As in years past, SAGES organized a debate around robotic surgery at this year’s conference. The debate, titled "Robotics: Hope or Hype?", was made up of two “pro” surgeons (Dr. Mark Talamini of UC San Diego and Dr. Richard Satava of University of Washington) and two “con” surgeons (Dr. Nathaniel Soper of Northwestern Memorial Hospital and Dr. W. Scott Melvin of Ohio State University ). Each physician was provided eight to 10 minutes each to justify their position, and the four treatises were promptly followed by an open-forum question-and-answer session.
Robotics—a widely debated topic—can quickly evoke strong opinions, as well as mixed feelings. The rise of robotics has been stepwise: its first ascent can be traced to urology (where robotics has found widespread use for prostatectomy), then gynecology (specifically, hysterectomy), and now, general surgery, where one of the more discussed applications is colorectal surgery.
Robotics a complex, mutilayered debate
Has the increase in adoption been justified? The answer is not a clear “yes” or “no.” Unpacking this question reveals several layers of complexities: the response can vary depending on countless factors, including the procedure in question, the degree to which cost is being taken into account, and the benchmark against which the robot is being compared.
Common dilemmas include whether to compare the robot to open surgery or laparoscopy. A clinical trial may show lower complications with robotic surgery than those with open surgery, but this advantage is often erased when compared to laparoscopy.
There is also the issue of whether we are discussing the robot as it pertains to novice (and/or less-skilled) versus seasoned, highly-skilled surgeons. Physicians with below-average surgical skills may find that the robot helps them overcome challenges with minimally invasive surgery such as precision and dexterity. Unfortunately, these benefits are often lost on advance laparoscopists.
Pro team wins crowd over with promise of more technological improvements to robot
Based on level of audience applause, the moderator of this year’s SAGES robotic surgery panel judged the “Hope” (pro) team as the winners of the debate. The Pro camp relied significantly on the promise of yet-to-be-implemented future applications in making its case for robotics. Robotics, they argued, is still in the early stages of development but is on its way to becoming a true force, despite some admitted limitations, including absence of haptic feedback and mixed clinical results.
Clinical superiority: Not today, but maybe tomorrow?
Interestingly, both camps seemed to agree that the robot does not yet clearly offer superior clinical outcomes based on existing data. They diverged, however, on the cause and underlying implications of this current lack of clinical evidence.
Opponents pointed out the robot has been in existence for more than a decade, and that data for the robot’s alleged superiority should have surfaced by now. It was implied that the rate of adoption for robotics has been disproportionate to the level of evidence in favor of robotics—a telltale sign, in their opinion, of unsupported hype. Dr. Melvin was clear in demonstrating his objections against the robot, saying that “the best we see now is similarity [to standards of care]”. He reaffirmed this viewpoint during the Q&A session, when, upon being asked whether he would use the robot if cost were not an issue, he replied with a firm “no.”
In contrast, the pro team took a more optimistic outlook and argued that robotic surgery remains in the early developmental stages and has yet to be fully explored. To the point of lack of randomized human clinical trials (RCTs), it was said the RCTs, while ideal, are often difficult and not necessarily feasible. Stakeholders were urged to instead pay more attention to the comparative prospective studies that are indeed available. With additional research and development, they continued, robotic surgery can become the superior modality. For example, haptic technology for robotic surgery is currently being researched: if implemented, it could vastly improve the value proposition of robotic surgery. According to Dr. Talamini, advancements such as haptic feedback could allow robotic surgery to “do for advance laparoscopists what it is doing for novice surgeons.”
Both sides argued effectively, but the pro side may have made more of an impression on this front, especially if one likens the evolution of robotics to that of laparoscopy, which took several decades to become the accepted practice that it is now. This comparison shows robotics as a young technology that has the potential to become truly superior to laparoscopy down the line.
Robot costs undoubtedly high, but opinion split on whether they are justified
The cost of robotic surgery was also an issue tackled by both sides. Robotic systems cost about $1.8M in capital investment, $175,000 per year thereafter in maintenance, with another $1,500 in instrumentation per procedure. The pro team did not deny these facts and actually provided data that corroborated these added costs. They argued, however, that financial investment is often necessary for technological innovations.
Dr. Talamini analogized the investment in robotic surgery to other million dollar clinical technologies such as hybrid PET/MRI imaging equipment (priced at $5-$7M) to suggest that similarly steep financial investments have been readily made for other clinical technologies that do not face the same level of criticism as the da Vinci. He continued by arguing that the additional costs of robotic surgery are worth it since the technology has been able to reduce complication rates and lengths of stay.
The con team opposed this line of thought. Investment in robotic surgery is, in their opinion, not justified given inconclusive data and the state of today’s economic climate.
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Market competition may help to resolve robotic debate
As outlined above, both sides conceded that current clinical outcomes data is inconclusive and that robotic surgery comes at a high cost. Optimism for the robot was couched by the hope that more competition will enter the market in the future, catalyzing innovation and putting downward pressure on pricing.
Among the potential competitors are Titan Medical’s Amadeus system and University of Washington’s two-armed open-source robotics platform, called the Raven (it is worth noting that Titan Medical recently entered into an exclusive contract with Columbia University for developing a single incision port for the Amadeus). Both the Amadeus and the Raven are still in embryonic stages of development and are likely years away from FDA clearance, let alone widespread clinical use. Still, their presence, compounded with the buzz surrounding Intuitive Surgical’s soon-to-expiring patents on many of its robotic technologies, has many hoping that market-ready competitors will soon break-up the monopoly in the robotic surgery industry. The potential implications of such a scenario—competitive and perhaps lower pricing, faster pace of technological improvement—would be a welcome change for many hospital administrators. Until then, hospitals should practice measured adoption of any robotic surgery applications, and, for those already with robotic platforms, continue to instill clear privileging guidelines.