Five questions regarding surgical robot adoption

Surgery continues to drive hospital revenue, with Sg2®, a Vizient® company, projecting a growth rate of 3% for inpatient surgery and 19% for outpatient surgery over the next decade. A key question facing hospital leaders is: How many of these surgeries will be performed robotically?

In recent years, robotic-assisted surgery has seen growth in key service lines, including general surgery, orthopedics, urology and gynecology. Looking forward, Sg2 is projecting further expansion in these areas, along with emerging applications in other specialties such as cardiothoracic surgery, neurosurgery and bariatrics.

Currently, over 35 robotic systems are available across various surgical applications and more than 150 are in development. These next-generation robots are expected to bring advanced capabilities and will likely focus on more procedure-specific applications.

If your organization is considering adopting robotic technology, here are some questions that warrant consideration.

1. How are shifting sites of care impacting robot adoption?

Traditional robots, with their large footprints and required clearance, could be impeding the shift to ambulatory surgery centers (ASCs). Robotic procedures typically have higher supply costs and take longer, two things that don’t play well with the slim margins in ASCs. Besides the space and cost, physician preference for using surgical robots may keep some procedures in hospital-based surgical spaces.

Robotics are, however, advancing to address application and space constraints. A few suppliers have a single chassis system that can be used for the hip, knee, shoulder and spine. Additionally, there's a handheld navigation device that functions similarly to the larger robotic platforms. It is an open platform and can be used with most manufacturers' implants. In a market where manufacturers are marketing directly to patients, and some organizations feel the need to have robotics to stay competitive, a single chassis platform may meet their needs.

2. Does purchasing this robot make sense for our organization?

There are plenty of challenges with robotic assisted surgery (RAS), but no one should minimize the benefits that surgical robot systems bring to a health system’s recruitment strategy and its prestige in the eyes of prospective surgeons. It is up to health system leadership to determine whether the benefits outweigh the costs of buying the next, or first, system. There should be less focus on a single device or company and more emphasis on programmatic thinking to increase the chances of generating a return on investment.

Considerations for investment and deployment:

• Appetite for robotics. Ask for your surgeons’ opinions about the benefits and risks of robotic surgery technology.
• Well-trained, experienced surgeons. Provide training and focus on improving recruitment and retention capabilities. Robots can be an aid in recruiting young surgeons who are trained with the technology.
• Dedicated robotic OR teams. A physician champion and a reliable, consistent team in the OR are critical. The team must work especially well together during surgery and be familiar with the robotic setup, procedure and room turnaround.
• OR schedules and staffing. Longer case times with robotic surgeries affects scheduling.
• Key metrics. Track data and turn them into actionable insights to solidify a robotics program and pinpoint opportunities for expansion.
• Marketing plans. Attract patients with education seminars and diversified advertising to help achieve a positive return on investment.
• Alternative payment model incentives. These may influence the use of high-cost robotic surgery.

3. What are the foundational elements of a good robotics program?

As you look ahead and plan for robotic use at your healthcare system, there are three key elements foundational to any robotics program: patient selection, privileged criteria and monitoring usage and outcomes.

• Patient selection: Robotic surgery should be reserved for complex cases or super-obese patients with proven benefit. Given the price tag for robotic use across all procedures, providers should find the sweet spot where patient benefits outweigh procedure costs.
• Privileging criteria: There is a learning curve associated with robotic use and outcomes. Establishing and maintaining strict privileging criteria will ensure surgeon proficiency and reduce operative time and improve patient outcomes.
• Monitoring: Monitoring robotic usage and outcomes are necessary to validate cost, outcomes and increased access to minimally invasive surgery achieved through robotic utilization and to iterate on robotic strategies currently in place at your healthcare systems.

While tracking internal data at your organization is necessary, peer-reviewed evidence should also play a role, albeit the quality and quantity is highly variable. Regardless, robotic utilization should be reserved and prioritized across procedures that confer both patient and physician benefit to optimize outcomes and costs.

For example, robotic use in ventral hernia repair has shown some benefit in terms of recurrence rates and complications in addition to quality of life or postoperative pain for extremely complex cases. Vizient’s data demonstrates that providers are adopting robotics for inguinal hernia repair, which may reduce the technical complexity of the procedure while conferring some patient benefits in terms of recurrence and pain, but again, only in complex cases.

However, on the other end of the spectrum, patient outcomes in gastrectomy procedures are similar between robotic and laparoscopic approaches, though the robotic approach may confer more of an ergonomic benefit for the physician.

4. Is there a service line experiencing changes that might impact our strategy?

Orthopedic robotics is one category experiencing regular advancements. Changes in technology and new entries into the market will offer new opportunities. Most orthopedic robotic platforms are closed systems, requiring the use of the robotic manufacturers' implants. Purchasing a robot versus alternative models such as placement, cost per click, or rental, which are dependent on multiple factors, is not advisable. With an estimated useful life of seven years, purchasing a robot would lock a hospital into using certain manufacturers' implants with little leverage for negotiations of the implant price. This can vary depending on the long-term strategy for the department.

Given the shift to ambulatory sites of care with its limited space and tighter margins, robotic manufacturers are moving toward implant-agnostic or closed systems that are more compact and easier to use.

5. What innovations are on the horizon that might change market dynamics?

The Da Vinci robot has dominated the market since its entry in 1997. While the Senhance product competes with the Da Vinci robot in U.S. markets, it has not displaced the market leader.

While the competition is still working to penetrate the market, they are being strategic about their approach and innovating to be able to compete with Da Vinci for market share.

• For example, a limitation of the Da Vinci robot is its size, and as the market is looking to move procedures to ASC, new robots like the Hugo (Medtronic) and Ottava (Johnson & Johnson) are introducing modular solutions or hardware integration designs, respectively, that are compatible with typical ASC facility designs.
• Another point for the Di Vinci robot is its haptic feedback. The most recently approved Da Vinci robot has incorporated this feature, but the Hugo robot is also looking to incorporate this technology.
• Artificial intelligence and machine learning are new technologies that will likely be incorporated into future iterations of robots, ideally assisting in real time decision making, improving surgical planning and improving precision.
• Building on current virtual trends, experts expect further advances in telesurgery, enabling surgeons to remotely perform procedures.