it, Bydon, of the Mayo Clinic, said.
