Robotic surgery is here to stay. But when things go wrong, who’s to blame?

South China Morning Post

Six thousand surgical robots performed a million operations last year but proof of advantage over normal techniques is not conclusive

South China Morning Post |

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A demo of the da Vinci Xi Surgical System at the Faculty of Medicine at the Chinese University of Hong Kong.

Time was when the requisite qualities for a surgeon were distinctly biological – “eye of a hawk, heart of a lion and hands of a lady”. But in modern-day hospitals, machines are quietly supplanting handicraft in the operating theatre.

Six thousand surgical robots globally performed a million operations last year. The market was worth US$6 billion. A basic system costs US$2 million. Robotic surgeries are 6-28 per cent more expensive than the laparoscopic equivalent (averaging US$2,200 more), but proof of advantage over standard surgical techniques has been elusive: complication and success rates are comparable.

Surgical robotics is poised to go “generic” as original patents expire and new developers and applications enter the field. Next-generation devices will feature enhanced voice control, “fly-by-wire” algorithms to counter perceived faulty operator intent and eventually AI-driven autonomy and self-learning. “Medusa” snake-head flexible endoscopic systems promise scarless surgery through natural orifices. Star Trek’s Dr “Bones” McCoy’s refrain “I’m a doctor, Jim, not an engineer” never rang truer.

With sufficient data speeds, operating consoles can be far removed from the mechanical system. The first telepresence surgery “Operation Lindbergh” was performed in 2001 – a transatlantic procedure by surgeons in New York on a patient in France; and 5G remote surgery was tested on an animal in China just this year.

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Looking beyond civilian health care, the Pentagon’s Defence Advanced Research Projects Agency is developing a battlefield surgery robotic “trauma pod”, and the US space agency Nasa is already testing its Extreme Environment Mission Operations (Neemo) telesurgery in a submarine.

How is safety monitored? The US Food and Drug Administration’s surgical devices division tracks adverse events through medical device reports submitted to its Manufacturer and User Facility Device Experience (Maude) database. A review in 2016 documented over 10,000 robotic procedure mishaps: failure of the system occurs in 5 per cent of surgeries.

Typical events include system errors requiring rebooting, abnormal robotic arm movements, loss of visuals and dislodged burnt/broken pieces of equipment. Injury (and even death) has been recorded in around 1 per 1,000 operations, although apportioning operator or system fault can sometimes be difficult.

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When surgery is performed by autonomous unthinking machines (albeit with the fig leaf of human supervision), then where does liability fall? In aviation, fault-attribution is overwhelmingly on pilot error, a finding rarely challenged probably because they are always the first at the scene of an accident. But using the operator as a convenient sponge for mishaps creates what cultural anthropologist Madeleine Elish calls the “human crumple zone”. 

In a future AI-dominated surgery, where human control progressively diminishes, it is iniquitous to seek to confine fault to the doctor and so shield the wider system – responsibility should more properly also be distributed among designers, engineers, manufacturers, owners and government health departments.

The future of surgery is dependent on a balance between zeal for innovation and the safeguards of evidence-based medicine. Some of us recall a bygone era of eminence-based medicine. That’s the surgical spirit: sometimes wrong, never in doubt. Although currently on probation, the emerging field of surgical robotics deserves the benefit of the doubt – and a new social compact.