Doctor Robot will see you now – but it’ll cost you more

Chris Middleton Profile picture for user cmiddleton September 26, 2018
Chris Middleton takes the pulse of robotic surgery and explains what the challenges are in this complex, pricey sector of the market.

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Artificial intelligence (AI) and robotics have long been forecast to play a key role in health and social care this century, as Western economies grapple with the problem of ageing people in ageing cities – on a limited budget.

Combined with sensors, wearable devices, and other technologies, the pattern-recognition ability of AI, for example, has already helped improve diagnoses for a variety of medical conditions, ranging from cancer to diabetes and common heart problems. This opens the door to an age of targeted, preventative medicine, along with lower healthcare costs.

Robots are being developed to connect and look after socially isolated people, while autonomous vehicles could democratise personal transport by making it accessible to all, regardless of age and (dis)ability.

This much is generally known, but less explored from a strategic and policy making standpoint is surgical robotics, which UK-RAS – the robotics research wing of the UK’s Engineering and Physical Sciences Research Council (EPSRC) – addressed recently with one of its excellent research papers.

Surgical robotics has evolved over a quarter century from a niche research field to a burgeoning area of innovation, spearheading research and development in precision medicine, personalised healthcare, and quality-of-life improvements, acknowledges UK-RAS in its paper, Surgical Robotics: The Next 25 Years.

However, while platforms like Intuitive Surgical’s da Vinci robot have been adopted throughout the US and in some UK hospitals to perform minimally invasive surgery, some are large, inflexible, and prohibitively expensive. In this limited sense, they’re analogous to the industrial robots that are gradually being replaced by smaller, smarter, programmable ‘cobots’ in manufacturing.

But the obstacles ahead are not only to do with surgical robots’ size, intelligence, and versatility. For robotic surgery to be clinically successful in the years ahead, according to UK-RAS, challenges need to be met not only in research, but also in regulation, intellectual property protection, and – in some countries – a culture of aggressive litigation.

But for national health services such as the UK’s NHS, financing is the major problem. And with the UK’s future position in Europe still unclear, any loss of a common regulatory framework and market may disrupt capital-intensive, large-scale research and innovation in the field, says UK-RAS.


So what are the other main challenges for the future? The white paper says:

The future will be defined by developments in two disparate yet interconnected settings: the research front and commercial organisations.

Research and development within academic institutions is expected to intensify and innovative solutions for patient benefit will continue to appear. On the other hand, economic sustainability and societal demand require a revisiting of institutional pillars that govern clinical translation. After all, despite the staggering amount of work, very few systems have seen clinical translation.

In short, the adoption of surgical robots to date has been slow, patchy, and unsatisfactory, says UK-RAS.

One reason is that – contrary to industrial robots, most of which operate in controlled zones – the obvious proximity of surgical devices to human beings means they are tightly regulated. For research and development in the field to be more fruitful moving forward, a certain amount of deregulation is essential, says UK-RAS, but without succumbing to market forces that may put public health at risk.

This is particularly true for future systems that entail smart, untethered microbots targeting cancer cells directly – making them closer to drugs than robots, perhaps. According to UK-RAS, there are lessons to be learned from the deregulation in HIV treatment that successfully sped up innovation in the United States in the early 90s.

Private vs Public

However, the differences between the publicly funded NHS in the UK and privatised healthcare in the US are stark, and may pose challenges for the future development of robotic systems.

UK-RAS explains:

Wealthy private hospitals in the United States were able to acquire the da Vinci robot primarily to showcase their technological proficiency. This drove early adoption and increased demand for the robot by hospitals first, and patients second.

The cost of using the robot, further, could be offloaded directly to the patients or insurance companies through increased hospitalisation and surgical fees. In contrast, such an approach was more complex to implement within the NHS structure in the United Kingdom.

In the public funded NHS, the cost could not be offloaded to the patients, but would have to be funded from the national budget. Hence, early adoption in such government-regulated domains is much more challenging.

There are other related issues. Rather than making proficient surgeons better, UK-RAS argues that robotic surgery is likely to improve the overall consistency, safety, and quality of care. It would also make long procedures less strenuous for both patient and doctor. However, these improvements would come via the significant capital cost of the robot, and the recurring operational cost of the associated tools, maintenance, and energy usage.

In other words, surgical robots may make treatment better on average, but at significantly greater cost, which runs counter to UK government’s aim to use technologies to do a lot more with less.

That said, UK-RAS argues that it is premature to evaluate the cost-effectiveness of new robotic systems too early in their adoption phase. Most studies assessing the financial burden of robotic surgery only have access to data from earlier-generation robotic systems. For a fairer comparison, we should wait until more systems have been adopted, says the report: a Catch-22 of sorts.

National Centres of Excellence

A related challenge is the extremely high cost of entry for budding innovators and startups. Successful research and development of surgical robots – not counting regulatory overheads – amounts to many millions of dollars. Such levels of funding are unattainable for entry-level researchers, particularly in the current climate.

As a result, UK-RAS says:

We need national centres of excellence to embed talented researchers to establish a critical mass and, more importantly, a vibrant ecosystem linking academia and industry, for addressing some of the major challenges in surgical robotics.

This issue is analogous to the high cost (time-wise) of software development for robotics, which has been largely disrupted by the Robotics Operating System (ROS).

ROS [] allows reuse of code and modularity to a degree previously unprecedented, and is removing the cost-to-entry for several research projects. A similar approach is required for hardware.

In essence, however, these are complete hardware systems, whereas what the academic community would really benefit from is reusable, modular, compact hardware components and open-source hardware platforms.

Existing endeavours such as Open Bionics and Yale OpenHand should be encouraged and looked to for inspiration, adds the white paper.

In the future, we’re less likely to witness the development of large, expensive platforms, and more likely to see the rise of smaller, smarter, more task-specific instruments that augment surgeons’ skills with advanced imaging and sensing techniques.

UK-RAS says:

Computer-assistance has been developing alongside mechatronic advances in surgical robotics to improve the surgeon’s experience by providing immersive visualisation, stereoscopic high-definition images, and intra-operative feedback through different perceptual channels.

As computational resources become more powerful, the fusion of information from a plethora of sensors makes the robot more and more aware of the surgical environment, and can potentially allow the surgeon to take full advantage of robotic assistance by letting the robot autonomously perform high-accuracy, repetitive sub-tasks under supervision.

Alongside autonomous platforms, UK-RAS predicts that some future surgical robots will work at microscopic scale, either to perform surgery in miniature, or as untethered agents to deliver drugs directly to where they’re needed.

As robot development advances towards the micro and nano scale, clinicians, engineers, and molecular biologists will need to join forces and combine their domain knowledge, says UK-RAS.

My take

A complex knot of challenges that needs to be unpicked with laser precision. For the UK, soon to be cut off from Europe, funding may prove to be a much bigger challenge than the government realises, if it is to reap the benefits from robotics and AI in the cash-strapped NHS.

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