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The same sorts of detection and emergency-braking features that have helped make cars safer may soon be coming to the operating room. These could show surgeons things they can’t see with their eyes, such as real-time blood flow, and enable them to avoid tissue damage as they operate.
Advancements in artificial intelligence and sensing technologies are breathing new life into the market for robotic-assisted surgical devices, making it easier for surgeons to navigate small incisions, understand changes to the body and limit strain on joints.
Performing a robotic procedure today can look a bit like playing a video game, but as the technology progresses, some futurists think we’ll reach a day when surgeons won’t even need to be in the operating room at all during a procedure.
“We want to remove surgeons from doing the fine precision work, which is really about how good you are with your hands, and move them into a more supervisory role of how and where you treat disease,” said Michael Yip, an assistant professor of electrical and computer engineering at the University of California, San Diego.
Part of Yip’s research involves ways for a robot to explore the body and give the doctor several courses of action from which to choose. Once the doctor picks, the robot could execute the procedure while the doctor supervises.
The concept of autonomous robotic surgical machines can seem straight out of science fiction, and they’re admittedly many years from ever becoming reality. But Yip thinks the technology could broaden access to top surgeons and specialists, making it so patients in rural hospitals or on battlefields can get the same treatment as those in big metropolitan areas with a wealth of nearby specialists.
Robotic surgery has long been part of American operating rooms, driven primarily by Intuitive Surgical ISRG, +0.75%, which dominates the market for soft-tissue robotic-assisted devices. But a crop of new entrants that happen to be some of the largest health-care companies in the world — Johnson & Johnson JNJ, -0.21%, Medtronic MDT, +1.85% and Stryker SYK, +1.58% — are investing billions of dollars into a new wave of surgical robots.
“We want to remove surgeons from doing the fine precision work, which is really about how good are you with your hands, and move them into a more supervisory role of how and where you treat disease.”
After robotic-assisted devices broke on to the scene with fanfare near the beginning of the millennium, excitement plateaued amid questions about whether machines were actually contributing to better patient outcomes compared with traditional laparoscopies, or minimally invasive procedures.
Now, scientists are excited about the potential for artificial intelligence, improved connectivity, and other technological advancements to make robotic surgery more accurate and accessible, giving a boost to a surgical phenomenon that still makes up a sliver of procedures done today.
In robotic-assisted surgery, doctors sit behind a controller and operate computerized instruments as they perform minimally invasive surgery. The technology is meant to let doctors perform these procedures with more precision and control than they might achieve by standing above a patient’s body and maneuvering the surgical instruments by hand.
The market for robotic-assisted surgery is $4 billion, according to estimates from Medtronic, already half the size of the market for traditional minimally invasive surgery.
That’s striking because robotic procedures currently only make up about 2% of all procedures, by the company’s estimates, while traditional minimally invasive surgery accounts for 30% to 35%. More than 60% of procedures are traditional open surgeries done with larger incisions.
“Both [open and traditional minimally invasive surgeries] will be drawn into robotic-assisted surgery,” said Robert White, Medtronic’s executive vice president for minimally invasive therapies, at an investor briefing in September according to a transcript. The company plans to launch a soft-tissue robot soon.
Hospitals tend to view robotic machines as marketing vehicles that can make their facilities stand out from rivals. Yet adoption varies depending on procedure type, and the scientific literature is mixed on whether robots provide benefits over more conventional procedures.
Technological enhancements could help the machines more uniformly bear out their early goals of improvements in patient outcomes and cost.
One key issue the surgical industry is looking to solve is visibility. Doctors can only see so much inside the body under regular “white light,” but some are upbeat that sensory improvements can help them detect in real time what can’t be seen with the naked eye.
Merged with 3-D scans of the body taken before a procedure, this information can help surgeons plot a course of action and adapt as a procedure unfolds.
By converting CT scans into three-dimensional models of the body, Stryker claims it can develop a more precise plan for where to place a knee or hip implant. The company’s Mako surgical robot takes that blueprint into account during joint replacements, which can allow a machine to set boundaries at the outset and restrain the saw blade before it hits nearby tendons or ligaments, said Robert Cohen, the chief technology officer for Stryker’s joint-replacement group.
Preventing damage to surrounding bodily structures is one benefit that orthopedic surgeons say they get from robotics. “Patients are experiencing less trauma to their joints and that leads to early recoveries,” said Dr. Charles Craven, who conducts hip and knee replacements with the Mako at Novant Health Clemmons Medical Center in North Carolina. He sees patients ditching their crutches and narcotics more quickly.
Intuitive Surgical is also drawing on 3-D scans by enabling doctors to create deeper models based on preoperative CT scans. The company fuses this information with fluorescent vision systems and intraoperative images like ultrasounds to give doctors a better real-time portrait of the body even as matter shifts in the middle of an operation, said Brian Miller, who oversees systems and vision at Intuitive.
The future of surgical visibility is starting to parallel the kinds of safety features that have recently made their way to cars. Side mirrors can’t technically reflect a driver’s blind spots, but newer models add little lights that indicate when another car is next to yours. They also cause the wheel to vibrate if you accidentally drift out of your lane.
The same type of signals can be applied to surgical robotics, said Todd Usen, the chief executive of Activ Surgical. His Boston-based startup’s software looks at the reflection of wavelengths to detect where veins, vessels and arteries are without the use of traditional dyes. It can also show things surgeons can’t see, such as a real-time portrait of blood flow.
Give these details to a surgical robot and the machine could make precise decisions about how far to push an instrument, taking into account information that didn’t show up on a pre-op scan. Get within a millimeter of an unexpected bodily “landmine” and the surgical instruments could automatically freeze without penetrating any further.
“Today, only a doctor can make that decision,” Usen said.
Right now, even though robotic arms are doing the cutting, surgeons still sit in the room and control the action. Usen sees a world where robots could eventually be working on one part of a surgery while a human surgeon controls another.
Intuitive’s Miller, however, is skeptical that surgeons could hand control over to a machine when conducting soft-tissue procedures, meaning those that don’t involve joints or bones.
“With soft tissue, when things can move around, the surgeon still needs to be in full control and make the final determination,” he said. “With knees, you’ve got the site fixed and it’s immobilized, but in soft tissue it’s a different story.”
Remote surgery is already coming up in conversation as hospitals begin to think about 5G connectivity, said Chris Penrose, an AT&T T, +0.09% executive focused on business applications for the new wireless standard that promises faster data speeds and a quicker lag time between when someone executes a command and sees it actually play out.
“You’re going to be able to have that same type of reaction time when you’re physically present but be able to do that from afar,” said Penrose. As that lag time shortens, doctors may be able to do more things remotely, like monitoring patients after surgery or even conducting procedures from another location.
Intuitive Surgical currently has a lock on the market for soft-tissue robotics. The company counts more than 5,500 da Vinci surgical robots in its installed base of devices and has notched a $70 billion market value by selling its machines, which can cost about $2 million apiece depending on features. Players like Stryker, Smith & Nephew SNN, +0.10% and Zimmer Biomet ZBH, +0.71% operate in the orthopedic-reconstructive space.
The field is about to get more crowded in the coming years, with Medtronic, the No. 1 player in the medical-device market, planning an international product launch that could provide some competition for Intuitive’s da Vinci. Dow Jones Industrial Average stalwart Johnson & Johnson is stepping up its efforts in the space as well, buying up Auris Health for $3.4 billion last year to gain access to the company’s Monarch robot for bronchoscopies. It also took control of a former soft-tissue robotics partnership with Verily, Google’s life-sciences arm, that focuses on merging robotics and health information.
The emergence of new players could bring down prices for surgical devices and help break Intuitive’s monopoly in soft-tissue robotics, said Dr. Conrad Ballecer, a general surgeon at Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix.
Ballecer helps train surgeons outside the U.S. on how to use the da Vinci machine for hernia repairs, and he’s found interest overseas, even if limited financial resources hinder how quickly international medical centers can add robots to their hospitals.
“Competition will not only drive costs down but also make it more accessible to surgeons on a global basis, and that’s ultimately not just a benefit to surgeons but also to patients,” Ballecer said.
While heightened competition may help lower the cost of surgical machines, it won’t reduce administrative complexity. “For hospitals it’s tough to manage all the logistics of each of these systems,” said Ryan Zimmerman, a former surgical director who now covers medical-technology stocks as an analyst for BTIG.
The ultimate winners, in his view, will be companies that can offer a “complete universal system” for everything from urology to orthopedics to the ears, nose and throat.
Another raging debate centers on whether robotic surgical machines can be compatible with the growing focus on value-based care in medicine, which says that health systems should deliver better quality care at a lower cost. It’s a shift from the fee-for-service model that has dominated American medicine.
Whether the devices actually provide an improvement in patient outcomes is still a contentious topic in scientific literature, though doctors like Novant’s Craven are optimistic that future research will bear out the positive results they’re seeing anecdotally with their patients.
The second part of the equation is the cost side. “Automation usually makes things cheaper, but that’s not necessarily the case so far,” at least in terms of direct costs, said Zachary Landry, the vice president of orthopedics and sports medicine at Novant Health. He cites the additional scans required for robotic procedures as one reason they could be costlier.
Looking at the broader array of medical costs shows a more complex picture. New research indicates that robotic surgery can lead to shorter hospital stays as a result of lower blood loss and less bodily trauma, factors that make the procedures more economically effective. One recent study found that patients also incurred lower out-of-pocket costs after robotic oncological procedures when compared with traditional laparoscopies.
After years of muted excitement over the robotic-surgery industry, the field looks due for a burst of enthusiasm as new players enter the space and technologists dream up ways to enhance the machines.
Emily Bary is a reporter at MarketWatch.
