Do you remember that viral video of a surgical robot stitching a grape back together? That video was uploaded almost 10 years ago. Since then, the field of robotic surgery experienced massive growth in terms of technological capabilities, investments and the number of robots deployed worldwide.

These sophisticated medical machines promise to make surgeries less invasive, accelerate the recovery and healing process and enable patients to return to their normal lives more quickly. Surgeons are offered a new way of performing surgeries with robots that provide unprecedented access to the human body and tools that feel like extensions of their own hands. Hospitals can also benefit from increased patient turnaround and from the perception of being at the forefront of medical technology by having some of the most advanced medical devices available.

At least that’s what the advocates of surgical robots say.

In this article, we will take a deep dive into the world of robotic-assisted surgery, what difference the surgical robots promise to make and what the reality actually looks like.

The robot surgeons enter the operating room

Traditional surgeries are highly invasive procedures. To perform an operation, a surgeon must first make a large incision, wide enough to accommodate the surgeon's hands and tools, to access the problematic body part. Afterwards, the patient must recover from the surgery, a process that can be lengthy, painful, and uncomfortable.

To address the problems of traditional open surgery, surgeons introduced laparoscopic surgeries. In laparoscopic surgeries, small incisions (usually 0.5–1.5 cm) are made in the abdomen to insert thin tubes with specialized instruments as well as tubes with a camera and light at the end. Because laparoscopic surgeries eliminate the need for large incisions, the recovery is quicker and less painful compared to traditional open surgery.

Laparoscopic surgeries are a significant advancement over traditional open surgeries, yet there is always potential for further improvements and innovations. One of those disruptive innovations is robotic-assisted surgeries. In many ways, robotic-assisted surgeries are similar to laparoscopic surgeries. Both procedures are minimally invasive and require only small incisions to insert the tools into the body. The key difference lies in the control of the tools: in laparoscopic surgeries, a surgeon directly manipulates the tools, whereas in robotic-assisted surgeries, the surgeon controls the tools via a robot. The surgeon uses specialized controls that translate their inputs into precise movements of the tools inside the patient's body.

The first surgical robot to receive FDA approval was the Da Vinci system, developed by Intuitive Surgical, in 2000. Since then, Intuitive has risen to become the leader in the space of surgical robotics. It currently offers a family of Da Vinci robots - Da Vinci Xi, Da Vinci SP and Da Vinci X. The company boasts that, through 2022, over 12 million procedures have been performed worldwide using Da Vinci systems. Every 17 seconds, somewhere in the world, a surgeon starts a procedure using one of over 7500 Da Vinci robots.

Other players include Medtronic and their Hugo robot, Johnson and Johnson’s Ottava robot, Stryker’s Mako, CMR’s Versius, Vicarious Surgical and more. Even Google with their life science company Verily worked together with Johnson & Johnson to create a surgical robot in 2015.

According to a report published by Bain & Company, the robotic surgery market was a $3 to $3.5 billion global market at the beginning of 2023, up from around $800 million in 2015. Another report estimated the value of the market at $5.16 billion in 2021 and projected it to reach $20.98 billion by 2030, while yet another report predicts the market value to reach $7.62 billion in 2024 and $11.76 billion by 2029. In either case, the image that emerges is that surgical robotics is a growing, multibillion-dollar market. As Bain & Company report states, 78% of US surgeons are interested in surgical robotics, which hints at the potential demand for these robots.

Robotic-assisted surgeries are frequently used by urologists, gynecologic surgeons, general surgeons, cardiothoracic surgeons, colorectal surgeons and orthopaedic surgeons.

What does a robotic surgeon bring to the operating table?

Since robotic-assisted surgeries are in many ways upgraded laparoscopic surgeries, they inherit many of their benefits. They don’t need large incisions. Instead, they require only a few small holes, called ports, through which the instruments and camera are inserted into the body. This makes the recovery and healing process quicker, allowing patients to leave the hospital sooner. Patients returning faster to their normal life benefit hospitals, too, as it increases the hospital’s efficiency and reduces waiting times for procedures.

Surgeons also benefit from using surgical robots. Operations performed with these robots are less fatiguing. Instead of standing for hours and hunching over the patient, the surgeon can comfortably sit while operating the robot. The less physically demanding the procedures are, the lower the chances of mistakes. Moreover, thanks to better visualisation tools, surgeons can access more information about the surgery and the patient, such as 3D visualisations. Future surgical robots could be equipped with image recognition and built-in machine-learning algorithms to analyse in real-time the surgery and provide even more information to the surgeon.

Another benefit for surgeons is the increased precision provided by the sophisticated tools attached to the robotic arms. These tools, significantly smaller than traditional surgical instruments, offer a greater range of motion, and the robot can translate the surgeon's controls into precise movements in tight spaces within the body. Furthermore, as is the case with the introduction of new tools in any field, new surgical techniques could emerge that would be challenging or impossible to perform without a surgical robot. An example here is Neuralink’s surgical robot designed to insert electrodes thinner than a human hair for their brain-computer interface. The Neuralink team concluded that no human neurosurgeon is capable of manipulating those thin electrodes so they made a robot.

While Da Vinci and similar robots are general-purpose surgical robots, capable of performing different types of surgeries, Neuralink’s robot represents a narrowly specialised surgical robot. It is possible we could see more narrow surgical robots, designed to do one specific procedure, like biopsy. A biopsy is a procedure that involves the removal of a small sample of tissue from the body for examination under a microscope to diagnose disease or monitor conditions. It is a common procedure that provides vital information about the patient’s health.

Doctors typically use needles to obtain samples from specific areas. The challenge lies in accurately placing the needle in the correct spot. Imaging techniques, such as CT scans, can help in guiding the needle to the targeted area. But even the most experienced doctor may need a couple of more scans and tries until the biopsy needle is placed in the correct spot. As you can imagine, this process can be painful for the patient and tedious for the doctor.

Robots like CRANE can help perform biopsies more efficiently by inserting a robotic arm with a biopsy needle into the CT scanner. This allows the doctor to know where the needle is in real-time and increases the chances of getting the needle into the right spot. Another example of a robotic-assisted biopsy is MURAB (MRI and Ultrasound Robotic Assisted Biopsy) which combines MRI and ultrasound imaging to guide a robotic arm to take a biopsy. Robots like CRANE and MURAB promise to make biopsy a less painful and more efficient procedure.

The dream of remote surgeries and opening access to top surgeons no matter where the patient is located

Robotic surgeons open the possibility of conducting remote surgeries. The first true and complete remote surgery was conducted on 7 September 2001 across the Atlantic Ocean, in which a surgeon in France remotely operated on a patient in New York over a distance of 6,230 km. Remote surgeries are possible, but the biggest challenge preventing them from becoming common is network speeds. These kinds of procedures require ultra-fast networks with as low lag as possible. As networks become faster and more reliable, the prospect of remote surgeries becoming a common practice draws closer to reality. Such procedures can allow world-class specialists to perform surgeries in any place in the world from the comfort of their hospital, opening access to top surgeons to more patients, no matter where they are located.

Militaries could be interested in remote surgeries. Top surgeons could be saving soldiers' lives while staying safely far away from active combat zones. If that were to happen, then the entire field of robotic surgery would come full circle, returning to the original idea that started the development of surgery robots.

Remote surgeries also open the possibility of performing operations in space. A surgeon can remain on the Earth while a robot translates their movements to a patient in Earth’s orbit. Although this vision is still far away in the future, NASA explores the concept of surgical robots in space with MIRA, a small robotic surgeon developed by researchers from the University of Nebraska-Lincoln. The robot has already successfully performed surgery-like tasks in an operating room where the surgeon was 900 miles (about 1450 km) away. The next step for MIRA is to be launched to the International Space Station in 2024. The robot will be tested to see if it is robust enough to survive the launch and how it performs in zero gravity. Inside a microwave oven-sized experiment locker, it will simulate gestures used in surgery by cutting stretched rubber bands and pushing metal rings along a wire, all without the guiding hand of a doctor or an astronaut. However, the mission’s goal is not autonomy, but to fine-tune the robot’s operation in zero gravity.

The lag is already a big problem for remote surgeries on Earth, but in space, this problem will be exacerbated. The lag between Earth and Moon is about a second. The lag between Earth and Mars is 5 to 20 minutes, depending on where both planets are. Because of the lag, remote surgeries with a surgeon on Earth might be limited to orbits close to Earth. Beyond low-Earth orbit, space settlements might still require a human surgeon, unless autonomous robotic surgeries become a reality.

Are we close to autonomous robotic surgeons?

Short answer, no. We are far away from autonomous robotic surgeons.

None of the currently available robotic surgeons are fully autonomous. Robots like Da Vinci are directly controlled by surgeons all the time. Some medical robots, such as the CyberKnife, a robotic system designed for radiotherapy, are to some degree autonomous but still require human supervision.

Creating a fully autonomous robotic surgeon is the Holy Grail of the field, yet there is no indication of such robots arriving anytime soon. The ability to autonomously perform a complex operation presents an enormous challenge for AI researchers and robotics engineers. It is more likely that simpler aspects of surgical procedures will be automated first, such as suturing wounds, leaving the surgeon to focus on the main procedure.

However, there are research projects pushing towards the vision of a fully autonomous surgical robot. An example here is STAR, a surgical robot developed at Johns Hopkins University (JHU), which successfully performed an almost autonomous keyhole surgery on a pig. Almost, because STAR needed some help from a human. As the team at JHU said, a fully autonomous STAR is likely decades away but they will continue work in the hope that in about five years, the technology will advance to the point where a first clinical trial on a human is possible.

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Big promises, mixed reception

The companies offering surgical robots and their advocates want us to see these sophisticated medical machines as the future of surgery. However, despite the potential benefits for the patients, surgeons and the hospitals using them, the reality of introducing a robotic surgeon is not as rosy as these companies claim.

The first issue with surgery robots is their price. According to a paper from 2011, the cost of purchasing the Da Vinci system was $2.6 million back then. And that’s just the beginning. Another $200,000 is needed for “start-up reusable equipment and accessories”. Annual maintenance costs $175,000 and consumables cost $2,500 per surgery. These numbers are over a decade old, but one surgical robotics market survey states $1.5 million as the average cost of a surgical robot in 2023, while this article from The New York Times from 2021 says that the average initial cost of a robotic setup is about $2 million.

The cost of purchasing and maintaining a surgical robot puts them beyond the reach of many hospitals. However, owning such a robot is one thing; actually using it is another. One might assume that with all the benefits of robotic-assisted surgery—such as shorter hospital stays, quicker recovery, and smaller scars—patients would prefer robots over conventional minimally invasive surgery using laparoscopy. Yet, I have found studies that showed the opposite.

In one study, given a choice between robotic-assisted surgery and laparoscopic surgery, 64.4% of 362 respondents chose the latter. 78.2% of those respondents have said they fear the outcomes of robotic surgery. A much larger study, done on almost 28 thousand EU citizens, also shows the public distrust in robotic surgeons. I also found a study where half of 789 respondents had a background in healthcare. 72% of them indicated that robotic surgery was safer, faster, and less painful or offered better results, but when asked if they would choose to have one, 55% would prefer to have conventional minimally invasive surgery.

Ultimately, the choice of whether the operation will be performed by a robot or by a human depends almost exclusively on the patient’s wishes. The picture that emerges from the studies I have found is that despite the push from companies offering surgical robots and their advocates, patients don’t trust them and prefer traditional minimally invasive procedures. For robotic-assisted surgeries to succeed, patients need to be educated about their benefits. Meanwhile, surgeons who provide robotic surgery should ensure their patients are comfortable with and understand this technology.

However, the validity of these claims needs to be verified first. And here is where another issue emerges - there is not enough research done to determine how much difference a robotic surgery makes. In its guide to introducing robotic-assisted surgery, The Royal College of Surgeons of England acknowledges the potential benefits the technology has to offer in the operating room and at the same time states there is a lack of good-quality data to determine how much robotic surgeons improve accuracy, efficiency and patient safety.

Similar sentiments were expressed in a recently published article in Nature Medicine. The article quotes a professor of surgery at the University of Oxford, who said that after 20 years since the introduction of robotic-assisted surgery, “there’s a very small amount of evidence that robots are better than a human surgeon”. Where studies have compared robotic surgeries to their laparoscopic counterparts, there appears to be little to no difference between these two types of operations, with the only clear difference being that the robotic surgeries take more time. There is a need for more studies to be done to test the impact of robotic surgeons and if they are worth the investment.

An interesting picture emerges, then. On one hand, we have patients who prefer human surgeons over robotic ones. Surgeons, meanwhile, are not sure robotic surgeries are actually better than laparoscopic surgeries and call for more research. If not patients or surgeons, who then asks for these robots? One paper proposes an answer, saying in its conclusion that “the propagation of robotic surgery is unlikely based on public demand and may be more related to institutional or surgeon perceptions.” Even though robotic surgeons do not offer any meaningful difference to the patient compared to laparoscopic surgeries, they could be beneficial to the surgeons and hospitals. There is also the prestige of having a surgical robot. One study I mentioned earlier found that hospitals with robot surgeons were perceived to be better by 53% of the respondents.

In any case, the future of surgery looks to be more and more robotic. Just as we transitioned from open surgeries to laparoscopic ones in some cases, we are now moving toward robotic surgeries. The adoption and public perception of robotic-assisted surgeries mirrors the path taken by laparoscopic surgeries. Laparoscopic surgeries underwent this process, encountering the cautious optimism and scepticism that often greet new medical technologies. It took years for laparoscopic surgeries to be considered safe and to become widely accepted both by patients and surgeons. Robotic-assisted surgeries are currently experiencing this phase.

Sources:

• Cepolina F, Razzoli RP. An introductory review of robotically assisted surgical systems. Int J Med Robot. 2022;18(4):e2409. doi:10.1002/rcs.2409

• Muaddi, H., Zhao, X., Leonardelli, G.J. et al. Fear of innovation: public’s perception of robotic surgery. Surg Endosc 36, 6076–6083 (2022). https://doi.org/10.1007/s00464-022-09011-5

• Boys JA, Alicuben ET, DeMeester MJ, et al. Public perceptions on robotic surgery, hospitals with robots, and surgeons that use them. Surg Endosc. 2016;30(4):1310-1316. doi:10.1007/s00464-015-4368-6

• Torrent-Sellens J, Jiménez-Zarco AI, Saigí-Rubió F. Do People Trust in Robot-Assisted Surgery? Evidence from Europe. Int J Environ Res Public Health. 2021;18(23):12519. Published 2021 Nov 28. doi:10.3390/ijerph182312519

• May, M. The next generation of robotic surgery is emerging: but is it better than a human?. Nat Med 30, 2–5 (2024). https://doi.org/10.1038/s41591-023-02740-7

• Robotic-assisted surgery: A pathway to the future, The Royal College of Surgeons of England, 2023

• Are Robotic Surgeries Really Better?, The New York Times, 2021

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