Sept. 26, 2023 \u2013 On her flight to Atlanta, Robin Pollack nibbled gummy bears and sipped a cranberry juice cocktail. It had been a week since she’d gotten robotic surgery to remove a cancerous stomach tumor at MD Anderson Cancer Center in Houston, and she was heading home \u2013 feeling surprisingly good.<\/span><\/p>\n The surgery required five small cuts. \u201cI now have four little dots and a 2-inch slit that he superglued shut,\u201d Pollack said. \u201cAfter surgery, I woke up hungry.\u201d<\/span><\/p>\n She was out of bed and walking in a day, and out and about town with her husband within a week, enjoying\u00a0<\/span>cr\u00e8me br<\/span>\u00fb<\/span>l<\/span>\u00e9<\/span>e and eggs Florentine.<\/span><\/p>\n \u201cI have not had one bit of pain since,\u201d she said 2 weeks after surgery. \u201cI have not taken pain medication, not even one Tylenol. I walked 2 miles yesterday.\u201d<\/span><\/p>\n A better post-operative quality of life is one perk of robotic surgery, said <\/span>surgical oncologist\u00a0Naruhiko Ikoma, MD,\u00a0<\/span>who performed Pollack\u2019s procedure.\u00a0<\/span><\/p>\n<\/section>\n There are pluses for the surgeon, as well. \u201cI feel more precise in terms of dissection and in suturing,\u201d said <\/span>Ikoma. \u201cIn conventional open operations, surgeons use instruments. \u2026 In robotic surgery, surgeons feel like they\u2019re operating with their own fingers with precise tips.\u201d<\/span><\/p>\n Robotic surgery, or robot-assisted surgery, is more than 20 years old, but experts believe it is now poised for growth. Propelling the technology forward are the very advantages that Pollack and Ikoma describe: improved accuracy, shorter recovery times, and less pain.\u00a0<\/span><\/p>\n About\u00a0<\/span>644,000 robotic surgeries<\/span><\/a> were performed in the United States <\/span>in 2021, a<\/span><\/a>nd that figure is expected to approach 1 million by 2028. Millions more have taken place worldwide.\u00a0The global market hit $6.3 billion in 2022 and is projected to reach\u00a0<\/span>$26.8 billion in<\/span><\/a> 10 years.<\/span><\/p>\n Robot-assisted devices are\u00a0<\/span>FDA<\/span><\/a>-cleared<\/span> across many specialties. For prostate <\/span>removals<\/span><\/a> and <\/span>hysterectomies, <\/span><\/a>the use of surgical robots is now more common than not. It\u2019s also <\/span>rapidly growing<\/span><\/a> in <\/span>bariatric surgery<\/span><\/a> and hernia repair, and has increased steadily in <\/span>hip and knee replacements<\/span><\/a>. Several surgical teams have pioneered robot-assisted kidney <\/span>transplants<\/span><\/a>, and recently the Washington University School of Medicine in St. Louis reported the first robotic <\/span>liver transplant in the U.S<\/span><\/a>.<\/span><\/p>\n<\/section>\n<\/div>\n The most widely used robotic system <\/span>in the U.S.<\/span><\/a>\u00a0is Intuitive Surgical\u2019s\u00a0<\/span>da Vinci<\/span><\/a>. The FDA first approved a da Vinci in 2000 and has cleared newer models since then. Today, more than 7,500 da Vinci surgical systems are in use in 69 countries across six continents.\u00a0<\/span><\/p>\n Dozens of other companies have entered the game. Advances in materials science are driving soft, flexible designs that can navigate winding pathways or operate on some of the body\u2019s most delicate tissues.\u00a0<\/span><\/p>\n Auris Health\u2019s Monarch, a flexible robotic endoscopic system, enters through the mouth into the trachea and bronchial passages to examine potentially cancerous tissue in the lungs. The platform recently earned a urological clearance for kidney <\/span>stone removal.<\/span><\/a> Other flexible robots enter the rectum and travel through intestines, as for colonoscopy. Still others snake through the nose to reach the brain, or the thigh\u2019s femoral vein to get to the heart.\u00a0<\/span><\/p>\n An upgrade of Stryker\u2019s Mako robot, currently used for hip and knee replacements, will enable its use in spine and shoulder surgery and could launch as early as <\/span>next year. <\/span><\/a>(The doctors interviewed for this article are not promoting or endorsing any products mentioned.)\u00a0<\/span><\/p>\n<\/section>\n Meanwhile, artificial intelligence, or AI, is letting researchers and developers make robots more autonomous, capable of performing surgical subtasks or even entire surgical procedures.<\/span><\/p>\n \u201cIt is an exciting time,\u201d said Michael Yip, PhD, an associate professor of electrical and computer engineering, and director of the Advanced Robotics and Controls Laboratory, at the University of California San Diego. \u201cThe diversity of robotic technologies is really widening exponentially.\u201d<\/span><\/p>\n Benefits for Patients<\/strong><\/span><\/p>\n Data shows that robotic surgery can help reduce bleeding, scarring, and recovery time, and it allows for shorter hospital stays, compared to traditional surgery.\u00a0<\/span><\/p>\n One of the most striking benefits: Many patients, like Pollack, do not need opioids \u2013 or any painkillers, for that matter. That\u2019s remarkable when you consider the norm.\u00a0<\/span><\/p>\n For kidney transplant, \u201cit\u2019s 100% narcotic use after an open transplant,\u201d said Thomas Pshak, MD, a robotic kidney and liver transplant s<\/span>urgeon\u00a0<\/span>at UCHealth University of Colorado Hospital. Open surgery patients go home with as much as\u00a0<\/span>a week\u2019s supply of opioids<\/span><\/a>, and sometimes need morphine or oxycodone in an IV after surgery.<\/span><\/p>\n<\/section>\n<\/div>\n Robotic surgery patients heal much faster, returning to work and normal activities within a few weeks, vs. the\u00a0<\/span>recommended 8 weeks<\/span><\/a> after open kidney transplant.\u00a0<\/span><\/p>\n \u201cA painless kidney transplant seems like science fiction, but here we are,\u201d Pshak said.<\/span><\/p>\n He uses a da Vinci surgical robot system with four slender arms, each about the size of a pencil, that hold surgical instruments and a high-definition camera. During surgery, he sits at a computer console a few feet away, looking through binoculars that provide a highly magnified 3D view of the operation site. With both hands on joystick-type controls, he guides the arms into the cuts to perform \u201cdelicate, precise movements,\u201d such as suturing the new kidney to blood vessels. Foot pedals engage and disengage the robot arms.\u00a0<\/span><\/p>\n Pshak performed UCHealth<\/span>\u2019<\/span>s first robotic kidney transplant in 2021 and has done more than a dozen since then, and even more donor kidney removals, using the robot. With robotic kidney transplant, \u201cthe biggest incision is about 2 inches, near the bellybutton,\u201d he said. For context, a traditional open kidney transplant involves a 10- to 12-inch cut.<\/span><\/p>\n<\/section>\n Robotics may improve access to surgery as well. One-third of patients waiting for a donated kidney have body mass indexes over 35. The higher BMI can mean longer, deeper cuts, increasing the risk of complications and negative outcomes. The less invasive robotic procedure could make kidney transplant possible <\/span>for these patients<\/span><\/a>.<\/span><\/p>\n Benefits for Doctors<\/strong><\/span><\/p>\n In a sense, robotics give surgeons superhuman skills. The robot can correct for any tremor in the surgeon<\/span>\u2019<\/span>s hand and lets a surgeon view hard-to-see creases, moving the camera and small tools into places the human hand can\u2019t reach.<\/span><\/p>\n \u201cI can set the [robot] arm movements to move at one-tenth of my normal hand movement,\u201d Pshak said. \u201cThat just allows for some insane accuracy.\u201d<\/span><\/p>\n In spinal surgery, robotics minimize the misplacement of a screw. That means \u201ca lower revision rate \u2013 having to go back and remove and replace a misplaced screw,\u201d said <\/span>Mohamad Bydon<\/span><\/a>, MD, a\u00a0<\/span>neurosurgeon\u00a0<\/span>and\u00a0<\/span>clinician-scientist<\/span> at the Mayo Clinic in Rochester, MN, where they\u2019ve been performing robotic neurosurgeries since 2018.<\/span><\/p>\n<\/section>\n<\/div>\n Bydon was the lead author of a\u00a0<\/span>study<\/span><\/a>\u00a0in\u00a0<\/span>Mayo Clinic Proceedings\u00a0<\/span><\/i>that reported that out of 402 screws placed in 77 patients who had robot-assisted spinal surgery, none had to be redone after surgery.<\/span><\/p>\n Other advantages, Bydon noted, include the ability to map out the surgery in advance, and sub-millimeter accuracy around a patient\u2019s nerves and spinal cord. “It p<\/span>reserves muscles, tendons<\/span>, and ligaments,\u201d he said.<\/span><\/p>\n Corey Walker, MD, is a\u00a0<\/span>neurosurgeon\u00a0<\/span>at\u00a0<\/span>Cedars-Sinai\u00a0<\/span>in Los Angeles who performed minimally invasive robotic back surgery on a high school football player last year after the player fractured his spine in three spots. The robots collect data that is fed back into AI algorithms to improve planning and accuracy. \u201cThe robot is not just giving us a technical advantage,\u201d Walker noted, \u201cbut also a data advantage.\u201d<\/span><\/p>\n After surgery, the football player was back to normal activities and training again within weeks instead of the\u00a0usual\u00a06 months.<\/span><\/p>\n With younger patients, Walker said, it\u2019s important to preserve their longevity and avoid injury to the muscles surrounding the spine. Robotic procedures \u201cleave as little of a footprint on the structure of the spine as possible.\u201d<\/span><\/p>\n<\/section>\n Robotic Surgery: What Patients and Doctors Should Know<\/strong><\/span><\/p>\n In the United States, academic medical i<\/span>nstitution<\/span>s and hospitals have developed their own\u00a0<\/span>credentialing<\/span><\/a> paths.\u00a0Many robotic surgeons train in conventional surgical techniques and later move into robotic procedures, taking web-based and in-person courses with equipment manufacturers, practicing on sample tissues, in virtual reality simulations, and on inanimate objects\u00a0(like picking up small items or peeling tape from a surface).\u00a0<\/span><\/p>\n Some surgeons and medical centers offer robotic training for those outside their institution. At the\u00a0<\/span>Ohio State University College of Medicine<\/span><\/a>, interested surgeons from around the world can visit, observing existing and emerging robotic procedures for $500 a day.\u00a0<\/span><\/p>\n \u201cThe biggest challenge with robotics is that it is so automated, it sometimes takes away from the residents\u2019 ability to learn the anatomy,\u201d Walker said. \u201cOur challenge is to still be able to teach residents the anatomy and to not become reliant on the technology.\u201d<\/span><\/p>\n<\/section>\n<\/div>\n Patients should look into a hospital\u2019s history with robotics and ask how many procedures their institution and surgeon have performed, as Pollack did before her surgery. Not all surgeries are suitable for robotics; patients and surgeons should discuss pros and cons.<\/span><\/p>\n<\/section>\n Challenges<\/strong><\/span><\/p>\n Robotic surgery is not without controversy. A\u00a0<\/span>2021 review of 50 randomized trials<\/span><\/a> comparing robot-assisted surgeries with laparoscopy and\/or open surgery for belly or pelvic surgery found little difference in outcomes.\u00a0<\/span><\/p>\n Some older studies suggest risks or potentially worse outcomes for some procedures. In 2018, a\u00a0<\/span>New England Journal of Medicine<\/span><\/i> multicenter study<\/span><\/a> led by <\/span>MD Anderson Cancer Center\u00a0<\/span>researchers reported that, in women with early cervical cancer, laparoscopic or robotic minimally invasive radical hysterectomy was linked to lower rates of disease-free survival and overall survival, when compared to open abdominal radical hysterectomy. And in 2021, the\u00a0<\/span>FDA cautioned<\/span><\/a> against robotically assisted surgical device use for mastectomy.<\/span><\/p>\n Still, scores of other recent studies back up robot-assisted surgery\u2019s benefits.<\/span><\/p>\n One drawback: It\u2019s not available everywhere. “You have to be at a place that is willing to invest in it and that believes in it as a technology,\u201d Walker said.\u00a0<\/span><\/p>\n For certain specialties, the high cost (the da Vinci\u2019s price tag is reported to be\u00a0<\/span>$2 million)<\/span><\/a> may not outweigh the return on investment, Yip said , stalling growth.<\/p>\n<\/section>\n According to Francis Sutter, DO, chief of cardiac surgery at\u00a0<\/span>Lankenau Medical Center<\/span><\/a>, part of Main Line Health, and a longtime robotic surgeon, the number of robotic heart surgeries has fallen in the past 10 years.\u00a0<\/span><\/p>\n \u201cThere\u2019s not a market for it,\u201d he said. “I hope there will be more interest from cardiac surgeons in the years ahead.\u201d<\/span><\/p>\n What\u2019s Next?<\/strong><\/span><\/p>\n Semi-autonomous devices that perform surgical tasks \u2013 like holding a clamp in place or removing damaged tissues \u2013 could start to emerge clinically in the next 10 years, Yip said.\u00a0<\/span><\/p>\n Like a self-driving car, they use sensors to localize with respect to anatomy and map the environment.<\/span><\/p>\n Someday, we may see fully autonomous robots capable of performing an entire procedure.\u00a0At Johns Hopkins last year, surgeons tested\u00a0<\/span>a new robotic technology<\/span><\/a> called Smart Tissue Autonomous Robot (STAR) that visualizes and plans its next surgical move almost in real time. They successfully practiced with it in four experiments, sewing together pig intestines, tissue that\u2019s soft, pliable, and difficult to operate on.<\/span><\/p>\n<\/section>\n<\/div>\n For hemorrhage control, Yip said, \u201cthe computer recognizes blood and will immediately try to suck up the blood, find the source, and clamp it.\u201d Such robots could be airdropped during, say, natural disasters to stabilize injured people. The technology could also\u00a0<\/span>open the door to remote \u201ctelesurgery<\/span><\/a>.\u201d<\/span><\/p>\n![\"photo](\"https:\/\/img.wbmdstatic.com\/vim\/live\/webmd\/consumer_assets\/site_images\/article_thumbnails\/news\/2023\/09_2023\/robotic_kidney_innovation\/1800x1200_3uc_health_robotic_kidney_innovation.jpg\")
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