SOFT TISSUE ROBOTIC SURGERY & TELE-SURGERY: THE NEXT SURGICAL FRONTIER?

- Is there a capability??

- Is or will there be a demand?

- Should it be pursued?

- If so, how?

This may be hard to believe but, Intuitive Surgical’s dominant da Vinci platform can trace its origins to a relationship fostered between the Stanford Research Institute – SRI, and the Defense Advanced Research Projects Agency – DARPA, that began in the 1990’s.? This relationship helped to fund and spur along innovation of this incredible soft tissue surgical robotics system.? DARPA was interested in a system that could project telemedicine enabled robotic assisted surgery forward to care for wounded soldiers on the battlefield.? The surgeon would control the system from a console in a remote safe location while the soldier being operated on would be at a forward operating base where surgical care would be feasible.? ?

Does this sound crazy?? Was this idea too ambitious for the capabilities of the time?? Maybe, but it was done!? Albeit, on a small scale and not in an actual military setting.? In 2001 a trans-continental robotic assisted cholecystectomy was performed between New York City and Strasbourg, France.? This was done with Computer Motion’s ZEUS system, a company that would later go on to merge with Intuitive.? That operation was performed over 8,700 miles (14,00 kilometers) away folks!?

Is this idea beyond reach now over twenty years later? ?Absolutely not!? Think about the tremendous advancements in technology that have spanned the past two decades.? Miniaturization of high-definition cameras and components, development of mature high-speed communication networks that are only getting faster, better chips and computer processing technologies, and the list goes on!? The technology to enable this capability and this capability at scale has arrived.? This can be done.?

Is there a true market demand for this?? There may not be a huge demand signal for this now, which I think reflects the lack of visibility that this capability truly exists, and the fact that the buzz about surgical robotics in general is keeping it out of the spotlight.? However, lurking in the under currents, I anticipate a legitimate market demand for this capability will materialize, and the first company that can reliably service this demand will possess a massive first-mover advantage that will serve to build a tremendous barrier to entry.?

If there isn’t a company focusing some modicum of energy and bandwidth here, there should be.? The only thing that is guaranteed is change.? If companies cannot readily adapt to the changes in market forces and consumer desires, well you know what happens next….. ?There are plenty of business school papers and case studies on this subject, so I won’t bore you with that narrative.? Laparoscopy was once shunned by the medical and surgical establishment but rather quickly became the standard of care for a myriad of operations in the developed world across numerous specialties.? Surgical robotics was once met with much skepticism and consternation by many surgeons when it was a nascent technology in the 1990’s.? Now it is a 60-billion-dollar global market and growing rapidly.? That’s billion with a B! ?

As I have mentioned before, venturing into this realm will need to be done with the utmost control, safety, predictability, and reliability.? And yes, regulatory institutions will be involved, as they should be for patient safety and oversight.? However, an optimal equilibrium will hopefully be achieved where the grip of regulation will be such that patient’s safety will be paramount while allowing industry to exercise the freedom to aggressively continue to innovate in this domain within reason. ?A crawl, walk, run model will be prudent.? Begin with basic surgical cases and indications with follow-on expansion into more complex adjacencies as the learning curve is navigated.? Think initially cases being performed such as cholecystectomy, appendectomy, inguinal hernia repair, ventral hernia repair, hysterectomy, salpingectomy, oophorectomy, etc. and progress stepwise in complexity from there.?

As this is undertaken and matures, a surgeon will certainly need to be at the bedside for the entirety of the robotically controlled portion of the operation to expeditiously intervene should complexities arise.? Much like with Transaortic Valve Replacement procedures, a cardiothoracic surgeon is present in the event that rapid surgical intervention is required.? Eventually, as the technology matures and a track record of safety is established, having a surgeon at every bedside during the robotically controlled portion of the operation could extend to having a surgeon or surgeons readily available in the facility where these procedures are being conducted to respond to a particular room where an issue has arisen.? There are more questions than answers to think about in this potential advancement in surgical care, but the conversation needs to start somewhere.? There are a tremendous number of patients in underserved and rural areas of the world that could be incredibly well served by democratizing and advancing this type of technology.?

I believe this is a sector of surgical innovation and healthcare innovation that with the right mindset, discipline, and patience is ripe for incredible growth.? However, do surgical robotics and digital health companies want to expend capital and cultivate the resources, assets, and capabilities to develop and enable this at scale?? It would sure be expensive. ?Let’s be honest, it is hard enough to get a surgical robotics company up and running and to keep it running.? Who would be crazy enough to pursue this?? Visionary healthcare and industry leaders who can anticipate how the topography and climate of healthcare deliver will change in the decades to come, that’s who.? Will strategic partnerships or joint ventures emerge between best-in-class surgical robotics companies and best-in-class telemedicine-digital health companies that could take this leap and answer the call??

Think about a partnership between the likes of Intuitive Surgical and Proximie.? An established powerhouse and undisputed leader in soft tissue surgical robotics and a growing best-in class-tele-presence solution that can amplify one another’s core areas of expertise and create an incredible robotic tele-surgical solution that can extend across the globe in a microseconds.? It’s pretty incredible to think about and I believe it can be done!? Could this be something that a strategic company such as Medtronic will want to develop with their Hugo system or Johnson & Johnson with their evolving Ottava platform?? What about the startup side of the house?? CMR Surgical and Versius, Distal Motion’s Dexter platform, or Virtual Incision’s MIRA system?? After all, MIRA just launched to the International Space Station with experiments being controlled from their headquarters in Lincoln, Nebraska to the ISS.? Impressive!?

The capability is here, so who wants to pursue it?? This is certainly a sticky question, but I believe the market demand for this is coming and those who are thinking ahead will be poised to capitalize upon it to the tremendous benefit of patients worldwide if done safely and reliably.? If we think about layering in artificial intelligence, artificial reality, machine learning, and the internet of things into this capability the conversation gets really spicy and that is beyond the scope of this article, so I digress…..?

To bring things full circle, since SRI and DARPA were the two entities that brought the conversation about this capability forward decades ago, do we need to extend this capability into the military setting as well? ?The short answer, yes.? The long answer, I will address this in a future article to pay homage to where this all began. ?Stay tuned for that.? ???

In conclusion, there will continue to be advancements in how we deliver safe and effective surgical care and surgical care at scale.? The perceived impossibilities of today will become the realities and standards of care tomorrow.? Surgical robotics and telesurgery I believe will become coupled and firmly entrenched in this continuum of surgical innovation.? The next digital revolution that will enable this to grow at scale is upon us whether you like it or not so buckle up.? Exciting days ahead!