Nailing Down the Numbers Surrounding Robotic Surgery

Ryan Black
FEBRUARY 26, 2018
data analytics, population health, robotic surgery da vinci, da vinci system black box, da vinci surgery studies, hcanews

The Thoracic Surgeon

John Lazar, MD, said the machines make hospitals more attractive to prospective surgeons. “You’re not going to attract a new surgeon if you don’t have it. You’re not going to get a urologist or a gynecological oncologist when that’s literally the standard of care for them,” he said. “Forget thoracic and general surgery. To attract the new talent, you’ll have to have it.”

Many surgeons like to use the da Vinci, Lazar said, and that group isn’t composed only of young ones: He pointed to a 68-year-old surgeon who was one of the most prolific da Vinci users in the country.

Lazar is a thoracic surgeon at MedStar Georgetown University in Washington, DC, and its director of Thoracic Robotics. Although he understands the issues that skeptics like Horovitz raise—expense, lack of haptic feedback, and limited comparison studies—he expects most of those issues to be resolved in time.  

“A surgeon now has 360 degrees of wristed movement with 3-D visualization,” he said. “We are doing things we really couldn’t do before, and it’s ever expanding.” Lazar expects a form of haptic feedback to be instituted eventually but said that the current lack of it does not hinder his ability to operate gently and precisely. 

The da Vinci also has given Intuitive a near monopoly on the market, which experts said can chill innovation and keep prices steep. New features and lower prices will come when someone decides to be the Nikon or Fuji to Intuitive’s Kodak, Lazar said.

One of the biggest deficiencies right now, he said, is the lack of standardization. Industries pursue automation to ensure consistency and quality, but guidelines regarding use of robots do not yet exist.

Each healthcare system has different criteria for credentialing their surgeons, Lazar said. Intuitive offers an online course that may be required, and test labs enable surgeons to use the robot to build muscle memory and practice operations on animals or cadavers. After that, a surgeon might have 20 to 30 proctored cases for which they have a preliminary privilege to operate, with mentoring continuing until the surgeon is trusted.

“One of the things that’s got a lot of movement right now is standardization. So, whether you’re in Arizona or you’re in New York, there’s a standard for things like cost and length of procedure,” Lazard said. But developing such guidelines would require defining both best uses and quality measures.

The Urologic Surgeon

Robotic surgery seems ripe for standardization and quality measurement. A team at the Keck School of Medicine of the University of Southern (USC) in Los Angeles recently ran a pilot study on a black box for the da Vinci that could inform such consistent use. Andrew Hung, MD, a urologic surgeon and robotics researcher, led the study. The experimental technology, which records all the robot’s output data, paired with the video it captures, would allow any surgical procedure performed with a da Vinci to be re-created in 3-dimensional space.

If one can re-create the work of both a good surgeon and a bad surgeon, Hung said, one can begin to define better validation standards that will deliver consistent patient outcomes. That could come well down the line, though—the study was just a pilot-run one, and all the tools for processing the data must be built from the ground up, never mind the analytics that could compare surgeon performance.

Still, Hung likes that robotic surgery could remove at least 1 human element. Traditionally, surgeons earn the right to perform surgery based on assessments from other surgeons. “The problem is that even when using thoroughly validated assessment tools, there’s going to be disagreement,” Hung said. “The goal of our study is to utilize objective data that comes directly from the robot as the surgery is being performed. There is no human bias in there.”

Machines like da Vinci have claimed the greatest foothold in urologic surgery. Hung said that in his facility, and others nationwide, radical prostatectomies are almost universally performed using the robot. Where Horovitz might see a shiny device that adds time and expense, Hung sees dexterity that could level the playing field. “This kind of technology has allowed more surgeons to operate at a level that they may not have been able to otherwise,” he said. 

As always, the question of true automation arises: If the machine has an advantage over the human hand because of its precision, and it is capable of producing sufficient data to one day model and re-create the perfect surgery, will it eliminate the surgeon?

“Some folks have asked if what I am doing is putting the nail in the coffin for my own profession,” Hung said. “That may be an outcome, but it’s likely many, many years down the line.”

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