The Impact of Technology on Surgery: The Future Is Unwritten

Mario Morino, MD


Annals of Surgery. 2018;268(5):709-711. 

In This Article

The Influence of Economy on the Future of Surgery

Different authors have proposed different models to evaluate the factors that drive to the adoption of a new technology into clinical practice. In my opinion, one of the most interesting theories was proposed by Wilson,[6] who identifies 3 factors: patients' demand for technology, low cost to surgeons for learning and using the procedure and manufacturers' aggressive promotion of the technology. This last point will prove to be by far the most important driving force, strictly dependent on the potential economical impact of the considered technology. A low cost technology applicable to a limited number of patients will determine a different level of promotion by a company compared to a highly expensive technology potentially applicable in very frequent pathologies.

Consider 4 examples of technologies in the field of MIS: SILS, NOTES, Transanal Endoscopic Microsurgery (TEM), and Robotic Surgery.

SILS included the development of special access ports and a few dedicated instruments. The technique is very complex for surgeons, the demand from patients for a reduction in scars is limited, the economical impact for companies is also limited. After a decade of practice the interest in SILS is fading away.

NOTES was proposed in the early years of the new century, but the need for a specific technology was not met by the industry in the last 15 years. Transoral, transgastric, or transvaginal cholecystectomies did not appeal to patients nor to surgeons and eventually the project has declined. Nevertheless, new techniques, such as Transanal Total Mesorectal Excision (TaTME), are increasingly performed thanks to the application of the concept of NOTES.

TEM was developed by Gerhard Buess in 1983,[7] it was used only in a few European centers in the 1990s and finally reached the deserved success in the new millennium for local excision and for a new access to rectal cancer radical surgery, the TaTME. Why was TEM underestimated and had such a delayed diffusion? Indications surely were limited, but mainly the technique was perceived as difficult at the time, requiring a long training not easily supported by a business model and the instrumentation is reusable therefore limiting the interest for the company to push its diffusion. The delayed diffusion of TEM represents the perfect example of the overwhelming importance of manufacturer promotion in respect to the other 2 driving forces for the diffusion of the technology as described by Wilson.[6]

ROBOTIC SURGERY offers the best example of the power and efficacy of a well-conducted aggressive promotion of a technology by a company.

At the dawn of the new millennium, there were a few companies developing different concepts of robotic surgery, but later on, one company succeeded in conquering the market. Intuitive Surgical Inc (Sunny Vale, CA) did manage to become the only manufacturer in the field of robotic surgery. Moreover, Intuitive Surgical Inc blocked the development and marketing of different technologies in the field by owning so far almost 3500 patents, preventing this way any competition that is the fuel of progress.

From this monopolistic situation, the company designed a marketing strategy that led to a very large diffusion of the Da Vinci technology, even in the absence of good clinical evidence of its efficacy.[8] Although in clinical use for almost 20 years, with thousands of published articles, there are no randomized controlled trials (RCTs) demonstrating the superiority of robotic surgery over standard laparoscopy.[9] This is of no surprise. The way robotic technology is conceived overlaps the characteristics of standard laparoscopy, so that any advantage could be limited to a reduced need for training or an increased confort of the operator, both difficult to translate into a real clinical benefit for the patient. Different it would be if robotic technology were used to overcome the current limitations of laparoscopy or to allow to perform surgery through flexible endoscopy taking advantage from automation, miniaturization, and flexibility to access upper or lower GI pathologies through natural orifices.

On the contrary, while a sophisticated technological tool such as the Da Vinci could represent a step forward in the management of complex cases in limited indications, the economical issues related to the development of a billion dollars technology, push the industry to extend clinical application to more diffuse pathologies including very basic procedures such as inguinal hernias.[10]