The first use of robots in medicine, however, came much later. Robotic surgery originated alongside minimally invasive surgical techniques in an effort to improve sight of the surgical field, as well as extend dexterity beyond that of a surgeon’s hands in the confined spaces of the body. Surgical robots helped provide the fine-motor control and magnified three-dimensional imaging and depth perception generally lost in keyhole surgery.
In 1985, a surgical robot was developed for neurosurgical biopsies, and this was quickly followed by specifically designed equipment to assist in prostate removal and total hip replacements. The da Vinci® robot evolved out of work with telemedicine, and enabled a surgeon to work remote from the patient while directing robotic arms via controls and a display. It was FDA approved for laparoscopic procedures in 2000.
While robotic surgery offers considerable technical advantages over traditional laparoscopy, the improvement in patient outcomes measured in trials ranges from significant to marginal at best. When looking at clinical studies, the appropriate comparison is laparoscopic versus robotic-assisted, not open technique, which generally has a higher complication rate. Disadvantages of robotic surgery, in addition to the up-front capital and maintenance costs, include increased set-up and operating times, and the requirement for additional training. Cost is the key factor in any debate regarding the place of robotic surgery in modern practice.
Handmer and colleagues conducted a randomised study to demonstrate this point. They showed that despite the wide-spread ‘hype’ and adoption of robotic-assisted laparoscopic radical prostatectomy (RALP), Australian Fellowship-trained laparoscopic radical prostatectomy (LRP) surgeons achieve comparable functional outcomes to their robotic-assisted peers. Their advice to patients is to select a surgeon based on experience and trust rather than the ‘tech’ they use.
Private health facilities were early adopters of robotic technology in Australia with a da Vinci system installed at Victoria’s Epworth Hospital in 2003 to perform robotic-assisted radical prostatectomies. In 2008, the Royal Brisbane and Women’s Hospital (RBWH) became the first public hospital in Australia to have a da Vinci Surgical Robot purchased by government funding ($AU 3.5 million, at the time) and thus making the technology available to public patients. Hall and colleagues conducted a cost analysis at the RBWH comparing open radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RALP) and found, due to the activity-based funding formulas in place, the average expense of a RALP admission was approximately $AU 12K while a RRP cost the hospital $AU 2K on average. As indicated above however, that the readmission rate and associated costs for the open group were significantly higher than that of the robotic group. Although not included in his analysis, Hall surmised that these readmissions would impact waiting lists and so ultimately cost the hospital.
To justify its cost, robotic surgery is more suitable for patient groups where there is clear evidence of greater benefit, such as obese patients and those with cancer of the lower rectum, where space is extremely limited. Total knee replacement surgeries, where alignment and positioning of the prosthetic is critical to long-term performance and quality of life. The most obvious use for and benefits of robotic surgery in a country as large as Australia is as a technological add-on for telemedicine in remote and rural areas. For public patients in NSW, the wait has been a long one with robotic assisted procedures only becoming available in 2017 with the opening of the Surgical & Robotics Training Institute at Sydney’s Royal Prince Alfred Hospital. For many patients, robots will continue to be in the realm of science fiction into the foreseeable future.