April 2, 2014 • 41 mins
How are robots used in medical procedures today? We look at the history, present and future of robotic surgery. Is it effective?
Learn more about your ad-choices at https://www.iheartpodcastnetwork.com
See omnystudio.com/listener for privacy information.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Brought to you by Toyota. Let's go places. Welcome to
Forward Thinking. Hey there, everyone, and welcome to Forward Thinking,
the podcast that looks at the future and says, doctor, doctor,
give me the news. I'm Jonathan Strickland, I'm Lauren, and
(00:20):
I'm Joe McCormick. So, um, I heard you guys had
a movie scene that you wanted to talk about. But
it's a movie. It's a movie I have not actually watched,
so I don't know what you're talking about here. You're
gonna have to tell everybody what you Jonathan. It's an
R rated film. That's why I wasn't able to get in.
You're not allowed to go to those. It was the
movie Prometheus, which I, like a lot of people had
(00:44):
some questions about. It involved a lot of really shady
plot lining. I hear. It was a beautiful film. Oh,
it was very pretty, and its vision of the relatively
near feature was really interesting in a number of ways,
some of which um are terrible and some of which
are are genuinely fascinating. There was one scene in particular
(01:06):
that I thought might be kind of relevant to this show,
and that scene is a horrifying, uh kind of body
violation scene featuring a dramatic surgery performed uh spur of
the moment, kind of entirely by a robot, right, not
by a human at all. It's automated, so one of
the surgery pod things I've heard about, right, right. Yeah,
(01:28):
the character hops into a big glass coffin and then
some knives pop out and start doing their thing. So
I guess this leads us into a discussion about robotic
surgery and how that's uh, that's a real thing, but
not necessarily a real horror show thing like what you
have just briefly described, right, No one would hope that
(01:50):
in real life robotic surgery is not quite so scary
and is in fact a good thing. Um though, I
guess we can debate that as it comes up. Sure, now,
this is not a new idea. It's not that robotic
surgery has debuted in the last year or two. It's
actually been around for a while. In fact, the first
documented case I could find was a case back in
(02:10):
five and it was using a surgical arm called the
Puma five sixty uh, used during a neurological biopsy. Now
this particular, in this particular case, the robot, as I
understand it was not performing the surgery, but was being
used in conjunction with this biopsy. UH. As the years
went on, you started to see more and more use
(02:31):
of robots because people were like engineers and doctors were
saying there was a lot of potential there. Other doctors
were very hesitant because we're talking about very delicate procedures.
This is in many cases a life or death situation,
and you don't want to take any liberties with that
kind of thing obviously, UM. But over the next couple
of years they started using them in other procedures robotic arms.
(02:54):
That is, for laparoscopic procedures, for example, which usually means
there's some uh your sing a flexible optic camera as
well for minimally invasive surgery in order to UM to
be able to handle things inside the body without having
to make a huge open cut, right and uh, laparoscopic
procedures can be performed by hand. Sure, I want to
(03:15):
make clear that's not something that's necessarily unique to robots.
So there are a lot of surgeons who have trained
in this art of trying to make small incisions in
the body and stick in their instruments and sort of
do what they need to do in there without making
big open cuts. But of course there are limitations to
what you can do by hand in that sense, and
we can talk about that more in a minuture. And
(03:37):
then we had other robots, and clearly one called robo Doc,
which is probably my favorite name, UH was the first
robot approved by the f d A, and they also
approved the STOP robotic system for endoscopic surgeries back in UH.
These the SAP led into another development. There was another
robot called Zeus, which followed a SUP and after use UH,
(04:00):
the work that went into ESOP and Zeus later informed
engineers who built the Da Vinci systems, which are probably
the best known robotic surgery tools out there right now.
They're the ones that if you read a story about
robotic surgery nine times off ten, it's a Da Vinci
system that we're talking about. Sure, they were finally approved
for FDA use in the year two thousand and UH.
(04:23):
We've even seen some transcontinental surgeries performed using robots because
one of the other things we'll talk about is that
using a robot assistant essentially or a robot, you know,
think of the robot as a replacement for the surgeon's
actual hands means that the surgeon could potentially perform that
surgery while not even being present within the room. They
(04:44):
could be and that, like in this case, on the
other side of a continent. So that's kind of exciting. Um,
So we're gonna talk about all of that, but we
should also mention that it's not this using robots and
surgeries not something that was immediately embraced, and still to
this day, it is a controversial subject. It's one of
(05:05):
those that has there are a lot of both advantages
and disadvantages, and you have to weigh them very heavily
before you can say outright is it a good or
bad thing? Especially you know, it may be particular case
to case basis. But a two thousand four report in
the Annals of Surgery urged caution and skepticism about robotic surgery,
saying that this is a direct quote, robotic surgery is
(05:26):
a new and exciting emerging technology that's taking the surgical
profession by storm. Up to this point, however, the race
to acquire and incorporate this emerging technology has primarily been
driven by the market. In addition, surgical robots have become
the entry fee for centers wanting to be known for
excellence and mentally invasive surgery despite the current lack of
(05:47):
practical applications. Therefore, robotic devices seem to have more of
a marketing role than a practical role. Whether or not
robotic devices will grow into a more practical role remains
to be seen. Uh And in fact, the report went
on to suggect us that it's possible that by the
time robot surgery would be practical enough for it to
be universally adopted, something better would come along, which is,
(06:10):
you know, another thing to consider. Yeah, well, one thing
this brings up. The first thing I would say to
note is that that was from two thousand four and
things have come a long way since then. But the
other thing to note, I think is that it's pretty
much inarguable that in the future robotic surgery will offer
big benefits. So the big questions are does it currently
(06:31):
offer big benefits now? And I think that's where most
of the controversy lies. Well. And like I said, there
is also that possibility that by the time robotic surgery
can demonstrably show that it is beneficial, that something else
comes along by that point. But I expect that they're
going to be at least a few surgical procedures that
(06:53):
will still benefit from robotic surgery even if something else
comes along. I can't see, and granted this might be
uh short sightedness on my part, but I can't see
some magical techniques sweep in and revolutionized surgery across the
board to the point where the robotic surgery progress we
see right now ends up being futile. Well, nanobots, rot
(07:17):
healing fog um. Well, that brings up a good point, actually,
which is something that I want to clarify before we
move on. We keep saying robotic surgery, and that's often
the term people use when they're talking about these existing systems.
But if you have in mind the definition of a robot,
one thing that should be pretty central to that is autonomy,
(07:38):
something that that's often the case. Yeah, I think I
think for a lot of us, when we hear the
word robot, we think of some form of autonomous being
that is capable of of following instructions from a human
but is able to do so on its own. It
doesn't have to necessarily have human oversight or control every
step of the way. Now that's not the case with
(07:59):
all robot but it's the ones like like when we
think of manufacturing robots, they're automated, right, It's not someone
who's actually moving levers so that a giant arm is
going to to weld a card door onto a frame.
That's not how that works. It's all automated. That's not
necessarily a case with surgery. With surgery, what we're generally
talking about is what should probably be called robot assisted surgery,
(08:20):
at least for today, meaning that what happens when you
go in for robot surgery is a surgeon sits down,
a human surgeon sits down at a terminal and controls
a device that cuts you and does all kinds of
wonderful things inside your body. That was such a magical description.
Uh yeah, So usually you have a combination of things.
(08:44):
In fact, you you you really do need a combination
of things, including you have to have some sort of
camera view inside the patient, usually so you have a
monitor that gives you a view of what you're doing.
From what I understand, using these monitors is incredible challenging
for people, and the reason for that is that one
your your actions maybe in reverse to what you're seeing
(09:07):
on the monitor. Right, It's not like a mirror where
if you move right, the instrument moves right. Uh, if
you're doing this by hand. So let's say that you
have your you're using tools that are inside the patient.
There's a camera inside the patient, you're watching a monitor,
and you are moving based upon what you see there.
So if you move the instrument right, you may see
(09:28):
in the monitor that the instruments moving left, So that
could be very confusing. It can be difficult to coordinate
your hand eye coordination so that you don't cause any problems.
It requires practice, like anyone who's had to change the
button configuration on on their Xbox. It's like that, but
times a million, and with a person. So and then
you also have the issues of you might not have
(09:49):
the right kind of haptic feedback while you're working within
the patients, so it's harder for you to judge if
you are cutting into healthy tissue, or if you're cutting
into anything at all, or especially if you don't want
to be cutting into something. Um There's also the challenge
of the fact that you're working within a three dimensional
environment a patient's body, and you're looking at it on
a two dimensional screen. These are all challenges that we
(10:12):
humans have to overcome in order to be able to
do this successfully. And and of course there are some
surgeons out there who are really really good at it.
But the idea was that maybe with robots and UH
and offloading some of that control over to an automated system.
Will not maybe automated, but a robotic system could minimize
some of those challenges or at least make them easier
(10:35):
to overcome. Certainly, and some some code developing technologies are
making this easier. For for example, we have the ability
to put stereoscopic cameras inside patients these days and create
and on the spot three D model of what's going on.
So so that kind of thing can can vastly improve
the experience of the doctor and the patient who are
going through this kind of surgery. Another thing that's developing
(10:57):
is the idea of the force feedback. Yeah, you can
um with these robotic systems. The controls you have in
your hand have the potential to give you resistance so
that you feel as if you're actually cutting right. So
you and you can also up from some of these
systems having barriers so that once you reach a certain level,
(11:18):
like if you have if you have designated certain tissue
as being healthy, and your your robotic UH instrument is
getting closer and closer to cutting into that you start
encountering more resistance, which essentially tells you to back off
until the point at which I mean, like some some
of these robots will actually stop if they hit one
of these barriers that you have defined to make sure
(11:38):
that they will not cut open something that they're not
supposed to, right, So in this case, you know, it's
it requires that you have to define these areas. It's
not that the robot automatically necessarily knows uh that something
is healthy tissue versus not healthy. Although we're seeing some
other technologies come out that are pretty cool that could
aid in that where if you were to pair those
(11:58):
technologies with the robotic systems, we could eventually get to
a point where we have robotic tools that can on
the fly determine whether or not the tissue you're working
with is healthier diseased. Are you talking about the vaporizing
I knife. Absolutely, that's a cool thing, different technology, not robotic,
but very cool for surgery. The ideas you're cutting on um,
(12:21):
say you're trying to exercise a tumor. This is a
knife that. Uh, it burns the tissue as it's cutting
it and then sniffs the smoke to tell if the
place you're cutting is cancer us or not. And that
allows you to know almost instantly where the margins should be,
so you could understand, I mean you could you could
easily imagine a robotic system that incorporates some sort of
(12:43):
technology similar to that and being able to aid a
doctor even if you're not able to ahead of time
determine exactly what zones are good zones versus bad zones.
So um, Yeah, we're talking a lot about what we'll
talk mostly about the Da Vinci line think because again
that's probably the most popular I would imagine. UM. It's
(13:04):
it's built. Like I said, upon the success of previous
UH projects like ESOP and Zeus, Um, it's one that
you can, you know, if you hear about robotic surgery, UH,
it tends to be the systems that pops up. I
mean occasionally you might run into some of the older ones,
but this is the one that I think is considered
the state of the art these days. Yeah, I was wondering, well,
(13:26):
what kind of procedures are done with robot assisted surgeries
these days? I think a big one is prostate surgery. Yeah,
that's that's the one. A lot of the studies have
been around prostate surgeries in particular. In fact, I've read
several statements that it's basically becoming the norm in prostate surgery,
like these days, you're just likely to get a robot
(13:47):
assistant procedure if you go in for a prostate act
to me, yeah, this is this is one of those
deals where uh, it's it's been shown to be an
effective means of of performing surgery. Uh. In fact, we'll
talk a little bit later about a study that specifically
looked at cases of people who underwent prostate surgery and
(14:08):
had a you know, the ones that had robotic assisted
prostate surgery versus the ones that we're going to just
strictly human surgeons. And it's an interesting result, actually very
promising for the future of robotic surgery in general. But
beyond that, I've also seen that it's being used for
things like coronary uttery bypasses, gall bladder removal, hip replacement,
(14:29):
kidney removal or or transplants, hysterectomys, and more, although not
necessarily with the same success rate as prostate surgery. Right,
there are questions about all these, but I think before
that we should talk about what at least are the
proposed advantages that a robotic system could provide over a
standard open surgery or a handheld laper scopic surgery. Well,
(14:54):
it's finally tuned as surgeons hands are. As you were
saying before, think Joe, robots can can operate at a
much smaller and more delicate level than than even the
very best human surgeon. So you therefore have the opportunity
to make your surgeries minimally invasive. And that just basically
(15:14):
means having smaller incisions, um you know, in some cases
for heart surgeries, not having to crack the breastbone, which
is a terrific boon as you can imagine. Right. Well,
there are actually two aspects to that. One, I guess
is the whole minimally invasive approach, and the other is
just the scaling down of movement in general, which no
(15:35):
matter what situation you're in, it does give you an
advantage as a surgeon. To imagine, say you want to
move your hand one centimeter, but that translates to I
don't know much smaller measure of the actual tool moving
maybe one millimeter. Oh sure, yeah, you can. You can design.
In fact, these these robots systems are designed so that
they can translate human movements into much smaller like like
(15:58):
it's a scales it down so much that you can
make very very precise movements that would be difficult for
even the most skilled surgeons. Going on with that minimally
invasive there are a lot of benefits to that, right,
I mean apart from just the fact that you already
mentioned one with heart surgery, I mean, not having to
crack the breastbone is huge. Uh. The fact that any
time you're going to have minimally invasive, if that's the
(16:20):
way it goes, you're gonna have smaller incisions, so you
heal faster. There's a much lower risk of infection. Uh,
it tends to be people people have reported having better
quality of life after that kind of surgery. It's less
trauma to the body, and that overall, especially in the
case of someone who needs surgery for anything, is probably
going to be uh pretty important. Right. And again, like
(16:41):
we said, minimally invasive doesn't necessarily mean that it was
robotic surgery. A human can do these uh sort of
procedures too. But robots can do them and a degree
that we just can't write. The idea is that you
can go further and further down that rabbit hole of
of being minimally invasive, even to the point of perhaps
just having single incision surgeries. I saw a cool uh
(17:05):
TED talk with a person named Katherine Moore, and she
was talking about a prototype of a surgical robot that
would be a single incision surgical robot. So it just
it inserts, say just a single tube into the patient
through a single incision, and out of that tube comes
your camera and several telescoping surgical instruments, so you don't
(17:28):
even have to come in from multiple directions. That would
be pretty incredible. Yeah, So the benefits there are pretty
pretty easy to understand. The idea that you heal faster,
that you have much lower risk of infection. I mean,
that's that's huge important news. The precision is also really
important because again, you can end up having a surgical
procedure where you get the specific UH outcome that you
(17:53):
desire with as few side effects as possible, right right.
And you can also with the precision factor in things
like a robotic control system for your hands. So imagine that. Well,
you don't have to imagine. You probably know from experience
that human hands are not perfectly steady. You know, even
somebody with the surgeon's hands might have slight tremors in
(18:16):
their movement, especially after you've been doing a surgery for
some seven or eight hours. In these procedures are not
necessarily quick, right, So, uh, what if you have a
machine that is able to detect unintended tremmors in your
movement and filter those out? Well, in fact, that's something
that Da Vinci claims to do with their systems. So
(18:38):
in other words, uh, the movements that the surgeon makes
consciously are the only ones that get translated into actual
surgical procedures. Anything that was an unconscious movement is filtered out,
and thus you don't end up negatively impacting the patient. Right. Um, So,
there have been a lot of questions about whether robot
assisted surgery offers any like measurable bowl net benefit to
(19:01):
the patient today. Right, Because, as it turns out, one
of the things we'll talk more about a little bit later,
these systems are really really expensive. So to justify the expense,
you have to say, well, what's the actual benefit is there?
A benefit. Well, we mentioned prostate cancer that that robotic
surgery is kind of the norm for prostate cancer these days.
I think that that's the only one that's been proven
(19:22):
by scientific study to to have an advantage. I don't
know if it's the only one, that's the only one
I've seen. Okay, well, well, to to be fair, robotic
surgery is still even though it started back in it's
still relatively young, and it's hard to do, uh, studies
to show continued success because you don't have a lot
of you don't have a very large pool of patients
(19:43):
to look at. It's a relatively small sample size, right,
and very few of them have had robotic surgery long
enough ago for you to say, look, you know, and
at five years the success rate was blah blah blah,
ten years. You know, we don't have enough of a
size there. But we have had some studies, right. Uh.
The one I wanted to talk about that you just mentioned, Lauren,
(20:04):
was the one about prostate surgery. It was a U c.
L A study. It was published in February in the
journal European Urology, and it found that prostate cancer surgeries
performed by robotically assisted surgeons as opposed to the traditional
open procedures have a superior success rate, like measurably. Uh.
They measured the cancer margins in excised tissue from these
(20:26):
removed prostates, and the robotic surgery was quote associated with
five percent fewer positive margins. So that was thirteen point
six percent versus eighteen point three percent. And in a
cancer surgery, you don't want positive margins, you want the
thing removed. Positive margins means that there was cancer at
the edge of the thing they took out, which suggests
(20:47):
that there could still be cancer cells left within the patient, right. Uh.
And so what's more, the patients who had the robotic
surgery in these uh in this study had a one
third reduction in the likelihood of needing to get another
therapy for their cancer within the next two years. That's
and that you know, for cancer patients, that's a that's
(21:09):
huge news too. I mean, obviously, managing cancer is is
a life altering experience, and uh so any patient who
would have that kind of um benefit, I mean, it's
kind of hard to I don't know that you can
overstate how beneficial it is. So another potential advantage we
talked about briefly, or a little bit earlier, was the
(21:31):
ability to perform surgery. A doctor could perform surgery even
if that doctor is nowhere near the patient using robotics,
using a telesurgery, right, the idea of telepresence, where the
doctor's presence is pretty much taken up by this this
robot that's following the doctor's commands, right, And that can
be terrific for many different situations. If you've got an
(21:53):
expert in a certain kind of surgery, um, but he
or she cannot be in the physical location or cannot
be there quickly enough to perform surgery, then uh yeah, yeah.
This is one of those things I often hear about
for cases where you have people, like say in a
scientific research center in a really remote location like I
don't know, Antarctica, and you may or may not have
(22:16):
someone at that center who has the training and ability
to perform particular medical procedures. But if you had one
of these robots and the ability to connect with someone
who does have that expertise, you could still have that performed.
You know, you might be in a place and you know,
Antarctica obviously is an extreme example, but it's also but
it's also one that's realistic because there are scientific research
(22:38):
centers in Antarctica and it's not easy to get people
in and out of them. Right. Well, you can't always
predict when you're going to need a complicated surgery. I mean,
what if you're down there and suddenly you need an
appendeck to me and if that has to happen fast
and if you don't, you know, if you don't have
the means of getting someone to come and grab them
by air and lift them out, and if you know
(22:58):
that's just not an option, then you really are limited.
So these are there are definitely cases in extreme circumstances
where this would be really really useful. Right And though
we have seen that tested before, telesurgery is more thought of,
I think as a potential future benefit than as a
really current benefit. Yeah, there's some big challenges there too.
(23:21):
As of right now, the latency issue. Even though we
are getting faster and faster computers and internet connections, um,
it's still not quite quickly enough that I would personally
want someone um performing robotic surgery from across the country
and certainly not from like Antarctica. Right, So latency just
in case you guys don't know. That's essentially the delay
between when you take an action and when that action
(23:42):
is carried out by whatever electronic device you're using, right,
And so it's really frustrating when you're like playing a
shooter game online. It could be deadly if you're like
cutting somebody exactly. Yeah, So it's one of those things
that we have to get better and better at at
delivering high speed uh access. And that's we're starting to
(24:03):
see that happen. But yeah, like you said, Lauren, it's
it's one of those things that is kind of delaying
tellusurgery from being a common practice in the present. Though.
One interesting way around that could be the development of
more autonomy in the surgical robots themselves, where you've got
robots that are well trained enough that they can do
the precision activity on their own with merely kind of
(24:27):
a supervising human surgeon on the other end, who doesn't
have to do each individual cut with his or her hand. Well,
we'll talk more about autonomy and the challenges there too. Uh.
And then we have one other benefit here that I
see the idea that a robots can take our jobs. Yeah, no,
that's a great thing. Um no, No, honestly it is.
(24:47):
I mean, surgery requires multiple staff members to be on hand.
I'm sometimes working, as I said before, for very long
hours under really high degrees of concentration, which can lead
to a lot of fatigue and honestly medical problems for
those surgical staffers themselves. UM. Automation could could really allow
for needing you know, fewer surgeons and nurses on hand,
(25:08):
thus thus reducing their workload and reducing their personal fatigue. Um.
And could also increase the number of surgeons capable of
performing certain complex surgeries. Um. It could it could overall
potentially reduce the cost of surgeries due to you know,
needing fewer staffs that staff members on hand. Um. But hey,
(25:31):
let's talk about that wacky cost thing, because that's kind
of a big issue. Well, I was going to say,
because I agree that that is a potential benefit for
the future, but as of now, these kinds of systems
are more labor intensive and cost more. Um. So yes,
it's it's no secret that robotic surgery is mega expensive,
(25:52):
so of course you know they're going to negotiate prices.
But to get a ballpark idea, there was a two
thousand eight New York Times article that reported DaVinci systems
we're selling for an average of one point three million
a piece up front, that was And so you take
that and then you add on hundreds of thousands more
dollars in service upgrades and components that you have to
(26:12):
replace after every surgery or at least very frequent right.
But but but they've got to be cheaper now, right,
I mean, so today they have to be cheaper, right. Yeah.
A piece that was published from the Wall Street Journal
just today. We are recording this, by the way, on
April first, so hopefully this is not an April Fools joke.
But but yeah, they reported that the current range for
(26:36):
da Vinci systems is some one point eight five million
dollars to two point three million dollars. I don't know
if those numbers may include some of those other extra
costs I was talking about rolled in. That's the possibility.
I I it did not give me specific details it down.
But so robotic procedures in general are more costly than
traditional surgeries. Just one example, there's a study published in
(26:59):
jama in uh and it tried to compare costs for
US one specific procedure. So it was just looking at
robotically assisted hysterectomys versus laparoscopic hysterectomies that traditionally you know,
laparoscopic done by hand among women with benign gynecologic disease.
That was the title. Uh. And the study found that
(27:19):
the robotically assisted surgeries and the laparoscopic history ectomies had
similar morbidity rates, but the robots were more costly. So
the outcomes were comparable, but the robot procedures were just
more expensive. On average, the total costs of a robotically
assisted procedure were two thousand, one and eighty nine dollars
(27:39):
more than for a laparoscopic procedure. Right, So we're starting
to see kind of those those criticisms that were brought
up in that two thousand four report are still, at
least in some cases, uh, possibly valid. I mean, the
idea that a robotic assisted procedure may come across as
more of a marketing tool than a practical will in
(28:00):
the in the current state of the way the technology
fairs right now. Right, there's this idea among some surgeons
that there's this possible illusion of advantage caused by the
dazzling technology of a robotic surgeon. Um. So, some surgeons
have alleged that patients seem to want robotic procedures even
if the patients are told that they cost more, and
(28:23):
there's no evidence in this particular case that they're better
than the old surgery. Uh, it's just like they seem
to see the option of a robot and think, wow,
that looks really high tech. It must be the best,
and so they want to go with it, even if
it's not necessarily the best. If it's just as good
but costs a lot more, um so that that would
(28:44):
be a problem. On top of that, The other issue
or ain't another issue I should say, is that these
these systems are not small. We're not talking about a
robotic arm that fits on a little side table and
you just lay it down next to the patients. It's
not like inspector gat backpack. No, we haven't reached that
level yet either. Yeah, these are big, big systems, which
(29:05):
means they take up a lot of rooms, so you
have to have the space to to house them and
be able to move them around. And when you add
that to the cost, so we're talking about the cost
of purchasing, maintaining housing this thing, being able to move
it around the facility. UH, you know those. This means
that it creates a really big barrier for a lot
of medical centers to uh, And they have to make
(29:27):
a tough decision. Do they go and invest in getting
one of these things and making sure that their facility
can handle it? Uh? Spending all that money knowing that,
at least for some procedures, there is not a scientifically
measurable benefit to having that versus the traditional procedures. Do
they go ahead and do that anyway? Uh? And and
(29:51):
by doing that, they know that they're not going to
be able to use that same money for something else.
And this is a big issue. A lot of medical
centers feel pressured to go into getting these robotic surgery
systems because again, there's this perception that the newest is
the best, and therefore if they don't have it in
order to be considered a good center, then they're going
(30:12):
to need this exactly right. If they don't have it,
then they're not obviously not a cutting edge medical center.
So it's kind of this this rough place right now. Now.
That's not to say that robotic surgery isn't going to
continue to improve. I fully believe that we're going to
see it. Sure. I mean robotics overall as a field
is is improving probably every day and every year. It's
(30:35):
pretty incredible. I got worse yesterday, but I got twice
as better today, so it's averaging out. Yeah, we just
say that the line is on a constant incline. I mean,
you see some dips here and there, but you know
the trend is there. Well, you know, speaking of that,
it's not like these machines are are insusceptible to things
like recalls, like any other bit of machinery. There was
(30:57):
a class to recall of Da Vinci models see robots
in because a friction issue was causing some robots to
freeze up during surgeries. UM. It was it was determined
that that probably these machines weren't being tested entirely properly
before leaving the factory UM, which was causing these small malfunctions.
It is a it is a small recall in a class.
(31:19):
To recall a product could cause temporary or medically reversible
problems in a patient. So it's a voluntary thing and
the device doesn't need to be taken off the market.
But you know it's I just wanted to say like
that kind of stuff does happen, right, Well, there have
been people who have actually criticized robotic surgical procedures for
being they think dangerous or there there are legitimate safety questions,
(31:42):
right right. They may be, they may not always be reliable, right. Uh. Yeah.
In a small anonymous survey of a hundred and seventy
six doctors, some fifty seven percent of surgeons who had
used a da Vinci machine for prostate surgery UM said
that they had experienced and irrecoverable intraoperative malfunction either before
or during a surgery, which I'm not positive about the
(32:03):
definition of that, but I'm pretty sure it's like a
surgical blue screen of death. Yeah, yeah, that's that's a
phrase you don't want to hear during any kind of
medical procedures. Blue screen of death. Absolutely not. And okay, so,
so surgery has always come with a certain amount of risk.
You are you are never going to be completely safe
when people are cutting you open and doing stuff to
your inside, sure, or just undergoing general anesthesia. Oh absolutely,
(32:27):
there There are any number of wacky things that can
go wrong with our bodies at any given moment, let
alone when we're when we're in a hospital. Um, which
was probably the cheeriest thing I've ever said on this show.
But sorry, guys, them's the facts were weird meat machines. Um. Furthermore,
the under reporting of things going wrong during surgeries to
the f d A is widely accepted to be an issue. Um,
(32:51):
I mean not not just in robotic surgery, and in
any kind of surgery across the medical industry in general. However,
researchers at Johns Hopkins did a study of the Da
Vinci surgeries that had taken place between the year two
thousand and twenty twelve and found evidence that adverse events
related to these devices maybe and I quote vastly under
(33:11):
reported and in fact, in question was officially raised by
the American Congress of Obstetricians and Gynecologists about the usefulness
of robotic his direct Me procedures. Um. So some one
in nine women will undergo his direct Me at some
point in her life. Um. And it's also the type
(33:32):
of robotic surgery that's apparently the most likely to cause
a patient harm. Some fort of patient injuries that have
been reported. Um, we're during this type of surgery in fact, um,
so you know, they also went into everything else that
we've talked about with with cost and all of that.
But but this surgical procedure in particular might have been
(33:53):
one that was adopted too widely, too soon. Yeah, you
see that over and over the idea from the critics
of robotic surgery. They're they're criticizing not so much the
idea in UH in theory, but just as it's practice,
were rolling it out too fast. Yeah, and the marketing
is too aggressive with with the prostate removal surgeries. I
(34:16):
would say that using robotic surgery in general has been
rolled up pretty quickly across a lot of different surgical procedures.
With the prostate removal surgery, as that study from U
c l A found out, it actually looks like there's
a demonstrable benefit there and that that's that's fantastic. Whether
or not that was rolled out too quickly in that surgery,
(34:36):
I don't know, but it does look like they're uh,
it is definitely beneficial to have the robotic assisted surgery,
But in other cases we may not be there yet.
It doesn't mean we won't get there. It just means
that the implementation we have right now may not be ideal.
In fact, it may not even be anything wrong with
the technology. It may be that surgeons are still learning
(34:57):
how to use it at its most effective way. So
there may be some cases where it's I wouldn't call
it human failures so much as we haven't figured out
how to leverage the technology in the way that's most beneficial. Right. Well,
one thing that would obviously be a big benefit in
the future would be the idea of autonomous surgery, like
truly autonomous robotic surgery, unless you tick off your autonomous
(35:20):
robotic surgeon, in which case you know you've got terminator
all over the place. That actually kind of also comes
into play in Prometheus because it occurred to incurred to
me that the ship's doctor is the android character. So
so you're technically dealing with all robot surgery all the
time on that ship, and not all of it goes well. Okay.
So well, here's the thing about autonomous autonomous robotic surgery
(35:41):
is I think it's a really interesting idea. I think
it's going to be one of the most challenging applications
for any sort of autonomous robot. First of all, we're
really far out from having autonomous robots that could do
something as delicate as a surgical procedure delicate and important. Yeah,
without without human uh interaction, without without a human controlling it.
(36:05):
And the reason why I say that is because not
only are we talking about life or death procedures, but
we're also talking about the human body, which does not
come in one shape and size. Right, There's a lot
of variation there. Even with a simple, quote unquote simple
surgical procedure, you can have a lot of complications that
can crop up, and robots have to be able to adapt,
(36:29):
to recognize a detective adapt exactly just the way a
human would, and that's hard to do. But that does
raise the question of how would you do this? How
would you program a robot to autonomously performer a surgical procedure?
And I think one of the things that would be
really crucial to this would be a learning robot. So
(36:50):
perhaps a robot that would be connected to the to
the human controlled system, so it studies what the human
surgeons do. Maybe you give it ten thou zen surgeries
to analyze, You select your ten thousand best variations of
the same surgery, and say learn from these. Honestly, I
would imagine that it would have to involve a lot
(37:10):
of work with human cadavers too, you would have to.
I had an opportunity to talk with some robotics experts recently,
and uh, then they were showing me robots that do learn,
and they learned by you showing them that you want
them to do certain tasks in a certain order, and
if they make a mistake, you can correct them, so
(37:31):
that they learned that. All right, that was an exception
to what I'm supposed to do. I won't do that again.
And then once they learned the procedure, they'll repeat it
exactly over and over and over again. However, that's also
a procedure that involves uniform material that doesn't change from
case to case. So it's different from surgery. Yeah, so
so you're going to need to, I mean a just
(37:52):
like I, like a human surgeon, have a lot of
practice on things what can't be hurt. Be those be
those models or cadavers, um and and be incorporate a
whole lot of sensory technology, like like the most advanced
room bow you have ever met in your life, that
that is able to tell from from the inside of
you what you what its surroundings are. There is a
(38:12):
lot of potential there for it to really revolutionize the
way we think about medicine. I mean, right now, medicine
is a thing you go to, right, you go to
the hospital, you go to the doctor. But if you
could have, say a really versatile general robotic surgeon that's
small enough to fit in a backpack, I mean that
(38:33):
what a bizarre world that would be that you could
carry around a limitless supply of medical treatment with you
where you go. But I would I would let myself
get critically injured all the time. I mean, as opposed
to just happening accidentally, and I just you're inviting it. Well,
you can see how that would make a big difference
(38:54):
for say, people who are in any kind of exploring capacity,
so you're exploring space, or you're exploring remote wilderness, or
a military capacity on things like a triage on the battlefield.
So now I'm thinking that the quote I should have
used should have been a movie quota show said pain
don't hurt, because I didn't realize that that was Lauren's philosophy. Um,
(39:15):
but you hadn't, this would be this would be pretty phenomenal.
And these are advances that we do think are quite
a ways down the road. We don't want We don't
want anyone to go away from this episode thinking, oh,
you know, within like a year or two, we're going
to have these incredible robots. These are these are enormous challenges,
(39:35):
and not that they are challenges that will never overcome.
It's just gonna take a lot of work. I expect
that there will be such a thing. Whether I see
it in my lifetime or not, I don't know, um,
but I I certainly hope to see extreme advances in
this field. I think it's could be incredibly beneficial. One
of the other interesting things, and we didn't really cover
(39:57):
this earlier on, is a robotic surg tree is one
of those fields where there seems to be another issue
with cost, and that generally speaking with electronics, we think
the longer something has been around, the less expensive it
tends to be because we improve on manufacturing processes, materials
become cheaper, we streamline everything, and so therefore you end
(40:17):
up saving money down the road. Uh. The one criticism
I've seen about robotic surgery says that at least in
these stages, that's probably not going to be true because
while we perfect means of creating robotic surgery tools, from
for that we're state of the art like three years ago.
We're continuously improving all the other technologies that you would
(40:39):
want to include with the current generation of robotic surgeons,
thus keeping that price either steady or climbing. Uh for
the for the near future, Oh, share in medical research alone.
I mean, I mean the capacity to test all of
this is very expensive, and that's not going to get
cheaper ever, right right, unless we can suddenly start cloning
(41:00):
beings and have absolutely no ethical issues with it. It's
uh that probably will come after we have robotic surgeons. Jonathan,
why do you have to end every podcast with the
idea of cutting up clones? I everybody needs a hobby.
And on that note, if you guys have any suggestions
for future episodes of Forward Thinking, let us know. Send
(41:21):
us an email our addresses f W Thinking at Discovery
dot com, or drop us a line on Twitter, Facebook,
Google Plus. We are at all three of those with
the handle f W Thinking and we will talk to
you again really soon. For more on this topic in
the future of technology, visit forward thinking dot Com, brought
(41:55):
to you by Toyota. Let's go places
Brought to you by Toyota. Let's go places. Welcome to
Forward Thinking. Hey there, everyone, and welcome to Forward Thinking,
the podcast that looks at the future and says, doctor, doctor,
give me the news. I'm Jonathan Strickland, I'm Lauren, and
(00:20):
I'm Joe McCormick. So, um, I heard you guys had
a movie scene that you wanted to talk about. But
it's a movie. It's a movie I have not actually watched,
so I don't know what you're talking about here. You're
gonna have to tell everybody what you Jonathan. It's an
R rated film. That's why I wasn't able to get in.
You're not allowed to go to those. It was the
movie Prometheus, which I, like a lot of people had
(00:44):
some questions about. It involved a lot of really shady
plot lining. I hear. It was a beautiful film. Oh,
it was very pretty, and its vision of the relatively
near feature was really interesting in a number of ways,
some of which um are terrible and some of which
are are genuinely fascinating. There was one scene in particular
(01:06):
that I thought might be kind of relevant to this show,
and that scene is a horrifying, uh kind of body
violation scene featuring a dramatic surgery performed uh spur of
the moment, kind of entirely by a robot, right, not
by a human at all. It's automated, so one of
the surgery pod things I've heard about, right, right. Yeah,
(01:28):
the character hops into a big glass coffin and then
some knives pop out and start doing their thing. So
I guess this leads us into a discussion about robotic
surgery and how that's uh, that's a real thing, but
not necessarily a real horror show thing like what you
have just briefly described, right, No one would hope that
(01:50):
in real life robotic surgery is not quite so scary
and is in fact a good thing. Um though, I
guess we can debate that as it comes up. Sure, now,
this is not a new idea. It's not that robotic
surgery has debuted in the last year or two. It's
actually been around for a while. In fact, the first
documented case I could find was a case back in
(02:10):
five and it was using a surgical arm called the
Puma five sixty uh, used during a neurological biopsy. Now
this particular, in this particular case, the robot, as I
understand it was not performing the surgery, but was being
used in conjunction with this biopsy. UH. As the years
went on, you started to see more and more use
(02:31):
of robots because people were like engineers and doctors were
saying there was a lot of potential there. Other doctors
were very hesitant because we're talking about very delicate procedures.
This is in many cases a life or death situation,
and you don't want to take any liberties with that
kind of thing obviously, UM. But over the next couple
of years they started using them in other procedures robotic arms.
(02:54):
That is, for laparoscopic procedures, for example, which usually means
there's some uh your sing a flexible optic camera as
well for minimally invasive surgery in order to UM to
be able to handle things inside the body without having
to make a huge open cut, right and uh, laparoscopic
procedures can be performed by hand. Sure, I want to
(03:15):
make clear that's not something that's necessarily unique to robots.
So there are a lot of surgeons who have trained
in this art of trying to make small incisions in
the body and stick in their instruments and sort of
do what they need to do in there without making
big open cuts. But of course there are limitations to
what you can do by hand in that sense, and
we can talk about that more in a minuture. And
(03:37):
then we had other robots, and clearly one called robo Doc,
which is probably my favorite name, UH was the first
robot approved by the f d A, and they also
approved the STOP robotic system for endoscopic surgeries back in UH.
These the SAP led into another development. There was another
robot called Zeus, which followed a SUP and after use UH,
(04:00):
the work that went into ESOP and Zeus later informed
engineers who built the Da Vinci systems, which are probably
the best known robotic surgery tools out there right now.
They're the ones that if you read a story about
robotic surgery nine times off ten, it's a Da Vinci
system that we're talking about. Sure, they were finally approved
for FDA use in the year two thousand and UH.
(04:23):
We've even seen some transcontinental surgeries performed using robots because
one of the other things we'll talk about is that
using a robot assistant essentially or a robot, you know,
think of the robot as a replacement for the surgeon's
actual hands means that the surgeon could potentially perform that
surgery while not even being present within the room. They
(04:44):
could be and that, like in this case, on the
other side of a continent. So that's kind of exciting. Um,
So we're gonna talk about all of that, but we
should also mention that it's not this using robots and
surgeries not something that was immediately embraced, and still to
this day, it is a controversial subject. It's one of
(05:05):
those that has there are a lot of both advantages
and disadvantages, and you have to weigh them very heavily
before you can say outright is it a good or
bad thing? Especially you know, it may be particular case
to case basis. But a two thousand four report in
the Annals of Surgery urged caution and skepticism about robotic surgery,
saying that this is a direct quote, robotic surgery is
(05:26):
a new and exciting emerging technology that's taking the surgical
profession by storm. Up to this point, however, the race
to acquire and incorporate this emerging technology has primarily been
driven by the market. In addition, surgical robots have become
the entry fee for centers wanting to be known for
excellence and mentally invasive surgery despite the current lack of
(05:47):
practical applications. Therefore, robotic devices seem to have more of
a marketing role than a practical role. Whether or not
robotic devices will grow into a more practical role remains
to be seen. Uh And in fact, the report went
on to suggect us that it's possible that by the
time robot surgery would be practical enough for it to
be universally adopted, something better would come along, which is,
(06:10):
you know, another thing to consider. Yeah, well, one thing
this brings up. The first thing I would say to
note is that that was from two thousand four and
things have come a long way since then. But the
other thing to note, I think is that it's pretty
much inarguable that in the future robotic surgery will offer
big benefits. So the big questions are does it currently
(06:31):
offer big benefits now? And I think that's where most
of the controversy lies. Well. And like I said, there
is also that possibility that by the time robotic surgery
can demonstrably show that it is beneficial, that something else
comes along by that point. But I expect that they're
going to be at least a few surgical procedures that
(06:53):
will still benefit from robotic surgery even if something else
comes along. I can't see, and granted this might be
uh short sightedness on my part, but I can't see
some magical techniques sweep in and revolutionized surgery across the
board to the point where the robotic surgery progress we
see right now ends up being futile. Well, nanobots, rot
(07:17):
healing fog um. Well, that brings up a good point, actually,
which is something that I want to clarify before we
move on. We keep saying robotic surgery, and that's often
the term people use when they're talking about these existing systems.
But if you have in mind the definition of a robot,
one thing that should be pretty central to that is autonomy,
(07:38):
something that that's often the case. Yeah, I think I
think for a lot of us, when we hear the
word robot, we think of some form of autonomous being
that is capable of of following instructions from a human
but is able to do so on its own. It
doesn't have to necessarily have human oversight or control every
step of the way. Now that's not the case with
(07:59):
all robot but it's the ones like like when we
think of manufacturing robots, they're automated, right, It's not someone
who's actually moving levers so that a giant arm is
going to to weld a card door onto a frame.
That's not how that works. It's all automated. That's not
necessarily a case with surgery. With surgery, what we're generally
talking about is what should probably be called robot assisted surgery,
(08:20):
at least for today, meaning that what happens when you
go in for robot surgery is a surgeon sits down,
a human surgeon sits down at a terminal and controls
a device that cuts you and does all kinds of
wonderful things inside your body. That was such a magical description.
Uh yeah, So usually you have a combination of things.
(08:44):
In fact, you you you really do need a combination
of things, including you have to have some sort of
camera view inside the patient, usually so you have a
monitor that gives you a view of what you're doing.
From what I understand, using these monitors is incredible challenging
for people, and the reason for that is that one
your your actions maybe in reverse to what you're seeing
(09:07):
on the monitor. Right, It's not like a mirror where
if you move right, the instrument moves right. Uh, if
you're doing this by hand. So let's say that you
have your you're using tools that are inside the patient.
There's a camera inside the patient, you're watching a monitor,
and you are moving based upon what you see there.
So if you move the instrument right, you may see
(09:28):
in the monitor that the instruments moving left, So that
could be very confusing. It can be difficult to coordinate
your hand eye coordination so that you don't cause any problems.
It requires practice, like anyone who's had to change the
button configuration on on their Xbox. It's like that, but
times a million, and with a person. So and then
you also have the issues of you might not have
(09:49):
the right kind of haptic feedback while you're working within
the patients, so it's harder for you to judge if
you are cutting into healthy tissue, or if you're cutting
into anything at all, or especially if you don't want
to be cutting into something. Um There's also the challenge
of the fact that you're working within a three dimensional
environment a patient's body, and you're looking at it on
a two dimensional screen. These are all challenges that we
(10:12):
humans have to overcome in order to be able to
do this successfully. And and of course there are some
surgeons out there who are really really good at it.
But the idea was that maybe with robots and UH
and offloading some of that control over to an automated system.
Will not maybe automated, but a robotic system could minimize
some of those challenges or at least make them easier
(10:35):
to overcome. Certainly, and some some code developing technologies are
making this easier. For for example, we have the ability
to put stereoscopic cameras inside patients these days and create
and on the spot three D model of what's going on.
So so that kind of thing can can vastly improve
the experience of the doctor and the patient who are
going through this kind of surgery. Another thing that's developing
(10:57):
is the idea of the force feedback. Yeah, you can
um with these robotic systems. The controls you have in
your hand have the potential to give you resistance so
that you feel as if you're actually cutting right. So
you and you can also up from some of these
systems having barriers so that once you reach a certain level,
(11:18):
like if you have if you have designated certain tissue
as being healthy, and your your robotic UH instrument is
getting closer and closer to cutting into that you start
encountering more resistance, which essentially tells you to back off
until the point at which I mean, like some some
of these robots will actually stop if they hit one
of these barriers that you have defined to make sure
(11:38):
that they will not cut open something that they're not
supposed to, right, So in this case, you know, it's
it requires that you have to define these areas. It's
not that the robot automatically necessarily knows uh that something
is healthy tissue versus not healthy. Although we're seeing some
other technologies come out that are pretty cool that could
aid in that where if you were to pair those
(11:58):
technologies with the robotic systems, we could eventually get to
a point where we have robotic tools that can on
the fly determine whether or not the tissue you're working
with is healthier diseased. Are you talking about the vaporizing
I knife. Absolutely, that's a cool thing, different technology, not robotic,
but very cool for surgery. The ideas you're cutting on um,
(12:21):
say you're trying to exercise a tumor. This is a
knife that. Uh, it burns the tissue as it's cutting
it and then sniffs the smoke to tell if the
place you're cutting is cancer us or not. And that
allows you to know almost instantly where the margins should be,
so you could understand, I mean you could you could
easily imagine a robotic system that incorporates some sort of
(12:43):
technology similar to that and being able to aid a
doctor even if you're not able to ahead of time
determine exactly what zones are good zones versus bad zones.
So um, Yeah, we're talking a lot about what we'll
talk mostly about the Da Vinci line think because again
that's probably the most popular I would imagine. UM. It's
(13:04):
it's built. Like I said, upon the success of previous
UH projects like ESOP and Zeus, Um, it's one that
you can, you know, if you hear about robotic surgery, UH,
it tends to be the systems that pops up. I
mean occasionally you might run into some of the older ones,
but this is the one that I think is considered
the state of the art these days. Yeah, I was wondering, well,
(13:26):
what kind of procedures are done with robot assisted surgeries
these days? I think a big one is prostate surgery. Yeah,
that's that's the one. A lot of the studies have
been around prostate surgeries in particular. In fact, I've read
several statements that it's basically becoming the norm in prostate surgery,
like these days, you're just likely to get a robot
(13:47):
assistant procedure if you go in for a prostate act
to me, yeah, this is this is one of those
deals where uh, it's it's been shown to be an
effective means of of performing surgery. Uh. In fact, we'll
talk a little bit later about a study that specifically
looked at cases of people who underwent prostate surgery and
(14:08):
had a you know, the ones that had robotic assisted
prostate surgery versus the ones that we're going to just
strictly human surgeons. And it's an interesting result, actually very
promising for the future of robotic surgery in general. But
beyond that, I've also seen that it's being used for
things like coronary uttery bypasses, gall bladder removal, hip replacement,
(14:29):
kidney removal or or transplants, hysterectomys, and more, although not
necessarily with the same success rate as prostate surgery. Right,
there are questions about all these, but I think before
that we should talk about what at least are the
proposed advantages that a robotic system could provide over a
standard open surgery or a handheld laper scopic surgery. Well,
(14:54):
it's finally tuned as surgeons hands are. As you were
saying before, think Joe, robots can can operate at a
much smaller and more delicate level than than even the
very best human surgeon. So you therefore have the opportunity
to make your surgeries minimally invasive. And that just basically
(15:14):
means having smaller incisions, um you know, in some cases
for heart surgeries, not having to crack the breastbone, which
is a terrific boon as you can imagine. Right. Well,
there are actually two aspects to that. One, I guess
is the whole minimally invasive approach, and the other is
just the scaling down of movement in general, which no
(15:35):
matter what situation you're in, it does give you an
advantage as a surgeon. To imagine, say you want to
move your hand one centimeter, but that translates to I
don't know much smaller measure of the actual tool moving
maybe one millimeter. Oh sure, yeah, you can. You can design.
In fact, these these robots systems are designed so that
they can translate human movements into much smaller like like
(15:58):
it's a scales it down so much that you can
make very very precise movements that would be difficult for
even the most skilled surgeons. Going on with that minimally
invasive there are a lot of benefits to that, right,
I mean apart from just the fact that you already
mentioned one with heart surgery, I mean, not having to
crack the breastbone is huge. Uh. The fact that any
time you're going to have minimally invasive, if that's the
(16:20):
way it goes, you're gonna have smaller incisions, so you
heal faster. There's a much lower risk of infection. Uh,
it tends to be people people have reported having better
quality of life after that kind of surgery. It's less
trauma to the body, and that overall, especially in the
case of someone who needs surgery for anything, is probably
going to be uh pretty important. Right. And again, like
(16:41):
we said, minimally invasive doesn't necessarily mean that it was
robotic surgery. A human can do these uh sort of
procedures too. But robots can do them and a degree
that we just can't write. The idea is that you
can go further and further down that rabbit hole of
of being minimally invasive, even to the point of perhaps
just having single incision surgeries. I saw a cool uh
(17:05):
TED talk with a person named Katherine Moore, and she
was talking about a prototype of a surgical robot that
would be a single incision surgical robot. So it just
it inserts, say just a single tube into the patient
through a single incision, and out of that tube comes
your camera and several telescoping surgical instruments, so you don't
(17:28):
even have to come in from multiple directions. That would
be pretty incredible. Yeah, So the benefits there are pretty
pretty easy to understand. The idea that you heal faster,
that you have much lower risk of infection. I mean,
that's that's huge important news. The precision is also really
important because again, you can end up having a surgical
procedure where you get the specific UH outcome that you
(17:53):
desire with as few side effects as possible, right right.
And you can also with the precision factor in things
like a robotic control system for your hands. So imagine that. Well,
you don't have to imagine. You probably know from experience
that human hands are not perfectly steady. You know, even
somebody with the surgeon's hands might have slight tremors in
(18:16):
their movement, especially after you've been doing a surgery for
some seven or eight hours. In these procedures are not
necessarily quick, right, So, uh, what if you have a
machine that is able to detect unintended tremmors in your
movement and filter those out? Well, in fact, that's something
that Da Vinci claims to do with their systems. So
(18:38):
in other words, uh, the movements that the surgeon makes
consciously are the only ones that get translated into actual
surgical procedures. Anything that was an unconscious movement is filtered out,
and thus you don't end up negatively impacting the patient. Right. Um, So,
there have been a lot of questions about whether robot
assisted surgery offers any like measurable bowl net benefit to
(19:01):
the patient today. Right, Because, as it turns out, one
of the things we'll talk more about a little bit later,
these systems are really really expensive. So to justify the expense,
you have to say, well, what's the actual benefit is there?
A benefit. Well, we mentioned prostate cancer that that robotic
surgery is kind of the norm for prostate cancer these days.
I think that that's the only one that's been proven
(19:22):
by scientific study to to have an advantage. I don't
know if it's the only one, that's the only one
I've seen. Okay, well, well, to to be fair, robotic
surgery is still even though it started back in it's
still relatively young, and it's hard to do, uh, studies
to show continued success because you don't have a lot
of you don't have a very large pool of patients
(19:43):
to look at. It's a relatively small sample size, right,
and very few of them have had robotic surgery long
enough ago for you to say, look, you know, and
at five years the success rate was blah blah blah,
ten years. You know, we don't have enough of a
size there. But we have had some studies, right. Uh.
The one I wanted to talk about that you just mentioned, Lauren,
(20:04):
was the one about prostate surgery. It was a U c.
L A study. It was published in February in the
journal European Urology, and it found that prostate cancer surgeries
performed by robotically assisted surgeons as opposed to the traditional
open procedures have a superior success rate, like measurably. Uh.
They measured the cancer margins in excised tissue from these
(20:26):
removed prostates, and the robotic surgery was quote associated with
five percent fewer positive margins. So that was thirteen point
six percent versus eighteen point three percent. And in a
cancer surgery, you don't want positive margins, you want the
thing removed. Positive margins means that there was cancer at
the edge of the thing they took out, which suggests
(20:47):
that there could still be cancer cells left within the patient, right. Uh.
And so what's more, the patients who had the robotic
surgery in these uh in this study had a one
third reduction in the likelihood of needing to get another
therapy for their cancer within the next two years. That's
and that you know, for cancer patients, that's a that's
(21:09):
huge news too. I mean, obviously, managing cancer is is
a life altering experience, and uh so any patient who
would have that kind of um benefit, I mean, it's
kind of hard to I don't know that you can
overstate how beneficial it is. So another potential advantage we
talked about briefly, or a little bit earlier, was the
(21:31):
ability to perform surgery. A doctor could perform surgery even
if that doctor is nowhere near the patient using robotics,
using a telesurgery, right, the idea of telepresence, where the
doctor's presence is pretty much taken up by this this
robot that's following the doctor's commands, right, And that can
be terrific for many different situations. If you've got an
(21:53):
expert in a certain kind of surgery, um, but he
or she cannot be in the physical location or cannot
be there quickly enough to perform surgery, then uh yeah, yeah.
This is one of those things I often hear about
for cases where you have people, like say in a
scientific research center in a really remote location like I
don't know, Antarctica, and you may or may not have
(22:16):
someone at that center who has the training and ability
to perform particular medical procedures. But if you had one
of these robots and the ability to connect with someone
who does have that expertise, you could still have that performed.
You know, you might be in a place and you know,
Antarctica obviously is an extreme example, but it's also but
it's also one that's realistic because there are scientific research
(22:38):
centers in Antarctica and it's not easy to get people
in and out of them. Right. Well, you can't always
predict when you're going to need a complicated surgery. I mean,
what if you're down there and suddenly you need an
appendeck to me and if that has to happen fast
and if you don't, you know, if you don't have
the means of getting someone to come and grab them
by air and lift them out, and if you know
(22:58):
that's just not an option, then you really are limited.
So these are there are definitely cases in extreme circumstances
where this would be really really useful. Right And though
we have seen that tested before, telesurgery is more thought of,
I think as a potential future benefit than as a
really current benefit. Yeah, there's some big challenges there too.
(23:21):
As of right now, the latency issue. Even though we
are getting faster and faster computers and internet connections, um,
it's still not quite quickly enough that I would personally
want someone um performing robotic surgery from across the country
and certainly not from like Antarctica. Right, So latency just
in case you guys don't know. That's essentially the delay
between when you take an action and when that action
(23:42):
is carried out by whatever electronic device you're using, right,
And so it's really frustrating when you're like playing a
shooter game online. It could be deadly if you're like
cutting somebody exactly. Yeah, So it's one of those things
that we have to get better and better at at
delivering high speed uh access. And that's we're starting to
(24:03):
see that happen. But yeah, like you said, Lauren, it's
it's one of those things that is kind of delaying
tellusurgery from being a common practice in the present. Though.
One interesting way around that could be the development of
more autonomy in the surgical robots themselves, where you've got
robots that are well trained enough that they can do
the precision activity on their own with merely kind of
(24:27):
a supervising human surgeon on the other end, who doesn't
have to do each individual cut with his or her hand. Well,
we'll talk more about autonomy and the challenges there too. Uh.
And then we have one other benefit here that I
see the idea that a robots can take our jobs. Yeah, no,
that's a great thing. Um no, No, honestly it is.
(24:47):
I mean, surgery requires multiple staff members to be on hand.
I'm sometimes working, as I said before, for very long
hours under really high degrees of concentration, which can lead
to a lot of fatigue and honestly medical problems for
those surgical staffers themselves. UM. Automation could could really allow
for needing you know, fewer surgeons and nurses on hand,
(25:08):
thus thus reducing their workload and reducing their personal fatigue. Um.
And could also increase the number of surgeons capable of
performing certain complex surgeries. Um. It could it could overall
potentially reduce the cost of surgeries due to you know,
needing fewer staffs that staff members on hand. Um. But hey,
(25:31):
let's talk about that wacky cost thing, because that's kind
of a big issue. Well, I was going to say,
because I agree that that is a potential benefit for
the future, but as of now, these kinds of systems
are more labor intensive and cost more. Um. So yes,
it's it's no secret that robotic surgery is mega expensive,
(25:52):
so of course you know they're going to negotiate prices.
But to get a ballpark idea, there was a two
thousand eight New York Times article that reported DaVinci systems
we're selling for an average of one point three million
a piece up front, that was And so you take
that and then you add on hundreds of thousands more
dollars in service upgrades and components that you have to
(26:12):
replace after every surgery or at least very frequent right.
But but but they've got to be cheaper now, right,
I mean, so today they have to be cheaper, right. Yeah.
A piece that was published from the Wall Street Journal
just today. We are recording this, by the way, on
April first, so hopefully this is not an April Fools joke.
But but yeah, they reported that the current range for
(26:36):
da Vinci systems is some one point eight five million
dollars to two point three million dollars. I don't know
if those numbers may include some of those other extra
costs I was talking about rolled in. That's the possibility.
I I it did not give me specific details it down.
But so robotic procedures in general are more costly than
traditional surgeries. Just one example, there's a study published in
(26:59):
jama in uh and it tried to compare costs for
US one specific procedure. So it was just looking at
robotically assisted hysterectomys versus laparoscopic hysterectomies that traditionally you know,
laparoscopic done by hand among women with benign gynecologic disease.
That was the title. Uh. And the study found that
(27:19):
the robotically assisted surgeries and the laparoscopic history ectomies had
similar morbidity rates, but the robots were more costly. So
the outcomes were comparable, but the robot procedures were just
more expensive. On average, the total costs of a robotically
assisted procedure were two thousand, one and eighty nine dollars
(27:39):
more than for a laparoscopic procedure. Right, So we're starting
to see kind of those those criticisms that were brought
up in that two thousand four report are still, at
least in some cases, uh, possibly valid. I mean, the
idea that a robotic assisted procedure may come across as
more of a marketing tool than a practical will in
(28:00):
the in the current state of the way the technology
fairs right now. Right, there's this idea among some surgeons
that there's this possible illusion of advantage caused by the
dazzling technology of a robotic surgeon. Um. So, some surgeons
have alleged that patients seem to want robotic procedures even
if the patients are told that they cost more, and
(28:23):
there's no evidence in this particular case that they're better
than the old surgery. Uh, it's just like they seem
to see the option of a robot and think, wow,
that looks really high tech. It must be the best,
and so they want to go with it, even if
it's not necessarily the best. If it's just as good
but costs a lot more, um so that that would
(28:44):
be a problem. On top of that, The other issue
or ain't another issue I should say, is that these
these systems are not small. We're not talking about a
robotic arm that fits on a little side table and
you just lay it down next to the patients. It's
not like inspector gat backpack. No, we haven't reached that
level yet either. Yeah, these are big, big systems, which
(29:05):
means they take up a lot of rooms, so you
have to have the space to to house them and
be able to move them around. And when you add
that to the cost, so we're talking about the cost
of purchasing, maintaining housing this thing, being able to move
it around the facility. UH, you know those. This means
that it creates a really big barrier for a lot
of medical centers to uh, And they have to make
(29:27):
a tough decision. Do they go and invest in getting
one of these things and making sure that their facility
can handle it? Uh? Spending all that money knowing that,
at least for some procedures, there is not a scientifically
measurable benefit to having that versus the traditional procedures. Do
they go ahead and do that anyway? Uh? And and
(29:51):
by doing that, they know that they're not going to
be able to use that same money for something else.
And this is a big issue. A lot of medical
centers feel pressured to go into getting these robotic surgery
systems because again, there's this perception that the newest is
the best, and therefore if they don't have it in
order to be considered a good center, then they're going
(30:12):
to need this exactly right. If they don't have it,
then they're not obviously not a cutting edge medical center.
So it's kind of this this rough place right now. Now.
That's not to say that robotic surgery isn't going to
continue to improve. I fully believe that we're going to
see it. Sure. I mean robotics overall as a field
is is improving probably every day and every year. It's
(30:35):
pretty incredible. I got worse yesterday, but I got twice
as better today, so it's averaging out. Yeah, we just
say that the line is on a constant incline. I mean,
you see some dips here and there, but you know
the trend is there. Well, you know, speaking of that,
it's not like these machines are are insusceptible to things
like recalls, like any other bit of machinery. There was
(30:57):
a class to recall of Da Vinci models see robots
in because a friction issue was causing some robots to
freeze up during surgeries. UM. It was it was determined
that that probably these machines weren't being tested entirely properly
before leaving the factory UM, which was causing these small malfunctions.
It is a it is a small recall in a class.
(31:19):
To recall a product could cause temporary or medically reversible
problems in a patient. So it's a voluntary thing and
the device doesn't need to be taken off the market.
But you know it's I just wanted to say like
that kind of stuff does happen, right, Well, there have
been people who have actually criticized robotic surgical procedures for
being they think dangerous or there there are legitimate safety questions,
(31:42):
right right. They may be, they may not always be reliable, right. Uh. Yeah.
In a small anonymous survey of a hundred and seventy
six doctors, some fifty seven percent of surgeons who had
used a da Vinci machine for prostate surgery UM said
that they had experienced and irrecoverable intraoperative malfunction either before
or during a surgery, which I'm not positive about the
(32:03):
definition of that, but I'm pretty sure it's like a
surgical blue screen of death. Yeah, yeah, that's that's a
phrase you don't want to hear during any kind of
medical procedures. Blue screen of death. Absolutely not. And okay, so,
so surgery has always come with a certain amount of risk.
You are you are never going to be completely safe
when people are cutting you open and doing stuff to
your inside, sure, or just undergoing general anesthesia. Oh absolutely,
(32:27):
there There are any number of wacky things that can
go wrong with our bodies at any given moment, let
alone when we're when we're in a hospital. Um, which
was probably the cheeriest thing I've ever said on this show.
But sorry, guys, them's the facts were weird meat machines. Um. Furthermore,
the under reporting of things going wrong during surgeries to
the f d A is widely accepted to be an issue. Um,
(32:51):
I mean not not just in robotic surgery, and in
any kind of surgery across the medical industry in general. However,
researchers at Johns Hopkins did a study of the Da
Vinci surgeries that had taken place between the year two
thousand and twenty twelve and found evidence that adverse events
related to these devices maybe and I quote vastly under
(33:11):
reported and in fact, in question was officially raised by
the American Congress of Obstetricians and Gynecologists about the usefulness
of robotic his direct Me procedures. Um. So some one
in nine women will undergo his direct Me at some
point in her life. Um. And it's also the type
(33:32):
of robotic surgery that's apparently the most likely to cause
a patient harm. Some fort of patient injuries that have
been reported. Um, we're during this type of surgery in fact, um,
so you know, they also went into everything else that
we've talked about with with cost and all of that.
But but this surgical procedure in particular might have been
(33:53):
one that was adopted too widely, too soon. Yeah, you
see that over and over the idea from the critics
of robotic surgery. They're they're criticizing not so much the
idea in UH in theory, but just as it's practice,
were rolling it out too fast. Yeah, and the marketing
is too aggressive with with the prostate removal surgeries. I
(34:16):
would say that using robotic surgery in general has been
rolled up pretty quickly across a lot of different surgical procedures.
With the prostate removal surgery, as that study from U
c l A found out, it actually looks like there's
a demonstrable benefit there and that that's that's fantastic. Whether
or not that was rolled out too quickly in that surgery,
(34:36):
I don't know, but it does look like they're uh,
it is definitely beneficial to have the robotic assisted surgery,
But in other cases we may not be there yet.
It doesn't mean we won't get there. It just means
that the implementation we have right now may not be ideal.
In fact, it may not even be anything wrong with
the technology. It may be that surgeons are still learning
(34:57):
how to use it at its most effective way. So
there may be some cases where it's I wouldn't call
it human failures so much as we haven't figured out
how to leverage the technology in the way that's most beneficial. Right. Well,
one thing that would obviously be a big benefit in
the future would be the idea of autonomous surgery, like
truly autonomous robotic surgery, unless you tick off your autonomous
(35:20):
robotic surgeon, in which case you know you've got terminator
all over the place. That actually kind of also comes
into play in Prometheus because it occurred to incurred to
me that the ship's doctor is the android character. So
so you're technically dealing with all robot surgery all the
time on that ship, and not all of it goes well. Okay.
So well, here's the thing about autonomous autonomous robotic surgery
(35:41):
is I think it's a really interesting idea. I think
it's going to be one of the most challenging applications
for any sort of autonomous robot. First of all, we're
really far out from having autonomous robots that could do
something as delicate as a surgical procedure delicate and important. Yeah,
without without human uh interaction, without without a human controlling it.
(36:05):
And the reason why I say that is because not
only are we talking about life or death procedures, but
we're also talking about the human body, which does not
come in one shape and size. Right, There's a lot
of variation there. Even with a simple, quote unquote simple
surgical procedure, you can have a lot of complications that
can crop up, and robots have to be able to adapt,
(36:29):
to recognize a detective adapt exactly just the way a
human would, and that's hard to do. But that does
raise the question of how would you do this? How
would you program a robot to autonomously performer a surgical procedure?
And I think one of the things that would be
really crucial to this would be a learning robot. So
(36:50):
perhaps a robot that would be connected to the to
the human controlled system, so it studies what the human
surgeons do. Maybe you give it ten thou zen surgeries
to analyze, You select your ten thousand best variations of
the same surgery, and say learn from these. Honestly, I
would imagine that it would have to involve a lot
(37:10):
of work with human cadavers too, you would have to.
I had an opportunity to talk with some robotics experts recently,
and uh, then they were showing me robots that do learn,
and they learned by you showing them that you want
them to do certain tasks in a certain order, and
if they make a mistake, you can correct them, so
(37:31):
that they learned that. All right, that was an exception
to what I'm supposed to do. I won't do that again.
And then once they learned the procedure, they'll repeat it
exactly over and over and over again. However, that's also
a procedure that involves uniform material that doesn't change from
case to case. So it's different from surgery. Yeah, so
so you're going to need to, I mean a just
(37:52):
like I, like a human surgeon, have a lot of
practice on things what can't be hurt. Be those be
those models or cadavers, um and and be incorporate a
whole lot of sensory technology, like like the most advanced
room bow you have ever met in your life, that
that is able to tell from from the inside of
you what you what its surroundings are. There is a
(38:12):
lot of potential there for it to really revolutionize the
way we think about medicine. I mean, right now, medicine
is a thing you go to, right, you go to
the hospital, you go to the doctor. But if you
could have, say a really versatile general robotic surgeon that's
small enough to fit in a backpack, I mean that
(38:33):
what a bizarre world that would be that you could
carry around a limitless supply of medical treatment with you
where you go. But I would I would let myself
get critically injured all the time. I mean, as opposed
to just happening accidentally, and I just you're inviting it. Well,
you can see how that would make a big difference
(38:54):
for say, people who are in any kind of exploring capacity,
so you're exploring space, or you're exploring remote wilderness, or
a military capacity on things like a triage on the battlefield.
So now I'm thinking that the quote I should have
used should have been a movie quota show said pain
don't hurt, because I didn't realize that that was Lauren's philosophy. Um,
(39:15):
but you hadn't, this would be this would be pretty phenomenal.
And these are advances that we do think are quite
a ways down the road. We don't want We don't
want anyone to go away from this episode thinking, oh,
you know, within like a year or two, we're going
to have these incredible robots. These are these are enormous challenges,
(39:35):
and not that they are challenges that will never overcome.
It's just gonna take a lot of work. I expect
that there will be such a thing. Whether I see
it in my lifetime or not, I don't know, um,
but I I certainly hope to see extreme advances in
this field. I think it's could be incredibly beneficial. One
of the other interesting things, and we didn't really cover
(39:57):
this earlier on, is a robotic surg tree is one
of those fields where there seems to be another issue
with cost, and that generally speaking with electronics, we think
the longer something has been around, the less expensive it
tends to be because we improve on manufacturing processes, materials
become cheaper, we streamline everything, and so therefore you end
(40:17):
up saving money down the road. Uh. The one criticism
I've seen about robotic surgery says that at least in
these stages, that's probably not going to be true because
while we perfect means of creating robotic surgery tools, from
for that we're state of the art like three years ago.
We're continuously improving all the other technologies that you would
(40:39):
want to include with the current generation of robotic surgeons,
thus keeping that price either steady or climbing. Uh for
the for the near future, Oh, share in medical research alone.
I mean, I mean the capacity to test all of
this is very expensive, and that's not going to get
cheaper ever, right right, unless we can suddenly start cloning
(41:00):
beings and have absolutely no ethical issues with it. It's
uh that probably will come after we have robotic surgeons. Jonathan,
why do you have to end every podcast with the
idea of cutting up clones? I everybody needs a hobby.
And on that note, if you guys have any suggestions
for future episodes of Forward Thinking, let us know. Send
(41:21):
us an email our addresses f W Thinking at Discovery
dot com, or drop us a line on Twitter, Facebook,
Google Plus. We are at all three of those with
the handle f W Thinking and we will talk to
you again really soon. For more on this topic in
the future of technology, visit forward thinking dot Com, brought
(41:55):
to you by Toyota. Let's go places
Fw:Thinking News
Hosts And Creators
Jonathan Strickland
Joe McCormick
Lauren Vogelbaum
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Las Culturistas with Matt Rogers and Bowen Yang
Ding dong! Join your culture consultants, Matt Rogers and Bowen Yang, on an unforgettable journey into the beating heart of CULTURE. Alongside sizzling special guests, they GET INTO the hottest pop-culture moments of the day and the formative cultural experiences that turned them into Culturistas. Produced by the Big Money Players Network and iHeartRadio.