Will Intuitive Surgical’s da Vinci system be dethroned as the industry leader? Can one robotic platform handle all surgeries? Will autonomous robots take over in surgery? These topics and more were tackled during MD&M East’s June 12 panel discussion, “Robotic Surgery - Visions of the Future.” Led by Shana Leonard, Informa Markets’s vice president of content, the panel featured Gianluca De Novi, PhD, CEO at XSurgical; Anthony Fernando, Chief Operating Officer & CTO at TransEnterix; and Dave Saunders, chief technology officer at Galen Robotics.

“When you really look at the industry, there’s probably 40, 50 surgical robots that are actually out there,” said Saunders. “Intuitive Surgical fills a niche, and they make a lot of money doing it for abdominal and urological surgeries. There are lots of things that the da Vinci does not and cannot do. . . . There are lots of surgeries that are very specific to how my technology is optimized that I don’t think da Vinci would ever be appropriate for either. And they don’t have an incentive to optimize their technology for the kinds of areas I’m going after because it would amount to overengineering. . . . And if we look at the recent acquisition of Auris by Johnson & Johnson, that robot does a very specific thing that is incredibly high impact, but its usage and utility is extremely narrow. It’s kind of miracle surgery.”

So, “there is no one technology that is appropriate for all things,” Saunders continued, adding that the three robotic platforms from each of the speakers “fill very different niches. . . . Each robot is optimized for the kinds of surgeries that it needs to go into. And when you look at the industry, specialties are segmented, so I’m going after neurosurgeons, otolaryngologists, whereas you’re dealing with abdominal surgeries and general surgeries,” he said, speaking to another panelist. “There’s just different markets as well in terms of who’s purchasing the robots, so I feel very strongly that the industry has a lot of growth potential, and there is room for a lot of robotic technology to support a very wide breadth of surgical procedures,” he said.

“Competition drives innovation,” added Fernando of TransEnterix. “There’s plenty of room for other companies to come in and compete. . . . There’s an opportunity to innovate in different ways, and not just in surgery but many other stakeholders you can please as part of introducing robotics.”

“You need to add a certain degree of novelty,” De Novi said. “You really want to make something that’s effective and reliable but . . . no one else can do and patients can benefit.”

In terms of challenges, the biggest could be reimbursement. “It’s really difficult right now especially in the U.S. because there aren’t any specific reimbursements that are going to allow you to do robotics surgery. . . . You have to fit in the existing economic model,“ Saunders said. “So I have to build a robot that not only has great utility for surgeons, but I have to have something that fits into their economics. And if that isn’t a consideration upfront, the company is going to have no traction.”

In addition to addressing economics, robotics companies also need to drive efficiency. “Efficiency needs to be factored in because it’s projected just in the U.S. a shortage of surgeons in the next 10 years. So whatever technology, your robotics need to be significantly more efficient than today in order to not feel any impact on the healthcare system as a whole,” Fernando pointed out.

De Novi said his company’s perspective is a little different, as they are developing robotic solutions for procedures that would need to be performed in the event of a disaster or on the battlefield. “There are a number of procedures that are very effective when they are administered in the first hour—it’s called the ‘golden hour.’ So the outcome of whatever injury depends on what happens in the first hour or two. So rather than having civilians or military moved . . . you can have a better patient outcome if you have at the first medical outpost already the best tools to provide this kind of surgery. And that will decrease dramatically especially for the government the costs of the outcomes of those injuries. So that’s essentially where the gain is.”

And back to cost considerations, capital cost may not be the issue. “I don’t think the cost of capital is a big issue. Any healthcare system is willing to invest,” said Fernando. “It’s the cost of the procedure and the operational expense. . . . But there has to be synergies and consolidation—not just multiple robots for different purposes, and the robot’s purpose is going to be somewhat limited if the robot can't integrate with other devices and equipment in the OR.”

Added Saunders: “Cap Ex is not a problem. It really comes down to the utility of the robot is an issue—physicians have to want to use it. And I think there’s a big issue with interoperability when it comes to integration. . . . In the medical industry, most companies are actively resistant to any form of interaction between other medical devices.

“We’re supposed to be making the lives of surgeons and therefore patients so much easier. The idea that all of these robots can enable MIS [minimally invasive surgery] is better for everybody here,” he continued. “The benefit for laparoscopic surgery is clear. And so to enable more surgeons to be able to do those procedures, which are more difficult than standard open procedures, is a win for everybody, even if the surgery might be a little more expensive from an op ex standpoint right now. . . . But if the hospital is forced to buy 20 different robots, you are never going to realize those benefits.”

When asked how manufacturers could get surgeons to use robotics, Gianluca acknowledged that “there are a lot of technologies that can make a procedure more effective, more precise, but in terms of time, they are more time consuming.”

Fernando said he believes the next wave of robotics will focus on the surgeon and the institution as a whole. Saunders added that “robotics is enabling a larger population of surgeons who might not have done laparoscopy if they could only do it manually. Now that’s already a benefit. But there’s also this additional benefit—laparoscopy requires a high level of dexterity, and that dexterity has a shelf life.” Robotic technologies could “extend the careers of surgeons” already there, said Saunders, which is “almost as good as increasing the surgeon population in general.” And they could also reduce surgeon risk. For instance, the benefit of pedicle-screw-driving robots is not that they can drive pedicle screws better than surgeons—they can’t—but they can operate while the x-rays are being used to ensure the pedicle screws are on the right trajectory, which means that the surgeon doesn’t have to expose themself over and over again and increase their cancer risk, which is kind of an occupational hazard for spine surgeons.

“So there are a lot of really interesting side benefits to allowing technology to fit in where it belongs, and that’s something the whole industry needs to pay attention to—robots have their place, and the more we think about the whole ball of wax, the more we realize that surgical robots really, truly have a meaningful need today.”

In terms of artificial intelligence, augmented reality, and other emerging tools that could further advance robots, AI is anticipated to have a profound effect on the segment. “We are investing a lot in AI,” said De Novi. “The mission of the company is to deliver probably in the next decade or two a fully autonomous robot.”

Saunders said earlier that “our goal is to be an active, robotic assistant for surgeons, allowing surgeons to be where they would normally be in the surgical theater, allowing them to do the procedure as they would normally do, but give them the ability to boost their dexterity. Or if they are already one of these superhumans who have dexterity that few people can match, actually allow that to be consistent, day in, day out,” said Saunders. “And because there is a robot holding their hand, we can give them safety capabilities that a human hand alone simply cannot match. Our paradigm is to merge into procedures as they currently are.”

Fernando said that healthcare is a “relatively conservative group across the board. So I think we are in the early [stages] of technology adoption. It will progress into collecting data, and more data will help drive machine learning and artificial intelligence and augmented reality. So there has to be some progress, but the foundation is being set, and I think it will evolve relatively fast into data-driven, decision-driven surgery. We are expecting a very rapid adoption within the next 10 years.”