A growing, aging population means a greater need for surgery. Increased life expectancy will be the primary driver behind increased surgical volume, and there are not enough surgeons to meet the demand.
WHAT ROBOTS ARE DOING NOW
Autonomously suturing soft tissue (pig intestine) as well or better than human surgeons in an experimental system.
Milling bone with submillimeter accuracy prior to placing joint implants.
Semi-autonomously harvesting and implanting individual follicles for hair transplantation.
Assisting neurosurgeons treating epilepsy. Robots place electrodes into the brain instead of on the brain surface and need 2–3 mm holes in the cranium instead of a 4×4 cm craniotomy. Robots can reduce operative time by half.
Assisting orthopedic surgeons in knee and hip replacement. Platforms offer real-time virtual imaging and robotic-arm guidance for cutting and removing diseased tissue and placing implants.
Assisting gynecologic, general, ENT and urologic surgeons in over 700,000 soft tissue procedures per year.
SEPARATING HYPE FROM REALITY
Today, we are still in the very early stages of the robotic surgery revolution.
Robotic surgery (or robotic-assisted surgery) promises to alleviate some of the anticipated surgeon shortage, but, for now, the technology doesn’t necessarily mean better health outcomes, decreased cost or across-the-board efficiencies.
Current data on the clinical benefit of robotic surgery is equivocal. For soft tis-sue, most studies show (at best) parity between robotic surgery and established methods of minimally invasive surgery. Though robotic surgery often cuts down on post-op recovery time, actual operative time is increased for many procedures (decreased for fewer), due in part to surgeons’ learning curve with the technology. Except in certain situations (prostate cancer, for example) there has been little ironclad evidence for robotic surgery’s improvement in morbidity or mortality.
For orthopedics, the data show that operative variables (implant positioning, soft tissue balancing) are better controlled with robotic surgery than with manual surgery. However, there have been few high- quality studies on patient functional outcomes and survivorship.
PLATFORMS IN HUMAN TRIAL PHASE OR APPROVED BY FDA OR CE MARK
Smith & Nephew
Smart Tissue Anastomosis Robot (START)
In 20 years, people will think it’s crazy that a doctor still does surgery.
ROBOTIC SURGICAL SYSTEMS COST A LOT UP FRONT AND HAVE HIGH RECURRING COSTS
A da Vinci laparoscopic robotics system (Intuitive Surgical) will set you back $1.5–$2 million. Annual service contracts run between $100,000 and $170,000, not including the cost of consumables—single use tools and supplies. It’s estimated that a facility needs to perform 100 robotic surgeries per year to produce a viable financial return within six years. Per case, da Vinci costs $3,000 more than traditional laparoscopic surgery for removal of an ovarian cyst, and up to 3x more for gallbladder removal.
Orthopedic robots can cost about $1 million up front. Knee joint replacement costs $2,700 more with a robot.
However, in a value-based reimbursement environment, costs will eventually be outweighed by improved outcomes and consequent savings.
» The economics of robotic surgery will win out. As the financial sophistication of healthcare organizations increases, and as value-based medicine takes hold, there will be more rigorous evaluation of major purchasing decisions, i.e., for surgical robots and robot assistants. Joint replacement, for example, costs more when performed with a robot. But with the advent of new bundled cost containment models (CMS’s Comprehensive Care for Joint Replacement Model), improved outcomes (fewer hospital admissions and joint revisions) will result in increased institutional revenue. If robots improve outcomes, thereby lowering overall costs, institutions will buy them. Goldman Sachs estimates that the number of robotic surgeries will double in the next two years.
» Efficacy data will improve. Robotic platforms that can demonstrate improved clinical outcomes and greater efficiency will dominate the market. In the next 20 years, premier robotics companies will lock in their customer base, and continue to make money off recurrent revenue streams (service contracts and consumables).
» Efficiency will improve as surgeons become more familiar and comfort-able with robotic platforms.
» New models of financing robot utilization (e.g., OMNIBotics’ pay-per-procedure) will lower the barrier to entry for healthcare organizations.
» The calculus behind whether to purchase a robot will change. Currently, the decision to purchase a surgical robot is often not based on cost considerations or improved patient outcomes, but rather on marketing and recruiting objectives: patients want the newest technology, conflating technology with quality; new surgeons, trained in robotics, want to employ those skills. Smaller hospitals in particular feel they are in an “arms race” for patients and talent against larger institutions, but their surgical volumes can be low. With increased hospital consolidation and the move toward providing surgical care at high-volume centers, smaller, lower volume institutions will evaluate hard cost-benefit metrics against softer ones like marketing and recruiting.
In 100 years, we will think it was crazy that we used to cut the body open.
Surgery will move into a new phase, incorporating AI, enhanced instrumentation and enhanced visualization. At the same time, some conditions previously treated with surgery will be treated with non-invasive methodologies.
Surgery 4.0 Verb Surgical, a joint venture between Johnson & Johnson and Verily (formerly Google Life Sciences) proposes a new paradigm: digital surgery.
Platform, not robot Flexible digital surgery platforms will allow for a la carte selection of appropriate technology. Advanced imaging and machine learning algorithms, but not robots, may be required for one procedure; robots may be added for another.
An App Store for surgery? Open platforms allow for plug and play of different functionality (instrumentation, visualization, robotics), giving the surgeon unmatched flexibility. Currently, a surgeon is “locked into” using a particular robot’s instrumentation and visualization and software. In 10 years, a surgeon will be able to choose visualization from one company, instrumentation from another.
Standardization and improvement of surgeons’ performance As in manufacturing, digital surgery platforms will use information and standardized processes to reduce variability, optimizing surgeons’ outcomes across the board.
PILLARS OF DIGITAL SURGERY
THE PACE OF TECHNOLOGICAL DEVELOPMENT WILL BE FAST
Autonomous driving is a difficult machine learning problem. It relies on multiple inputs, constant surveillance of the environment, constant adjustment. Autonomous vehicles will likely be fully functioning within three years. Having cracked the code that allows for control in high-risk situations like driving, the machine-learning workforce that gave us autonomous cars will turn its attention to a new challenge: surgery.
Because soft tissue is deformable and moves easily, robotic manipulation of it presents a more challenging machine learning problem (more movement = more data inputs) than operating on fixed or rigid targets.
The majority of robotic surgery platforms focus on fixed targets:
ELECTRODE PLACEMENT IN THE BRAIN TO TARGET EPILEPTIC FOCI
ABLATION (FOR CARDIAC ARRHYTHMIAS)
JOINT REPLACEMENT & OTHER ORTHOPEDIC
Currently, robot assistants help plan surgery and/or aid the surgeon in performing it by enhancing dexterity or removing the surgeon from dangerous environments (radiation in endovascular procedures, for example). As haptic feedback, visualization and device dexterity improve, robots will increasingly take over more tasks for any given procedure.
The incorporation of AI into surgical platforms will have profound effects in dynamic surgical environments, like soft tissue. The da Vinci platform essentially enhances the surgeon (better dexterity, better visualization, better access). In the next 10 years, we will see robots start to autonomously perform discrete (but complicated) surgical tasks like the anastomosis of bowel. Once AI is built into platforms, robots will not just assist in key components of surgery, they will perform entire surgeries themselves, allowing a single surgeon to oversee multiple operations.
Robots will get smaller, allowing for more flexibility (to use in a broad range of procedures) and better access to difficult sites.
Limited by both pain and infection, surgery treats primarily external conditions
First surgical case performed with anesthesia
First successful gallbladder operation
Germ theory of disease; surgical antiseptic techniques become more widespread
Alexander Fleming discovers penicillin
First open-heart surgery performed with the use of a heart-lung machine
First robot-assisted surgery, for hip replacement
First laparoscopic cholecystectomy performed with video
FDA approval for Intuitive Surgical’s da Vinci platform
400,000 robotic surgeries (all types) performed in the US, with an annual growth rate of 25%
95% of radical prostatectomies performed by robots
753,000 yearly surgical procedures with the da Vinci system alone
First robotic heart transplant
Robots routinely perform soft-tissue surgical tasks autonomously, like anastamosing bowel
Majority of surgical tasks are performed by robots overseen by humans
Nanosurgery—the end of invasive procedures
Low-acuity surgeries and procedures (joint replacement, cataract surgery, endoscopy) are performed in various settings: ambulatory surgery centers (ASCs), hospitals or hospital outpatient departments. Though the explosive growth of ASCs has leveled off since the mid-2000s, the number of centers and surgeries performed there continues to increase. Hospitals, which formerly opposed the formation of ASCs, are now opening new ASCs on their own or in joint ventures with physicians.
Ownership Any number of parties: physicians, management companies, hospitals.
Location Anywhere, subject to certificate of need (CON) programs currently active in 34 states. CON programs regulate the opening of new healthcare facilities in a given location.
Reimbursement Approximately 60% of what hospitals are paid for any given procedure (due to different payment schedules for ASC- versus hospital- based procedures).
Cost of care Savings of more than $40 billion for procedures in ASCs versus a hospital. For example, in 2014, cataract surgery cost $2,932 in an ASC, $5,672 in a hospital. Savings would also accrue to patients themselves; it’s estimated that a family of four would save $525-$874 a year if all outpatient surgery was reimbursed at ASC rates.
Efficiency 25% increased efficiency in ASCs over hospitals.
Quality Similar or superior to hospital- based care.
Patient satisfaction Often higher in ASCs secondary to a number of factors (ease of parking, ease of navigating smaller buildings, care team focus on specific types of procedures).
Value-based models will push more low-acuity surgical care to ASCs, which deliver reduced cost, increased efficiency and patient satisfaction, and equal or better quality. Despite political opposition from hospitals that wish to preserve their higher reimbursement, the numbers are too compelling. Hospitals will still be the location for emergency/trauma/high-complexity surgeries. The number of ASCs will increase steadily (as will the number of ASCs with hospital partners) unless there is a closing of the gap in reimbursement between care in ASCs versus hospitals, in which case ASC-based care will accelerate dramatically.
Equal or better outcomes
Improved patient satisfaction
Improved physician satisfaction
THOUGH THE TOTAL NUMBER OF SURGERIES will increase, the conditions for which surgery is needed will decrease.
COMMON SURGERIES (PER YEAR)
KNEE 700,000 (2030 estimate: 3.48 million)
ROTATOR CUFF REPAIR
CANCER TUMOR REMOVAL
NONINVASIVE, EMERGING ALTERNATIVES
COMPOUND DROPS that prevent oxidative damage and abnormal protein aggregation will prevent cataracts from developing
STEM CELL REACTIVATION or implantation for cartilage regeneration
STEM CELL REACTIVATION or implantation for tendon and muscle regeneration
STEM CELL REACTIVATION or implantation for degenerative disk disease
NANOPARTICLE “SWIMMERS” that clear atherosclerotic plaques
TARGETED THERAPIES signal transduction inhibitors, apoptosis inducers, immunotherapy
CATARACT SURGERY COST 2014
$2,932at an ACS
$5,672at a hospital