A pair of robotic clamps approaches a tiny, glistening orb and proceeds to lay an almond-shaped flap of celluloid-thin skin over exposed flesh. The Da Vinci robot (or, robotic arms remote controlled by a surgeon looking through a high def camera) proceeds to mend a wet grape, the test subject chosen to demonstrate the robot's superhuman suturing ability with perilous, but measured, precision. After a miraculous finale– the execution of a perfect knot– the camera zooms out to underscore the enormity of scale, the fragility of the task, immediately projecting leaps of the imagination to tumors, cysts, and miniscule tissues.
But that's not the end. Rather than fading to black, the video ends on a lengthy disclosure statement listing potential "complications." "[U]p to and including death," it says. This week, that warning rang particularly true: on Monday, MIT released a study linking surgical robotic machine failures to 144 deaths in the US since 2000, finding drastically higher risks for certain types of surgery and far too little study of robots' mechanical reliability.
It's left plenty of people in the press and medical community asking, just because robots can perform on the delicate skin of a grape, should they go to work on the complex web of human fascia?
THE IMPETUS FOR THE DEVELOPMENT OF SUCH A TOOL WAS FAIRLY STRAIGHTFORWARD: surgeons wanted to be able to perform surgeries with as few incisions as possible so patients would recover more quickly and cost hospitals less money. During the 1980s, healthcare in the United States gradually became more centralized — and privatized. Doctors were being paid based on what they billed for with few questions asked. By the end of the decade, it had started to become apparent that this was a system rife with exploitation, and combined with the overall effect of inflation, healthcare was quickly becoming the most massive expenditure of the United States GDP. In 1984, engineers released The Arthrobot: a cross between Siri and a claw machine, piloted by a handful of biomedical engineers at the University of British Columbia, Vancouver. It was even programmed to say, “You are doing a great job.”
Robotic surgery has also been extremely desirable in the military and space travel. In the early ‘90s, after the first successful robot-assisted surgery was performed (a gallbladder removal, or cholecystectomy), NASA began investigating how robotic-assisted surgery could be beneficial in developing what they termed medical “telepresence.” The idea being that, whether a person was in space, a soldier in far-flung corners of a war-torn country, a scientist in the most remote of arctic locales, or even a civilian trapped by a natural disaster, if robots could be deployed and a surgeon could operate the machine remotely, it would likely change the way we practice medicine forever. It would also, perhaps, make humans braver: imagine what expeditions could be pursued if remote health care was accessible. Another popular anecdote is that of a physician behind enemy lines operating remotely on wounded soldiers still on the battlefield using not just robots, but real time, high speed data transmission, which would provide the kind of visuals that are the crux of this technology.
What may have once been considered a pipe dream of science fiction authors has become more and more of a reality: in 2010, the first ever all-robotic surgery was performed in Montreal, where each element of the surgical procedure was robot-assisted.
Robotic medicine in film
1980: Luke Skywalker gets a brain-powered prosthetic hand in Star Wars: The Empire Strikes Back
1987: Police officer Alex Murphy's body is reconstructed as a robot in RoboCop
1996: Geordi La Forge replaces VISOR with ocular implants in Star Trek: First Contact (one of numerous examples of not-so-far-off futuristic medicine in the series)
1997: 3D organ and tissue printing in The Fifth Element
2012: Robotic surgery in Prometheus
2013: Raven II (an actual research robot) in Ender's Game
2013: A robot which scans for and cures diseases in Elysium
Obstetrician/gynecologist and surgeon John Petrozza Jr., M.D. was one of the first physicians to utilize robotic technology when it came to Mass General Hospital in 2005– the technology was first introduced into areas involving fine suturing, like urology and reproductive medicine. He’d already been making use of laparoscopic techniques for many of the gynecological surgeries he performed, so when a surgical robot arrived at the hospital (to the tune of $1 million), he wasn’t sure what to do with it at first.
Petrozza and his colleagues were trained on inanimate objects—practicing suturing on foam and maneuvering peg transfers—and in “dry labs,” experimenting on computer-generated models. They graduated to anesthetized pigs and were then proctored on five human cases before taking on their own. He quickly discovered that through robot-assisted surgery, he could suture in ways he never had before; “The robot is basically an extension of our arms, but it allows us to control things a little bit differently, to create angles that we don’t have with traditional surgery and allows us to maneuver a little bit differently, like using your non-dominant hand.”
To be clear, the relationship is a master-slave one; the robot doesn’t make any decisions and merely responds to orders. Petrozza mainly chooses to use the technology for “those procedures that were very suture-intensive,” since suturing requires fine motor skills and can be fairly nuanced, particularly in gynecologic surgeries. But as technology evolves, Petrozza, who has been using the technology at Mass Gen for almost ten years now, isn’t ruling it out the possibility of a true robot surgeon.
Between 2007 and 2011, robot-assisted surgeries grew by 400% in the United States. By 2013, hospitals had purchased about 1,400 da Vinci systems.
Between 2007 and 2013, over 1 740 000 robotic procedures were performed in the U.S.
and robot money
Petrozza says that if his robotic arms were to fail him mid-surgery, he feels confident that he could finish the job. “If necessary I could disengage the robot and convert the procedure [to either an open or laparoscopic surgery],” he says, “but if a surgeon wasn’t confident in those traditional methods and had only been trained on a robot — what would they do?”
Considering the current state of robotic surgical technology, that leaves plenty of terrifying scenarios—from mechanical failure at the most basic levels to program interference.
This past April, a study at the University of Washington robotics lab tested DoS attacks on a Raven II, a laparoscopic surgical robot with seven arms specifically designed for research purposes. Attacks made it significantly harder to grasp and move blocks, which “makes sense,” the authors noted, because in DoS attacks, “overshoots and undershoots are expected to happen quite often.” (Imagine what “overshooting” could do to a skinned grape. Now imagine a gynecological or urological surgery.) Currently, attacks can’t be mitigated by existing encryption; there is “no mitigation mechanism against it.”
“The risks tend to be downplayed a bit,” a prominent surgeon and researcher, who preferred to remain anonymous, told Hopes&Fears. “What tends to happen now is that certain hospitals, medical centers, and academic institutions push the robotics...It costs a lot to buy one of these things [Ed note: $1-2.3 million], with a standard yearly maintenance fee, often up to $150,000.” That high rate could be attributed to the fact that Da Vinci robot's parent company Intuitive Surgical holds a monopoly over the market.
Currently the FDA database lists 2,805 medical device reports (MDRs) of suspected device-associated injuries and malfunctions related to the Da Vinci robot, 225 of which are deaths– the majority reported to the FDA, a representative notes, relate to gynecological and urological procedures. He also qualified that “an increase in the number of reports does not by itself suggest a faulty or defective medical device.”
Research does. Just this week, MIT found that at least 144 deaths are linked to robot-assisted surgery since 2000, and the “death rate for head, neck, and cardiothoracic surgery is almost 10 times higher than for other forms of surgery.” Common problems include uncontrolled movement. Downed video feed. Falling of burnt/broken pieces of instruments into the patient. In 2013, the Associated Press recounted cases of "a robotic hand that wouldn't let go of the tissue" and another which repeatedly hit a patient in the face.
Most common reported causes of injuries in robot-assisted surgeries, according to a recent study
Device and instrument malfunctions, such as falling of burnt/broken pieces of instruments into the patient
Electrical arcing of instruments
Unintended operation of instruments
The findings line up with a building consensus among independent researchers that robotic surgery is overblown. Googling “robotics surgery study” pulls up study after study showing more expenses, longer surgeries, and higher rates of complications among robot-assisted surgeries from researchers at Columbia, Mass General Hospital, and the Rush University Medical Center. In 2011, a study from Johns Hopkins found that patients are being misled about the benefits. In 2013, the president of the American Congress of Obstetricians and Gynecologists wrote an open letter expressing that the profession needs to “separate the marketing hype” from reality. Another 2013 study from Johns Hopkins has shown that cases have been underreported to the FDA.
And research itself has been allegedly limited. “The company will sometimes send threatening letters when they hear of an upcoming study,” the surgeon told me. Did he think any other research had been buried because of threats? “Yes. Definitely.” Intuitive Surgical declined to comment for this piece.
Between 2009 and 2012, the overall complication rate was 7.1% for robotically assisted oophorectomy
compared with 6.0% for laparoscopic oophorectomy.
“Plastic versus silverware”
“What is now marketed as a robot is not truly a robot,” he added. “The [surgical robot] was developed in the Argonne National Labs in Chicago purely for mixing radioactive chemicals– [they are an update on] the gloves people use to mix radioactive chemicals behind a glass screen.”
Except that gloves serve a clearly practical purpose. He pointed out that not only are remotely operated mechanical arms exorbitantly expensive to upkeep, but also that they might be used around ten times before they have to be replaced. “We compare it to your knife and fork,” he said. “You can have plastic utensils, but if you use silverware, you can use it thousands of times.”
He added the disclaimer that someday robotic systems could significantly improve manipulations in “small confined spaces” and “small-sized things which need multiple stitches," but colleagues, too, oppose recommending robotic surgery across the board. "We have not seen the automated commercial plane succeed, and the automated surgeon is an even more difficult hypothetical I cannot envision," said Dr. Marty Makary, leader of a 2011 study at Johns Hopkins finding that hospitals were misleading patients about the benefits of robotic surgery (such as "improved cancer outcomes"). While he's personally seen those claims scaled back since the study, the tech still doesn't live up to the hype. "There is a promising role for robotics in surgical care, but it’s not a technology we should adopt just because it’s cool," he said. "We should adopt technology when it helps patients."
Most studies and researchers acknowledge that improvements will come when other companies break the monopoly (which won't be easy, given that Intuitive Surgical owns 1,800 patents, Forbes reports). But there are other companies like TransEntrix, who announced the upcoming release of the SurgiBot in the near future, with promises to be cheaper than the Da Vinci model. Researchers are currently imagining brain surgeries through cheeks, and heart surgery by injecting nano-robots through the neck. In March, Johnson&Johnson announced that it will partner with Google to develop robotic surgical technology, Google suggesting that it would work toward developing better imaging technologies and consolidating medical data. (The company’s life sciences division is also working on a pill that could detect cancer and a contact lens that can measure glucose levels.)
Hopes&Fears asked Nancy Leveson, co-author of the recent MIT study, whether any new investments made her optimistic about robotic safety. They do not. “These have nothing to do with safety,” she responded. “And since when did Google develop safety engineering expertise? Simply throwing more technology at a problem that stems from too much technology is not going to help.”
She doesn’t see any need for a replacement to laparoscopic procedures, which are much safer. “There are lots of ways that technology can be used to enhance human capabilities and not just used to replace humans,” she added. “The results from the former approach are much more likely to be effective than the latter one. But everyone seems to assume that computers are better at everything than humans.”
Studies, however, link robotic surgery to lower readmission rates and better long-term outcomes. Readmission rates are lower for robot-assisted surgeries: 1% versus laparoscopic (2.5%), open (3.5%), vaginal (2.4%).
Study published in the Journal of Minimally Invasive Gynecology
Robotic surgery resulted in less additional treatment for cancer patients
A study by UCLA. Note: UCLA has a robotic surgery department
Cover image via http://www.dlr.de/