The Doctor is In: Remote Surgery in the Digital Age
What will it look like when our machine overlords attempt to update our hardware?
Shaky hands? Not on this doctor! In over 3000 operating rooms worldwide, patients are actively being operated on by robotic doctors, hydraulic arms working away to measure, incise, and suture upwards of 200,000 patients each year (1). According to hospitals, “robotic-assisted surgery offers all the benefits of other forms of minimally invasive surgery, including less blood loss, less pain, fewer adhesions, shorter hospital stay, improved cosmesis and quicker recovery”, all of which allow the hospital to turn through more patients faster, with fewer complications and unexpected costs. In most cases the doctor is there in the room, but in the case of St. Joseph’s Hospital in Canada, the doctor may be hundreds of miles away (2). However, over a decade after the first remote surgery, there are still only a handful of facilities that perform surgery this way.
A Short History of Robotic and Remote Surgery
Like many great innovations, the seeds of remote surgery were planted in the government. In the 1970’s NASA proposed the use of remote controlled robots to perform surgical operations on astronauts (2). As part of a Small Business Innovation Research (SBIR) contract, Computer Motion began research on a robotic arm, which was cleared for surgical procedures by the FDA in 2001 (3). At the same time, research on robotic surgery for soldiers was being conducted at for the Defense Advanced Research Project Agency (DARPA) Defense Sciences project (4). After licensing this technology and taking the organization public as Intuitive Surgical in 2000, the new company faced intellectual property litigation from Computer Motion, eventually resolving the dispute through a merger of the two firms in 2003 (5).
While the potential to perform remote surgery was always a goal for both organizations, it was not until 2001 that the transmission speeds were fast enough to carry out a procedure. In that year, a team in New York operated on a patient thousands of miles away in Strasbourg, France using the ZEUS machine in what became known as the “Lindbergh Operation” (6).
The Future of Remote Surgery
Robotic surgery has clear operational benefits for hospitals, as patients experience better health outcomes while hospitals experience fewer costly complications and cost overruns, for which they can’t charge insurers.
Once surgeries are performed remotely, there are additional benefits. For one, utilization rates of specialists can be higher than in traditional hospitals, which require a flow of patients. As the operator, a class-leading surgeon could perform an operation on a patient in New York and then immediately operate on a patient in Beijing, delivering the highest quality of care anywhere in the world.
Conversely, as a provider you can locate your specialists in the lowest labor cost environments, such as India, that are already experiencing an influx of medical tourism. Instead of flying around the globe, patients can receive care from an Indian specialist from Europe, allowing for a more fluid global ‘supply chain’ of care.
From a societal perspective, remote surgery allows high quality care to delivered in places that are underserved, for example war zones. In Syria, the government has tortured or killed hundreds of doctors, forcing thousands more to flee, leading to a ‘care desert’. If a machine can be controlled and protected by humanitarian organizations, patients can receive the care they need without having each specialization represented in-country (7).
Barriers to Adoption and Next Steps
Despite the many benefits of robotic/ remote surgery, adoption has been limited, due primarily to 1) cost (upwards of $2 million dollars per machine), 2) regulatory ambiguity and 3) limited applicability (8). Addressing cost, Intuitive Surgical should develop multiple tiers of machines, allowing for deployment in scenarios that would otherwise be cost-prohibitive. In the case of regulation, hospitals need to communicate to legislators the benefits that these machines can unlock, presenting a unified front regarding proposed solutions.
To expand applicability, IS needs to continue to invest heavily in haptic feedback technologies that give the operator the ability to ‘feel’ in more sensitive procedures, as well as the integration of AR/ VR that enable a more fluid operator experience. For applicability in a diverse array of procedures such as developing countries or space travel, some baseline degree of automation has to be built into the product, as delays of even a few seconds in feedback can lead to deadly consequences. Without automating certain responses, doctors may not be able to react quickly enough to unexpected complications, such as a ruptured artery, that the machine could theoretically identify and address instantaneously. Surgeons be worried: the ultimate promise of remote surgery will be realized when the surgeon becomes an operator.
- “The Slow Rise of the Robot Surgeon”. MIT Technology Review. 24 March 2010. Retrieved 23 March 2013.
- Eveleth, Rose. “The Surgeon Who Operates from 400km Away.”BBC – Future. BBC, 16 May 2014. Web. 18 Nov. 2016.
- “Important Historic Robotic Companies and Systems.”Digital Surgery. N.p., n.d. Web. 18 Nov. 2016.
- “Intuitive Surgical.” International Directory of Company Histories. The Gale Group, Inc, 2006. Answers.com 30 Jan. 2009. http://www.answers.com/topic/intuitive-surgical-inc
- Yahoo finance, Wednesday, April 1, 2015, ISRG http://finance.yahoo.com/q?s=isrg&fr=uh3_finance_web&uhb=uhb2
- Marescaux J, Leroy J, Rubino F, Vix M, Simone M, Mutter D. Transcontinental Robot Assisted Remote Telesurgery: Feasibility and Potential Applications. Annals of Surgery 2002;235:487-92
- Taub, Ben. “The Shadow Doctors.”The New Yorker. N.p., 20 June 2016. Web. 18 Nov. 2016.
- Rosen, Jacob, Blake Hannaford, and Richard M. Satava. 2010. Surgical Robotics: Systems Applications and Visions. Springer.
- Wilhem, Katharina. “Visions of a Prophet: Insights into the German Mind”. Harvard University Press, 2016.
Student comments on The Doctor is In: Remote Surgery in the Digital Age
Why worry about haptic feedback and automating certain responses when grape-suturing robots and jeopordy-solving computers can coexist?  Granted, a grape isn’t a human and jeoporday isn’t a surgical procedures repository (and neither have been integrated as of yet), but a grape-suturing robot and Watson are, nonetheless, demonstrative of the potential for extant technologies to work together to overcome the inefficiencies of human-based medicine.
 Da Vinci Robot Stitches a Grape Back Together. (2014, January 09). Retrieved November 18, 2016, from http://www.youtube.com/watch?v=0XdC1HUp-rU
There are obviously huge benefits to the expanded use of these technologies, however they do create some additional risks. A study released in 2015 that focused on 14 years of robotic surgeries in the US showed:
“1,166 cases of broken/burned parts falling into patients’ bodies, which contributed to 119 injuries and one death.
Uncontrolled movements and spontaneous powering on/off of the machines are said to have caused 52 injuries and two deaths.
Electrical sparks, unintended charring and damaged accessory covers are linked to 193 injuries, including the burning of body tissues.
And the loss of quality video feeds and/or reports of system error codes are said to have contributed to a further 41 injuries and one death.” (http://www.bbc.com/news/technology-33609495)
In comparison to the total number of surgeries these numbers are very small. The benefits may actually outweigh the risk, but it is important to note there clearly are some new risks. If you are forced to train surgeons on how to deal with technical problems, it is just another thing that could distract them from their main purpose. Hopefully technical glitches can be minimized going forward.
Another benefit to robotic-assisted surgery especially in the cath lab is decreased physician exposure to radiation (http://www.dicardiology.com/article/reducing-physician-radiation-dose-robotics; also some information on radiation risks for ICs http://www.acc.org/latest-in-cardiology/articles/2015/12/31/10/12/radiation-safety-for-the-interventional-cardiologist). Robotic systems can also address orthopedic issues which are becoming common among ICs from standing and wearing lead aprons all day. Physician health and safety are an increasingly important topic as physicians weigh long-term career longevity and workplace safety.