Are robots the future of healthcare?

Healthcare challenges that people living in the 21st century have to confront will be numerous. Rises in cases of heart disease, cancer, strokes and diabetes are only a few of the most prevalent, exacerbated by a large ageing population that will also require access to healthcare for injury related issues and degenerative diseases such as Alzheimer’s.

Qatar is not immune to these global trends in healthcare. According to a World Health Organisation (WHO) report from May of 2012 obesity in the country is considerably higher than global and regional averages. There is a definite concern and a significant commitment in line with the country’s National Vision 2030, under the branch of human development, to develop quality healthcare in the country. The same WHO report shows while regional per capita expenditure on health is around QR364, Qatar spends around QR5460 per capita.

Ballooning healthcare costs for governments and patients, and great divides in the quality of healthcare one can be exposed to depending on where you live, could mean the difference between life and death, a sad reality for many around the globe. One positive however is that robotics technology could be the solution to some of these problems.

At a car assembly plant today almost all work is automated, robotic arms work tirelessly to shape, weld and bolt all the parts that make up the final product that rolls off the assembly line, all done with a certain level of autonomy on the part of the robot with minimal human interference. The automated assembly line was the great gift to all manufacturing industry, being able to produce a result quicker and cheaper, all while maintaining certain standards, and has been able to sustain global consumerism needs. The question now becomes, can robotics technology meet the growing demands of the healthcare industry and are there innovative solutions currently being developed?

The prevalent application of robotics in healthcare today is in the field of minimally invasive surgery. First approved in the United States (US) in early 2000, the da Vinci Surgical System (see box out) right now has a monopoly in the robotics surgery market. Hamad Medical Corporation (HMC), Qatar’s leading government healthcare provider has many of these robots and uses them to perform a range of surgeries.

Leading this drive to integrate robotics into the healthcare system is a Qatari, Dr. Abdullah Al Ansari, chairman of surgery at HMC. He informs TheEDGE that “more than a 150 patients underwent different surgeries in HMC performed with the aid of the robot, among them being heart bypass, urology, general and paediatric and even ear, nose and throat (ENT) surgeries.”

According to Dr. Ansari when it comes to radical prostate surgery and cancer removal the da Vinci surgical system is used for around 70 to 80 percent of surgeries in the US. The main advantage being an ability to perform a customarily complicated procedure with ease, thanks to robotics. “The pelvic bones are narrow and fixed so it is like working in a small cabinet,” says Dr. Ansari, “when working with your hands sometimes it is difficult to see things so you use feeling, the robotic arm provides freedom of movement and precision to work quickly.”

The benefits to surgeons in using the surgical robot over traditional approaches are numerous. The robotic arms only moves when a direction is applied, removing the occurrence of tremors during surgeries. An increased range of motion, up to seven different directional movements can be made to the robotic arms improving dexterity and access, all advantages to surgeons working in delicate and tight places. Enhanced visualisation is also a key factor, like the robotic arms that move the surgical instruments, the camera can be moved. “If I am looking at something that is hidden, I can move my field of vision without having to move myself or the patient,” points out Dr. Ansari. “I can create a different perspective. In real life this is difficult, the camera can take you to edges or corners that you could never reach in the past,” he adds.

While the system aids surgeons, there are definite benefits for patients too. Surgeries such as a coronary heart bypass surgery require large incisions that destroy skin and muscle on the way to the organ, but now three small incisions of around 1.5 centimetres between the ribs is all that is required. Patients can be up and about in one to two days after surgery. This is a significant advantage to hospitals in certain countries says Dr. Ansari, “People don’t feel it here because it’s free but a night’s stay in the hospital ward can be as much as QR4000 to QR5000. A lot of developing countries don’t have an understanding of bed costs in government hospitals or they would be investing in high technology for increased patient recovery time.”

HOW SAFE IS IT?

The current system is however not without its detractors. While there are legitimate concerns as to the effectiveness of robotics over traditional methods, Dr. Ansari, a strong proponent for the implementation of robotics tools in surgery alludes to the “people who either don’t know how to use robotics tools or do not have access to a robotic surgical system yet, discourage patients from certain types of procedures in an attempt to alter the market towards services they can offer.”

The ability to play on the fears of patients can be a serious factor when it comes to presenting patients with surgical options. Speaking from experience Dr. Ansari says there is a tendency for some to think “you are experimenting on them. These are their words, not mine. They don’t understand that this is equipment and not a drug trial. I have to explain that I am using more advanced tools to perform their operation.”

Surgical robots are also an expensive investment. Professor Lord Darzi is head of the division of surgery at Imperial College London where he specialises in the field of robot assisted surgery and also sits on the Supreme Health Council (SHC) of Qatar. He tells TheEDGE that robot assisted surgery will only become affordable to a degree “It depends on how you cost a procedure,” he explains. “If the robot is saving time or if it is reducing trauma of the surgery then there is the likelihood the patient will go home earlier, not just saving hospital costs but also surgeon costs,” adds Lord Darzi.

Surgeons need to find unconventional ways of justifying the cost of these devices, the da Vinci surgical system is around US$1.75 million (QR6.4 million) with the disposable instruments costing anywhere from US$1500 (QR 5460) – US$2000 (Q7280) per surgery.

“Cost effectiveness is not the reason we employ these tools,” concurs Dr. Ansari. “We buy cutting edge technologies to give the patient the highest quality of care possible. If you work for a private company and you want to make a profit then yes, maybe the more operations you do you can drive down the cost and justify it.”

Dr. Ansari then explains that not every operation that can be done using a surgical robot should be. “We have about five or six cases everyday, but I don’t use the surgical robot, I can use the natural opening and perform the surgery to provide a better quality for the patient. I think it is unethical to use it when regular surgery can provide a better outcome,” he adds.

The da Vinci Surgical System like all medical robots today, operates on a master-slave basis. Unlike the certain level of autonomy robots in other fields are afforded, in the medical field its movements are strictly controlled and only work on mirroring the movements of a qualified surgeon. The system consists of three main components; the surgeon console is where the surgeon sits with his or her head immersed in a viewing area that shows them a high definition 3D image inside the patient’s body, the master controls are operated using fingers as you would do regular surgical instruments, the robotic arms and camera replicates the movements made by the surgeon and finally the ‘vision system’ that renders the video from the camera.

QUALITY TAKES PRECEDENT

Speaking with doctors in the field of robotic surgery research, it seems the priority of healthcare technology is not to develop cost effective solutions but to create systems that will be able to deliver the best patient care possible. The Qatar Robotic Surgery Centre (QRSC) is a joint initiative of Hamad Medical Corporation and the Qatar Science and Technology Park (QSTP) that was established in 2010, with the directive of being a training institute in robotics and minimally invasive surgery and a research centre for advanced surgical technologies. Since its conception the QRSC has trained more than 250 surgeons in different specialities, and become one of the busiest training centres in the region.

Dr. Abdullah Ansari is also the clinical director of the QRSC, and meeting us at the high tech offices in QSTP, which is estimated to cost around US$65 million (QR235 million), outlines their mandate for the research. The three main areas of focus are improvement of instrumentation and preciseness of tools, image-guided navigation, and simulation. One of the disadvantages in the current robots is the lack of feedback, so you cannot tell how hard you are gripping tissue or how hard you are cutting.“With 3D video and the high levels of magnification in the robot you develop something I like to call ‘visual feeling’ so you can see how much you are cutting,” says Dr. Ansari, “but we are doing a lot of research in this field.”

NO AUTONOMY FOR FUTURE ROBOTS

A pressing question for most is whether surgical robots can and will perform operations autonomously. Lord Darzi seems to think that this will not happen in surgical practice but will become prevalent in other facets of healthcare like assisted living, and areas of rehab, he however adds the caveat that “you may see some degree of autonomy in surgery in scenarios where you can repeat the same procedure using imaging, so you can practice and record the best practice run and repeat the procedure by playing the tape over and over again.” Dr. Abulaban, surgical training manager at QRSC, questioned the ethics behind having an autonomous robot perform the operation. “What if something went wrong-who would be held accountable? At the end of the day it is a human life that is being put in your hands,” he says.

It seems that doctors and researchers in the field of robot-assisted surgery firmly believe that robots for the near future are a tool to better augment surgeries and not a device that can work on its own.

QRSC is involved in numerous joint projects with leading robotic research organisations in the world, that include the Imperial College London’s Lord Darzi (also the chairman of the QRSC International Surgery Panel) and Professor Guang-Zhong Yang. They have been working on ‘flexible access bio-inspired platforms’ like a robotic snake that can enter through natural orifices and perform surgeries.

This is the immediate future of what robotics in healthcare will look like. Lord Darzi comments “what we have today (da Vinci surgical robot) is probably equivalent to the first car ever built for the road,” he says “They are big, cumbersome and have their limitations. What we are designing are bio inspired robots that will really take us into a new era of smaller, cheaper robots that will also allow for improved access during keyhole operations.”

Robot assisted surgery is a relatively new field with the scope being rather restricted. Dr. Ansari states that with organisations like the QRSC “Qatar can play a leading role in the region and at the world level in this field. Clinical applications are growing very fast and robot-assisted surgery could become the standard to perform certain types
of surgeries.” The plan, he went on to say was to develop QRSC in line with the vision of Qatar. “The aim in Qatar is mainly to identify unmet clinical needs, with the ultimate goal of improving the quality of healthcare.” The future of robotics in surgery seems as promising as the human drive to invent new ways of performing surgeries.