Robotic-assisted surgery is revolutionizing healthcare by enhancing surgical precision, reducing recovery times, and addressing critical staff shortages.

In September, Taiwan’s National Health Insurance Administration (NHIA) made a move that will significantly enhance patient outcomes and quality of life. The administration expanded coverage to 46 types of surgical procedures performed using da Vinci robotic-assisted systems, expected to benefit around 8,400 patients annually.

Under the updated policy, patients will only be responsible for copayments related to material costs, NHIA Director-General Shih Chung-liang told the media in a July press briefing. The expansion will add approximately NT$285 million (US$8.75 million) to the National Health Insurance (NHI) budget annually.

The newly approved procedures include urological surgery, general and gastrointestinal surgery, thoracic surgery, gynecological surgery, and cardiothoracic surgery. Funding for these procedures will be based on their complexity, with coverage ranging from NT$30,000 to NT$50,000 for hernia repairs, and nearly NT$100,000 for a total gastrectomy with lymph node dissection.

The expanded coverage offers numerous benefits for both patients and healthcare professionals, notes Willie Lee, Taiwan director of marketing at Intuitive Surgical, the American multinational behind the da Vinci systems.

“One of the biggest challenges hospitals face is a shortage of  healthcare staff, especially nursing teams,” says Lee. “These workforce challenges make robotic-assisted surgery increasingly vital.”

Intuitive’s da Vinci systems, which feature four arms operated by a single person, help reduce the need for additional staff. In general, robotic surgery requires only three people – a surgeon at the console, a bedside assistant, and a circulating nurse – compared to the five or six personnel normally needed for open surgery. “The potential in this field is enormous,” Lee says, adding that over 9,000 da Vinci systems have now been installed in hospitals globally.

In terms of patient outcomes, robotic-assisted surgery (RAS) in many cases offers a clear advantage over minimally invasive thoracoscopic and laparoscopic methods. Dr. Chao Yin-kai, vice chief of Chang Gung Memorial Hospital’s Department of Surgery, points out that one of the most significant benefits is the reduction in unplanned conversions from minimally invasive surgery to open surgery.

“In lung cancer surgeries, for example, robotic systems reduce the risk of complications such as excessive bleeding or tumor behavior that would normally require a switch to open surgery,” he says.

Additionally, robotic surgery enables more precise lymph node dissections, a crucial factor in controlling cancer spread. “By removing more lymph nodes with greater accuracy, we can better control the disease while minimizing the risk of post-surgery complications,” says Dr. Chao. This precision is essential in complex surgeries like those for esophageal cancer. 

Another advantage of RAS is that it accelerates patients’ return to normal life. “Enhanced recovery protocols allow patients to go home faster and resume normal activities much sooner,” says Dr. Chao. This expedited recovery is particularly important for cancer patients, who will be more likely to start adjuvant treatments like chemotherapy on time.

Despite the clear advantages, the adoption of RAS has not been without challenges. The high initial cost of acquiring and maintaining robotic systems remains a significant barrier for many hospitals.

“There is no denying that the cost of robotic surgery is higher than traditional methods, at least in the short term,” says Lee. However, he points out that the long-term savings, particularly from reduced complications and shorter hospital stays, make robotic surgery a cost-effective solution. The enhanced ergonomic features and lightweight tools also mean the possibility of prolonging surgeons’ careers.

Taiwan’s NHI system has played a pivotal role in expanding access to robotic surgery. In recent years, the NHI has started to cover an increasing number of robotic-assisted procedures, reducing the financial burden on patients.

“Since 2017, we have seen a significant increase in the number of reimbursable robotic surgeries, from prostatectomies to complex liver and lung surgeries,” says Lee. “This has been a game-changer for adoption.”

Private insurers have also begun to offer coverage for robotic surgeries, further mitigating the cost barrier for patients. Dr. Chao says this financial support, combined with the undeniable benefits for patients, is helping to drive broader acceptance of RAS in Taiwan.

The training issue

While traditional laparoscopic surgeries require years for a surgeon to master, robotic surgery significantly shortens the learning curve. This technology enables surgeons to achieve proficiency more quickly, accelerating their ability to perform complex procedures with greater precision.

In the United States, many residency programs now require surgeons to learn robotic surgery as a standard approach alongside traditional and laparoscopic surgery, notes Dr. Charlotte Wu, urology residency program director at the Johns Hopkins School of Medicine and assistant professor of urology through the James Buchanan Brady Urological Institute.

In Taiwan, the adoption of robotic surgery training has been slower, largely due to procedural challenges in obtaining approval for reimbursement to the hospitals from the NHI system. Still, surgical societies are now creating training programs to ensure that Taiwanese doctors are proficient in the latest technologies. These efforts aim to bridge the knowledge gap and equip healthcare professionals with the skills needed to perform advanced robotic procedures.

Dr. Chao likens the training process to learning to drive a sports car – first, you need to understand your machine, and second, you need to master the procedure. The training process includes extensive simulation exercises, animal surgeries, and observation of live procedures. Surgeons must also work with experienced proctors before performing their first surgeries independently.

Having performed RAS for a decade, Dr. Chao is an active member of the Upper GI International Robotic Association (UGIRA). The international organization aims to promote excellence in robotic surgical practices through education, training, research, and collaboration among healthcare professionals.

“I now train surgeons from across Taiwan and Southeast Asia through UGIRA,” says Dr. Chao. His hospital has established Taiwan’s only da Vinci surgery training center in collaboration with Intuitive, further solidifying its position as a leader in the field. “In terms of expanding this training and collaboration, one bottleneck is that we can only train one to two surgeons per year. We need to open more training capacity to meet the growing demand.”

The NHI’s comprehensive data recording makes Taiwan an ideal place for expanding training, he adds. Its wealth of data is invaluable, as “data is power,” especially in creating more evidence for the benefits of RAS. In many areas, the question remains whether robotic surgery delivers better outcomes than traditional minimally invasive procedures. Few countries have been able to answer this definitively, and “Taiwan offers the ideal environment to prove this concept,” Dr. Chao says.

Intuitive’s Lee adds that the digital ecosystem is a key component of modern surgery. Surgeons and care teams can analyze data from patient outcomes, operating rooms, and entire surgical programs. They can identify trends, such as complication rates or the length of stay, and use this information to improve future procedures.

This data-driven process creates a continuous cycle of improvement. Surgeons gain insights from past procedures, make adjustments, and generate new data that further inform their practice. “We call this a ‘virtuous loop’ where data is aggregated and consolidated to provide actionable insights that help care teams improve with each procedure,” he says.

The way forward

Future RAS systems may further incorporate AI and machine learning to enhance surgical decision-making and improve outcomes. AI can help identify critical structures during surgery, improve pre-operative planning, and provide real-time feedback to surgeons.

One important driving factor for these developments is increased competition, notes Dr. Chao. At present, Intuitive Surgical holds a dominating position in the market, having the highest revenue share among its competitors. Fortune Business Insights attributes its supremacy primarily to its diverse product offerings and robust global distribution network. 

In orthopedic surgery, players in the market include Medtronic, Stryker, Smith & Nephew, and Zimmer Biomet, all of which contribute significantly to the market alongside newer entrants like TransEnterix Surgical, Verb Surgical, and THINK Surgical.

Additional players are entering the market. For example, Taiwanese startup Astron MedTech, recognizing the unrealized potential of RAS in orthopedics, developed robotic systems for foot and ankle surgery.

“There’s been significant development in robotic systems for spine and knee replacements, but the foot and ankle area remains relatively untapped,” says Tsai I-lin, co-founder and COO of Astron MedTech. “That’s where we see a major opportunity.”

In the orthopedic space, there’s still a long way to go before robotic systems become fully compatible across different platforms, Tsai says. Without that compatibility, hospitals face the obstacle of investing huge sums of money in equipment that may only be used for a limited number of surgeries.

“Our approach is different. Instead of developing a fully robotic system, we’re focusing on a hand-held, minimally invasive device that could provide optimal outcomes yet reduce costs for hospitals,” notes Tsai. “This allows us to offer a more affordable solution while still addressing demand. We’re taking a more measured approach – starting small to penetrate the market and then scaling up as we grow, without requiring heavy capital investment upfront.”

The future of RAS will also increasingly include the most vulnerable patients – children and infants. Johns Hopkins’ Wu explains that systems have started being used in some areas of pediatric surgery, but not yet for infants.

“One of the main challenges of RAS in pediatric surgery is the size of the instruments relative to the smaller anatomy of children,” she says. Ongoing research and development efforts focus on miniaturizing robotic tools to suit pediatric patients. As these tools become smaller and more refined, they enable surgeons to perform complex procedures with greater precision, reducing the risk of damage to delicate tissues.

RAS systems provide high-definition 3D visualization and fine motor control, which are particularly beneficial in pediatric surgery where precision is crucial. These systems allow surgeons to make smaller incisions, leading to less trauma, faster recovery times, and reduced post-operative pain. The potential for even more advanced robotic systems to provide higher levels of accuracy could make RAS the preferred method for many pediatric surgeries.

In August, one such system passed its initial test when a seven-year-old boy became the first child to undergo surgery using a pioneering new device for urology. The boy was operated on in the UK by consultant pediatric urologist Ewan Brownlee using the robotic-assisted Versius system, developed by Cambridge-based CMR Surgical. The Versius aims to increase precision using small surgical instruments, robot-assisted manual control, and a magnified screen.

“Ultimately, my hope is that there can be more minimally invasive procedures for children… not just in the UK but potentially around the world,” Brownlee told Euro News in August. “The robotic-assisted technology should make it more straightforward to do these minimally invasive procedures where sometimes open procedures can’t really be carried out.”