In the distant future, patients may consult a robot doctor and undergo invasive procedures, without any interaction with a human being. From my viewpoint as an Orthopaedic Surgeon, that day is fortunately a long way off, and humankind still needs me. However, surgeons and doctors of all specialities are increasingly using robotic technology to benefit their patients.
This article discusses various robots used in healthcare today, and what particular advantages they offer.
The robot will see you now..
Firstly what is a “robot”? The word robot is derived from the Slavic word meaning ‘servitude’. It was first used in 1921 in a play called R.U.R (Rossum’s Universal Robots) written by a Czechoslovakian author named Karel Čapek. The play perhaps acts as a warning regarding Artificial Intelligence, and begins in a factory that makes artificial people, called roboti (robots), from organic matter. The robots seem happy to work for humans at first, but a robot rebellion eventually leads to the extinction of the human race, a theme which was echoed sixty years later by the Terminator movie franchise.
A robot is essentially a machine which is capable of carrying out a complex series of actions automatically. Robots come in all shapes and sizes, such as large scale industrial robots manufacturing vehicles on an assembly line, to microscopic nanobots which can enter the bloodstream.
Robots in healthcare can be classified in many different ways:
- Autonomous: programmed to carry out a set task without any human intervention
- Semi-autonomous: requiring some input from a human operator
- Haptic: providing sensory feedback to the human operator
Robots in Orthopaedic Joint Replacement
Hundreds of thousands of joint replacements are performed worldwide every year to replace worn cartilage in knee and hips. Each implant is designed to replicate joint movement in a certain way, and need to be inserted in a certain alignment and rotation to make them function most efficiently.
Human beings, even orthopaedic surgeons, are prone to varying degrees of error, depending upon experience and skill levels. Robotic surgery aims to remove surgical errors by providing a higher degree of accuracy and reproducibility of results. Here, several robotic systems currently available in Singapore are discussed:
The Makoplasty system (Stryker) is used to perform total hip, partial and total knee replacements. It involves a pre-operative CT scan of the lower limb to generate a virtual 3D model of the joint. The implants can be positioned in any position that the surgeon desires on this 3D map.1 The surgeon then uses a robotic arm to remove the exact amount of bone required. Haptic (tactile) feedback, as well as visual and auditory cues, are given to prevent the surgeon from straying outside the preplanned area.
In comparison with standard surgical techniques, robotic-assisted surgery is purported to have the advantages of:
- Increased surgical accuracy
- Optimization of component position
- Improved patient outcomes in joint replacement procedures2
Early results so far are very promising. In a multicentre study, 909 knees underwent partial knee replacement using robotic-assisted surgery. There was a knee replacement survivorship of 98.8% at 2.5 years, with 92% of patients very satisfied or satisfied with their knee function.3
Another recent commercially available Orthopaedic robot is the Navio Surgical System (Smith and Nephew). This system uses a robotic handheld burr to assist with partial and total knee replacements. The difference with this system is that there is no pre-operative CT scan. Instead, the surgeon registers a number of points on the bone of the joint surface to be operated on, creating an intraoperative 3D map of the knee joint. This enables ‘real time imaging’ during the surgery.
The Navio handpiece is used to burr away the desired bone according to a patient-specific plan. Although the Navio equipment is smaller and more portable than a Makoplasty machine, it does not provide haptic (tactile) feedback, and it is vital that the surgeon accurately registers the intraoperative points, as there is no CT-based 3D virtual model.
There is currently no short term data published regarding Navio system outcomes.
The Robodoc system was first used in 1992 to assist with a total hip replacement case in the United States. It relies on a preoperative CT scan of the limb to create a 3D plan, which the surgeon then uses to map regions of the joint during surgery. The difference between Robodoc and the other systems is that the robot is fully autonomous. Once the surgeon has guided the robot cutter arm to the bone surface, the Robodoc machine will automatically mill away the bone without any guidance from the surgeon. The surgeon then manually implants the joint replacement as per usual.
There is evidence to suggest that the Robodoc system has some advantages in performing total knee replacement4 and total hip replacement5. Use of the Robodoc system for total knee replacement is not FDA-approved in the United States of America.
The Da Vinci Surgical System enables surgeons to perform operations through a few small incisions, rather than one large one. It gives a magnified vision system within the patient’s body, and utilises instruments that can bend and rotate more than the human hand. The surgeon’s hand movements are translated into smaller, precise movements of tiny instruments inside the body, which are 100% controlled by the surgeon. Unlike the Makoplasty system, there is no haptic (tactile) feedback.
Dr Fang Jan Lee (Consultant Urologist at Singapore Medical Specialists Centre) says that the main advantages of operating using Da Vinci are magnification, reduction of hand tremor, and a 3D image which is useful for depth perception, compared to a standard 2D telescopic image seen during conventional surgery.
Currently, the Da Vinci system is used for a variety of general (intra-abdominal / colorectal), urological and even cardiac surgical procedures. Two controversies, which relate to all robotic surgical procedures, are:
- Whether robotic surgery actually improves outcomes
- Cost effectiveness of the robotic procedure
Whether the Da Vinci system can provide better outcomes in the long term (eg. at 5 years or more) for a particular procedure, is unknown. A randomised controlled study looked at removal of the prostate gland (a procedure for prostate cancer known as prostatectomy) through a conventional open incision, versus minimally invasive surgery using the Da Vinci robot6. At 3 months (a very early stage) there was no difference in outcome between procedures with regards to urinary and sexual function, although those undergoing robotic surgery spent less time in hospital.
Advantages of robotic surgery over open surgery
One area where robotic-assisted surgery may have the advantage over open surgery in prostate cancer, is with regards to surgical accuracy. A study showed that prostate cancer patients who had robotic-assisted surgeries showed fewer instances of cancer cells at the edge of their surgical specimen (a clear surgical margin). It may be that patients undergoing robotic surgery are less likely to need additional cancer treatments such as hormone or radiation therapy, with potential reduction in costs and side effects from those additional treatments.7
Using a robot for surgery has obvious technical advantages. Over time it may be become clearer which cases are more suitable for robotic surgery eg. complex cancer cases vs simple cases which can be performed through standard techniques.8
Cost effectiveness is a relative term and depends upon many factors, not least the insurance system in which the machine is used. The Da Vinci robotic system costs around US $2 million. A study in Germany9 found superior outcomes for robotic surgery for prostatectomy with regards to surgical margins, blood transfusions required, and length, although operating time was longer. Fewer complications and readmissions were seen in the robotic group, therefore the overall cost of care in the 2 years following surgery was lower.
Whether robotic surgery is superior to conventional surgery, and in what way, requires more research over a longer period of time. What is clear however is that robotic technology is here to stay. This is a nascent (early) period in robots being used for surgery, and as more surgeons are trained in robotic procedures and expertise in techniques improves, robots will eventually become indispensable. For the time being, the robot is only as good as the hand and brain that guides it – so choose your surgeon wisely.
Dr Alan Cheung is a Consultant Orthopaedic Surgeon at Singapore Medical Specialists Centre. He specialises in Sports Injury, Adult Reconstruction and Trauma, and trains in BJJ at Evolve MMA.
Images courtesy of Stryker Corporation and Transmedic Group.
- Roche M at al. Robotic-assisted unicompartmental knee arthroplasty: the MAKO experience. Orthop Clin North Am.2015 Jan;46(1):125-31.
- Werner SD et al. Makoplastyand the accuracy and efficacy of robotic-assisted arthroplasty. Surg Technol Int. 2014 Mar;24:302-6.
- Pearle AD et al. Survivorship and patient satisfaction of robotic-assisted medial unicompartmental knee arthroplastyat a minimum two-year follow-up. 2017 Mar;24(2):419-428.
- Liow MH et al. Early experiences with robot-assisted total knee arthroplasty using the DigiMatch™ ROBODOC® surgical system. Singapore Med J.2014 Oct;55(10):529-34.
- Nakamura N et al. A comparison between robotic-assisted and manual implantation of cementless total hip arthroplasty. Clin Orthop Relat Res. 2010;468(4):1072-1081.
- Yaxley JW et al. Robot assistedlaparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. 2016 Sep 10;388(10049):1057-1066.
- Hu JC et al. Comparativeeffectiveness of robot-assisted versus open radical prostatectomy cancer control.Eur Urol. 2014 Oct;66(4):666-72.
- Manciu S. Robotic Surgery: A Solution in Search of a Problem-A Bayesian Analysisof 343 Robotic Procedures Performed by a Single Surgical Team. J Laparoendosc Adv Surg Tech A. 2017 Apr;27(4):363-374.
- Niklas C et al. daVinci and Open Radical Prostatectomy: Comparison of Clinical Outcomes and Analysis of Insurance Costs. Urol Int. 2016;96(3):287-94.