The Future of Robotic Surgery
In 2017, a freak thing happened one morning when I woke up.
I was a 4th year General Surgery resident at the time. I went to be the night before, like I always did in residency, tired as f**k.
As such, I slept like I always did, i.e. I didn’t get enough.
So that morning when I woke up, I didn’t think anything was different.
Until I went to brush my teeth and I stretched my arms above my head.
That’s when it happened.
Both my hands went numb (more specifically several fingers).
I also experienced some of the worst pain that I have ever experienced in my life.
Well, after seeking evaluation, getting some imaging, and seeing multiple doctors, I was diagnosed with multiple disc herniations in my neck.
And all I could think about was if my surgical career was over before it really began?
Think about that. I survived poverty, the Naval Academy, almost dying multiple times, only to have my surgical career jeopardized by some disc herniations.
Thinking about that made me depressed. However I didn’t stay that way for long.
You see, as a result of standing long hours and careening my neck downward, wearing loupes, etc in the operating room, my ergonomics placed a huge strain on my spine.
My awesome physical therapist urged me to make some changes. So I had to look inward because at the time I really wanted to be a Vascular Surgeon.
But that specialty and its operations would not be great for my long term health.
So what do I do?
Well it turns out, there was a newer technology, that was just gaining traction at my hospital system.
You’ve probably heard of it…
Robotic surgery via the Da Vinci Xi system from Intuitive.
It turns out, fate already had an answer for me and it was staring me in the face.
The first time, I took the platform seriously was when I hurt my neck as a result of that commitment I was able to operate without pain.
From that moment on, I was hooked on robotic surgery and made an concerted effort to learn everything I could about it.
Now, the Da Vinci platform isn’t perfect. In fact there are a lot of things they can improve on. Right now they are the standard in the United States.
However outside the U.S., there are some competitors starting to emerge. The one I keep hearing about is Hugo™, from Medtronic.
Recently I came across a photo on a social media site, so naturally I shared it on Twitter:
I haven’t seen Hugo™ in person, but I can tell you right now based upon that photo they have a least five issues to deal with.
Surgeon ergonomics
As I stated above, the Da Vinci Xi system ergonomically is unmatched at this point. What makes ergonomics difficult on the Hugo™ platform is the amount of freedom you’re allowed to move with the platform. This isn’t good.
Long hours immersed in a 3D environment, requires concentration/focus on the task at hand, so having a platform that isolates movement to the extremities is important. Simple things, like a head rest, and limiting the extent of movement of the extremities, provide ergonomic benefits that aren’t appreciated until you’ve spent long hours on the console. Hugo™, has none of this.
Sensory Overload
The Hugo™ platform uses glasses to enhance the image on the screen. This is more like augmented reality. However it can lead to sensory overload and make it hard to concentrate on what you’re doing. When operating on the robot, it’s actually ideal to lock your eyes into the environment. I would be more impressed if they adopted/developed a similar visor to the Oculus for use with this platform.
Price
While I have not seen the cost structure for this platform, I can surmise they are coming in at a lower price point than Intuitive. there are a number of countries/economies which are going to be essentially priced out of the Intuitive platform and Intuitive has no reason to lower the price. Thus to be competitive, Medtronic will need a large number of countries to adopt the platform to equate to Intuitive’s current footprint. I The below data is from 2015, but shows you how much of a head start Intuitive has. As such I am not convinced, Medtronic can catch up.
Hospital and Surgeon Adoption
This is might be the most important component here. Intuitive has roughly a decade head start on any of its competitors. Robotic Surgery programs are difficult to build. It requires demonstration of a clear benefit to patient care, the ability to recoup initial upfront cost, and an ability to increase the number of operations done at your institutions secondary to added efficiency. For Intuitive, their catalyst was the benefit shown in radical prostatectomies. Once a hospital decided to purchase the platform, it was easy for Intuitive to spread to other specialities such as Gynecology, General Surgery, Thoracic Surgery, etc. There’s multiple motivations here on all sides (surgeon, hospital, and Intuitive).
Additionally, there is a learning curve for everyone involved in robotic surgery. Once you are through it and running smoothly, you’re less likely to change to a different technology unless there is a clear benefit to switching. Thus naturally there is a moat around Intuitive because of that friction.
Number of Components Required
The easiest way to say this is that there are way too many components in the Hugo™ system. Hell, I think Intuitive has too many components as well however until they are able to build entire operating rooms specifically for robotic surgery, that isn’t going to change. But Medtronic, decided to separate the arms and make them move on their own individual bases. This is bad and honestly scares me. Robotic instruments are long and there is no haptic feedback in the system. So making sure you have a great understanding of where the arms are and stability of the robotic trocar sites is paramount. When I see that many base components, it adds to the probability that something will shift during the operation. And thats no bueno.
I have other observations but these five jump right out at me. And let me say, I could be 10000% wrong on this.
Honestly I hope that I am wrong. Competition is needed in the robotic surgery space, because it will help lower the costs, increase access to care, and advance surgical technique, which all ultimately helps patients and is what I personally care about.
Also, I’d be remiss if I didn’t shout out Dan Connally (@dpconnally) on Twitter, who gave me the inspiration for writing this.