They are called surgical robots, but they are neither one nor the other. Since the first ones were installed in Spanish hospitals in 2005, more than 65,000 people have been operated on with them, and that figure does not include trauma operations (knee, hip and spine) which are also, increasingly, performed with the assistance of this technological tool, according to data from ABEX. Because that’s what robot surgeons are, a tool. They are not robots because they do not make decisions and they are not surgeons, because, obviously, that can only be, for now, a human being.
The best known of them, the most installed and, until very recently, the only one that existed, for patent reasons, is the da vinci robot, developed by the American company Intuitive Surgical and approved by the authorities of that country in the year 2000. But it is no longer the only one. Until now, only Da Vinci robots had been installed in Spanish hospitals, a hundred in these seventeen years. But in February, the Barcelona Foundation Puigvert began to operate with HUGO. “At the moment, HUGO only has certification for urology,” explains Salvador Morales-Conde, president of the Spanish Association of Surgeons“but the company that markets it is pending its approval for general surgery.”
Surgical robots do not operate; those who operate, with their assistance, are the male or female surgeons. To summarize, we could say that it is a very sophisticated scalpel that the doctor does not need to hold with his hands and that incorporates a camera, tweezers, a needle and the rest of the instruments that are needed in an intervention. “Before we operated with open surgery”, summarizes Ana Belén Cuesta, a gynecological surgeon at the King Juan Carlos Hospital Madrid that has been operating with a robot for five years. “That means we had to open the abdominal cavity. Then we started using laparoscopy to make the surgery less invasive. When the robot came up, I had a lot of doubts because I didn’t see any advantages to it. But since operating with it I have found that it does make up for what laparoscopy lacks,” she says.
Because what robot surgeons do is replace laparoscopic surgery. This surgical technique, developed mainly in the last part of the last century, consists of opening one or several small incisions in the body through which tubes with surgical instruments and a camera are inserted. The advantage of laparoscopy over open surgery was enormous, as the scars are much smaller, postoperative pain is also less, and recovery is much faster. The robot does the same thing with the difference that the surgeon does not have to hold and move the tubes himself, but operates the device from a console. “With the robot”, continues Ana Belén Cuesta, “we see the interior of the abdominal cavity in 3D when laparoscopy only allows us two-dimensional vision. This is important because we can appreciate the structures of the organs much better. In addition, laparoscopy uses rigid instruments, it is as if we had to operate with a wrist that has no mobility. The robot’s instruments, on the other hand, can move in all directions and thanks to this we can reach smaller spaces or spaces that are more difficult to access with laparoscopy”.
And there is another difference: in laparoscopy, the surgeon is located next to the patient moving the tubes, but if he uses a robot, he is sitting in front of a console. “The operations we do are usually long, especially oncology ones. And in a laparoscopy, when you have been operating for four or five hours in the same position, with stiff shoulders… there comes a time when you can’t take it anymore and you may even have small tremors in your hands. The robot prevents this by stabilizing the instruments. And besides, you get less tired because you’re sitting in front of a console with something like a joystick and some pedals”, adds Cuesta.
Those are the obvious advantages of robotic-assisted surgery. But not everything is idyllic. For starters, there is the price. A Da Vinci robot costs between 1.5 and 2.5 million euros, and in addition the hospital must pay a minimum of 140,000 euros per year for maintenance. That high price is the first thing wielded by those who oppose the implementation of this technology. But it is not the only thing. It is also more expensive to trade with a robot, even without taking into account the purchase price and maintenance of such instruments, revealed a Article published by a team of researchers from the American Medical College of Wisconsin in 2016.
The defenders of this technology often argue that, despite the high purchase and maintenance price, robot-assisted surgery has advantages such as shorter duration of operations or shorter recovery time for patients. But published research does not confirm these facts either. In June 2021, the magazine Annals of Internal Medicine published a research over 50 studies looking at nearly 5,000 robotic surgery patients. The authors concluded that there is no difference between robotic-assisted surgery and laparoscopy in the likelihood of complications even in the long term. And he also points out that, for example, in gynecological surgery, robotic operations increased their duration by 13% compared to laparoscopic ones. And a study signed by researchers from the University of California at San Diego, published in March 2022, ensures that after ten years of using a robot as a surgical assistant in their hospital, patients operated on with it remain hospitalized longer than those who have been operated on laparoscopically.
Nor can technical failures be ignored because, after all, the robot surgeon is just a machine and these also fail. Other study published in 2016 analyzed the technical problems encountered in robot-assisted surgeries after fourteen years of use: in the cases analyzed they found that 10.4% of the surgeries had to be interrupted due to some technical failure that forced the robot to be reprogrammed, restart the system or directly continue with the surgery by conventional procedures without the assistance of the robot.
But according to Julio Mayol, medical director of the San Carlos Clinical Hospital of Madrid and president of the Spanish Society of Surgical Research, “robots can help us reduce the variability of practice and increase the safety of surgery. It is true that their price is high, but that is going to change from now on because Da Vinci’s patents end and as there is going to be more competition, they will be cheaper”.
Mayol acknowledges that the current situation is not ideal: “It is debatable how they are being used. We should have defined a group of patients with characteristics that allow us to understand how this technology can be implemented in the best possible way. For that we would need to work in a network, as is done with transplants, that there are some centers that transplant and patients who need a transplant are sent to them. That’s what you have to organize with robotic-assisted surgery, but that’s hard.”
But despite the fact that this does not happen, the drop in the price of robots and the entry on the scene of new models from other companies will make their implementation jump in the coming years. The 65,000 operations carried out in Spain with robots in these seventeen years are a very small part of the surgeries carried out in our country, 3,600,000 in 2019, but it is indisputable that there will be more and more. As Mayol sums it up: “If you want to be part of the evolution of surgery, you can’t just watch it”.