Abstract
Today we are fortunate to be joined by Dr. Santiago Horgan. Dr. Horgan is a Professor of Surgery at University of California, San Diego. He is also the Chief of the Division of Minimally Invasive Surgery, the Vice Chair of Business Development, Founder and Director of the Bariatric and Metabolic Institute, the Director of the Minimally Invasive Surgery Fellowship and the Center for the Future or Surgery, and the Medical Director of the Simulation Center.
Dr. Horgan's work in surgical robotics has been impressive to say the least. He has published well over 30 manuscripts on surgical robotics in peer-reviewed journals and is recognized around the world as a thought leader and expert in the development and application of robots in surgery. His first publication on this topic was in 2002, and some of his early work was published in JLAST. We will get back to that later.
For starters, Santi, welcome, and thanks for taking the time to have this conversation.
Thank you, Dan. It is my pleasure. It is really an honor to have this interview with you.
Let me just start by asking what is I think on everyone's mind: when did you first get involved with the use of robots for surgery, and why? What was it that got you into this, and not just in a small way, but in a very big way?
I got involved very early in the game. In 1999 I got a chance to see the da Vinci robot at the American College of Surgeons Clinical Congress in San Francisco. At that time the system was not yet approved by the FDA [Food and Drug Administration] in the United States. I liked the system a lot, and I met with the company, and they said, “You know, we want you to try it, and we want to go to Europe with a small team from the United States.” I was very lucky to be part of that team. In general surgery there was me and Bill Kelly from Richmond, VA.
So we went to Brussels to see Guy Cadière using the pre-FDA platform. We got real hands-on while in Brussels.
And then when I came back, I was really convinced that this technology did have a future in surgery, and I wanted to be involved from very early in the game. I was, again, very lucky to have a chair and a chief of general surgery in Chicago, Drs. Haran Abkarian and Scott Helton, who supported my vision.
We did some fundraising and were able to acquire one of the da Vinci systems. We made a reservation for purchase before it was even FDA-launched. With that we did our first case just 2 months after the device was approved by the FDA. That was almost 14 years ago.
So 14 years ago you saw something in the whole surgical robot space that captured you. Can you recall at that time what it was specifically? And is that the same thing that today keeps you continuing to be engaged in this?
You know, when I saw it the first time and I saw the degrees of articulation and the phenomenal three-dimensional image, I thought that it was perfect for some operations where we needed more dexterity. I originally got engaged because of that, and I am still engaged because of that.
It is amazing that in 14 years I keep the same passion, and I am as impressed as I was before about what you can deliver in some areas of surgery with this articulation and quality image.
So enhanced optics, the ability to have increased degrees of articulation in the abdomen, and the refinement of movement that the robot can provide in certain operations are superior to what we can do laparoscopically?
Yes. You know, I am a surgeon that can still do the same operations laparoscopically, so it is not that I cannot do them without a robot. I think that I am a good self-study in that I can see the value, because I can do both operations. It is not that the da Vinci is allowing me to do things I cannot do laparoscopically, so that my lack of skill is overcome with a robot. What I see is that even though I have skills to do the operations well laparoscopically, with a robot I can deliver a much better operation. So it really improves in a big way what I can do.
I think this is an important point that I want to take a moment on. Many of the touted advantages of the robot have been that surgeons who do not have great laparoscopic skills can now use the robot and perform operations that they might not otherwise be able to perform laparoscopically.
Correct.
But you are saying that it is not about doing something that you could not otherwise do laparoscopically, it is doing something you currently can do laparoscopically, but doing it better?
That is correct. I think that is what enhances the value of the technology. For example, nobody questions today that there is a better option than clipping short gastric vessels. Instead, we are using other devices where energy is used to divide short gastric vessels in a much more efficient way.
It is true also that if Dan Smith or Santiago Horgan encounters a situation where the energy device is not available in the middle of a case, we would finish the case safely because we know how to do it with clips. But we know there is a better way to do it.
With the da Vinci system, I think it is the same. I can do it, but I know there is a better way to do it. There are some areas in the abdomen where the system can enhance what you do, which I think adds significant value.
Well, actually, I like that point. I have not heard it put quite that way, but I think it is a great analogy. You describe the robot as an adjunct for certain operations. This is a good segue to my next question. What are the procedures that you think the robot particularly enhances?
We have published a lot on kidney donors, and we are the leaders in the country and worldwide in this area. We are proving that the robot makes the operation even safer with a great outcome and product at the end of the day.
I think that for achalasia, for myotomies, the da Vinci system is better. There should be no question about that. We have now a lot of papers published where we are proving a 0% perforation rate when we do the myotomy with a robot, versus what is published, that goes from 3% to 16%.
Another is esophagectomy for cancer or any work that you need to do in the chest and from the abdomen, for example, esophageal diverticulum and some leiomyomas. We have been doing esophagectomies robotically now for almost 13 years, and we never had to convert one to an open operation. When we look at the impact of minimally invasive surgery on esophageal disease, it is very minimal. Use of the robot could help more intrathoracic esophageal operations be done laparoscopically, and this could have a significant impact on reducing morbidity of surgery for these patients.
There is no question about it when we talk about liver resections. We have experience with formal right hepatectomies or formal left hepatectomies with a robot with minimal or no transfusions. You know, the dissection of the cava, the portal vein, the hepatic artery is greatly enhanced with the robotic system.
Many of the things you have just outlined are not very common operations. They are done in small numbers, open or laparoscopic, at relatively few select centers. There has been a lot of interest, and the company has been eager to try to promote the robot's use for more common procedures, like cholecystectomy, hysterectomy, and sleeve gastrectomy. Do you have comments about that?
We did a study many, many years ago showing a better leak rate when [the robot is] used with gastric bypass. That was early in the experience for everybody. Actually, that was a little bit of an overkill. We now know that we can do that operation without the robot with the same outcome. Sleeve gastrectomy is the same—it is not an example where the robot adds any benefit. I feel that it does not.
In terms of hysterectomy, it may be the same story as we saw with urology, where most of the hysterectomies are still done open. Will the da Vinci system allow patients who are undergoing an open operation to have it laparoscopically because the skills are enhanced? I think that that is an area where it may. I would like to see what happens if we take away the da Vinci system, how many prostates will be done laparoscopically, or are we going to go back to an open operation like we were before.
So that I do not know. So in those areas, I think that there is a potential benefit.
Let's transition to the cost discussion. Many of the enhancements used as examples in our conversation today, such as a LigaSure or an Harmonic Scalpel, are fairly low-cost enhancements. A robot certainly would not fit in anyone's definition of low cost, in terms of both very high acquisition cost and a fairly high ongoing maintenance cost.
Since we do not charge or get paid more when a procedure is done robotically, where do we find the value to be able to bring this to patients?
The value is, can we do this operation minimally invasively? Can we reduce hospital stay? The more operations you do, the more specialists that can do robotics, the more areas where we can see a benefit, then the more distributed that cost of maintenance is going to be.
Are you aware of any studies, either complete or ongoing, that are looking at the return on the investment in a robot, and in particular the shorter hospital stay?
No. I have done a very thoughtful examination of the cost data from robotics, and the data are all over the place. There are papers arguing one side, that it saves money; papers that argue the other side, that it does not save money, and in every specialty, urology, obstetrics/gynecology, colorectal, cardiac, and so on. So it is difficult to make a statement, because we have not analyzed, in my view, cost very seriously.
I think that that needs to be done, you know, to really analyze the data more thoughtfully and understand what the real cost and what the real implications of using the systems are. If my kidney donor goes home earlier, and I can save more grafts because my rejection rate is lower with this system, then that is a big saving.
The question is, how do you quantify in terms of dollars saving one kidney? I do not know, and I am sure that nobody knows what is the cost of one kidney not rejected. Maybe for the bottom line there is no cost, but for the patient and the family there is a big cost.
Do you think we have enough penetration and evolution of the use of robots in surgery to be to the point where there is a return on investment, or are we still in the phase of technology introduction, where we are not going to see that direct return on investment yet?
We have been out there now for 13 years, so, you know, we should be seeing a return on investment. The question is, do you see that when you do not upgrade the system that often, or do you see that when you do not upgrade the system at all, and you stay with an old system and you can do the same operations? The cost of buying a new robot is going to be very difficult to subsidize through the years. You know, $2 million, two or three systems every 4 years is a lot of money. In 13 years, we have four systems launched, the regular, S, SI, and XI, each one with a higher cost.
We may argue that that is capital cost, and capital cost is part of building and maintaining the hospital, but in today's economy, there has to be a return on investment.
And the perfect example of that is Latin America. The penetration of the systems in Latin America where they analyze cost extremely closely because there is no money at all, we only have 20 robots sold. And the reason is they cannot see how they can make back those dollars from the initial investment. In the United States, the cost is more hidden, so it is more difficult in terms of dollars.
I think that when you add the quality of what you deliver to the equation it may get easier. I know that I do a better operation with a robot, so—is somebody going to pay for quality, or are people going to pay for outcomes? It is a difficult question to answer.
So, let's talk about the future. Based on where we are at today, I am going to ask you two future-oriented questions. One is how you see the future in the context of what we have today, which is a single manufacturer, not a lot of competition in the market. As you have articulated, no evidence of prices going down, only going up. And the other is if you could start with a clean slate, and you are the boss of the robotic future, what would that future look like?
So let us start with the first one. What do you think the future is of robots? Has it run its course, or is there still a bright future for continued growth and innovation with our current robotic capabilities and market?
I think that the robot is here to stay. It is not going to go away. What I also think is that we need to see more companies in the market, and I think that robotic surgery will greatly improve when we have more competitors. Right now it has been a one-company-run show. And this is like if Ford was the only car company, where would we be?
We know that competition drives excellence and lower costs. We see that on TVs, on computers, on cars. But when you own the market, it is very difficult. You pretty much do whatever you want. So I am a believer that robotics is going to stay. I know of other companies coming out with less expensive products.
We now have the equivalent of a Ferrari in our currently available robot. The question is, do we really need a Ferrari, or we can do the job with a Mercedes Benz or a Honda Civic? How much complexity in the robotic system do we need?
In my view, we went from riding a bicycle—laparoscopy—to a Ferrari—da Vinci—and I know people who own Ferraris, and they do not drive their Ferrari to work every day, they use regular cars.
It is too expensive.
Correct, it is too expensive. And it is too much of a risk. So they do have it, but they use it only for special opportunities. So are we going to go a future where we are going to have more platforms that are going to be cheaper, will improve your skills, will give you articulation, and will not be that expensive? I think that that is the future.
When do you think we will get there?
I am aware of other companies out there right now. They have platforms that are very close to clinical use, and I think that they are awaiting the perfect timing with a lawyer, analyzing when expiration of patents occur, and see what they can do. And I think that that would be very healthy for the robotic world, to have two or three companies competing. That will, without a question, bring costs down.
It makes no sense that we have more cases being done robotically and we are paying more for the system. We should be paying less. But that will only happen when we get more companies out there. That will force the market to drop their price. Right now, we say it is a one-company game, and you can do pretty much what you want.
So now let us paint a picture of that future. We have competition. We have deeper penetration. We have the Ferrari robot for some things. We've got a utility robot for other things. What will surgical practice in that era look like? Will you and I sit in our office and operate all day from a console in our office? Will you will sit in your console and do telerobotic surgery? What do you think that future is going to look like for the surgeon in practice?
That is a very good question, and it is a challenging one, because we know that we can do operations from the distance. We also know that the outcome of a good operation does not rely only on the surgeon, but also on the team.
So am I going to be comfortable operating on a patient in Germany when I am here alone without seeing what happens after I am done, and how do they track the follow-up of the patient, and how do they deal with complications? Well, I am not, and I am sure that many are going to be like me.
But we can proctor those surgeons from the distance. We can coach the operations. We can get them out of difficult situations when they are challenged by the anatomy of the patient. So I do see a benefit there. We are going to have a lot of surgeons with a lot of experience who are going to be available to do that and to give a hand in those critical circumstances. So I do see that happening. In terms of how the world is going to look, it is exactly what you are saying. We are going to have a Ferrari for that need, and then we are going to have other platforms that are less complex for other things.
Let us talk about cholecystectomies. We do a million a year in the United States. Do we need a da Vinci system for every one of them? No. But if we want to lower the risk of common bile duct injury, we need to do something. And that something has not happened in 25 years of laparoscopy. So something different needs to happen.
So do we need a different robotic platform to help surgeons do the operation better without adding too much cost? Because you know, Dan, nobody questions that when they put you in the console you are a better surgeon. The issue is cost.
If we were talking about the same cost, people would be using the da Vinci system to do a gallbladder, those who struggle. But at the cost that it is right now, it is going to be very difficult to make a difference.
Now, if you are a surgeon with a common bile duct injury of 3%, maybe you need to look into robotics, because with all the lawsuits you get, you are going to get—you are going to save a lot of money by just buying one robot, maybe. But that needs to be proven. We have not proven that robotic surgery decreases the risk of common bile duct injury. If we could, that would be a huge benefit to everyone. Use of the robot to eliminate certain complications with common operations could be a future that everyone would embrace, especially if it can be delivered at a reasonable cost. That is the future I hope for with robots in surgery.
Well, there is a theme here, and I do not want to put words in your mouth, but the theme that I have heard throughout these answers is the value of the robot to enhance the quality of surgery and the outcomes, not to replace the surgeon or a baseline expectation of surgeon skills.
Correct.
You cannot remove the human element and the surgical skill or replace that with a robot. You can enhance it, and the barrier to us really understanding the full capability of that enhancement has been a high price of entry and ongoing use of the robot. And in today's healthcare economics, the real difficulty is justifying that expense without being able to quantify what that enhancement really means. If it is an extra $50 for a Harmonic Scalpel, and it will get you out of the operating room 15 minutes faster, the math on that is pretty easy. But at significant higher cost to use a robot, getting out of the operating room an extra 30 minutes early, or out of the hospital 1 day earlier, does not add up from an economic standpoint.
So the last question I want to ask you as part of this is, why did you choose JLAST for your publications on these topics?
It is the same reason why we are choosing it today. JLAST is very open-minded to new technology, to look at the future and to analyze the importance of a paper. That is what we like. We have no questions about where we could send this to be published, be accepted quickly, not to go through a 2-year round of reviews and edits.
We think that the way JLAST analyzes papers is extremely fair, and that is what we like about it.
Well, as its Editor-in-Chief, I appreciate your continuing to submit this kind of work to JLAST. Anything else you want to say, Santi, on the robot topic?
No. I really liked our discussion, I think this is a very fair discussion.
I hope so. I did not want to be controversial, but actually I have learned a lot. You have helped me reshape some of my thinking about the robot and its role and sparked a little bit of an interest on my part to where this technology really may be able to take hold and have a positive future.