There’s no doubt that robotic surgery is increasing in popularity and prominence as hospitals and medical facilities are trying to leverage technological advancement to achieve better outcomes, improve safety, and reduce costs. However, there are still some questions as to how robotic surgery will develop and evolve in the coming years. Jeff Berkley, CEO and founder of Mimic Technologies, recently spoke with Surgical Products and discussed the future of robotic surgery, the challenges and roadblocks to its development, and what is holding certain surgeons back from embracing robotic surgery and robotic technology. 

SP: What are some of the challenges that come about as a result of robotic surgery? 
Berkley: It really all starts with education. Almost 90 percent of all surgical cases are still done open. The leading application for the DaVinci robot is hysterectomies, and 40 percent of those are done open. So why is this when minimally-invasive surgery in general has such obvious benefits like lessened recovery time, less pain, and less scarring?  It’s highly preferred if you can find someone who’s good at it. So why hasn’t it been adopted?

The first reason is that there is a lack of knowledge from some surgeons about the absolute benefits of minimally-invasive surgery. We’ve taken a surgery that has a good amount of complexity as open and made it more complex by making it minimally-invasive. Then there’s the difficulty of training these surgeons, especially when they're already in their clinical practice and don’t have much time for additional training. So you already have a challenge with learning minimally-invasive surgery. Then you add robotics to the mix. It definitely makes minimally-invasive surgery easier to learn. The learning curve is certainly less.

I firmly believe that somebody who is on his or her tenth case on the robot is going to be much more highly skilled than a tenth case for someone using a laparoscopic approach.  It’s simply easier if you are given an adequate amount of training. You just become an expert much, much faster. However, if you go from a laparoscopic technique to a robotic technique, you almost have to unlearn the skills you’ve developed. In my opinion, if you are starting in your fellowship and have your choice, you are going to reach expert level faster using the robotic technique.

What you also sacrifice is sense of touch. The farther away you get from the patient the less sense of touch you have. With open surgery, you have your hands right on the organs. Then there are laparoscopic tools where your sense of touch is already deadened. The robot itself does not relay any force signals. So you do miss out on that.

SP: What holds surgeons back from embracing robotic technology and robotic surgery?

Berkley: To me, it is access to training. This is something that’s much more challenging for robotics. If you are trying to learn just basic laparoscopic skills, you can start practicing right away. The instruments you need aren’t terribly cost-prohibitive. But when it comes to working on the robot, there’s no alternative to training on the robot itself.
Simulation can change this. We have two versions of our simulator. One is a less costly offline trainer that isn’t going to tie up the robot for training purposes and isn’t risking wear and tear on the robot.

Then there are advantages of simulation, when you are trying to emulate a $1.8 million robot for less than $100,000, it is not going to be exact. But there are validation studies that show working on the simulator of the robot is just as effective for assessing the surgeon’s skills and getting somebody up the learning curve as using the robot itself. However, you can still use a surgeon’s console for simulation training as well.

There’s real OR costs with training with the robot. You need a staff. You have to set up the robot. Also, typically people who are going to train on the robot have to come in nights and weekends.

What we find is a lot of our customers do have the skill simulator for use in the OR. It works well for something like warming up before surgery while the robot is being set up for the patient.

The importance of access to training and access to training for the purposes of skills retention we think is crucial, and this is something simulation offers.

SP: Given some of the uncertainty regarding robotics right now, how do you expect the technology and adoption of it to develop over the course of the next several years?

Berkley: The adoption of robotics has been fast, but there are challenges. There is the ability to get trained, and then there’s the cost. But part of the cost is there is just one robot manufacturer right now. But I fully expect within the next decade we are going to see the cost of robotics go down, and it will no longer be cost-prohibitive to do robotics. This means you are going to have much more ability to do precise, complex cases in a minimally-invasive fashion.