Applications and Economics Aspects of
Fernando F. Nunes, Guilherme T. Kappaz, Maurice Y. Franciss, Leandro C.
Barchi*, Bruno Zilberstein
Gastromed Institute, Av. Nove de Julho, 4.440; Jd. Paulista- Cep: 01406-100, São Paulo, Brazil
Leandro Cardoso Barchi, Gastromed Institute, Av. Nove de Julho, 4.440; Jd. Paulista- Cep: 01406-100, Sao Paulo, Brazil,
Tel: +55-11-3082-8000; E-mail:
Received: April 29, 2016; Accepted: July 05, 2016; Published: July 16, 2016
Nunes FF, Kappaz GT, Franciss MY, Barchi LC, Zilberstein B (2016) Applications and Economics Aspects of Robotic Surgery.
Int J Adv Robot Automn 1(2): 1-3. DOI: 10.15226/2473-3032/1/2/00110
Currently robotic surgery is widely accepted as a minimal
invasive access and makes reference to surgery procedures
assisted by electromechanical computer which serves as a bridge
between the surgeon and his surgical actions on the patient.
It requires a human operator to its activities, even when the
operator is working remotely. The presence of robotic technology
improves the activities of a human operator, but does not replace
The concept of robotic surgery begins with the work of Scott
Fisher (NASA) in the second half of the 80s, while developing
virtual reality projects associated with 3-dimensional images. At
the end of that decade, the start and development of laparoscopic
surgery was presented as a revolution in the operating concept
of that time, which was characterized by the statement "great
surgeons, large incisions" with Jacques Perissat´s pioneer
laparoscopic cholecystectomy. Just after that period Richard
Satava and NASA began to develop studies on telesurgery into a
military program. In the early 90s, several surgical robotic systems
began to take place, such as RoboDoc®, capable of performing
vascular anastomosis and Artemis® with remote handling. In
1992, the US military developed the DARPA® program, in order
to save soldiers on the battlefield using high technology, where
a vehicle equipped with high-tech imaging could make diagnosis
and initiate procedures remotely to where the wounded soldier
was located. In 1993, Alberto Roveda performed liver biopsy
in swine, with the surgical station located in the Laboratory of
NASA in Pasadena, California, and the animal far distant in Milan.
From this and other experiences, robot surgery commercial
activities took place and the first one to be used was AESOP®, a
mechanical arm which used voice command to control the optical
movement on videosurgery. Soon, Zeus® and Da Vinci® surgical
systems were developed, and in 1997 the first robotic surgery
was performed in the city of Brussels, by Jacques Himpens and
Cardiere. From that date on, various procedures with different
complexities had been performed with this technology.
Robotic surgery is seen as a promise in several surgical areas,
as there is no strong scientific evidence demonstrating increased rates of surgical complications compared to conventional or
even laparoscopic surgery. In general, there is a common opinion
about the needs of years of training and experience to perform
procedures using remote technology. The literature suggests
advantages over other forms of surgical access, including
superior visualization of the operative field with images in three
dimensions compared to traditional laparoscopy and better
surgical ergonomics; and present as disadvantages the size of
materials, the lack of flexibility of power devices and the difficulty
to perform operations that use different quadrants or surgical
sites. This technology is not yet widely available to all surgeons
and training is still not accessible.
Perhaps the greatest enthusiasm in robotic surgery points
to pelvic surgery because of its good mobility and performance
in a restricted confined field when compared to conventional
or laparoscopic surgery. In 2009, a report about the acceptance
of robotic surgery showed that 795 units of Da Vinci were
sold in December 2007, mostly in North America and Europe,
and in the same period 50,000 radical prostatectomies were
performed in the US, with 60% of penetrance of these surgeries
in the US market, with an increase of 50% over the previous
year. Despite its advantages, high costs and longer operative
time were disadvantages found about this technology [1,2].
Randomized and non-randomized studies have confirmed the
benefits of laparoscopy in rectal cancer surgery. However, due to
long learning curve and high conversion rate, the global impact
of the use of this method is still modest, especially in obese
male patients. It is estimated that only 10% of colorectal cancer
surgeries are currently treated by laparoscopy, with increasingly
use of robotic platforms added to the perspective of visualization
improvement, exposure and dissection of important structures in
narrow space, such as the pelvic cavity. Besides all that, the great
mobility of instruments, capable to rotate from 180° to 540°
allows better performance in the pelvic cavity . There are even
better results in the quality of oncological resection with clearer
margins, higher number of lymph nodes resection and decrement
of surgical complications as the learning curve is exceeded . Precise dissections provide fewer complications related
to erectile dysfunction in postoperative of total mesorectum
resection in rectal cancer surgery after 3 months of surgery. This
time was also sufficient to significant reduce urinary dysfunction.
In patients receiving different approaches, same results are
reached after 6 months postoperatively . Other studies
demonstrate that the conversion rate to open surgery is almost
5% smaller in robotic or robot-assisted surgeries groups when
compared to traditional laparoscopy. However, most reports
do not show statistical difference between minimally invasive
methods regarding conversion rate. Yet, there is little bleeding
(mean of 283 ml in the European study) considering an average
of surgical time of 297 minutes, well accepted for this surgery
risk level. Surgical margins were considered appropriate in
several studies, with 97% survival in 3 years [4-6].
Robotic surgery is considered purely an extension of
laparoscopic surgery, with improvements in the surgeon's
ergonomics and more precise movements due to trembling
corrections, 3-D vision, and movement accuracy, among other
reasons. It is considered by some American authors as the best
minimally invasive method for the treatment of malignant
gynecologic lesions, presenting reduction of operative time,
ranging from 4.5 to 10 hours, and lesser bleeding, with volumes
from 50 to 1500 milliliters. It is also considered the best option for
complex surgeries such as myomectomy, hysterectomy and deep
endometriosis [5-6]. It was also identified shorter hospitalization
stays, less postoperative pain and better lymph node dissections
in oncologic surgery compared to open and laparoscopic surgery
In general surgery, the use of robotics contributes to
improvement of dissection in oncological surgeries and better
image quality by three-dimension platform as in any other
procedure. However, it has the limitation to be mostly used in
single abdominal quadrant surgeries. It presents the advantage of
better dissection in complex surgeries, safer micro suture as well
as reconstructions. In surgery for morbid obesity it is possible
to conclude that there are better outcomes when using robotic
technology, mainly in revisional surgeries. The operative time
ranges from 90 to 300 minutes, with very low conversion and
complication rates, as well as mortality. These results are similar
to those found in laparoscopy surgery, independently of the
surgical technique (Sleeve Gastrectomy or Gastric Bypass), but
with much higher costs [6,8]. In surgery for achalasia, it has been
proven that after 30 procedures performed robotically, surgical
time of myotomy with partial flap is equivalent to the same
surgery performed by laparoscopy. Bleeding and hospital stay did
not change in relation to the technique used. Nevertheless, there
were more complications in laparoscopic surgeries compared to
robotic surgery, with 8% more esophageal perforations for the
first procedure, all corrected immediately and without clinical
consequences for the patient [9,10].
Cardiothoracic procedures require concentration and
precision from the surgeons. In Lung resection, studies have shown that difficulties were overcome with the use of robotic
in thoracic surgery, mainly due to ergonomics because of the
presence of only the robot arms and the assistant in the surgical
field, avoiding the inconvenience of collisions between two
people in tight space. Three-dimension high quality visions are
a significant differential, which adds to the procedure, more
accurate resections and free margins. The same benefits are
found in cardiac surgery such as valve replacements, where
the improvement of image quality and accuracy of movements,
minor camera movements compared to those made by human
hand, such as tremors and rotation, significantly reduces surgical
time. Thus, it keeps surgeons with better proportion of time and
maximum concentration on the procedure. According to Park,
et al, the disadvantages of this technology are the difficulty of
surgeon training and the costs of the materials. In their report,
the cost for annual maintenance is US$100,000. The robotic
instruments have a finite number of uses that varies from 10 to
12, depending on the instrument. Each instrument costs $2000
and can be used for 10 times, with a cost of US$200 per case. The
drapes used for the robot arms and camera cost US$130, so that
the total disposable cost per case is US$730. Associate with the
huge initial investment to acquire the robot platform, this will
be the most difficulty for emergent countries to apply the robot
technique routinely [11,12].
Minimally invasive surgery with robotic assistance is
considered very safe in pediatric patients and can be applied in
various areas of pediatric surgery. Cholecystectomy is excellent
for the development and training of new surgeons joining this
technology. Procedures considered delicate and complex, such as
hepatobiliary, urological pyeloplasty and solid tumors in thoracic
surgery are ideal for this technology due to augmentation
in technical accuracy. Procedures like esophagostomy and
enterostomy gather the group of operations indicated for robotic
surgery, without increasing complications neither surgical.
Nonetheless, randomized trials must be performed in order
to confirm the advantages of robotic surgery in the pediatric
Table 1: Advantages and disadvantages of robotic surgery.
Best view quality
Coasts of the materials
Coast of manutention
shorter hospital length of stay
Difficulty of surgeon training
Instruments have a finite number of uses
Camera rotate from 180° to 540°
Better precision of dissection
More linphonodes dissection in oncologicals surgeries
Less functionals urologic complications
The main disadvantage found when comparing robotic surgery
to conventional laparoscopy is the high cost of the technology.
According to Barbash and Glied, the acquisition of a unit may
cost from US$ 1 to US$ 2.5 million to a hospital. Estimation on
robotic surgery costs varies according to assumptions about the
frequency which the robot is used. Reports about the analysis
of robot-assisted procedures costs published since 2005 in a
range of 20 different surgical procedures, the additional variable
cost of using this technology was US$ 1.600 more expensive.
When the amortized cost of the robot itself was included, the
total additional cost of using a robot-assisted procedure rose to
US$ 3.200. Because there is only one company responsible for
manufacturing the platforms used in robotic surgery, the prices
exercised by the market are still very high. It is believed that
in the near future, with the emergence of new technology and
the breaking of the current monopoly, the cost will be reduced,
thereby reducing the amount paid out per procedure [10,15].
Robotic systems also require high cost maintenance fee and
specific materials expenses. The use of robotic systems may
also require longer operating time than alternative techniques.
Some of the new costs will be offset by reducing postoperative
in-hospital costs, reducing hospital stays with better and quicker
patient recovery and also quicker return to work [10,15].
The use of robotic surgery has increased in all major centers.
Technical advantages such as better precision movements and
three-dimension images turn the procedures safer and may
decrease surgical time. These advantages are gained according
to the improvement in the experience of the surgeon. The high
cost is still considered the main hindrance in the use of this
technology, but the expectation is that, with new companies'
development, costs will decrease. These higher costs may be
attenuated by faster recovery, shorter hospitality stay and faster
return of the patient to its activities, which leads us to consider
that this technology as viable and promising.
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