DEXTERITY Kent Bowden, DO, says FlexDex gives you robot-like functionality at a fraction of the cost of a robotic surgery system.

If your facility can't afford or doesn't really need a $2 million robotic surgical system, you can just buy the arm. "Surgeon-powered" robotic arms that move like a surgeons' wrist and robotic-arm assisted technology that provide more accurate placement and alignment of artificial joints can do (almost) anything a robot can do at a fraction of the cost, giving you the benefits of a robot without the exorbitant price tag. Here's some background on both handheld options.

The $500 robotic surgeon
The FlexDex robotic arm is surgeon-powered and costs $500. No electronics, no battery and no motor. Its blue plastic mount attaches to a surgeon's wrist like a corsage. It transfers the motions of the hand, wrist and arm into robotic-like movements that can be used to perform less complex minimally invasive procedures. Its sensitive controls respond to the surgeon's slightest movements. In or out, up or down, left or right, wherever the surgeon moves his hand and wrist, the tip of the instrument moves in unison — unlike traditional straight-stick laparoscopic instruments that move in the opposite direction of the surgeon's hand. Plus, it can rotate or roll infinitely, giving surgeons the same ability to sew laparoscopically as a robot.

Yes, a robot arm also moves like a surgeon's wrist, but it takes a $2 million robot on the back end to drive it. Only a handful of surgeons are using FlexDex during a limited rollout. One of them is Kent Bowden, DO, a general surgeon at Munson Healthcare Cadillac (Mich.) Hospital. He's used it in about 20 cases, including inguinal and ventral hernias and to repair a colonic serosal tear.

"It makes laparoscopic surgery more like open surgery," says Dr. Bowden. "It give you so much flexibility. Plus, no additional staff is needed, no consoles, no huge capital expenses."

PRECISION Stryker's Mako uses a pre-op CT scan to do the modeling for unicompartmental knee arthroplasties.

FlexDex is currently used for small incisions and stitching, but with full 360-degree rotation and 180-degree angulation, Dr. Bowden says he's excited to see where this technology goes next. "Cautery? Dissection? This could be used with every type of laparoscopic tool: grasper, dissectors, scissors. The way this device moves is the most novel I've ever seen."

Shirin Towfigh, MD, FACS, a hernia and laparoscopic specialist at the Beverly Hills (Calif.) Hernia Center, sampled FlexDex at the March SAGES conference in Houston. It takes some time to get used to, she says, but it allows for suturing with a flexible tip at an angle that's "better than with the chopsticks that we use for laparoscopy now," she says.

The great value of robots, she adds, is that they provide the ability to "act like an open surgeon inside the belly with minimally invasive access."

The only concern? It's not quite as stable at the tip as you'd like, says Dr. Towfigh.

Robotic-arm assisted technology
When Tom Antkowiak, MD, MS, first saw robotic-arm assisted systems come into play, he was hesitant, unsure whether they were "a game-changer or a gimmick," he says. Now, having used them reliably, he says they have made him more comfortable doing unicompartmental knee arthroplasty (UKA) procedures in an outpatient setting.

"We started to see a difference in immediate patient outcomes, from doing unis the standard way versus using the robot," says Dr. Antkowiak, an orthopedic surgeon with the Midwest Institute for Robotic Surgery at Silver Cross Hospital in New Lenox, Ill. The differences for patients were apparent in almost every measurable category: less pain, improved motion, fewer (or no) ligamentous injuries, the ability to walk without an assistive device and higher satisfaction scores.

"Pretty quickly I became a believer in the technology," he says.

Dr. Antkowiak still does some UKA procedures "the old way," though the majority of them use the robotic-arm assisted system — and "85% to 95%" of those patients go home the same day. He has access to 2 different types: Mako from Stryker; and Navio from Smith & Nephew (see "What's Hot in Orthopedics" on page 51). One key difference between the two, as he sees it, is that Stryker's Mako requires a pre-op CT scan to do the modeling, while Smith & Nephew's Navio uses an optical probe as a means of intraoperative mapping. Regardless of the system, the robotic arm acts as a "well-informed governor."

"The arm does nothing by itself," he says. "It doesn't do anything but keep the tip of the bur in the range of its preset limits. If I faint while I'm holding the bur and it slams toward an area it shouldn't, it turns off. In addition, everything is on the screen, so I see the area that needs to be milled out. An additional benefit is that it can tell me how much extension there is and how tight or loose the joint is, so it's more precise information. It requires a lot less feel or guesswork."

What about outcomes between UKAs performed using a robotic-arm assisted system and those that were performed manually? According to a Stryker-backed study prepared by Baker Lily, just 1 (0.4%) of 284 robotic-assisted UKAs required revision surgery, whereas 46 (3.5%) of the 1,312 UKAs performed non-robotically required revision.

Robotic-assisted systems do, however, have some roadblocks to adoption. Chief among them is cost. Dr. Antkowiak suggests surgical facilities might pay anywhere from $300,000 to nearly $1 million, depending on the system. Also, the reimbursement is the same.

"It's about being able to add value, and that's a challenge," he says. "But we have found that because of the advantages it offers, there's a sophisticated patient population that's expecting the greatest technology and biggest precision, so the system will pay itself off."

Another common criticism is that they may increase set-up time and increase case times. Yes, it does require some extra setup — registration and placing arrays, for example — but he says once a surgical team works out the necessary protocols, operating times will return to normal: 45 minutes to an hour for a UKA, he says. As for multiple orthopods from multiple groups sharing use of the system, he says scheduling hasn't been an issue, though "that would be a good problem to have."

"When you explore any new technology and tease apart the data, it's very important to keep an open mind," he says, adding that he expects robotic-assisted arms to expand to not only hips and UKAs but also total knee replacements. "It's important to understand the patient population and their desire to have access to the best and latest technology available. If you truly run the numbers, looking at what cases you've done to help pay for the technology, I think you'll see the same benefits seen by us: an increase in market share and volume." OSM