Robotic Surgery the 21st Century Can Rightfully

Robotic Surgery

The 21st century can rightfully be considered as the era of technology when the new inventions and discoveries will most likely affect all the segments of human life. At this point, some of the breakthrough inventions of our times have been in the medical field. Robotic surgery has become an almost common practice in the advanced medical world and new uses for robotic assisted surgery are everyday set in place. However, such developments also attract different interests and implications.

Robotic surgery, also known as computer assisted surgery, is a technological development that uses robotic systems to aid physicians in surgery, particularly to overcome limitations in minimally-invasive surgery, micro surgery, or to enhance the surgeon's abilities in open surgery. Typically, the surgeon uses a telemanipulative device that mimics the motions of the human hand and arm. Different instruments are used to replace traditional tools that perform certain actions (e.g. rib-spreading, etc.) in a smoother and less invasive motion than with human hands. Essentially, the main focus of robotic surgery is to reduce trauma, reduce time in surgery, and improve minimally invasive surgical techniques (McConell, et al., 2003).

Political Impact

There are certain political aspects to be taken into account when considering the role of robotic surgery in modern day medicine. The price of such equipment ranges from "$1 million to $2.3 million, plus up to $170,000 per year in maintenance, according to Intuitive Surgical" (Torres, 2011). Despite such costs, more and more elite hospitals are investing in such technology. However, such investments come with additional costs not only for the patient but more importantly for the health care system that ensures coverage for complex surgeries. The practice nowadays ensures the coverage of surgeries that are more efficient and more and more often these are the surgeries assisted by robotic devices. However, the government covers these costs similar to the costs of an old fashion intervention although the investments in such instruments are far greater. Therefore, at the political level there is the discussion on whether the government can improve the coverage of such medical expenses taking into account the investments being done in state of the art technology? Thus, "in the current U.S. political environment, restricting coverage is difficult when a new technology is more effective, even if it is much more expensive than the technology currently available" (Weissman, and Zinner, 2013).

However, due to the expense and availability of robotic surgery, the use of the system is very economically, or class driven, which has political and social implications. Providing adequate care will require insurance companies to agree to procedures that, like any surgery, have risks. Society has trouble, at times, accepting the use of robotics based on media or science fiction portrayals, but need to realize that a great percentage of modern manufacturing already uses robotics. While robotic surgery has the potential to save thousands of lives, there is a cost and fear factor that will likely influence politicians and regulators (Ting, 2002).

The expense of the system seems to be driving the political paradigm. Our nation's healthcare costs have soared out of control and millions of Americans are not able to afford even minimal insurance. Now we are increasing the use of robot-assisted procedures about 30% per year since 2010, which require more machines, training, and upkeep. On average, experts believe that robotic surgical machines cost between $2-3 million, with annual service fees approaching $150,000 or more. To understand this in retrospect, this would add between $6-10,000 to each surgical procedure, at present a cost simply absorbed by the healthcare facility. Hospitals argue that many patients want this type of surgery, and they must use it to remain competitive. Thus, the central political issue at hand is how to use political and social systems to change the way that hospitals are reimbursed for costly procedures. Right now, it appears that many hospitals are making up for the fiscal outlay on robotics by performing more operations -- otherwise the costs may be passed on to patients via higher insurance premiums or services may be cut -- neither of which is an acceptable answer to the issue (Pho, 2012).

Consumers and the media seem to believe that robotic assisted surgery is based on a market driven technology. When one combines this with privacy issues, there is a duality -- some patients want the latest and best technology, others are wary that it is a gimmick. Indeed, when one opens the door for an independent company to have access to patient information and records during updates and maintenance, how is HIPPA enforced through the robotic manufacturer? The additional spending on robotics effects consumers, and also public and private insurers, including Medicare and Medicaid. This is a political issue since currently most insurers, especial Medicare and Medicaid, do not pay additional reimbursements based on robotic assisted procedures. The cost/benefit ratios are at the heart of the issue. A recent scholarly article in the New England Journal of Medicine noted:

The diffusion of robotic technology depends on fragmented, not centralized, decision making. Decisions to purchase robots are made not by payers but by hospitals, which compete with one another to attract surgeons and their patients. Hospitals, seeking surgical volume, find it difficult to resist surgeons' preferences, even without favorable direct reimbursement, and surgeons feel compelled to keep up with market demands so as not to lose patients (Barbash and Flied, 2010).

It is often difficult to delineate the political from the social implications of new technology. Once consumers become comfortable with robotic technologies in their homes and automobiles they are then faced with becoming familiar with it in the healthcare market. Many consumer advocate groups ask about the role robotics may play within the socio-political structure of 21st century society, and how humans will adapt to this change. Of particular interest in robotic surgery is the replacement of highly-skilled knowledge workers with machines, and what framework based on the needs of the consumer vs. The improvement of technology (Weiss and Tscheligi, 2010).

In fact, robots play a critically evolving role in modern medicine. Surgeries may be transformed, medical schools use robots to teach and practice upon, tele-medicine uses robotics to help those in remote areas, robots are used to help patients use damaged or amputated limbs, implants may be used to help all sorts of issues (cardiac, neurological), and nursing "bots" that help elderly patients cope with day-to-day activities. The RIBA (Robot for Interactive Body Assistance) lifts individuals who are too weak to sit, walk or stand; and the Lokomat robot combines medical and engineering expertise to assist individuals who have suffered a stroke, brain or spinal cord injury, or harm to their nervous system. These are all technologies that are in place for society at present (Alison, 2011).

Legal Implications

Aside from the political implications the use of new technologies has on the medical health care system, there are also legal implications. This is largely due to the fact that in traditional medical surgeries the liability and responsibility rested mostly on the surgeons, the hospitals, and the ones directly or indirectly involved in the procedure. With the use of new equipment that implies handling of sensitive, precise, but at the same time mechanical devices, the eventuality of failure is further divided between the doctors and the manufacturer of the technology (Mavroforou et al., 2010). Therefore, while in traditional surgical performances the professional responsibility lies in the doctors, in robotic assisted surgery, this responsibility can also be shifted with the manufacturer of the technology as the machinery used may be subject to error. Despite these implications, the legal framework to include such additional responsibility is yet to accommodate shared blame in case of medical error. This is perhaps the most important legal implication robotic assisted surgery trigger.

Another legal implication for the use of such technology is related to the patient. In this sense, "the clinician-patient relationship may be disrupted, and the impact of state and international borders on medical licensing and care is unclear (…). In one such case, the patient was located in Strasbourg, France, while the surgeons were based in New York, NY. Study results suggested that remote robot-assisted surgery appears feasible due to an uneventful postoperative course for this sole patient." (United Health Care, 2010).

Further, while new avenues open up regularly using robotic techniques, increased specialized training is necessary and to maintain licensure, increased high quality assessments will be necessary to ensure high-quality care. The legal basis for professional liability remains the same, but litigation using robotic surgery could, in theory, become quite complex. Does the manufacturer bear any potential liability or is it the responsibility of the surgeon alone? What about design or software flaws or issues? In the case of an undesirable outcome, who bears the brunt of professional liability? Ethically, too, upkeep, maintenance, regular updates to software, adequate testing and maintenance are necessary for the machines to work correctly. The manufacture may recommend, or even schedule regular service, but like any machine, it would be the owner's responsibility to ensure compliance (Mavroforou, et al., 2010).

What are the failsafe mechanisms that should be put into place regarding robotic surgery? Let us suppose that there is a critical surgery underway; the power is interrupted and before the backup generator kicks in, the robotic system is rebooted. Is damage done? By whom? An act of God revolving around the power? Additionally, if all the power went out, it would still be possible, perhaps not ideal, but possible for the surgeon to use manual intubation and old-fashioned techniques to complete the surgery and close the wound. What level of user competencies should be required regarding less than ideal conditions; or should the system provide its own backup power source?

On the legal side, there are even current law firms that claim to specialize in Robotic Surgery Risks. Their claim revolves around the DaVinci Surgical System, manufactured by Intuitive Surgical, Inc. They lawyers claim that minimal training was provided to many physicians coupled with design issues cause certain individuals to face an increased risk of surgical complications. "In addition to mistakes caused by inexperienced surgeons, da Vinci surgery complications may arise from the device's use of monopolar energy to cut, burn and cauterize tissue. The da Vinci robot also appears to have defective and inadequate insulation for the arms" (Saiontz & Kirk, 2012). This view holds that it was the design issue and the manufacturer's failure to provide and ensure adequate training, not necessarily the fault of malpractice within the healthcare system.