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Surgical Robots, AR & the Future of the Digital OR

Converging technology and the next logical step toward “intelligent” operating rooms

“The future of all surgery is minimally invasive surgery”
—Dr. W. Scott Melvin, Chief of the Division of General Surgery,
Montefiore Medical Center and Albert Einstein College of Medicine

When “what ifs” become reality
No doubt most everyone has seen the virtual reality (VR) television commercials, where as soon as anyone straps on the VR goggles they are immediately immersed in wild visuals from places like panoramic mountain peaks to rollercoaster rides to house-to-house combat.

What if, instead of jaw-dropping exteriors and hair-raising action sequences, the scenes were replaced with interior vistas of the human body? What if the VR goggles were augmented reality (AR) goggles that closely tracked the progress of a scalpel in the metallic clutches of a robot…or a human surgeon?

What if cascades of data flowing from that same human body were analyzed and reported back on the AR goggles’ heads-up display? What if the robot’s journey could be minutely scrutinized not only by the surgeon but also by those on the operating room’s entire surgical team?

And what if the AR goggles could speak, instantaneously snapping out answers to any query from the surgeon—or from any one of the surgical team’s members—about the patient’s condition, or delivering up analytics about similar operations, procedures and outcomes?

That new OR automation reality is here today, but in scattered pieces.  Surgical simulation software, intraoperative imaging devices, surgical navigation systems, augmented reality, and surgical robots, are being brought together into what’s being hailed as the “intelligent” or “digital” operating room.

Surgical robotics, haptic-enabled augmented reality, sensor technology, GPUs, miniaturization, Cloud computing, simulations, and data analytics, are converging as the next logical step in the refinement of traditional open surgery into that of minimally invasive surgery (MIS); what MIS pioneer,  Dr. W. Scott Melvin, surgical chief of the NYC-based Montefiore Medical Center, calls the “future of all surgery”.

MIS means that the days of breaking apart a chest bone to perform open-heart surgery are over. Instead, MIS replaces all that patient trauma and the visual gore of such a scene with small incisions—keyhole-size or smaller—some of which might well be microscopic.

Technology is coming in for a landing into the operating room in a very new and very big way.

The digital OR changes everything, and the surgical robot is the main actor.

Technology as surgical change agent
If MIS is really to be the future of all surgery, it can’t move forward without surgical robotics, and also without the sensor technology that’s now finding its way into robotics.

The journey of robots into the OR was set into motion three decades ago. The beginnings of its next massive iteration into that of an OR of intelligent machines is taking place right now.

Technology first revolutionized surgery in the 1980s when the German gynecologist Kurt Semm “transformed the use of laparoscopy for diagnostic purposes into a modern therapeutic surgical concept.”

Technology shrunk the size of an incision to that of a keyhole when Semm performed the first laparoscopic appendectomy.”

Minimally invasive surgery (MIS) was born, and technology was the change agent. The results of less patient trauma with faster recovery times has vaulted minimally invasive surgery to be seen as the future of all surgery.

Technology intervened again when Dr. Camran Nazhat married a video camera to an endoscope.  What went on in the darkness beneath a keyhole incision could then be preserved.

Today, technology once again has a rendezvous in the operating room, and this time, instead of human surgeons hunching over patients, the keyholes are being patrolled by robotic surgeons; the successes of which have spawned the development of a dozen or more specialized robotic surgical tools.

In the seventeen years since Intuitive Surgical’s robot, the da Vinci, received FDA approval, fifty additional have become market participants (WinterGreen Research). Of that number, twelve surgical robots have arisen to vie for space and notable purpose in operating rooms.

Technology as surgical change agent
If MIS is really to be the future of all surgery, it can’t move forward without surgical robotics, and also without the sensor technology that’s now finding its way into robotics.

The journey of robots into the OR was set into motion three decades ago. The beginnings of its next massive iteration into that of an OR of intelligent machines is taking place right now.

Technology first revolutionized surgery in the 1980s when the German gynecologist Kurt Semm “transformed the use of laparoscopy for diagnostic purposes into a modern therapeutic surgical concept.”

Technology shrunk the size of an incision to that of a keyhole when Semm performed the first laparoscopic appendectomy.”

Minimally invasive surgery (MIS) was born, and technology was the change agent. The results of less patient trauma with faster recovery times has vaulted minimally invasive surgery to be seen as the future of all surgery.

Technology intervened again when Dr. Camran Nazhat married a video camera to an endoscope.  What went on in the darkness beneath a keyhole incision could then be preserved.

Today, technology once again has a rendezvous in the operating room, and this time, instead of human surgeons hunching over patients, the keyholes are being patrolled by robotic surgeons. 

In the seventeen years since Intuitive Surgical’s robot, the da Vinci, received FDA approval (2000), fifty additional robots have become participants in the global surgical marketplace (WinterGreen Research). Within this nascent industry, a dozen or so surgical robots have arisen to vie for space and notable  presence in operating rooms.

Leading Developers in Surgical Robotics
Auris Surgical Robotics
Accuray
Corindus Vascular Robotics
Hansen Medical (merged with Auris)
Intuitive Surgical
Mako Surgical (now a subsidiary of Stryker)
Medrobotics
Medtech S.A.
THINK Surgical, Inc.
Titan Medical
TransEnterix
Verb Surgical
Virtual Incision Corporation

Going small on disease
Maybe the ultimate step beyond that is miniaturization. Instead of a giant, OR-filling, robot hulking over a surgical table, a mini- or micro-size robot may literally enter through the keyhole incision and disappear into the darkness beneath. How about a cellular-size robot, or nano-size that could look a cancer cell in the eye

Marketplace, Revenue and Growth Through 2018

The global surgical automation market is growing at a CAGR of 11 percent, while the Asian market on its own is increasing at a 12 percent clip.

Of course, if surgical automation and the digital OR hit any of its anticipated technological milestones, both CAGRs could far easily exceed those very healthy 11 and 12 percent compound annual growth rates. In fact, WinterGreen Research  generously conjectures that the global market “could be worth $20 billion by 2021.”

Nearly five years ago (2014), when healthcare automation technology began to scale, the global surgical automation market bulked up to $3.2 billion. This year (2018), it’s expected to reach $5.4 billion. A billion short of doubling over a five-year span.  

The piece of that increase owned by Asia looks like this: $324.8 million in 2013 to and $574.1 million in 2018, at a CAGR of 12 percent.

The Micro-Market Monitor’s take on Asia: “Asian surgical automation markets are expected to witness a healthy growth rate over the next five years due to technological advancements, investments by venture capitalists, as well as by a wide range of government bodies worldwide investing in this market, which will propel the digital OR into most favored status. 

Asia’s booming medical tourist industry
An added advantage for Asia would be if the digital OR could become an integral part of its multi-billion dollar medical tourist industry.

Patients Beyond Borders, which tracks the booming medical tourism trade worldwide, reports that the global market is expanding by up to 25 percent each year and is worth upwards of $55 billion annually. Medical tourism sees more than 11 million consumers annually, nearly four million of whom travel to Southeast Asia for their medical care.

And the tourists aren’t as far flung as one would think:  Every year, Indonesians leave their country to spend $11.5 billion a year on healthcare abroad, much of it in Southeast Asia, especially Malaysia.

Bangkok alone has over a thousand hospitals, many of which the Thai Ministry of Public Health claims receive 2.5 million medical tourists annually.  Both Korea and Japan are getting into the action as well with record inflows of Chinese patients arriving for treatment these last two years. And then, of course, there’s the New Delhi Apollo Hospital’s Institute of Robotic Surgery (also in Kolkata, Chennai, Hyderabad) where it’s all robots all the time.

Asia has a giant upside in expanding its medical tourist industry, as well as huge resident populations that would also benefit from economies gained from the speed and reduced trauma from robot-administered MIS.

The Lancet’s Global Surgery Survey 2030 reports that “5 billion people do not have access to safe, affordable surgical and anesthesia care when needed” and more than half of that population lives in Asia; especially hard hit are the “low-income and lower-middle-income countries, where nine of ten people cannot access basic surgical care.”

Surgical robots and digital ORs in Asia, if planned well, could leverage the lucrative medical tourism business to spin out the social benefit of better healthcare for their general populations.   

Surgical robots: outcomes over price?
Of the 313 million surgical procedures undertaken worldwide each year, only 6 percent occur in the poorest countries, where over a third of the world’s population lives (Lancet). It’s difficult to envision a $2 million da Vinci robot (Intuitive Surgical) getting into service for any of those nine of ten who need it most.

And prices for Western robots do not look like they are coming down anytime soon. If anything, prices are on the rise. Part of the expense may well be attributed to the surgical philosophy when building surgical robots, where surgical outcomes outweigh price. In fact, Intuitive Surgical’s CEO, Gary Guthart, said as much in a Bloomberg interview (Inside the Future of Robotic Surgery) when asked why the da Vinci costs so much.

Human life and well-being are serious business in Asia as well as in the West, but price looms as the deal breaker for affordable surgeries.

Lower pricing and innovation driven by the need for lower costs have bred an indigenous all-Asian movement for more affordable surgical robots. The Transformation of Robotics in Asia cites five contenders: Micro Hand S, EMARO, the Revo-i system, Robodoc, and the AmaKris SR 2.

If Asia could raise a champion machine to fill the affordable surgical robot space, it could well become a world standard (think, the Toyota of surgical robots).

As the Lancet survey reports that “143 million additional surgical procedures are needed in LMICs [lower to middle income countries] each year to save lives and prevent disability,” such a surgical robot champion could quickly establish itself as the low-cost specialist for LMICs and also become an instant revenue champion for its developers and investors.

 AR through the keyhole
Dr Shafi Ahmed, a Bangladeshi-born cancer surgeon at The Royal London Hospital, used his AR specs when removing a tumor from the colon of a London man in his 70s. With a 360-degree camera rig mounted over the operating table, Ahmed captured every movement from the procedure in 4K and livestreamed it globally.

It is moments like this from his OR that the future of the “digital OR” begins to glimmer with potential: “About 13,000 students from 113 countries tuned in, sending Ahmed questions that popped up on the lower corner of his Glass – to which he replied by simply speaking out loud.”

That was AR used in teaching, and that’s the extent of surgical AR today. The next step is to push AR through the keyhole of minimally invasive surgery, down deep into the dark interior of the human body.

When technology comes to automate the operating room once again, AR through the keyhole might well be its first innovation; and sometime thereafter, the AR specs might well be worn by a surgical robot.

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