Essential elements to the establishment and design of a successful robotic surgery programme

THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERYInt J Med Robotics Comput Assist Surg 2006; 2: 28–35. ORIGINAL ARTICLEPublished online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/rcs.77

Essential elements to the establishment anddesign of a successful robotic surgery programme†

Vipul R. Patel*

Department of Robotic and MinimallyInvasive Urologic Surgery, The OhioState University Medical Center,Columbus, OH 43210, USA

*Correspondence to: Vipul R. Patel,538 Doan Hall, 410 W 10th Avenue,Columbus, OH 43210, USA. E-mail:[email protected]

†In the past 3 years, author hasacted as a paid consultant for acompany with a vested interest inthe product being studied.

Accepted: 6 February 2006

Abstract

Introduction The application of robotic assisted technology has created anew era in surgery, by addressing some of the limitations of conventional openand laparoscopic surgery. To optimize success the incorporation of roboticsinto a surgical program must be performed with a structured approach. Wediscuss the key factors for building a successful robotic surgery program.

Materials and Methods Prior to implementing a robotics program certainessential elements must be examined. One must assess the overall goalsof the program, the initial applications of the technology and the timeline for success. In addition a financial analysis of the potential impact ofthe technology must also be performed. Essential personnel should also beidentified in order to form a cohesive robotic surgery team. These preparatorysets help coordinate the establishment of the program and help to preventunrealistic expectations; while generating the best environment for success.

Results Once the purchase of the robotic system has been approved arobotic surgery team is created with certain essential components. This staffincludes: the surgeons, nursing staff, physician assistants, resident/fellows,program coordinator, marketing and a financial analysis team. This team willwork together to achieve the common goals for the program.

Conclusion Robotic assisted surgery has grown tremendously over the lasthalf decade in certain surgical fields such as urology. The success of programshas been variable and often related to the infrastructure of the program. Thekey factors appear to be creation of a sound financial plan, early identificationof applicable specialties and a motivated surgical team. Copyright 2006John Wiley & Sons, Ltd.

Introduction

The 1990s witnessed the laparoscopic revolution in which many operationswere adapted from the traditional open surgery to the minimally invasiveapproach. Shorter hospital stays, reduced postoperative pain, lessened sur-gical blood loss and better cosmetic outcomes made operations such aslaparoscopic cholecystectomy, nephrectomy and pyeloplasty the standardsof care (1). While initially there was a learning curve involved, favourableresults prompted surgeons to develop minimally invasive techniques for mostbasic surgical procedures. While basic laparoscopy has become part of main-stream surgery, many complex procedures have proved more difficult tolearn, due to the limitations of conventional laparoscopic instrumentation.These limitations include poor ergonomics, two-dimensional (2D) viewingscreens, counter-intuitive motion and non-articulating instrumentation. The

Copyright 2006 John Wiley & Sons, Ltd.

Designing a Successful Robotic Surgery Programme 29

steep learning curve for more advanced laparoscopicprocedures, especially those involving reconstruction,caused the growth of laparoscopy to reach a plateau. Itwas believed that further development would only occurthrough more advanced training or the innovation of newtechnologies.

The new millennium has signalled the emergence ofrobotic surgical technology, making further advancesin minimal access surgery possible. The application ofsuch technology in surgery has been different fromthe traditional usage in industry, where autonomationand repetition are pivotal. In surgery, the concept ofrobotic-assisted surgery is more appropriate, since thesurgeon controls the robot in real time, guiding itthrough the constantly changing operative environment.The emergence of robotic and telepresence surgery haveeffectively addressed some of the difficulties associatedwith conventional laparoscopy. While initially limited toa few surgical subspecialties, the utility of robotics isnow continually expanding (2,3). It is envisioned thatin the future, robotic technology will be used to assistand enhance almost all types of surgery. However, priorto this becoming mainstream, further refinement andimprovement is necessary. In the interim it has becomeobvious that surgical programmes in both the privateand academic sectors must prepare themselves for theincorporation of robotics. Thus, robotic surgery will notonly require specialized training to those already inpractice; but more importantly it will impact surgicalresident training.

As with any new surgical technology its adoption andapplication must be performed with the most clinicalefficiency for the surgical team, and the least potential foradverse effect to the patient. This requires a structured andmethodical plan for incorporation prior to the purchaseof the robot.

This article discusses the essential elements necessary toestablish the foundation and to prime the programme forlong-term success. The author has significant experiencein the initiation, growth and evolution of two successfulrobotic surgery programmes. Of these, one was multi-specialty, one centred in urology, one in an academicsetting and one in private practice. These experiencesprovide a unique personal insight into what stepsare necessary to construct a successful robotic surgeryprogramme.

Currently in the USA there are over 300 establishedrobotic surgery programmes, with a total of almost 400robots. While each of these programmes was initiated withthe expectation of success and growth, this was not alwaysthe end result. Large and small institutions, academicand private hospitals, primarily urology or cardiacprogrammes, have each had variable and unpredictablesuccess. The reason for the lack of uniformity has notalways been evident or been linked to one particularfactor or characteristic. While it is not always possibleto determine which programmes and what characteristicswill translate into success, it has become evident thatthere are ways to optimize the chances of success. In

many cases the reason for the lack of success has been thelack of a comprehensive plan of action or the paucity ofmotivated surgeons willing to, or capable of, incorporatingrobotics into their practice. It is possible that these failurescould have been avoided with careful planning. The bestapproach undoubtedly is to analyse the infrastructure ofthe institution, the goals for the robotics programme andthe resources available.

Materials and methods

A structured plan of action

It is helpful to set up a leadership team to manageand direct the initial foundation and growth of theprogramme. The leaders of the programme must decideon certain short- and long-term goals desirable for thehospital system and on the necessary metrics to measureprogress. This can be achieved by the pre-emptive creationof a structured plan for implementation, including ananalysis of the economics of the programme, along withthe evaluation of the organization’s own infrastructure.There are certain questions that must be answered tohelp assess how well prepared an institution is to begin aprogramme and what changes need to occur:

1. What is the motivation for initiation of the programme?Determining why a robotic surgery programme isimportant to the institution and understanding thevision for the future will likely help define theprogramme and those that will be a part of it.This helps decide upon the metrics to evaluate theprogramme and upon the areas to concentrate theinitial effort. Possible reasons for initiation include:providing state-of-the-art minimally invasive patientcare; competition with other hospitals for marketshare; economic growth; or because of surgeon andpatient demands.

2. What are the initial and long-term financial commit-ments and the expected returns on investments? Theadoption of robotic technology can place a financialstrain on any institution. It is important to under-stand the huge financial commitment required toestablish and maintain a robotics programme. A thor-ough understanding of the capital and ongoing costs,third-party payer reimbursement and procedure vol-umes will help prevent any potentially detrimental,unrealistic expectations.

3. Which surgical services are most optimally suited forthe immediate incorporation of robotic technology,and what is the plan for incorporation of others? Thehospital should also survey the physicians and staff asto the potential utility and willingness to incorporaterobotics into their practice. An idea of which serviceswill be prioritized is also important. Initial selectionof services that have the most applicability and ofsurgeons that are most apt to have success will increasethe likelihood of the programme starting well. Having

Copyright 2006 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2006; 2: 28–35.DOI: 10.1002/rcs

30 V. R. Patel

surgeons who will champion the adoption of roboticsfor a specific procedure at the institution is important.While the systems were initially purchased for cardiacuse, the majority are now concentrated in the fieldof urology. Other services, such as gynecology andgeneral surgery, have also had success in utilizingrobotics for complex procedures

4. What is the anticipated timeline for success and theexpected learning curve? It is essential to understandthat with any new technology there will be a period oftrial and error. The learning curve for robotics, whileconsidered less than that of conventional laparoscopy,does exist and can provide a formidable challengeto those that are not adequately prepared to handleit. The learning curve also brings with it a timelinefor training, adoption and successful implementation.Realistic credentialing criteria and uniform plans fortraining must be put in place prior to the creation of aprogramme to minimize adverse patient outcomes andoptimize surgical success.

5. What peer-reviewed data is available to validate theefficacy of the procedures to be performed, andwhat established benefits are there for the patient?A thorough review of the literature and understandingof procedure-specific patient outcomes will help toprovide realistic expectations, metrics for success andan outline for the goals of the programme.

After these five questions are answered to the satisfactionof the leadership committee and a determination ismade that the programme should be created, then theseessential elements should be put into place.

Essential components

Over the last decade successful robotic surgery pro-grammes have advocated the importance of a teamapproach. Robotic surgery is definitely best performedwith a team approach, as each vital component con-tributes to the success of the programme and individualpatient outcomes. The essential components of the teaminclude personnel in the operating room and in the hos-pital administration.

Preparation and implementation

The robotWhile in other surgical programmes the choice ofinstrumentation is often quite diverse, the choice forrobotic surgery at this point in time is clear. The da Vinci

robot produced by Intuitive Surgical (Sunnyvale, CA)remains the only Food and Drug Administration (FDA)-approved master–slave surgical system still in existenceable to provide the benefits necessary for the facileperformance of robotic surgery (Figure 1).

The robot is based on a master–slave relationshipconcept, whereby the surgeon (the master) controls all themovements of the robot (the slave) using surgical joysticks

Figure 1. The da Vinci robot

Figure 2. The actions of the robot are controlled via ‘surgicalmasters’, joysticks that translate the surgeon’s motions to therobotic instruments

from a remote console (Figure 2). The surgeon sees thesurgical field via an immersive environment consisting ofa viewing screen showing the three-dimensional (3D)image from the binocular laparoscope (Figure 3). Inaddition, the image is magnified ×10. The miniaturerobotic instruments are less than 1 cm in size withthe ability to articulate with seven degrees of surgicalfreedom (Figure 4). The system also provides motionscaling and the elimination of tremors (4). Each of thesurgeon’s movements are translated to the robot andperformed in real time without any perceptible delayor decay in function. These technical innovations allow



Figure 3. The surgeon views the ×10 magnified 3D view via abinocular viewing screen at the console

Figure 4. The robotic instruments have seven degrees of surgicalfreedom

the surgeon to have better vision and more versatilearticulating instrumentation, translating into improvedsurgical precision (Figure 5).

It appears that currently the robotic instrumentationis ideally suited to procedures that require intricatedissection and suturing in confined spaces, such asprostatectomy and cardiac valve replacement and repair(Figure 6). The robot has not yet been utilized extensivelyin the fields of orthopaedics, neurosurgery or headand neck; however, this will likely change as robotictechnology evolves and more applicable instrumentationis introduced.

The surgeonsTypically robotic surgical teams are led by one or twosurgeons in each specialty who possess the experience

Figure 5. Excellent visualization of the surgical field

Figure 6. Articulating instrumentations facilitate suturing inconfined spaces, such as the pelvis

and technical expertise best suited for success in roboticsurgery. The majority of robotics teams are dual-surgeonled, and consist of a combination of an open and alaparoscopically-skilled surgeon working together. Thesuccess or failure of a programme has been correlatedwith the selection of the surgeon. Surgical champions areessential because they provide the experience, expertiseand the willingness to tackle the learning curve.

It has been established that the addition of roboticassistance has the potential to level the playing fieldbetween laparoscopically-skilled and naive surgeons.For the classically trained surgeon, the challenge of astandard laparoscopic approach to prostatectomy is oftena daunting task. Difficulties with counter-intuitive motion,2D vision and non-wristed instrumentation often madethe learning curve insurmountable. The application ofrobotic technology to this task has definitely simplifiedthe transfer of surgeons’ open skills to the realm oflaparoscopy. This translates into a reduced learning curveand therefore a likely reduction in patient morbidity.Ahlering et al. (5,6) reported this ‘robotic revelation’ – theuse of a robotic interface to successfully transfer open


32 V. R. Patel

surgical skills directly to the laparoscopic arena. Wehave previously reported a learning curve for roboticprostatectomy of approximately 20–25 cases (7). Otherexperienced open surgeons have also enjoyed similarsuccesses (8).

The chance of a surgeon’s success can be optimizedby providing the appropriate training, support staffand sufficient patient volumes. Basic robotic trainingis provided by the company (Intuitive Surgical) for allsurgeons who will use the system and consists of a2 day training on the utilization of the robot. Prior tothe first procedure, it is suggested that additional trainingis necessary for credentialing. Case observation of threecases performed by an expert is optimal, along withstudy of procedure videos. In addition, the presenceof a qualified proctor for the first three cases helps todecrease the learning curve and maximize the chancefor successful outcomes in the initial cases. These aresuggestions based upon the experiences of programmesaround the country; however, credentialing is hospital-specific.

Initial patient selection is also important to theoverall learning curve. It is essential for surgeons toexercise clinical judgement by selecting cases appropriatefor the learning curve. Patients with appropriate bodymorphology, health status and with disease characteristicscan help to facilitate a successful outcome. The surgeonshould also prepare the team for the learning curve,while always keeping the patients’ best interests at theforefront. The surgeon should also consult with theanaesthesiologist by explaining the proposed procedure,the surgical nuances of robotic surgery and the expecteddeviations from the traditional approaches. This will helpthe anaesthesiologist to most adequately prepare thepatient for surgery.

The operating room nursing staffThe nursing staff in the operating room is essential tothe success or failure of any surgical procedure, especiallywith robotics. Robotic surgery is a form of telepresencetechnology where the surgeon operates at a distance fromthe patient while looking into a 3D viewing screen ina distant surgical console (Figure 7). The surgeon nolonger has the ability to directly observe the patientor communicate with his/her assistants. The patient iscompletely under the control of the bedside assistantand nursing staff. This concept of remote surgery ischallenging for any surgical team and represents a vitalpart of the learning curve. It is therefore essential forthe surgery staff to be top quality and to understand theprocedure fully. It is well established that a dedicated,consistent, educated and competent team is more likelyto achieve efficiency and help to decrease the learningcurve.

It is recommended that, depending upon the expectedsurgical volume, two and four teams of OR personnelbe trained. Each team should consist of an experiencedsurgical technician and a circulator. They should be

Figure 7. The remote surgeon performs telerobotic surgery

experienced in the specific specialty and with theprocedure being performed for optimal understandingof the anatomy and techniques. It is also helpful to have anursing supervisor oversee the robotic nursing staff, sinceit is necessary to periodically train new staff or enforcenew concepts as the programme evolves.

The surgical physicians’ assistantsIt is anticipated that surgical physicians’ assistants willhave an increasing impact upon the growth and adoptionof robotic surgery. The role of the physician’s assistant iscritical, as the remote-controlled nature of the proceduremakes the bedside assistant’s quality essential. Whileinitially a team of two or more surgeons will embarkupon the task, it is economically quite challenging tohave two surgeons occupied for each case after the initiallearning curve is surmounted. An appropriately trainedassistant has the potential to replicate or surpass thetechnical assistance provided by an assistant surgeon dueto the replication of the same procedure. This individualwill remain constant, while residents, fellows andsurgical assistants may often change. This reproducibilitymaintains the quality and provides the operating surgeonthe reassurance of consistent assistance and outcomes atall times.

The physician’s assistant also plays a vital role inacademic medicine and resident education. The PAis able to help instruct the residents on the bedsideprocedure, and prepare them for future roles as a bedsidesurgeon.

Surgical fellows and residentsWith robotic surgery being a relatively new concept, themajority of institutions that have a robotics programmeare still in the process of establishing their ownprogrammes and refining their skills. Therefore, theeducation of fellows and residents with direct hands-on experience has only recently become a reality. Robotictraining of residents does provide a challenge for thesupervising surgeon, due to use of a remote consoleand lack of haptic feedback. While there are challenges



in training, it is essential to address and provide anadequate foundation of robotic experience for residents.Any academic programme today must have a designatedprogramme and curriculum with a plan for graduatingresidents to have at least basic robotic skills. An optimalbaseline experience would be with the set-up and dockingof the robot, assisting in surgery and console experience,performing parts or all of the procedure in at least 20cases.

Hospital administration and personnelOne of the key elements for success of any new surgeryprogramme is the concordance of vision and goalsbetween the surgery team and the hospital administration.Understanding each other’s goals, needs and expectationsis necessary for developing the foundations of theprogramme and harnessing the growth. In order forany robotic surgery programme to achieve success, theadministration, support staff and operative team must allbe a part of the same team and work together towardscommon goals. There are certain essential components tothe administrative staff.

Robotic programme coordinatorA programme coordinator provides a liaison between theadministration and operative staff, and is directly respon-sible for the coordination of the overall growth of theprogramme. The programme coordinator’s responsibili-ties include coordination of website design, marketing,patient education and evaluating the avenues of growth.This individual allows the surgeons to concentrate on theclinical effort and serves as the ‘go to’ person for basicquestions regarding the programme.

Marketing team

Marketing and website design are an essential partof the success of any programme. Marketing alsoprovides an avenue for physicians to refer patients forspecialized robotic surgery. Prior to the purchase ofa robot and the establishment of the programme, awell-balanced marketing team with dedicated financialresources should be assigned. The team should consistof experienced personnel who understand the nuancesof the local geographic area and the areas for potentialexpansion.

The marketing plan should begin by performing ananalysis of the existing patient and referral base andconsidering the most likely avenues for growth of theprogramme. It is understood that in order for mostprogrammes to have significant growth in volume,they will have to draw from outside their normalreferral patterns. Establishing such patterns is a taskfor the marketing team. The timing of the marketingis also essential, as it is less beneficial to market theprogramme prior to the achievement of consistency andproficiency of the surgical procedure. Once superior

outcomes from robotic surgery are achieved, patients willgravitate towards this approach instead of conventionalsurgery.

The websiteThe marketing strategy consists of access to an educa-tional website, illustrating background information on thedisease process and the potential advantages provided bythe application of robotic technology. It is also essential toprovide references to published peer-reviewed data andcontact information for the patients.

Patient education brochuresPatient education brochures and information packets forreferring physicians are important in order to provideinformation about robotic surgery, both for physicianreference and for patients to make informed decisionsabout their options for care.

MediaThe introduction of robotics into modern-day surgeryhas also produced new levels of marketing. Some of themarketing strategies and resources have come from themanufacturer of the robotic system, while the majority hascame from hospitals and surgeons. It is not uncommonthese days to pick up a periodical, see a televisionadvertisement or drive by a billboard expounding theexpertise in robotic surgery that a hospital possesses.

The arrival of a ‘robot that performs surgery’ oftenraises the interest level of the local media and presents anopportunity for ‘getting the word out’. Media sources suchas TV, newspapers and other periodicals are importantsources of information for patients and physicians.

Establishment of a business plan

Prior to the purchase of a robotic system, each institutionmust do its due diligence in establishing the economicboundaries. A thorough market analysis of the economicimpact of such a programme on the institution must betaken. The business plan should include an evaluationof the direct costs for purchase of the robotic system,associated instrumentation, costs of facility renovationand of staff recruitment and re-training. A study of thepayer mix, procedure reimbursement, patient population,competition and the anticipated growth in surgicalvolume. It is well established that unrealistic economicexpectations and the lack of an accurate businessplan can lead to financial catastrophe, providing theinstitution with little incentive to support or continuethe programme.

A four-armed da Vinci surgical system costs approx-imately $1.3 million, with recurring costs of $100 000yearly for maintenance. While this initial investmentappears substantial, it is not this that is the most concern-ing for hospitals; the per case cost of disposable robotic


34 V. R. Patel

instrumentation is often the key factor in the economicsof robotic surgery. The average cost per instrument percase is about $200 multiplied by the number of instru-ments used, typically three to five, bringing the total costto around $1000 per patient. Depending upon reimburse-ment, this can be a significant financial burden to anyprogramme. In addition to these initial start-up costs,the business plan must account for further growth of theprogramme. This may require more personnel, operativespace and other such resources.

A structured economic plan for any robotics programmemust take into account both direct and indirect costs,including cost of the robot and per case instrumentation,cost associated with renovation of the facility for therobotics programme, marketing and training of the staff,and must anticipate ongoing costs such as recruitment ofphysicians.

While it has been shown that the direct monetarycosts associated with robotic surgery are in generallyhigher than those associated with the same procedurefor conventional, open and laparoscopic surgery, thereis at this time no increased reimbursement by third-party payers. Neither surgeons nor hospitals receive anydirect financial benefit by performing the procedurerobotically, laparoscopically or as an open procedure.The combination of the capital cost of the machine,maintenance and the per case use adds up to a heftyamount. This economic burden is transferred directly tothe hospital without the patient or surgeon being directlyaffected by the increased costs.

The question is: if the economic plight of hospitalspurchasing the robotic system is challenging, then whyhas there been such an exponential rise in the purchaseof robotic systems? There must be some inherent benefitthat has been recognized by the 300+ institutions thathave purchased the robot and the surgeons who havebeen encouraged to use it.

Healthcare systems have purchased robotic systems forthe advancement of clinical care, marketing and indirecteconomic benefits. The arrival of a robotic system oftensignals to the community the image that the health systemis ‘cutting edge’ and capable of providing state-of-the-art patient care. Patients will often gravitate to theseinstitutions in search of potential excellence in healthcaremanagement. Marketing also increases the profile of therobotic systems and those adept at using it. It is difficultto put a dollar value on the media coverage that alsooften comes with the introduction of robotic technologyinto a new community. Outside of marketing and image,hospitals often also see an increase in patient volumefor the disease the robot is being used for, and often anindirect growth in non-robot-related surgical proceduresor medical visits. Many institutions have seen their ‘marketshare’ increase significantly after the establishment ofrobotic programmes.

Hospitals often encourage multi-specialty usage inorder to get the most diverse increase in patientvolumes. A multi-specialty use is essential, since thiswill increase the number of cases being performed. It

is also economically beneficial, as the costs of renovation,staff training and capital expenditure for the robot aredissipated across specialties. There is also economy formarketing, as it is most cost-effective to market roboticsurgery at a hospital as a whole, rather than just oneindividual or specialty.

Continual growth

The periodic self-evaluation of the robotic programme ishelpful and necessary to the overall health and growth ofthe programme. Initially, a frequent periodic evaluationevery 3–6 months will help ascertain how the programmeis developing, understand the obstacles and present themetrics determined previously for success.

The evaluation should consist of a repeated re-evaluation of the infrastructure of the programme, theeconomic impact and viability, the effective utilization orpossible need for more resources, and the evaluation ofthe programmes themselves. If the programme is meetingits goals, a possibility for expansion should be discussed.They should consider potentially new applications forrobotics, consider training new surgeons and targetingnew markets for patient referral.

Patient outcomes must also be evaluated at this timeto ensure that there is no undue morbidity from thenew approach, and that the outcomes are showing theappropriate trends. Comparison with the peer reviewliterature is helpful.

This periodic evaluation will help to identify any weakareas and will ensure that the programme continues togrow, maintains quality outcomes and stays on the cuttingedge.

Conclusions

Undoubtedly, robotic-assisted surgery has already made alarge impact into the way that many surgical proceduresare performed. It provides the ability for improvedvision and dexterity, potentially translating into improvedprecision and outcomes.

As robotic technology continues to improve and furtherapplications are explored, we would anticipate that itsutilization will expand. In order for this to occur safelyand effectively, a comprehensive pre-emptive plan forinstallation of the programme must be put into place.

Institutions in both the private and academic settingmust anticipate the challenges posed by the introductionof new technologies and provide an optimal environmentfor implementation of these programmes with maximalefficiency.

References

1. Patel V. Robotic-assisted laparoscopic dismembered pyeloplasty.Urology 2005; 66: 45–49.



2. Abbou CC, Hoznek A, Salomon L, Olsson LE, Labontou A.Laparoscopic radical prostatectomy with a remote-controlledrobot. J Urol 2001; 165: 1964–1966.

3. Menon M, Tewari A, Peabody J. Vattikuti Institute prostatectomy:technique. J Urol 2003; 169: 2289–2292.

4. Dharia SP, Falcone T. Robotics in reproductive medicine. FertilSteril 2005; 84: 1–11.

5. Perer E, Lee D, Ahlering T, Clayman R. Robotic revelation:laparoscopic radical prostatectomy by a nonlaparoscopic surgeon.J Am Coll Surgeons 2003; 197(4): 693–696.

6. Ahlering TE, Skarecky D, Lee D, Clayman RV. Successful transferof open surgical skills to a laparoscopic environment using arobotic interface. J Urol 2003; 10: 1738–1741.

7. Patel VR, Tully AS, Holmes R, Lindsay J. J Urol 2005; 174:269–272.

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Essential elements to the establishment and design of a successful robotic surgery programme