Adoption of Robotic-Assisted Surgery Lags in Canada

Robotic systems have emerged as a tool to assist surgeons in performing minimally invasive procedures in recent years. However, the adoption of robotic-assisted surgery has fallen behind in Canada. 

One reflection of this situation is that few trainees receive sufficient exposure to robotic surgery, according to a cross-sectional national survey of residency and fellowship program directors. Although 13 of the 24 program directors surveyed (54%) believed that robotic surgery would be relevant to residents’ and fellows’ practice, none felt that the trainees would gain the skills to independently perform robotic surgery. The study findings were published on June 26 in the Canadian Journal of Surgery. 

Canadian surgeons were among the early adopters of robotic surgery when it emerged roughly 15-20 years ago, but many still lack expertise in the technology, said Christopher Schlachta, MD, professor of surgery and oncology at Western University in London, Ontario, and medical director of Canadian Surgical Technologies and Advanced Robotics at London Health Sciences Centre. “The reasons it has not spread as quickly in Canada probably boil down to cost and evidence.” 

Cost and Evidence

Robotic systems such as those made by Intuitive — one of the leading medical robotics companies — can cost millions of dollars and require ongoing investment in disposable instruments and maintenance. That expense has slowed the adoption of the technology in Canada, partly because of its single-payer healthcare system. The cost is often passed on to patients and insurance companies in the United States, and governments of other countries with single-payer systems have invested in robotic systems. But in Canada, hospitals have predominantly had to foot the bill. 

“If we’re going to spend several million dollars on a robot, that’s several million dollars that we don’t have for other equipment in the hospital,” explained Schlachta. For that reason, Schlachta guesses that almost all the sophisticated robotic systems in Canada have been purchased through philanthropic donations to hospital foundations. 

In addition, well-designed clinical trials testing the technology have been difficult to conduct. Because of the training required and the lack of access to machines, by the time enough surgeons have the experience necessary for a trial, they no longer want to consider nonrobotic surgery, said Schlachta. The Canadian healthcare system is driven by evidence, and robotic surgery “has had some champions” but lacked compelling evidence to justify the financial investment, he added. The body of evidence supporting robotic surgery, however, is now growing. 

One of robotic surgery’s main benefits is its improvements in minimally invasive surgery. The technology improves surgeons’ precision, with four stable arms and powerful magnification. But it also makes it easier to use laparoscopic technology, said Schlachta. Laparoscopic procedures require significant training, so robotic systems can make minimally invasive surgery easier to perform for surgeons who have not yet acquired the skill. When Schlachta used one of the leading robotic consoles for the first time, he “was amazed at how easy it was to use.” Now, there are certain procedures he would only want to perform with the robot. 

Training Challenges

Robotic surgery enables the expansion of minimally invasive surgeries, agreed Sean Cleary, MD, chair of general surgery at the University of Toronto and president of the Canadian Association of General Surgeons. “It’s not really swapping out one technique for another. It’s broadening the ability of Canadians to get minimally invasive surgery and cutting-edge surgical techniques.” 

It is now clear that robotic systems are “without a doubt” a part of the future of surgery, and more hospitals are investing in the technology, said Cleary. Ontario has recently begun subsidizing the cost of disposable supplies used in robotic surgery for some procedures. But “what we need to do is not only broaden the number of procedures that are going to be supported in this way, but also help hospitals purchase the robot itself,” Cleary added. 

The limited number of robotic systems has created training challenges, particularly for general surgery, which is seen as a lower priority than urology or gynecology. “If the faculty are trying to learn how to do robotic surgery or don’t have enough experience, they have a hard time guiding trainees through operations. Then the trainees don’t have enough experience,” said Cleary. 

The University of Toronto has an optional robotic curriculum available to some trainees. But residents are skeptical about whether the tools will be available in their future practice, said Cleary. “Right now, some of them are having difficulty seeing how this is going to be relevant in their careers, and they see surgery in Canada falling behind other parts of the world.” 

Expanding Access

Despite the challenges, robotic surgery in Canada is starting to expand, thanks to new research and improved funding. In the past two years, the number of robotic surgery programs for lung surgery has expanded from two to eight, according to Waël Hanna, MD, head of thoracic surgery and director of the research program at the Boris Family Centre for Robotic Surgery at St. Joseph’s Healthcare Hamilton in Ontario. The expansion largely results from a new program through robotics company Intuitive that allows hospitals to lease robotic systems, in addition to recent research. 

The program that Hanna directs at St. Joseph’s includes all robotic surgeries it performs in research trials. “The reason we do all this is because we wanted to prove the benefits of robotic surgery so we can gain traction and funding from the government,” said Hanna. In addition to improving minimally invasive surgery, robotic surgery augments surgeons’ capacities as the technology advances to include imaging and artificial intelligence tools. 

Although Canada has been slow to adopt robotic surgery, Hanna sees a silver lining in the research that has been produced. Canadian patients have been eager to enroll in the trials for the chance to have access to robotic surgery, which allowed for research including the only randomized trial testing robotic technology for lung cancer surgery, said Hanna. 

In some fields, such as urology, robotic surgery is becoming the standard of care. “If a hospital wants to attract and retain talent, they have to have a robotic program,” he said. “Augmented operations are going to be necessary for the future.” 

Schlachta, Cleary, and Hanna reported having no relevant financial relationships. 

Gwendolyn Rak is a health reporter for Medscape based in Philadelphia.