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Minimally Invasive Surgery Through the Eyes of a Surgeon

A surgeon shares his unique perspectives on how minimally invasive surgery has changed over the past 20 years, the biggest obstacles currently standing in the way of taking minimally invasive and robotic surgery to the next level, and a fascinating vision for this field's future.

One of the best parts of an event like MD&M West is the opportunity to put a cross-section of experts from industry in the same room as engineers and end-users and talk about the biggest trends in medical devices. One such discussion that took place here in Anaheim, CA, on Tuesday included an expert robotic surgeon, an expert from Intuitive Sugical (which, as you likely know by now, pioneered robotic surgery a little more than 20 years ago), and a new robotic surgery company that is trying to to take this technology beyond the surgical suite.

I shared a few insights from this lively panel discussion here, but prior to the panel I had the opportunity to dive deeper into the mind of the panelist who provided the robotic surgeon's take on the transformation of minimally invasive surgery, largely aided by robotics. Christopher Macomber, MD, Macomber is chair of robotic surgery at Minneapolis, MN-based Abbott Northwestern Hospital, part of Allina Health Surgical Specialists.

MD+DI: What is the biggest change you have seen in minimally invasive surgery over the past 20 years and what has driven that change (technology, cost of care, OR infrastructure and/or real estate? Emphasis on value-based care? Or perhaps all of the above?

Macomber: I would have to say access to data/outcomes to know what new technology works well, what doesn’t, etc. I could come up with a list of a number of very exciting new technologies, including robotics, however, these advancements are only great and only see growth if they provide a benefit (robotics is an exception to this rule to some extent). Laparoscopic technology was a major technological leap forward, but the concept has been around for over 100 years actually. It took extensive research, publications, and also ultimately changes in the surgical training models to determine the best uses, indications, etc. of this new technology.

Now, robotics is a different animal in that it’s cost profile is dramatically different, it provides some nice advantages, but they have been challenging to capture in studies done on it, except in a few very clear cut examples, i.e. robotic prostatectomies. It was initially thought that with the way laparoscopic surgery was adopted, robotics would have a faster approach, but I think that’s plateaued to some extent at the moment, mostly given the impending value-based care initiatives, as well as cost pressures. However, now that most surgeons coming out have been exposed to minimally invasive tech, whether that’s laparoscopic, robotic, endoscopic, etc, the market is really helping to decide what’s a major advancement or not.

MD+DI: What do you perceive to be the biggest obstacle currently in keeping the industry from taking minimally invasive and/or robotic surgery to the next level?

Macomber: Cost. But that is going to depend on what you consider the “next level.” If you speak with MIS/robotics businesses, that means increased adoption across more surgeons and across more surgical indications/procedures. The reality is, not every procedure can/should be done minimally invasively. There is certainly value in trying/exploring as otherwise you won’t know, but the push recently to expand your robotics program, increase surgeons and procedures being done, etc. has been based on a desire to increase volume.

The best example of this I can give is that there are a number of procedures across numerous specialities that will be required to be done in a formal ambulatory surgical center (ASC), not a hospital operating room. This means lower reimbursement per procedure. When you look at the contribution margin by procedure for some of these procedures, there isn’t a way for that to be sustainable as a robotic procedure at a lower reimbursement level, so organizations are going to have to avoid placing robots in ASCs. There are certainly exceptions to this around patient safety and what can be done surgically at an ASC, however, in general, as insurers and the market start to try and put downward cost pressure on providers and hospitals, unless the costs of MIS/robotic technology comes down, it’s going to plateau, and possibly even decrease. In our organization, we think it may mean shifting surgeons back to laparoscopy or open and away from robotics in some instances. At least until we can get a handle on how to sustain outpatient/ASC robotics. We are in the process of studying that now as some of these guidelines are already in place.

MD+DI: Looking ahead, how do you think surgery will be different 10 or 20 years from now, and what will drive those changes? Artificial intelligence? Advancements in robotics? Regulatory changes? More affordable robotic systems? Augmented reality? Or other emerging technologies?

Macomber: I think the biggest change initially will be new entrants into the robotics space. This will finally provide cost relief to the system and give hospitals flexibility in how they deploy robotics across their facilities. A lot will depend on what happens to our system, i.e. single payer or not. If we shift to a single payer system, the amount of capital in the system to allow for adoption of these more expensive technologies will likely be much less and therefore decrease use and adoption.

Organs and patients aren’t getting smaller or requiring more miniturization, so my hope for MIS/robotics surgery is that it will focus on procedural efficiency, decreased cost, easier set-up times, less infrastructure, wires and towers, etc. as that will make it lessburdensome for hospitals to adopt. I am waiting to see an AR or AI application in surgery. Obviously the big goal for a lot of companies in this space is to see if they can get robots to do some or all of the procedure. I think this will be both a technical hurdle and a patient confidence hurdle as anyone who does any degree of complex surgery knows that the variability in anatomy, particularly patients who’ve been operated on before, and the challenges with some operations is so difficult that it's very difficult to imagine a computer knowing how to make a decision in the OR. But surgeons also couldn't imagine that washing their hands was important as recently as 100 years ago, so who knows?

I ultimately don’t think it will change that rapidly in the next 10-20 years in a technology way, as the requirements in the operating room at this point lend itself to ways to be faster, safer and more efficiency. I could be wrong, but at the moment with the field scrambling to figure out how robotics does fit into each of the different specialities, having only mainstreamed laparoscopy in the last 15-20 years, too much advancement too quickly may result in a lot of failed technology as the industry won’t know how to, be able to, or afford to adopt it.

However, so much will depend on the insurance and regulatory market in the U.S. as this is the dominant country for a lot of this innovation. If the insurance/payer approach changes, we may be facing a substantial downturn in technology and surgical innovation just due to the lack of capital and money in the system. In addition, training of surgeons will be a major discussion going forward.

There is still a fair number of surgery I do that either needs to be done open or I need to convert to open. I even do some as hybrid open/laparoscopic/robotic cases using the benefits of each in the same procedure. If I hadn’t trained in such an outstanding program, where open and MIS surgery was taught so well and with great volume, it would have put me at a major disadvantage. So training will also play a major role in how this is shaped going forward and we can’t lose the other techniques, as surgeons will always need to be facile in all of the modalities in order to have a successful practice.

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