Opinion: Is robotic surgery coming to an operating room near you?

Future of robotic surgery

Can a robot do your knee replacement?

The short answer is no, it cannot. There have been some recent news articles highlighting advances in robotic surgery in orthopedics, particularly related to knee replacement surgery.

People are asking questions and I hope this article will inform patients and dispel any misconceptions the public may have.

Actual droid-like robots, resembling humans, do not currently exist for surgical purposes. However, robotic technology is actively under development. The machinery tends to resemble robot-like arms you might see on a car assembly line.

The surgeon must still set up and position the patient, do the surgical approach, map out the anatomy for the robot and a lot of the other standard work necessary for any operation. For knee and hip replacement surgery, these “robots” come in different shapes and sizes and have different features. All of them use navigational technology to assist us in making our bone cuts and preparing the surfaces to accept the new prosthetic joint components.

Currently, we use specialized jigs and cutting guides to make our cuts, and they are reliable but far from perfect. Unfortunately, despite having these guides, there is still a lot of “eyeballing” of cuts and the guides can be misleading in situations where patient anatomy is non-standard or atypical. An example may be a patient who has had a severe fracture close to the joint in the past, and the anatomy is distorted.

Robotic guided surgery enables us to use the system to map out the three-dimensional anatomy of the joint more accurately and reproducibly and then the robot helps us to make the required cuts more precisely without gigs. Some robots even limit where the saw can go, so soft tissues such as ligaments are not inadvertently cut during surgery. In that case there is a safety benefit built in.

The hope is robotic technology will improve the accuracy of our implant positioning, minimize soft tissue trauma, and improve patient outcomes and overall satisfaction with the surgery. Up to 20% of patients who have a knee replacement are not happy with the result, so any improvements would be welcomed by patients and surgeons alike.

The question then arises, why are we not currently using this technology more widely? The answer is more complicated than you may think. First and foremost is the cost. To move forward with robotic surgery, you must buy the machinery required which usually runs in the neighbourhood of $1 million per system. To make this technology widely available for most patients having joint replacement surgery at Kelowna General Hospital we would need two or three of them.

Then there are the costs of disposable items used during each surgery which could run about $500 per case. Some robotic systems require a pre-operative CT scan of the knee, which would increase the cost per case further and lengthen wait lists for CT scans.

A second common barrier to this sort of innovation is the extensive training required for the adopting surgeons. You don’t just unpack the robot and proceed business as usual. If this technology were adopted, surgeons would have to travel to distant centres to train on the equipment, usually at their own expense.

Further supervised on-site training is also required. Then all staff must go through a long and painful learning curve where the robot guided surgeries would take up to 50% longer compared to a normal case. That reduces overall productivity.

A typical full operative day of four knee replacements would be reduced to three for a year or longer until the entire team was up to speed and the surgery could be completed in a comparable time.

Surgeons are paid a fee per service, so losing one case per day equals a 25% pay cut, with no compensation to make up for that. Fewer surgeries would be done in general, impacting the waiting list.

Not every surgeon will be on board to make that sort of sacrifice. Nurses and/or staff would have to be trained and equipment would have to serviced and maintained, all at a cost to the healthcare system.

A final potential barrier to adoption of this robotic technology is the fact there is no clear evidence yet that it would result in superior patient outcomes.

You might think it would be a no brainer but a lot of us in the field are still very skeptical. If improved results cannot be demonstrated conclusively, there is no point adopting such disruptive and costly technology.

Study is ongoing in this regard, and if robotic surgery came to Kelowna General Hospital soon, we would be part of that groundbreaking initial research. It would certainly have to start with a few committed surgeons and a single robot and grow from there, but only if found to be beneficial for patients.

Other dilemmas moving forward would be choosing which patients get the benefit of robot-assisted surgery, given the anticipated gradual rollout and non-universal participation in the project. Some patients might not be as excited to participate, at least early in the trials.

Ultimately, I believe this technology has promise but is still under development and will undoubtably improve over time. One concern would be buying a robot only to have it become obsolete in a couple years.

I know that the orthopedic joint replacement group in Kelowna has an interest in pioneering this robotic surgery at our institution, but the hospital does not have funds in their budget for these types of endeavours.

The only way this moves forward is through interest from the community via donors or a funding campaign through the KGH foundation.

Stay tuned and you might see a robot coming to an operating theatre near you in the future.

Dr. Steven Krywulak is chief of orthopedic surgery at Kelowna General Hospital and practices out of Kelowna Bone and Joint Health.

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