Robot instead of a surgeon, reality or a media trick?

Sofia Ordonez (cnnmoney)

I’m sure that everyone of us, at some point, heard a futuristic statement that robots will replace us in our workplace. After sensing fear and some 20 seconds of thinking, we came to a conclusion that our job is unique, and no machine can ever reach our level of skill.

If you happen to be a surgeon, then it’s likely that you didn’t even spend those 20 seconds to think about this statement. Who could believe that a robot can entirely replace someone who has spent minimum of 11 years in education and specialization before he could start making decisions on his own.

You were right. It’s still a long journey to the point in time when a robot will be able to completely replace a human, even though robots of today can significantly improve the way in which operations are performed.

In the continuation of this post, you can see how robots are used today, and why the future of surgery is unimaginable without these machines.

ROBOTS AREN’T A NEWS IN SURGERY

Despite the common opinion, robots are not in a test phase. In western countries, they have been in use for 16 years. Back in 2000, U.S. Food and Drugs administration (FDA) granted permission for usage of the Da Vinci robot. Since then, these machines have been used as support in minimally invasive surgeries.

According to this research, 554 american hospitals used Da Vinci robot in 2013. It’s estimated that just in USA, this robot will participate in 500 000 operation every year.

This trend is not only noticable in North America, as it has significantly spread to countries of the European Union and Asia. India is an example of a country that has improved its so called medical tourism by using previously mentioned technologies, and more and more patients in need of a minimally invasive surgery come to India..

We can say that on our prestigious universities robots are hardly ever mentioned, and it’s completely understandable, having in mind that most hospitals in this part of Europe can’t really afford these machines. Why educate students about something they can’t try for themselves? On the other hand, students are deprived of information and skills which could make the difference on the labor market.

IS DA VINCI REALLY A ROBOT?

Company INTUITIVE SURGICAL is a global leader in the market of healthcare robotics. Their bestselling product is a robot with a distinct name – Da Vinci.

This robot isn’t a robot as we might imagine at first, nor is it an intelligent metal construction capable of making its own decisions. It’s actually a robotic platform controlled by trained professionals and its purpose isn’t to replace the surgeon. Da Vinci is designed to be a powerful and supporting tool used by surgeons in order to operate more precisely.

Da Vinci robot performing a test operation on a dummy doll. (wikipedia)

You’re probably asking yourself, why do we even call this machine a robot, if it doesn’t have its own intelect and cannot operate independently?

According to the definition of the www.freedictionary.com , a robot is a device that operates automatically, or by remote control. Second part of this definition makes Da Vinci robot a true robot, along with toy cars and helicopters controlled by a remote controller device.

Oxford Dictionary has a different definition of the word robot. Their opinion is that the robot is a machine capable of automatically performing a series of complex operations. That deprives Da Vinci robot of this prestigious title.

On the image below, you can see which definition is more relevant acording to Google search engine:

Google search results for the keyword “definition of robot“

These “lost in translation” discussions were the ideal platform for the industrial “behemeth” INTUITIVE SURGICAL to build its own propaganda, and a perfect daily news for the mass media.

MACHINES USED BY HUMANS ARE HUMANS

Regardless if Da Vinci is a robot or not, its 16 year old history left us with a lot of efficiency case studies.

Indeed, no one can dispute how robust and effective this platform is. This way of performing minimally invasive surgery is designed to combine the best of open and laparoscopic surgery.

It gives the surgeon better control. With help of robotic arms, he can perform operations more precisely and with smaller cuts. The most important benefits for patients are minimal bleeding, less pain and postoperative recovery period.

All these facts are valid only once this machine is used by the right people, and for the right cause. Unfortunately, quite often some unexpected circumstances arise, and that leads to these following controversies:

1. DA VINCI ISN’T SIGNIFICANTLY MORE SUCCESSFUL THAN LAPAROSCOPIC SURGERY

The nonprofit organisation ERCI summed up data from 4000 different studies about robotic surgery. Conclusion was that robotic surgery is indeed significantly more successful than open, and slightly more successful than laparoscopic surgery. At first sight, that doesn’t sound so controversial.

Controversial is the enormous difference in cost. Just one robot costs over 2 million dollars, once all its accessories are added. Because of that, the cost of robotic operation is on average 3 500 dollars more expensive than a traditionally performed operation.

In order to justify its price, which is 10 times bigger than any other surgery type, Da Vinci will have to improve its results significantly.

2. “SOLUTION IN SEEK FOR A PROBLEM”

Price of these machines is 2 million dollars, and that is a big investment. When any hospital invests that amount of money, it has to justify it to the investors, board or the community it serves. Previously mentioned circumstances made it possible for the robots to be used for a wider specter of operations, even though it isn’t realistic considering the specifications and anatomy of the machine.

Da Vinci was primarily designed as a solution for cardiovascular surgery, but many surgeons didn’t fall in love with this technology. Later on, it was used in gynecology where it wasn’t the quite the best solution for non-tumor operations. At that point, some critics described it as a solution that is seeking a problem.

Da Vinci robot performing an operation on grapes

After a long journey of wandering around, Da Vinci robot finally settled down in urology. As removing prostate was very difficult to perform by laparoscopic surgery, Da Vinci became the ideal tool for minimally invasive prostatectomy. Today, 90% of these operations in the USA is done by using this tool. It’s also used in other, previously mentioned medical specialties, but in none as dominant as in urology.

3. 144 DEATHS IN 100 000 CASES

Data provided by the U.S. Food and Drugs administration (FDA) from 2015, show 144 deaths in operations in which Da Vinci robot assisted . When we analyze these data more thoroughly, we can see that about 60% of these deaths are caused by problems and errors on the machine. The remaining 40% were caused by reasons directly related to other inherent risks, such as surgeon errors.

According to the report about unexpected events in robotic surgery, on average 550 events of this kind happen in 100 000 operations performed. What worries the most is the fact that the number of deaths and mistakes grows proportionally with the number of operations. This means that this device isn’t showing any progress. On the image below, you can see the main reasons for the mentioned errors:

Number of Da Vinci robot errors by procedure

This analysis failed to deliver results of comparison between operations assisted by the robot, and the conventional operations. Without that comparison, these results sound way too dramatic, and no one can prove if robot-assisted operations are better or worse than open and laparoscopic operations.

CAN WE MAKE A ROBOT THAT ISN’T JUST A MAN MADE OF METAL?

Robotic surgery market is growing each year , but the size of the market isn’t the thing that saves human lives. Newer generations of robots have to show significant technological progress in the future, if we want to adequately integrate them into our healthcare system.

Access to development of the new generation of robots is substantially transforming. There are many positive examples indicating that we will solve a lot of real life problems in a more creative manner.

GOOGLE IS A SEARCH ENGINE, WHAT ARE THEY DOING IN MEDICINE?

Since 27th march 2015, all eyes are on Google and Johnson & Johnson. On that date, it was announced that these two companies are working together on developing a new, ultimate platform for robotic surgery. Shortly after that, they founded Verb Surgical Inc., an independent surgical solutions company, to achieve this goal.

Johnson & Johnson owns Ethicon company, world leading distributor of robotic parts, and Google built an „empire“ using algorithms and robots. Having in mind their reputation and the revolutionary nature of Google, we can only believe that their solution for robotic surgery will also be revolutionary.

CEO of Ethicon Inc., said for news agency Reuters, that their platform is trying to resolve 3 fundamental shortcomings of all previous platforms:

1. Size of the device – all previous solutions are big as an average car, and the doctor has to be few meters away fom the patient due to the fact that he has to use remote controlling
2. Lack of intelligence – robots that are currently in use do not have their own intelligence and they are only as a tool.
3. Too expensive – Regardless of the status of any hospital, a price of 2 million dollars is a significant investment

The goal of this joint venture is to create an 80% smaller robot, affordable to most hospitals, and with its own intellect in order to assist the surgeon. Imagine a robot with machine learning capabilities, analyzing a recording of a surgery, then comparing it with other recordings from the database. Then, based on his conclusions, guides the surgeon by pointing out where he should cut.

SURGERY INSIDE AN MRI SCANNER

Experts from the Automation and Interventional Medicine research center , in cooperation with Brigham and John Hopkins University, developed a robot capable of performing certain operations inside the MRI scanner. In the beginning, it’s only the prostate biopsy procedure.

In a typical prostate tumor biopsy doctors use ultrasound to obtain the appropriate sample. As you can imagine, in most cases this method is pretty clumsy, as the image the doctor gets is usually not refined enough. Prostate biopsy usually ends when 12-20 samples are obtained, and each new puncture brings additional infection risks.

In its core, it is a device made of plastic and ceramic, it can move inside the MRI without decreasing the quality of the image. For now, it’s guided by the doctor who navigates according to the coordinates based on the MRI image.

Plastic robot performing prostate biopsy inside the MRI scanner (photo: Gregory Fischer/WPI)

Long-term goal is that the device works independently, by smart scanning the images, and adjusting the coordinates for real-time interventions.

If you are interested in additional informations about how this robot works, you can find it in this report.

SMART ROBOTS ON THE BALKANS

Fact that a smart robot is being developed in our neighborhood is something we should all be proud of.

Team of experts from the Faculty of Mechanical Engineering and Naval Architecture in Zagreb, has been working on developing Ronna robot , with purpose to assist in neurosurgical operations. Darko Chudy, probably the most famous Croatian neurosurgeon, is helping the project as well.

There are 2 reasons why Ronna has the potential to become special:

1. This creative team wisely uses cheaper industrial parts to form a more affordable final price of the device.
2. Focus of the team is to make a machine with its own intelligence, which will guide the neurosurgeon during the operation.

European Regional Development Fond invested 500 000 euros in this project, and Bojan Jerbić, leader of the Ronna team, says that Ronna will very soon participate in a real operation in Dubrava Clinical Hospital Zagreb.

Wrap-up

The question: „Can a robot replace a surgeon?“ is wrong in its core, and usually questions like these get media attention over and over again. The category of surgeons is completely unstable and varies depending on time and circumstances.

Having in mind that machines are mirrors reflecting us and our ideas, the key question we should be asking ourselves is which are the virtues of an ideal surgeon in his specific fragment of surgery?

Surgeon and his idea will have an impact on what will be reflected in the mentioned mirror. Will it be a better man, solving unsolvable problems, or just another robot?