Welcome to part two of this three-part series that is exploring experiences with Robotic surgery in Egypt. Last week we learnt from Dr. Ibrahim Fakhr about how he was introduced to the field of robotic surgery. We also spoke about some of the challenges to the adoption of this technology. Today we will continue our discussion.
Paul: What are some of the similarities and differences between robotic surgery and other surgical approaches that you have used?
Dr. Ibrahim Fakhr: Robotic surgery offers three very important advantages over open surgery. Firstly, you benefit from high magnification and an unobstructed field of vision. This is particularly important when you are performing surgeries in tight areas. Normally in some open surgeries you cannot have a very wide or clear field of vision, sometimes the angle of view is not convenient and there are some shadows. The second advantage is the ability to have a better access for some procedures. This is something that can be very difficult in some open surgeries. And finally, there is very limited scarring with the consequent early patient mobilization and shorter hospital stays.
The new Italian surgical robot also provides the added advantage of tactile sensations and this adds a lot to the robotic surgery. Actually at the National Cancer Institute, we don’t have the Italian robot as yet. We are still using the 3rd generation Da Vinci and we hope that we can have the Italian robot quite soon.
Paul: Considering the Egyptian context, could you describe any specific challenges and opportunities for the wider use of robotic surgery?
Dr. Ibrahim Fakhr: As I mentioned, the main deterrents to the wider use of robotic surgery, are the large capital investment required, especially following the devaluation of the Egyptian pound and also the high running expenses. We hope that running expenses will decrease a lot with the Italian surgical robot’s concept. We also expect that the Italian Surgical robot will decrease operating times as it doesn’t need to be repeatedly docked and undocked during the procedure.
These two advantages might catalyze robotic surgery in Egypt. Shorter operation times for each intervention performed with the surgical robots will, I believe, allow them to be used for more operations per day, this will also decrease the cost per operation. So I believe in the future, taking into account these advantages, we will have an increase in the number of robotic operations. Moreover, the availability of maintenance is crucial, in countries with a limited number of machines. In our institute, we had a global down time of the machine of about 24 months due to the absence of proper maintenance and an adequate supply of instruments.
A new National Cancer Institute project at the Sheik Zayed Hospital is currently underway. The goal is to establish a 1000-bed cancer center. We are now constructing the first phase of the project which is about a third of the final hospital. We are also planning to have several surgical robots, and of course it will be advantageous to have them at a cheaper price.
Paul: In addition to your outstanding credentials as a practicing and teaching surgeon, you are also a Deputy-General Hospital Manager, so are familiar with the administrative, operational and financial aspects of a hospital.
From this perspective what advice would you give to hospitals in Egypt and developing countries who might be considering the purchase of a surgical robot?
Dr. Ibrahim Fakhr: In terms of advice for those who seek to acquire a surgical robot, I would first recommend that they prepare a good business plan. This will have to involve a solid financial analysis, otherwise you may end up purchasing the equipment but then being forced to stop operating it. The maintenance costs are high, the instruments are expensive, and of course the initial capital investment is big. We hope that innovations in the robotic industry will help to reduce costs.
I believe the high capital costs of the surgical robots is a problem all over the world, and this is getting more attention in Egypt. But I also know that the high capital cost challenge is present in Europe, maybe not as much in the United States but certainly present in Europe, and I believe that the industry is aware of this problem. I believe that the Italians, British and Chinese are now seeking to bridge the big gap concerning this issue.
I hope that within the coming few years, we will have more competing robots and this will add a lot of dynamism to the market. I think the current monopolistic situation whereby the robotic surgery field has been dominated by a single company is unhealthy for the industry, and luckily enough, this has already come to an end. I believe that things are getting more interesting as other companies emerge and compete in this field. Overcoming these cost barriers will enable surgical robot to be used in even more hospitals in Egypt and also in other countries.
We must also of course give attention to training. Any hospital that is thinking of getting a machine will have to provide training in the different surgical procedures where the machine will be used, for example in pelvic surgery. It is also very useful for the base of skull surgery, for the surgeries of the chest especially when they are combined with neck or with abdominal surgery. So I believe this will enable you to address most of the different surgical oncology specialties. To take advantage of the increased scope and flexibility that the surgical robot offers you will need a full team of specialists to be able to reap the benefits of this range of capabilities. Of course, in equipping the surgical robot to serve the needs of the different specialties you will incur additional costs, but if it is well planned then it certainly becomes a worthwhile investment after all.
Paul: How do you see the field of robotic surgery evolving over the next 5 to 10 years? What from your perspective are key problems to be addressed and opportunities to be seized?
Dr. Ibrahim Fakhr: Well, I believe that what we need to provide the public with is more information about robotic surgery. They first need to understand that these robots are not those autonomous robots which are appearing in different sectors such as housekeeping, the military, and so on. Many of those robots are fully automated or self-controlled, they are sometimes left to operate without direct human control. But people need to understand that the surgical robot is actually an interface for the surgeon rather than an autonomous intelligent robot that is doing things on its own. This is still not very clear for many people at least in countries like Egypt where the robot is not well established as yet.
The other issue is that the robot is not a magical solution, it is not something that will replace a good surgeon. Also it will not replace or remove the need for making good decisions. Rather, this is a tool available to the surgeon, like any other instrument used in surgery such as the laparoscopic devices or in diathermy. It is a tool, albeit a very sophisticated tool, to be used only when it is appropriate. It is not that you require this because it is a la mode or the new trend! So we need to use the surgical robot when and where it is needed, where it is efficient and cost effective, otherwise it goes from being a useful instrument to a surgeon’s toy, or a patients’ trendy.
Therefore, judgement is needed as this can have very bad unintended consequences. This can be very bad for the industry because if you start using things that are not appropriate or relevant to the context after some time you will have a lot of problems, a lot of complications, for example the very high expenses linked to the use of the surgical robot. This will in turn have an adverse impact on the general use of these machines, due to medical insurance industry not being willing to cover these procedures because they will start to think that you are using these techniques unnecessarily, when there is not a good cost to value proposition.
Therefore, we need to keep a holistic perspective in our approach to these machines. It’s not a patient’s opinion, it is not a surgeon’s toy, it is not a mode or trend that we must feel compelled to follow. So this is a very serious situation. But we can learn from past experiences. We faced a similar challenge when laparoscopy was first introduced, it took a lot of time for people to understand that it is very useful, but it took time, so we do not want to repeat the same mistakes again.
Paul: Thank you Dr. Ibrahim Fakhr for sharing these insights with us.
We will continue our discussion next week during the third and final part of this interview when we will explore trends in the robotic surgery field, how this could influence their adoption and much more.
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