Robotic surgery shouldn’t be universally dismissed

A response to Why isn’t everyone excited about robotic assisted surgery? by Kelly Wright.

Yes, it’s cool.  The surgical robot is every gamer-cum-surgeon’s dream.

However, I, too, was a skeptic regarding incorporating robotic surgery into my practice.  I have been practicing minimally-invasive surgery for over 20 years, including residency.  I became convinced of the value of minimally invasive surgery after observing patients postoperatively.  I have laparoscopically repaired an obturator nerve transection, done a radical hysterectomy ,  and more than 100 laparoscopic sacrocolpopexies and urethropexies.  I have removed uteruses weighing over 2000g laparoscopically.  The robot did not impress me initially as something useful to add, particularly when I had the skills to perform these cases laparoscopically.

However, there is another side to this issue possibly better addressed by a veteran rather than someone still in training.  There is something to be said for surgical experience, technical knowledge and expertise gained after performing hundreds of cases on different body types in different circumstances.  A surgeon’s longevity, even with strict attention to proper operative ergonomics, may be restricted due to problems with arthritis, herniated discs, or other physical ailments which to a non-surgeon might not be as debilitating.  I found one day that due to the positioning issues I had with a particular type of case, my lower back began to bother me.  For the record, I am in top physical condition, better than most people half my age.  But much to my chagrin, I discovered I am human and not indestructible.  It was my own physical limitations that led me to engage in training on the robot.

As noted by Dr. Wright, studies have not demonstrated superior outcome to standard technique for robotic prostatectomy, and equivalent outcome compared with laparoscopic sacrocolpopexy.  In the case of the latter, operating times tended to be longer on the robot, with higher costs due to operating times and capital costs of equipment. However, thoracic surgery may be different.  More data is certainly needed.  Moreover, outcomes tend to be better with surgeons who perform many operations per year and who have greater experience.  In adding robotic surgery to my skillset, I reasoned that by embracing a technology allowing me to properly position my body, obtain 3D magnified visual information on the surgical field, I might be able to improve my surgical longevity.

I know of other surgeons with various physical ailments who are able to operate more effectively through the use of robotic technology.  Although this is not an issue being discussed, I believe it is a valid one.  I am a better surgeon now than I was 20 years ago.  My hope is to be able to continue at the top of my game for a long time.  Robotic surgical innovation has just begun.  Innovation is what propels us.  I believe that the surgical robot will evolve with surgeons and medicine, and allow us to do things not possible or practical even with laparoscopy.  Currently, I only use the robot for a few procedures, and continue to embrace standard laparoscopy for the rest.

I applaud careful evaluation of new technologies, but caution against straightforward dismissal based solely upon equipment cost.

Linda A. Kiley is an obstetrician-gynecologist. 

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  • Brandon Stein

    While the aspects in this article regarding the learning effect and outcome is important, I think it may be important to question the aspect of comfort and increased longevity for the surgeon. A study should be done to assess surgeon fatigue with lap vs robotic surgeons and then cost analysis should be done to see if the extra longevity of the surgeon is enough to make sense for us to buy robots for them. I understand that on a personal level that would be nice, but from a public health perspective I’m not quite convinced.

  • Anonymous

    The real issue is the ridiculous marketing of the robot, particularly in light of the lack of actual improved outcomes data. I don’t think that’s the same thing as saying it’s a useless tool. Ergonomics are an important consideration, and although these are improved for the primary surgeon at the terminal, they are, in my experience, absolutely dreadful for the assistants on the surgical field, who are maintaining awkward positions for marathon procedures. Eventually, the kinks will be worked out and the best practices will be identified, but until then, hospitals need to stop selling snake oil. 

  • Anonymous

    All I can give is my own experience, but I can honestly say that for a hysterectomy, the robot was a great choice for me. My scars are tiny, my hospital stay was very short, and I didn’t have nearly the complication issues that two friends having regular laparoscopy and traditional surgery at around the same time I did experienced.   That said, I did my research and picked the best physician in my town who does hundreds of these a year with a 0% mortality rate and a 2% significant complication rate.  I think it’s a great tool, but like any tool, it must be in the hands of someone who knows how to use it well to achieve the best results.

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