When you think about robotic surgery, "da Vinci" probably comes to mind, and with good reason. The da Vinci Surgical System has had a stranglehold on the robotics market ever since its launch in 2000 and is still the go-to platform for robotic-assisted abdominal surgery. But that might not be the case for much longer. Several compact platforms in development offer the benefits of robotic-assisted surgery at a fraction of the da Vinci's million-dollar price tag. Robotic arms are also making joint replacement more precise and spine surgery safer.

Assuming that only health systems with bottomless budgets have the means to purchase robots will have you playing catch-up to facilities with the foresight to realize that robotic assistance is evolving from supposed marketing gimmick to outpatient surgery mainstay.

End of a monopoly

In October 2017, TransEnterix received FDA approval for the Senhance Surgical Robot System, which was designed as a direct competitor of the da Vinci. The Senhance has one less arm than the da Vinci system and is comprised of 3 separate units that nurses need to wheel up to the bedside. But as far as operation — during which the surgeon sits away from the patient in a console where he controls the surgical instrumentation using joysticks and foot pedals — the 2 robots are virtually the same.

Cost is where the similarities end. TransEnterix wants to enter the market at a lower price point than the da Vinci, says Chris Schabowsky, PhD, the program manager in applied solutions at ECRI Institute, an independent healthcare research firm in Plymouth Meeting, Pa. He says the company plans to offer a less expensive robot by outfitting the platform with detachable instrument arms that can be sterilized hundreds of times. (Intuitive Medical, maker of the da Vinci, mandates its robots' arms can be used only 10 times before being switched out for new ones.) By not capping the number of uses for their instruments, TransEnterix lowers the platform's per-procedure cost. "You can sterilize the instruments hundreds of times as if they are traditional laparoscopic tools," says Dr. Schabowsky.

Although the da Vinci and the Senhance are the only 2 general surgery robots currently in play, Dr. Schabowsky expects to see several more platforms enter the marketplace within the next 5 years. He says Titan Medical is developing a robot that could be FDA cleared within a year. The robot promises to offer a unique, single-slice surgical solution, says Dr. Schabowsky.

"The da Vinci and the TransEnterix robots have 3 to 4 different ports of openings on the patient," he explains. "Titan Medical is trying to come up with a robot that uses a single port for all the instruments." However, similar to the da Vinci and the Senhance, Titan Medical's robot will be controlled by the surgeon from a console away from the patient.

As new robots continue to emerge, Dr. Schabowsky expects prices to drop and multiple versions of platforms to be developed at various price points to let hospitals and surgery centers right-size the technology to their budgets and clinical needs. "You can add robotics for what you need without investing more money than you'd like," he adds.

Specialized applications

Surgical robots are most often used for abdominal procedures, joint repairs and spinal surgery, and are contributing to the shift of surgeries from inpatient to outpatient ORs. "Because of added visualization and dexterity of the tools, you're able to do more complicated cases that are minimally invasive," says Jeremy Heffner, MD, a general surgeon at Midwest Surgical Specialists in Lima, Ohio. "Long-term, robotics will let more surgeons do more complex procedures."

Abdominal. The da Vinci platform established the robotic surgery market through laparoscopic prostatectomies, but that single focus is beginning to evolve. Dr. Heffner says using the da Vinci robot minimizes the risk of hernia repairs because he can dissect in areas he couldn't approach with a standard laparoscope. Plus, because he's able to do robotic hernia repairs in just 30 minutes, he can perform up to 6 cases per day.

Dr. Heffner believes robots will be used more in the general surgery arena because, "The technology lets surgeons perform open surgery from the inside, and we never had the ability to do that before."

The increased precision afforded by robotics will eventually help expand the technology's use to colon procedures, gastric surgeries, stomach surgeries and larger abdominal cases within the next few years — possibly even in the outpatient setting.

Joint replacement. Orthopedics is seeing similar advances thanks to surgical robots. Rather than viewing orthopedic robots as a passing fad, more companies are starting to realize the interest is growing among surgeons to have a robot in their armamentarium. "All the major industry players will likely offer robotic platforms within the next 5 years," says Joseph Nessler, MD, a surgeon at St. Cloud (Minn.) Orthopedics. "That increased competition will help drive down start-up costs."

One key orthopedic procedure that's been enhanced by robots is partial knee replacements. Surgeons often opt to do total knee arthroplasties when only partial knee replacements are necessary simply because of the technical complexity of placing implants into only part of the joint. That's where the robot comes into play. With robotic assistance, surgeons are able to position implants more accurately.

"Once you start doing partial knees with a robot, you see increased precision, and data show robotically placed implants have better survivorship than those placed manually," says Dr. Nessler.

Spine. "Previously, most spine surgeries were done with surgical navigation, which doesn't match the precision of robotics," says Jed Vanichkachorn, MD, MBA, MSHA, a spine surgeon at St. Mary's Hospital in Richmond, Va.

Aside from added precision, robot assistance also lets spine surgeons perform more complex procedures without intraoperative radiation. "That avoids exposing patients, staff and surgeons to potential harm," says Dr. Vanichkachorn.

He currently uses a robot for lumbar fusions, but foresees the technology being applied during cervical fusions and interbody fusions in the near future. Although he doesn't envision robots completely taking over spine surgery within the next 5 years, he says surgeons must be willing to adapt to using the technology in order to keep up with forward-thinking peers and increased demand from patients who want their procedures performed in facilities that have invested in the technology. "If you want to stay competitive in spine," says Dr. Vanichkachorn, "you need to use robotics at your facility."

Budget-friendly bots

The issue isn't whether or not surgeons are on board with robotic-assisted surgery; it's whether their facilities can afford it. So the question becomes: How do they convince their hospital or ASC to invest in the technology? Leadership at St. Cloud Orthopedics didn't think they could afford to add a robotic-arm surgical platform for use during knee and hip replacements. They were right. Turns out they could afford two.

The facility's general partner analyzed the expected growth of joint replacement business and how many cases the practice could add through marketing the robot. That analysis eventually gave the facility the green light on the purchase. The practice's return on investment was better than anticipated because St. Cloud's surgeons were early adopters of the technology. "Patient demand was there and grew, and the volume of surgeries increased," says Dr. Nessler. "So within the first year, both robots were fully paid for."

Although the cost of robots is still high, surgeons and researchers alike are confident the significant start-up costs of robotic surgery will begin to decrease within the next few years. That's because more surgical robots are set to enter the market and that competition will drive down price tags. "You see that in almost all industries," says Dr. Schabowsky. "New, innovative technology comes out and it becomes very cost-competitive." OSM