The Favorable Economics of Robotic Surgery

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Original story posted on: April 24, 2019

Surgery has a long history.

Even as long ago as in ancient Egypt, we have found remains showing evidence of trephination, the boring of a hole in the skull for brain surgery. More than a century of experimentation in repairing the intestines without causing sepsis eventually was solved with a stapling mechanism.

During the Civil War, surgery was performed without anesthesia. The battlefield at Gettysburg still echoes the lyrics of the song Soldier’s Joy:

“Twenty-five cents for whiskey, twenty-five cents for beer.

Twenty-five cents for morphine, get me out of here.”

A soldier suffering from gangrene would need to medicate while waiting for his leg to be cut off with a hack-saw – hopefully quickly.

During the 19th century, surgery reached a number of crucial milestones. At Massachusetts General Hospital in 1846, William Morton demonstrated the first public surgery, using ether as anesthesia. Patients thereafter could be put under the knife without pain, and without the shock that previously would come from pain. In 1867, England’s Joseph Lister introduced antiseptics to surgery. The popular mouthwash Listerine still bears his name. The infection became the exception instead of the norm.

The practice of surgery continued to see breakthroughs. The first appendectomy was done in 1885. The first heart surgery on the pericardium was in 1893. A cornea transplant was done in 1905. In England, a severely burned patient received the world’s first plastic surgery in 1917.

Progress accelerated even more in the post-war period. The first organ transplant took place in 1950. Three years later, the heart-lung bypass procedure was introduced. Heart transplantation started in 1957. 

Then, in 1975, a major breakthrough was made – laparoscopic surgery. Rather than having to carry around for the rest of their lives long, zipper-like, Frankenstein-style stitch marks, patients would have only a small skin surface wound to heal.

Ten years later, in 1985, the first robotic surgery introduced a new generation of technology into patient treatment. Fifteen years later, in 2000, the Intuitive Company introduced the da Vinci robotic surgical system. This robot dominates the world markets today, with around 4,500 systems installed worldwide. More than 43,000 surgeons have been trained in their use. As of 2017, more than 5,000,000 surgeries have been completed using da Vinci robots. 

To conduct a procedure in this fashion, the surgeon sits in a type of cockpit and remotely views the operation. Two hand-operated actuators control robotic arms. Foot-operated controls are used for other functions.

Robotic surgery allows work on a much smaller scale. For example, at the point of surgery, the doctor’s hand movement of a centimeter can be reduced to a millimeter or less. This enables a surgeon to employ much finer movement that is possible using bare hands. There is a well-known video showing a surgeon using a robot to sew a strip of grape skin back onto a grape. Such delicacy is impossible without robotic assistance. 

The camera system plays a crucial rule in such surgery. It magnifies images, allowing the surgeon to see small nerves and blood capillaries. Even more exciting prospects are found in the use of special dyes and light filters. These allow tissue such as cancer to take on a special glow and distinctive color. As a result, a surgeon more easily can remove cancer, but without excessive margins. In addition, this technique allows real-time detection of metastasis trails linking cancer to other tissue. These also can be isolated and removed.

Robotic systems typically employ multiple entry points into the body: one for a camera, one for an air pump, and two for surgical arms. This also is changing. Newer systems use a single entry point transiting 3-4 instruments, including the camera. Apart from reducing damage to the epidermis, a single-point system more easily can be re-positioned for multiple procedures.

It is now even possible to repair a valve inside a beating heart.

Progress continues. In 2017, the TransEnterix machine was approved. It allows 3-D, high-definition vision and forces feedback so the surgeon can “feel” the tissue being treated. In addition, the use of eye-tracking helps the machine automatically target lights and focus the camera. The Virtual Incision Corporation is developing a small robotic device that operates entirely inside the body.

Assessing the Economic Benefits of Robotic Surgery

A large amount of scientific research has been published on the economics of robotic surgery. A number of outcome variables have been used, including mean cost of care, the net profit for the hospital, the post-surgery, quality-adjusted life-years enjoyed by the patient, the amount of operating room time used, how many days the patient is hospitalized, and how long it takes them to return to their normal life.

Researchers also have measured a number of cost variables. These include the capital investment required to purchase, install, and operate the robot, training costs, how many surgery disposables are used in support of robotic procedures, operating room costs, and costs for supplies such as anesthesia and medication.

The results are very encouraging. For example, prostatectomy procedures have a 7 percent better success rate, and the hospital stays drop from around three days to only one. A similar story is found in cardiac surgery. Days in the hospital drop from 8.2 to 4.6 in this case. In addition, the amount of blood transfusion drops from 57 percent to only 7 percent, which is more than significant. Although total hospital costs are higher, postoperative costs are lower. Total healthcare costs are lower. Patients return to their regular life in a shorter amount of time. There also are favorable economics reported for using robots in nephrectomy and hysterectomy procedures.

In general, the economics of robotic surgery are more favorable for the patient and surgeon than for the hospital. More supplies are used, and large capital investment is needed in order to purchase the machine. Surgeons tend to take home more income.

But for the patient, the trauma of surgery is lessened, and they recover faster. Life is better.

And that is today’s good news.

Edward Roche, PhD, JD

Edward Roche is the director of scientific intelligence for Barraclough NY, LLC. Mr. Roche is also a member of the California Bar. Prior to his career in health law, he served as the chief research officer of the Gartner Group, a leading ICT advisory firm. He was chief scientist of the Concours Group, both leading IT consulting and research organizations. Mr. Roche is a member of the RACmonitor editorial board as an investigative reporter and is a popular panelist on Monitor Mondays.

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