How is surgical robotics evolving?
[JK] Nothing happens in a vacuum and surgical robotics is a clear example of that. In the 90’s, surgery shifted to minimally invasive procedures in the outpatient setting leading to laparoscopy or keyhole surgery. This is where you put instruments through a few small incisions versus one very large cut. In the 2000’s, robotic surgery was introduced and there was skepticism. By 2010, the momentum of minimally invasive surgery in a variety of indications was gaining traction and acceptance of robotic surgery was increasing. The promise of surgical robotics platforms became more evident. Now in 2020, everything is connected; it is not enough to look with one’s own eyes, we can look deeper and see more than meets the eye. There is increased excitement around image synchronization which can aid you in surgery so you can see how deep to cut, in order to avoid arteries and collect all of the tumor. This lets us, as surgeons, do more than what a human hand is capable of; now, a robot can assist us to execute a procedure more precisely and faster than a human hand.
What are the hurdles to acceptance for surgical robotics at healthcare systems?
[JK] One hurdle is that there are too many pieces and parts to a system; we still need to put them together. Another hurdle is that we need to enable the robotic systems to have more value. One way to do that is to improve the robots so that they are more actively assisting the surgeon. Not all robots have added value. About 10 years ago, a robot named Penelope was introduced to replace nurses in the operating room. The robot would change out the instruments for the surgeon during a procedure. It did not look like a robot; it looked like a set of drawers. If the surgeon said scissors, it would take the tool that was no longer needed and provide a pair of scissors to the surgeon. It never really took off because it offered no incremental value over a nurse. Now if that robot also autoclaved then it would have incremental value.
An additional hurdle is cost; there are significant economic constraints. However, we understand that innovation usually starts off as expensive and as it is expanded, it will become more cost-effective.
Another barrier is the speed of adoption of new technologies. Only 2% of surgical cases are performed robotically. While it has blossomed, it is still only 2% – there is a long way to go. In healthcare, there is resistance to acceptance of new technologies. In the graph of innovation, there are those that are the early pioneers, the followers and the ones that completely resist change or the laggards. It is the very early pioneers who push the boundaries and take the innovation forward. Most surgeons want to see a fine-tuned product. Currently, we commonly use robotic systems for surgical rehearsal and training. This is important as it helps us to assess the progress of training and to build out artificial intelligence and data. This is just the beginning. The actual surgical robotic platform technology is a mountain to move; we want to move it and create a new practice of surgery to enable the surgery of the future.
How do we increase adoption?
[AS] A large gap with surgical robotics is still the education and training. Currently only a few surgeons are really using robotics in any given large hospital system. We need to have more accessible programs for training. The high cost of the platforms also prohibits wide spread adoption due to limited capacity in any given region.
[JK] By improving access to training and education. Intuitive Surgical was one of the leaders in this. They launched in 2001 at a time when articles were being published about surgical robots going rogue; this would never be the case, but the company launched a robot and an empire of education. They put reps in every operating room and set a model for the industry on how to disseminate training on a new technology. Now, many are coming into the space – nationally and internationally.
What developments or future trends in surgical robotics are you excited about?
[JK] Right now, we are using virtual reality technology for surgical training – not to do the actual surgery, but to conduct a simulation of a surgery. It allows an experienced surgeon to rehearse or prep for a surgery or for inexperienced surgeons to gain expertise. This is constantly changing and likely, we will then be using these technologies not just for training, but also in the OR once approved by the FDA.
I think we will see disruptive change that brings value to the patient and surgical team. For new robots to be financially viable, they will likely evolve to use disposable pieces and be less expensive.
We are seeing disruptive imaging technologies. In the old days we had to make large incisions, as long as one foot, to make sure we removed all of the cancer. Now we can leverage imaging technologies which synchronize MRIs or CT scans with images that deploy fluorescent light; have tagged isotopes and light up suspicious growths on lymph nodes.
Further, these images are being imported into the robot. Today, a surgeon can have a CT scan digitized and allow one to overlay it on an image so you can see the vessels and organs. We use this as a surgical prep tool. The next step will be to actually use it for improved navigation in surgeries.
[AS] We envision leveraging more sensors with existing catheters to motorize the device and tie to a virtual anatomy which will assist in getting us closer to a fully automated robotic surgery.
[AS] We see robotics being made more accessible by placing them in ambulatory surgical centers. This will be a future trend and as the equipment cost becomes less of a barrier, robotic technologies will make their way to rural and smaller healthcare centers.
What investment trends are you seeing in surgical robotics?
[AS] We are interested in leveraging the existing robotic platforms and make them more versatile for the surgeon to operate and use. Orthopaedics, gynecology, kidney and prostate are very interesting, but we are looking ahead for other applications.
Surgical procedures for general laparoscopy can be done through robotics in simpler ways with high precision. We look for innovation in improved safety through robotic surgery. This can mean the need for more feedback through more sensors. This enables the ability to know when you are near a blood vessel, arterial or venous, and whether there is active blood flow or a clot. By knowing this, we can avoid tissue damage and other complications. Or we can assess the use of haptic feedback so that you can feel it go through the tissue.
Another opportunity area for investors is improved visibility to the surgical process with the addition of Virtual Reality (VR) and Augmented Reality (AR). This allows one to see more during surgery. Currently, there are limitations of visualization. The images are extrapolated and manipulated, and the user experience deploys a joystick approach. There are new and better ways to navigate the surgery.
AI is of course important; with AI, computers can observe repetitive surgery and build learning. This can inform improved learning and safety. Similarly, data and access to data is both a challenge and an opportunity. Partners of Cleveland Clinic need large data sets with images which are curated and tied to demographics and disease groups.
Connectivity is also improving every day. 5G will allow faster connection speed and decrease lag time. Ultimately, this will enable a new level of remote surgery to be executed and bring more access to rural areas.
Tell us about your robotics lab at Cleveland Clinic.
[JK] Cleveland Clinic is a leader on the cutting edge of medicine across many specialties and sub-specialties spanning surgeons to care- givers. Our expertise is rooted in our knowledge of healthcare and is a real asset that we hope to partner with engineering to help identify challenges in surgical robotics. We will seek to inform better design and build the right tools to fix these issues.
I have been involved with surgical robotics from the beginning and have published 20+ procedures. I have greater than 10 years in developing new robotic systems, many of which are commercialized and in the surgical suite. We opened this lab to focus on robotic solutions to identify and address the limitations. We seek to bring clinicians and engineers to our lab and a core focus will be on robotic automation. We are currently building our team, experimenting with tools and optimizing prototypes. We are platform agnostic; we use programmable robotics.
[AS] This lab will allow us to directly innovate on ideas that our clinicians come up with. We will have the ability to build and test concepts, pioneer new techniques, and develop software algorithms that will power the next generation of robotic computing.
Why a focus on robotic automation?
[JK] Robotic automation is a field leveler. The goal for the robot is not to have the robot do the surgeries; the goal is to have the robot become an extension of the surgeon to provide active assistance from the robot, so it is not a passive partner. This is moving towards having the robot be aware of surroundings and execute a responsive task. The key to accomplishing this is to have the robot be integrated into a digital bubble with the surgeon, the images, the data and AI all in sync. If the robot is in sync with the images and we can make it aware of its location, we can impact its actions.
[AS] We are very interested in building the future of automated robotics; but it can’t be done in one leap. I envision that we will get there through a series of smaller steps. For example, in one of our portfolio company, we are incorporating high resolution imaging data to drive technology-enabled surgical navigation. Centerline Biomedical is creating individualized data sets of the anatomy based upon images, registering the patient to that anatomical knowledge base, and allowing the surgeon to see and operate without radiation.
What are your thoughts on having multiple robots in the surgical suite?
[JK] If they do not overlap, that is fine. I can imagine having multiple specialty robots e.g. Medtronic has a robot for orthopedics, depending on the surgery or having one for imaging and interoperability and another for a different type of imaging. They ultimately need to complement each other.
What do you think is the key value of surgical robotics?
[AS] Cleveland Clinic is making investments in surgical robotics both clinically and financially. This is where the future is headed. Forward-looking approaches will only lead to more and more attention and value to robotics in healthcare. At Cleveland Clinic, we are exploring cutting-edge techniques and platforms with a view towards providing the highest quality of care and value to our patients. This will be achieved via improved, safer procedures, faster turnaround times in the operating room, or doing more procedures with direct and indirect savings. We are looking at this area holistically.
[JK] There is value in surgical robotics for multiple stakeholders; for the patient it will be better care. For the healthcare system, it will allow us to touch more lives and in a sustainable way. For the surgical team, robotics should not be restricted to a fortunate few or those who can afford it. The ultimate goal is the democratization of robotic surgery, so we all learn and improve.
Many people come from all over the world to get second opinions from the world-leading surgeons at Cleveland Clinic. Do you envision that Cleveland Clinic can someday go to the patient via surgical robotics?
[AS] Definitely. I can see where in the right situation with the right connectivity that a top surgeon in Cleveland Clinic can operate remotely leveraging robotics to drive high quality care across the world in the years to come.
More about Akhil Saklecha, MD, Managing Director, Ventures & Jihad Kaouk, MD, Director, Center for Laparoscopic & Robotic Surgery, Cleveland Clinic
About Jihad Kaouk, MD
Dr. Jihad Kaouk is an American Board certified Urologist who helps patients within Cleveland Clinic's Glickman Urological & Kidney Institute as the Director of the Center of Advanced Laparoscopic and Robotic Surgery. He also serves as a Professor of Surgery at Cleveland Clinic’s Lerner College of Medicine of Case Western Reserve University.
Complementing his role as Director, Dr. Jihad Kaoukholds the position of Institute Vice Chair for Surgical Innovations and the chair holder for the Zegarac-Pollock Endowed Chair in laparoscopic and robotic surgery in the Glickman Urological & Kidney Institute. Dr Kaouk is listed in Who's Who in America and Top Docs in America.
As such, he has performed groundbreaking surgical procedures, including the first robotic single port surgery through the belly button in 2008 and the first completely transvaginal kidney removal in 2009. These procedures, executed by Dr. Kaouk and his team, proved minimally invasive enough that the hospital discharged the patient within a day of the operation. Dr. Kaouk has one of the largest experiences in robotic surgery in the country with more than 1,200 robotic radical prostatectomy and about 500 robotic partial nephrectomy that he performed through the last 10 years. Recently, Dr. Kaouk patented a device for radiofrequency cauterization and the extraction of tissue used mainly during partial nephrectomy.
An MD with professional responsibilities beyond direct patient care, Dr. Kaouk presently works with a number of committees associated with Cleveland Clinic, including the Robotic Steering Committee and the International Medical Education Committee. Moreover, Dr. Kaouk engages in the academic progress of his field in his role as the Associate Editor of Urology journal, and as a Section Editor for The Journal of Robotic Surgery and the Arab Journal of Urology. He also acts as an Ad Hoc Reviewer for a number of peer-reviewed publications, among them the Journal of Urology, the Journal of Endourology, the British Journal of Urology International, and the World Journal of Urology. Previously, he has been a Guest Editor for Urology’s special supplement on renal cryoablation, and for a special issue of the British Journal of Urology International.
Since 2005, Dr. Kaouk has served on committees at the national and local levels. From 2005 to 2008, he belonged to the American Urological Association’s Urologic Diagnostic and Therapeutic Imaging Task Force, and from 2006 to 2010 he was on the Guide Panel of the Management of Incidentally Discovered Renal Masses committee.
Dr. Kaouk has lectured in more than 130 scientific meetings, chaired more than 20 urologic meetings and performed live surgery demonstrations in 18 medical centers worldwide. He has more than 260 peer reviewed scientific publications, 18 book chapters and hundreds of scientific abstracts and surgical illustration movies. Dr. Kaouk received 32 honors and awards for his work in the professional field, including Cleveland Clinic’s innovator award (which he won twice) and best surgical illustration movies. Prior to establishing his reputation as an innovative practitioner, Dr. Kaouk earned his medical degree from the American University of Beirut Medical Center where he also completed his internship in General Surgery and his Residency in General Surgery and Urology.
Presently, Dr. Kaouk holds membership with the American Urological Association, the Endourological Society, the Society of Robotic Surgery, and the Lebanese Order of Physicians.
About Akhil Saklecha, MD
Dr. Akhil Saklecha is the Managing Director of Cleveland Clinic Ventures where he leads investments into startup companies for one of the world’s top healthcare systems. He currently sits on the boards of Cardionomic, Cleveland Diagnostics, Enhale Medical, Enspire DBS, Mitria Medical, Navigate Cardiac Structures, Neurotherapia, and Zehna Therapeutics.
Prior to joining Cleveland Clinic Ventures, Dr. Saklecha was a Partner at Artiman Ventures, a Silicon Valley-based venture capital firm with over $1.2 billion under management. While at Artiman, he led investments in early-stage start-up companies and served on the boards of Cellmax Life, Oncostem Diagnostics, Slive, ApplyBoard, DateMySchool, and HomeUnion. In addition to his Board of Director roles, he also served as CEO of Slive, an early stage diagnostics company. Prior to joining Artiman, Dr. Saklecha served in administrative roles at Aultman Hospital in Ohio as Medical Director of the hospital’s regional transfer program and Chairman of the Emergency Department and Level II Trauma Center. He was also CEO of Canton Aultman Emergency Physicians, a professional services firm that provides physicians, mid-level providers, and coding expertise to multiple hospitals and urgent care centers. In this same time period, Dr. Saklecha participated at the local, state, and national levels of governing institutions within emergency medicine, healthcare quality, information technology, managed care, and emergency medical services.
Dr. Saklecha is Board-certified in Emergency Medicine and is a Fellow of the American College of Emergency Physicians. He continues to practice medicine on a part-time basis where he remains connected to clinical care, patients, and physicians. Dr. Saklecha graduated from the combined accelerated B.S./M.D. program at Northeast Ohio Medical University. He completed his residency in Emergency Medicine at Summa Health System and holds a M.B.A. from the University of Tennessee at Knoxville.