What is robotic surgery?
Robotic surgery, or robot-assisted surgery is a type of minimally invasive surgery where miniaturized surgical instruments are fitted through a series of quarter-inch incisions. When performing surgery, these miniaturized instruments are mounted on three separate robotic arms, allowing the surgeon maximum range of motion and precision. A fourth arm that contains a magnified high definition 3-D camera provides stereoscopic view to the operating surgeon.[i]
Robotic surgery has evolved from its first use in a robot-assisted neurosurgical biopsy in 1985 to the approval of ground-breaking da Vinci Surgical System by FDA for general laparoscopic surgery in 2000.[ii]
Robots are currently used for procedures such as prostate surgery, hysterectomies, the removal of fibroids, joint replacements, open-heart surgery and kidney surgeries. They can also be used along with MRIs to provide organ biopsies. Coupled with telesurgery (surgery from a distance), it can be used by institutions and surgeons to perform operations in far and remote areas with otherwise limited human resources and infrastructure. Imagine a neurosurgeon sitting in Boston performing a decompressive craniectomy on a patient lying on an operating table in sub-Saharan Africa. This not only solves the concern of performing highly complex procedures in hospitals with under-staffing or inadequate infrastructure, but also cuts on hospital expenditures This principle can also be used for performing surgeries in war-torn and crisis-affected territories where surgeons are often not so keen to go.[iii]
Robotic surgery is at the cutting edge of precision and miniaturization in the realm of surgery. It provides improved diagnostic abilities, a less invasive and more comfortable experience for the patient, and the ability to do smaller and more precise interventions. Like any other minimally invasive surgery, it offers advantages of fewer post-operative complications, such as surgical site infection, less pain and blood loss, quicker recovery and smaller, less noticeable scars. It can also provide a better work environment for the physician by reducing strain and fatigue.
Along with improved patient care and surgical efficacy, another aim of robotic surgery is to significantly reduce medical and surgical costs. This is not possible when most of the robotic surgical systems cost more than $1 million to purchase and $100,000 a year or more to maintain. This means that hospitals and institutions must evaluate the benefits of robotic surgery against benefit of traditional surgeries. Reduced post-operative stay and quicker recovery following a robotic surgery cuts down on hospital expenses. There is also a reduction in the number of resource personnel needed during a robotic surgery, thus cutting down on hospital expenditure. Yet, it is still disproportionate to the expenses of installing and maintaining robotic surgical systems and training human resources for operating and programming these systems.
With very little competition in robotic surgery market, the few manufacturers have the freedom to set their own price, making robotic surgery highly unaffordable and prohibitive for huge proportions of hospitals, healthcare institutions and governments across the world. This becomes especially problematic in Low- and Middle-Income Countries (LMICs) where human resources are limited and healthcare expenditure is minuscule. Take India, for example, where per capita healthcare expenditure is a meagre $267 and where there is one of the highest out-of-pocket expenditure.[iv] A robotic radical prostatectomy at All India Institute of Medical Sciences, the premier-most government funded health institute of India, costs around INR 1.3 lakhs per case (USD 2025), which is way above than per capita healthcare expenditure.[v] This does not include robotic surgeries at private hospitals which are neither funded by government nor get instruments at a subsidized rate.
The main strength of robotic surgery is that it significantly improves surgical accuracy, particularly among the less-skilled. It was expected that rapid technological developments will make these systems cheaper, smaller, smarter and portable. Imagine the lives saved by a portable robot surgeon rushed to a motorway accident, or to a nuclear accident, a battlefield or to any disaster where one surgeon could carry out several procedures at the same time with help from medical assistants at the scene. But have we actually followed up on this technological advancement and exploited this opportunity in places where it matters? Have the benefits of robot-assisted surgery actually been employed in war-torn Syria or in Fukushima after its nuclear disaster? Sadly, more than 30 years after the first use of robot in a surgery, its use still remains confined within the exorbitant walls of sophisticated operating theatres in first-world.[vi]
The main argument to robotic surgery is whether the costs are ethically justifiable. It is, in fact, unethical to approve new technologies that will add to the cost of medicine, given the number of people, especially in LMICs, with no or minimal access to essential health services, safe surgery, women and child health, health insurance and disproportionate out-of-pocket expenditure.iii A WHO and World Bank report shows that 400 million people do not have access to essential health services and 6% of people in LMICs are tipped into or pushed further into extreme poverty because of out-of-pocket expenditure.[vii] Should not then our concern be focused first on providing universal health coverage, identifying gaps and raising the standard of healthcare in marginal and impoverished community? Should not this excessive expenditure be focused on developing basic health infrastructure in these regions rather than spending it on ethically irrational and doubtful practice? This unfair allocation of health resources and expenditure is surely a deadlock for possible development and further acceptance of robotic surgery across several nations.
Another fundamental disagreement against robotic surgery by large swathes of professionals and societies is its dubious and vacillating ethical ramifications. Where favorable media reporting and hospital advertisements have been partly responsible for unchallenged popularity of robotic surgery, data is still incomplete on its actual effectiveness and advantages. Where this data is present, it shows no outstanding advantage of robotic surgery over conservative surgery.iii A surgeon may also be influenced unconsciously by career benefits and elevated social status that follows after including robotic surgery in his protocol.
There are also issues with latency. This refers to the time lapse between the moments when the physician moves the controls and when the robot responds. Also, there is still a chance for human error if the physician incorrectly programs the robot prior to surgery. Computer programs cannot change course during surgery, whereas a human surgeon can make needed adjustments.ii
It is clear that robotic surgery brings with it the risk of patient harm from insufficiently trained surgeons. There are individual differences among surgeons too on inadequate training on robotic surgery. Some find it easy and feel comfortable with the device, while others have individual differences.[viii]
Lastly, there is also the dissension among bioethicists and philosophers that the sick and vulnerable need human contact. The touch and sound of a doctor gives comfort and sense of security to a person on an operating table. A robot, either controlled or automated, fails to do any of that.
Towards an ethically judicious future
Although robotically-assisted surgery has been steadily increasing in popularity among surgeons and patients, that could end quite suddenly if public perceptions change. Grumbling of complaints and medical malpractice lawsuits are snowballing. Priority should be to reduce the costs of robotic surgery and develop an ethical framework and guidelines on its practice.
Francis Daniels Moore, a pioneer in numerous experimental surgical treatments, offers three criteria to make “surgical innovation acceptable”: (i) sufficient laboratory experience before conducting innovative procedures, (ii) sufficient intellectual and technical expertise available in the institution, (iii) good “institutional stability” based on its resources, support systems and staff.[ix]
A regulatory body should be established to certify that a surgeon is qualified. This should be based not on the number of procedures performed, but on a criterion level of skill. Anything else is ethically indefensible. Institutions should have the right level of in-house technical expertise by ensuring that they have well-trained and knowledgeable support staff with an understanding of the robot. We also need more surgical robotics companies to create a competitive environment that drives innovation and reduces costs.iii
An ethical framework is needed that is grounded in notions of patient autonomy, dignity, wellbeing, privacy and fair allocation of resources, and it needs to accommodate the ethics of care practice. Patients must be told of negatives and offered cheaper equivalent procedures if available. Hospitals must constrain their marketing to the facts and be wary of conflicts of interest so that informed consent is not compromised.ii
To quote Alexander Pope, “Be not the first by whom the new are tried, nor yet the last to lay the old aside”. Robotic surgery is still an evolving technology with no great data on its cost-benefit analysis yet. We need to reconsider our priorities and focus on offering equitable distribution of healthcare at places where it is much needed rather than indulging ourselves in fancy toys.
[iii] Robotic Surgery: On the Cutting Edge of Ethics. Sharkey N, Sharkey AJ. Computer 46(1):56-64. 2013. DOI: 10.1109/MC.2012.424
[v] Current Status of Robotic Surgery in India. Dogra P.N. JIMSA. 25 (3). 145. 2012.
[vi] Don’t dismiss robot surgeons. Noel Sharkey.
[viii] Ethical Reflections on Health Care Robotics. Senthilkumar S., Shanmugapriya T. IJIRCCE. 2 (2). 2014.
[ix] Moore F.D. Ethical problems special to surgery: surgical teaching, surgical innovation, and the surgeon in managed care. Arch of Surg 135:14-6, 2000