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TSS特别报道 — 医疗机器人:考虑周全

TSS EXCLUSIVE – Medical Robotics: Considerations Aplenty

by Vittorio Bollo


As the use of robotics goes from strength to strength in everything from manufacturing and mining to the gadgets we use, so the same is true in the medical field. The continued rise of robotics may be inevitable, but we should nevertheless stop and wonder: what are the pros and cons regarding robotics in the medical tech field? 


This article will explore some of the positive and negative aspects of robotic usage in healthcare, some of which will be quite obvious, others less so. 


First, Let’s (Try) to Get the Terminology Right 


Terminology in the robotics sphere can get confusing, so there’s need for clarity. For example, ‘automation’ and robotics are not the same thing. Automation is the machinery, software, or other technology used to carry out a task in place of a human worker. It can range from the fully mechanical to the fully virtual.

在另一方面而言,机器人学是一个多学科的工程分支,它结合了机器人里相关结构的设计、构造、编程和使用(应用);显然而见的是机器人可以作为自动化的一种形式使用,但并非所有的机器人都是自动化的,反之亦然;为了简单起见,在本文中,术语“robotics”和”robots”将交替使用(前者指代机器人学或者是这项技术,后者指代的是[自动化]机器人),但不可否认的是这种区别可能会带来问题,甚至连美国第一个工业机器人的发明者、物理学家约瑟夫•恩格尔贝格尔(Joseph Engelberger)也不确定这个术语,他有句名言就说到:“我无法定义一个机器人,但当我看到一个机器人时,我就知道它是谁。”感谢你(所提出的观点),乔。

Robotics on the other hand is a multi-disciplinary branch of engineering that incorporates the design, construction, programming, and use of robotic machines. Obviously, robotics can be used as a form of automation, but not all robotics is automation, and vice-versa. For the purpose of simplicity in this article, the terms ‘robotics’ and ‘robots’ will be used interchangeably, although that distinction can admittedly get problematic. Even the physicist Joseph Engelberger, the man who developed the first industrial robot in the US, was unsure about the terminology. He famously said, “I can’t define a robot, but I know one when I see one”. Thank you, Joe.


The Benefits of Medical Robotics


Greater Accuracy, Less Hassle

机器人手术通常更精确,因此在此需要人工手术的基础上进行干预——更具有干预性的手术:程序是由外科医生直接进行更准确;加州大学洛杉矶分校(UCLA)的头颈外科医生阿比·门德尔松(Abie Mendelsohn)博士指出:”多亏了机器人,外科医生的视觉(观察范围)被极大地放大、照明功能也非常好;例如,在脑部和脊柱外科手术中,机器人手臂可以让外科医生以3D的方式查看病人的解剖结构,这使得肿瘤可以到达以前外科医生几乎不可能到达的区域。
Robotic surgery is usually more precise and, therefore, more accurate in the required intervention compared to more invasive surgery in which procedures are directly undertaken by surgeons. Dr. Abie Mendelsohn, a head and neck surgeon at UCLA, states how a surgeon’s vision is hugely magnified and extremely well illuminated thanks to a robot. In one example, a robotic arm allows a surgeon to view a patient’s anatomy in 3-D during brain and spine surgery. This enables tumors to be reached in areas that were previously almost impossible for surgeons. 
According to Dr. Mendelsoh, a medical robot can also afford a surgeon far greater dexterity in their work during surgery: “The instruments can rotate several times over, which is much more than a human wrist can do.” With robotic machinery, surgeons and others in operating theaters are not having to strain their bodies as much as they do with traditional surgery. Shorter surgery times are also creating less stress on the body and less fatigue. Additionally, robots have been shown in the UK’s National Health Service (NHS) to greatly reduce the training time needed for surgeons to acquire critical skills.


Less Invasion, Less Pain, Quicker Recovery

从病人的角度来看,机器人(干预)的手术通常是首选,因为它们比传统手术的侵入性更小,其结果就是减少疼痛和身体创伤,加快病人的恢复时间;英国布里斯托尔大学机器人实验室(BRL)的Sanja Dogramadz博士证实了这一点,他说:“通过对器官和组织进行微创操作,机器人工具可以帮助减少创伤。”这还包括其他与手术相关的益处,例如更少的失血和减少患者(手术部位缝合后)的疤痕、输血量也减少了,而且由于所有这些的提升风险都降低了许多,以及在手术期间和手术后感染的风险也都降低了。此外,《福布斯》(Forbes)援引2017年的一项研究称:机器人手术减少了78%的辐射。

From the perspective of the patient, robotics are often the preferred surgical option because they are less invasive than traditional surgery. The result is less pain and physical trauma and quicker recovery times for the patient. This is confirmed by Dr. Sanja Dogramadz at the University of Bristol’s Robotics Laboratory (BRL) in the UK, who says, “By using minimally invasive access to organs and tissues, robotic tools can help to reduce trauma.” This also includes other surgery-related benefits such as less blood loss and reduced scarring for patients. There is also reduced need for blood transfusions and, as a result of all these reduced risks, less risk of infection both during and post-surgery. Furthermore, Forbes cited a 2017 study that showed 78% less exposure to radiation with robotic surgery.


With less trauma to the patient during robotic surgery, so the patient suffers less pain and less time is needed to heal. Subsequently, recovery times for these patients tends to be significantly quicker, meaning less expensive hospital stays.


At What Cost?


Are Costs Too High?

医用机器人可能很昂贵,据Cedars Sinai Marina del Rey医院估计,一个医疗机器人的成本约为200万美元;此外,在中型到大型医院中,机器人系统的维护费用每年可达10万至17万美元,这是购买机器人设备的所花费之外的费用;在2017年,斯坦福大学医学院(Stanford University School of Medicine)对近2.4万名肾癌患者进行了一项研究——该研究收集了2003年至2015年期间全国416家医院的数据,得出的结论是机器人辅助腹腔镜肾摘除手术实际上比传统腹腔镜手术更加昂贵。

Medical robotics can be expensive. Cedars Sinai Marina del Rey Hospital estimates that a single medical robot costs approximately $2 million. Furthermore, maintenance of a robotic system in a mid-size to large hospital can range from $100,000 to $170,000 a year, which is in addition to the cost of buying the robotic equipment. A 2017 Stanford University School of Medicine study of nearly 24,000 patients with kidney cancer, that comprised data from 416 hospitals nationwide between 2003 and 2015, concluded that robot-assisted laparoscopic kidney removal surgeries are in fact more expensive than conventional laparoscopic surgeries. 


The Stanford team did concede that robots were invaluable in more intricate surgeries, such as those for the removal of the prostate or part of the kidney. In those instances, the high capital expenditure costs of robotics could be considered justifiable. 


Furthermore, it is worth noting that the high capex costs of medical robotics can be offset by adjunct cost savings such as (usually) shorter surgeries requiring smaller teams in surgery and shorter post-surgery hospital time for patients. Those cost savings must surely make medical robotics a more economically feasible option in the future, as it is already the case today.


A Widening Health Gap and ‘Flashy Snob Appeal’


There is the danger that medical robotics will only serve to widen the gulf between poor and richer nations and communities around the world. It is a “health divide” that already exists, according to the World Health Organisation (WHO), in what it terms “profound inequities in the health status and disease burden of [global] populations.” It’s not unreasonable to caution that this technology will probably remain far too expensive for many countries and communities worldwide for years to come. What about them? 


However, it could be contended that as medical robotics get wider acceptance and usage, so derived economies of scale should result in lower unit costs. This is true of any technology which was initially capital intensive, not yet fully utilized by the market, and thus expensive. That inevitable development in the use of medical robotics should make the technology more accessible to those living in poorer countries and communities worldwide – or at least more so than is the case today. 

医疗机器人也被一些健康专家嘲笑为“奢侈品”,确切来说认为它并没有对医疗做出重大贡献;沃顿商学院医疗管理教授伊泽基尔•伊曼纽尔(Ezekiel Emanuel)在《纽约时报》一篇言辞激烈的专栏文章中指出将这种新兴技术称为“虚伪”和“伪创新”;他的同事盖伊•大卫(Guy David)会单独评论称由于美国多数医院无法仅靠价格竞争,它们往往求助于昂贵的技术,例如(利用)机器人技术以显得“尖端”,这可以被称为机器人的“势利价值”——这是值得考虑的一件事情。

Medical robotics have also been derided by some health experts for being ‘luxuries’ that don’t actually make a significant contribution to healthcare. Ezekiel Emanuel, Wharton a health care management professor at Wharton, referred to the emerging technology as “flashy” and a “pseudo-innovation” in a searing op-ed in the New York Times.  His colleague, Guy David, would separately comment that, since most hospitals in the US cannot compete on price alone, they often resort to expensive technologies such as robotics in order to appear ‘cutting-edge’. It’s what could be termed the ‘snob value’ of robotics and is worth consideration. 


Environmental Costs


A lesser-appreciated drawback regarding medical robotics is the environmental impacts thereof. This is highly relevant in the context of a 2015 study by Thiel, Eckelman et al., which stated that, “The operating room is the most resource-intensive area of a hospital…”. The study focused on four types of hysterectomy surgeries, namely vaginal, abdominal, laparoscopic, and robotic, undertaken at Magee-Womens Hospital (Magee) at the University of Pittsburgh Medical Center (UPMC). 


The study found that robotic hysterectomies produced 30% more surgery-related waste than the other three forms of surgical interventions. Robotic procedures resulted in the generation of six times more non-hazardous, non-recyclable waste than vaginal or abdominal procedures, and double that of laparoscopic procedures. In fact, robotic hysterectomies were found to have the worst environmental footprint of the four hysterectomy types studied in every impact category analyzed. Robotics were assessed to utilize more resources, especially packaging and plastics, and produce more waste. 


A Form of Slave Labor?

关于人工智能(AI)的出现以及它对失业和工作本身的未来意味着什么?人们已经说了很多;Starset Society在思考人工智能和全民基本收入(UBI)之间的共生关系,医疗行业的情况将与机器人等技术所影响的其他行业一样。

Much has been said about the advent of artificial intelligence (AI) and what it will mean in terms of job losses and the future of work itself. The Starset Society has even pondered the symbiosis between AI and universal basic income (UBI). This will be as true of the medical profession as any other impacted by technology such as robotics.

但机器人本身可能是一种奴役的概念呢?考虑一下美国数学家和哲学家诺伯特·维纳(Norbert Wiener)对任何工作场所的机器人的看法:“让我们记住,自动机器在经济上完全等同于奴隶劳动。”(意味着)任何与奴工竞争的劳动必须接受奴工的经济后果”。

But what about the notion that robotics itself could be a form of slavery? Consider what the American mathematician and philosopher Norbert Wiener had to say about robots in any workplace: “Let us remember that the automatic machine is the precise economic equivalent of slave labor. Any labor which competes with slave labor must accept the economic consequences of slave labor”. 

 维纳的主张可能看起来有些极端,甚至是对“奴隶制”一词本身的激进诠释 但他提出了一个有趣的观点:有一天机器人会被认为是一种奴隶劳动吗?同样重要的是这对那些与他们一起工作的医护人员意味着什么?就他们自己的道德而言,那就更不用说他们的收入潜力了。

Wiener’s assertion may seem extreme, even a radical rendering of the term ‘slavery’ itself. But he makes an interesting point. Will there come a time when robots are considered a form of slave labor? And, equally importantly, what will it mean for those healthcare professionals who work alongside them, in terms of their own ethics, not to mention their earning potential? 


What is clear is that the use of robots in healthcare is far more nuanced and complex than what one might initially assume. Their use is not simply about the positives of less-invasive surgery and faster and less painful recoveries for patients. 


There are also ecological and even ethical considerations that have global implications that need to be considered, if not actively addressed. As robotics becomes increasingly used in our healthcare, so too will the positives and negatives come into sharper, possibly more divisive focus.