I, Robot

Island Health robot has finally arrived. However, this is not a science fiction movie set in 2035, the producers and cast do not include Will Smith, and the robot is not automated and human-like. This is a Canadian reality show from 2025 set in Victoria, BC. The producers and cast include ordinary, kind-hearted individuals with one common goal: enhancing patient care through surgical innovation.

Thanks to generous community donors to the Victoria Hospitals Foundation, as part of the newly launched campaign “It’s Time for Surgical Innovation,” Vancouver Island patients can now benefit from robotic surgery in Victoria. The Island Health robot is called the da Vinci Surgical System, and it does not look like nor is it meant to replace humans.

Robotic surgery has been around for many years and is currently considered the standard of care in the United States. Initially used mainly in urology, it is now used in various other surgical disciplines as well, such as general surgery; ear, nose, and throat; and gynecology. It offers many benefits to both surgeons and patients.

For surgeons, robotic surgery provides improved ergonomics with less physical demand, allowing surgeons to remain in a tailored sitting position during long operations. It also provides better visualization and depth perception with 3D imaging and a surgeon-operated camera. These characteristics can result in reduced musculoskeletal and mental fatigue, improved performance, and fewer errors.[1] With additional freedom and dexterity, while eliminating tremors and increasing magnification to scale movements, robotic surgery allows for more efficient and more accurate surgery.

From a patient’s perspective, minimally invasive surgery has been long established to result in improved patient outcomes, and robotic surgery allows a greater proportion of operations to be completed in a minimally invasive fashion.[2]

Clinical benefits of robotic surgery are well known in the field of urology. In other disciplines, such as general surgery, the evidence is evolving, but at the very least, we know robotic surgery is noninferior and, in some instances, superior to laparoscopic surgery. In colorectal surgery, specifically rectal resection, lower rates of conversion to open surgery is a widely accepted benefit of robotic surgery.[3] This is especially the case in obese patients, where access to a deep, narrow pelvis can be challenging laparoscopically. Conversion to open surgery can have a significant impact on patient outcomes, such as increased wound complications, anastomotic leak, and overall morbidity.[4] Recent meta-analyses and systematic reviews have demonstrated that robotic surgery, compared with laparoscopic surgery, resulted in significantly faster bowel recovery, shorter length of hospital stay, and lower overall complication rates.[5,6] Urinary and sexual dysfunction have also been shown to be reduced in robotic rectal surgery compared with a laparoscopic approach.[7]

Despite the benefits of robotic surgery, its adoption in Canada has been slow, primarily due to cost. The purchase price of a robot is $2–3 million, with additional costs of around $3500 per case and $180 000 in annual maintenance. In a publicly funded health care system, justifying the additional cost may be considered prohibitive by some, and predictably, the majority of robotic systems are purchased through philanthropic donations to hospital foundations. However, the cost of surgery extends beyond the operating rooms, and the many benefits of robotic surgery may result in reduced overall costs. In a retrospective study from Kingston, Ontario, Patel and colleagues demonstrated that implementing a robotic colorectal surgery program in a Canadian tertiary care centre did not significantly increase the cost of care.[8] Additionally, access and cost-effectiveness are expected to improve as more competitors enter the robotics market. Last, studies comparing robotic surgery with laparoscopic surgery have indicated increased operative time as a downside (an additional 20 to 30 minutes in rectal surgery);[5] however, this will become a nonissue as surgeons become more efficient at docking and using the system.

To use robotic surgery in practice, it must be incorporated into surgical training. In a survey of program directors from Canadian general surgery residency and fellowship programs, less than 5% of resident clinical case volume constituted robotic surgery. More importantly, none of the program directors felt their trainees would be competent in using the robot after training. The good news is that skills acquired during laparoscopic surgery are translatable to robotic surgery, with a shorter learning curve.[9] With more robotic systems entering the market, lower costs, and increased accessibility, combined with dedicated robotic training programs in surgical residency, the uptake of robotic surgery in Canada should hopefully pick up the pace.

As for what comes next, the introduction of artificial intelligence and automation in robots could be used to guide and assess surgeons in performing surgeries more efficiently and effectively, which leads to the question: How far could or should this be taken? Could an automated robot using artificial intelligence turn on its own creator? Stay tuned.
—Sepehr Khorasani, MD, MSc, FRCSC

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References

1.    Falk V, Mintz D, Grünenfelder J, et al. Influence of three-dimensional vision on surgical telemanipulator performance. Surg Endosc 2001;15:1282-1288. https://doi.org/10.1007/s004640080053.

2.    Hu KY, Wu R, Szabo A, et al. Laparoscopic versus robotic proctectomy outcomes: An ACS-NSQIP analysis. J Surg Res 2020;255:495-501. https://doi.org/10.1016/j.jss.2020.05.094.

3.    Evans KM, Sahawneh JM, Ferrara M. Rectal cancer surgery: Is robotic surgery supported by solid evidence? Ann Laparosc Endosc Surg 2023;8:14. https://doi.org/10.21037/ales-22-76. 

4.    Parascandola SA, Hota S, Tampo MMT, et al. The impact of conversion to laparotomy in rectal cancer: A national cancer database analysis of 57 574 patients. Am Surg 2020;86:811-818. https://doi.org/10.1177/0003134820933551.

5.    Wang X, Cao G, Mao W, et al. Robot-assisted versus laparoscopic surgery for rectal cancer: A systematic review and meta-analysis. J Cancer Res Ther 2020;16:979-989. https://doi.org/10.4103/jcrt.JCRT_533_18.

6.    Safiejko K, Tarkowski R, Koselak M, et al. Robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection: A systematic review and meta-analysis of 19,731 patients. Cancers (Basel) 2021;14:180. https://doi.org/10.3390/cancers14010180.

7.    Flynn J, Larach JT, Kong JCH, et al. Patient-related functional outcomes after robotic-assisted rectal surgery compared with a laparoscopic approach: A systematic review and meta-analysis. Dis Colon Rectum 2022;65:1191-1204. https://doi.org/10.1097/DCR.0000000000002535.

8.    Muaddi H, Dare A, Walker R, et al. Bridging the gap: Assessing the integration of robotic-assisted surgery into Canadian surgical training programs. Can J Surg 2024;67:E250-E251. https://doi.org/10.1503/cjs.013123.

9.    Leijte E, de Blaauw I, Van Workum F, et al. Robot assisted versus laparoscopic suturing learning curve in a simulated setting. Surg Endosc 2020;34:3679-3689. https://doi.org/10.1007/s00464-019-07263-2.