Dr. Umamaheswar Duvvuri has used a snake-like robot to perform more than a half dozen throat surgeries over the past month. Simply put, the robot is more accurate than Duvvuri could hope to be.
Duvvuri, director of head and neck surgery at the University of Pittsburgh Medical Center (UPMC), said the Flex Robotic System surgical robot he's been using has sub-millimeter accuracy; it can "snake" its way to any place in the body and it causes less damage to soft tissue.
As far back as 2008, studies showed that patients undergoing minimally invasive heart-bypass surgery using a robot had a shorter hospital stay, faster recovery, fewer complications and a better chance that the bypassed vessels would remain open.
Last year, a Florida hospital proved robots could enable surgeons to remotely operate on patients. The Florida Hospital Nicholson Center in Celebration successfully tested lagtime created by the Internet for a simulated robotic surgery in Ft. Worth, Texas, more than 1,200 miles away from the surgeon at the virtual controls. Being able to perform remote surgeries would allow specialists to attend to any patient, anywhere in the world.
The Nicholson Center's simulator mimics procedures performed by a da Vinci robotic surgical system, the most common robotic equipment in use today; it's involved in hundreds of thousands of surgeries every year worldwide.
The Food and Drug Administration approved the da Vinci Surgical System from Intuitive Surgical in Sunnyvale, Calif. in 2000. Since that time, the da Vinci has been adopted by hospitals in the United States and Europe to treat a range of conditions. The system's console gives the surgeon a high-definition, magnified 3-D view of the surgical site.
Robots can also be used to deliver high doses of radiation with sub-millimeter accuracy anywhere in the body. The Accuray CyberKnife Robotic Radiosurgery System is one such system developed in 1990 by a professor of neurosurgery and radiation oncology at Stanford University. Approved by the FDA in 2001, the CyberKnife system can treat tumors anywhere in the body and has been used on 40,000 patients worldwide, according to the company.
While still needing skilled medical personnel to oversee them, surgical robots are increasingly showing up tableside in operating rooms, and they may some day allow people with only basic medical knowledge to perform operations outside of a hospital setting.
By 2020, surgical robotics sales are expected to almost double to $6.4 billion, according to a recent report by Allied Market Research. That would represent a 10.2% annual growth rate between 2014 and 2020.
In 2014, the gynecological application segment accounted for 28% of the surgical robotic systems market share; it is expected to maintain its dominance throughout the next four years.
The increasing need for automation in healthcare and growing demand for minimally invasive surgeries are driving the surgical robotic systems and procedures market, according to Allied. In addition, a rise in cases of colorectal cancer, neurological disorders and gynecological diseases, among others, would boost the adoption of robotic surgical systems well adapted for minimally invasive procedures.
"Surgical robotic systems offer less post-surgical complications and reduce labor cost," the study said. "Due to this, large-scale hospitals based in developed and developing economies are now favoring automated surgical/hospital services, which ultimately drives the market growth."
Roto-Rooter to the rescue
The Flex System is the first robot-assisted flexible endoscopic platform of its kind and the first to receive FDA approval with the word "robot" in its name, according Howie Choset, a professor of robotics at Carnegie Mellon University's (CMU) Robotics Institute, where it was invented.
The Flex System lets surgeons operate through non-linear winding paths, and through a single-site access into the body. The endoscope maneuverability comes from numerous mechanical links with concentric mechanisms. Each mechanism can be placed into a rigid or a limp state. By employing "follow-the-leader" movement with alternating rigid or limp states, the endoscope can be directed into any shape through the relative orientations of its linkages.
The Flex Arm robot is so easy to use, even a non-surgeon can learn it in 20 minutes, according Choset. As a result, the Flex System could some day allow military medics in the field to perform minimally invasive surgery on wounded soldiers, Choset said.
CMU has conducted studies with medical residents where the students used the Flex Arm system once a day for five days. "While everyone started off at different levels of skill, they pretty much came to same benchmark within three tries," Duvvuri said.
"What this told us is that anyone can learn to use this and it takes about three tries to learn how to use it in a surgically meaningful way," he added.
Once the Flex Arm robot maneuvers its way to a site within the body, surgeons can then deploy articulating instruments three millimeters in diameter, which further extends their reach to perform procedures.
"We've used it to tackle patients with tumors on the back of the tongue or oral pharynx region," Duvvuri said. "The typical [endoscopic] devices tend to be straight stick linear devices. When have to operate on the back of tongue, because it's curved, they tend to be more limited in what they can do."
Duvvuri also recognizes that surgical robots have their limitations. For example, a 5-in. tumor wouldn't be a good candidate for robotic surgery as it would require a much larger hole in a patient's body to be removed.
"I see these robots as tools," Choset said. "As those tools get better and better, you don't need as much specialization to do a task. Some procedures today [such as colonoscopies] we might call routine procedures and they are being done by non-surgeons, so surgeons are freed up to do more complicated tasks.
"I also do see robots being able to provide more feedback and visualization so physicians can make more informed decisions," Choset added.
While Choset doesn't see robots making medical decisions, he does expect them to improve accuracy during minimally invasive operations, damage less tissue and reduce the possibility of infection. As a result, they also hold the promise of decreasing costs from patient readmissions.
For example, heart bypass surgery traditionally requires that a patient's chest be opened by way of a one-foot long incision. A da Vinci robotic surgical system can perform the same operation by using three or four one centimeter incisions in the chest. Smaller incisions mean less tissue damage and a faster recovery.
Since the Affordable Care Act of 2010 created both the Hospital Readmissions Reduction Program and a new pay-for-performance system based on quality of care -- not the number of procedures -- robots could end up paying for themselves.
Snehal Chougule, a marketing executive with market research firm Allied Research, said a hospital that spends from $1 million to $2 million on a da Vinci robotic system, not including a $150,000 maintenance contract, could recoup its costs within two years.
"Hospitals consider many factors while offering robotic surgery, such as patient benefit, hospital competition and hospital costs. The trend toward robotic surgery also brings up such issues as overall healthcare spending, the comparative effectiveness of treatment options and the pace of technology adoption. Thus, it is worth to invest in surgical robots, despite of its high cost and comparative scant research," said Chougule said.
For example, Chougule said, one hospital with around 300 beds bought a surgical robotic system for $1.8 million and then used it to perform 650 surgeries last year. The number of surgeries is likely to reach 750 patients this year, as more prospective patients learn the technology exists.
While the particular hospital was last in its market to buy a surgical robot, it became a leader by performing twice as many robotic surgeries as other area hospitals and boasted the second-highest volume in the state, Chougule said.
"Many physicians say capturing the market share can be the biggest advantage of investing in the robot. So, if some hospitals can market this and can be first in their area to do so, then it will be easy to get money back in couple of years because they are getting patients and recognition for being advanced hospitals as well," he said.
As robot-assisted surgery achieves greater adoption, UPMC's Duvvuri sees the next step as semi-autonomous or robotic-guided surgery. For example, a CT scan could provide a robotic system with an overview of a patient's vasculature.
"So perhaps you overlay that image on a tumor and a robot guides the surgeon to stay away from no fly zones," Duvvuri said. "So while I see a greater role for robotics, I don't know that they will ever replace human surgeons."