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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