Yuman Fong, M.D., The Sangiacomo Family Chair in Surgical Oncology
In the three decades since robots first entered the operating room, these increasingly sophisticated machines have helped surgeons perform more than a million procedures, all over the human body: Bypassing a clogged artery. Removing a gall bladder. Replacing a hip. Removing liver tumors. And more.
For a growing number of cancer surgeons at City of Hope, robotic surgery is rapidly becoming the new normal. Well over 12,000 robotic procedures have taken place here, and the trend is clear.
“In terms of clinical as well as public acceptance,” said Yuman Fong, M.D., The Sangiacomo Family Chair in Surgical Oncology and chair of the Department of Surgery, “robotic surgery is no longer experimental. It's routine.”
So routine, in fact, that some surgeons now perform most of their procedures robotically, and more clinicians are joining them.
Rise of the Robots
“We are now at a pivotal point in the field,” Fong recently wrote, “when a technology is about to transform from a tool for innovators and experts to a tool for general practitioners.”
Robotic technology builds upon the considerable benefits of minimally invasive, manually performed laparoscopic surgery. Laparoscopy makes tiny incisions, which means less trauma, less blood loss, fewer or even no sutures (often a Band-Aid will do), much less pain and faster recoveries.
With newer robots, surgeons are able to work side-by-side.
The latest robotic machines add an astounding level of precision. 3D video screens enable surgeons to see more (even around corners), while ultra-miniature instruments are guided to remove the smallest, most awkwardly located tumors no human hand could ever reach.
As a result, more patients than ever can be “cured,” even while they spend less time than ever in the hospital.
Take liver surgery,” said Fong. “It used to require at least a day in intensive care, a total of seven to 10 days' hospitalization. With robotics, half our patients go home in 24 to 36 hours. It's practically an outpatient procedure.”
Similar progress is evident in other areas.
“Five years ago,” said Fong, “you couldn't even attempt esophageal surgery robotically. They sneered at you. Now it's the way we do most esophageal procedures. Using robotics for thyroid cancer was impossible five years ago. Now we have three different methods for doing it.”
Fong's colleagues echo his enthusiasm.
“We are doing much more complex surgery for kidney cancer,” said urologist Bertram Yuh, M.D. “[For many] patients who previously would have had their entire kidney removed, we are sparing most of their kidney, even with larger tumors.”
“In the past eight years of my practice,” said Yanghee Woo, M.D., a stomach cancer specialist, “I have performed over 200 robotic surgery operations ... approximately 70 percent of my gastric cancer operations performed for curative intent are using the robotic surgical platform.”
New Players in the Market
The platform is expensive. A robotic machine can cost upward of $2 million, and robotics can add thousands of dollars to the cost of an operation. Competition is expected to bring costs down. New players are entering the market, challenging the dominance of Intuitive, the company behind the da Vinci system used at City of Hope and nearly everywhere else.
Those new players will also speed innovation.
One recently approved technology makes no external incisions at all. Designed by Auris, the Monarch system threads a flexible catheter down a patient's airway to perform lung biopsies and, eventually, to remove diseased tissue. The same system may soon be able to perform urinary tract procedures.
Another competitor, Johnson & Johnson, has partnered with Alphabet – parent company of Google – to marry robotics and artificial intelligence, with an eye toward automating many surgical procedures. This may be the most exciting development of all.
“I believe that surgical automation is a road to offering perfect operations, consistency of procedures and ultimately optimal outcome for our cancer patients,” said Woo – and she's far from alone.
“If we can automate parts of the operation,” suggested Jae Kim, M.D., chief of Thoracic Surgery, “so I can focus more on the parts of the operation that can’t be automated, it would be a win for the patient.”
The Patient Piece
And how do patients feel about looking up, and seeing a machine instead of a human looking back at them?
“A small fraction of patients are amazed by it,” said Kurt Melstrom, M.D., a specialist in colorectal cancer. The rest? “I would say the majority of patients accept it as part of normal surgery ... it has just become another tool that is part of their overall care.”
Fong puts it even more simply.
“Patients don't care,” he said, “as long as the track record is good.”
Surgery Needs Surgeons
The doctor will always be there, Fong insisted. And a robot may not always be the right choice.
“Open surgery isn't going away,” he cautioned. Over the course of his 30-plus year career, Fong has done thousands of open procedures. Though he says he's now “reinventing” himself with robotics, he acknowledges that “some tumors are just too big, some procedures too dangerous, some would take too long” robotically.
“As we train new doctors in robotics, it's critically important to continue to teach open surgery skills as well.”
Ultimately it will always come down to the proficiency of the hands wielding the scalpel or manipulating the computer console.
“Better tools do not make for better surgeons,” said Woo. “They help good surgeons perform better operations.”