Is there a future for robot-assisted surgery?

Recently, there was a fascinating article in the Wall Street Journal regarding robot-assisted surgery. It reported the results of two articles published in JAMA that demonstrated that robotic-assisted surgery cost more and took longer without achieving superior results to laparoscopic surgery on average.

With this, my LinkedIn account lit up. Here are several of the comments that came through:

“I’ve come to assume that robotic surgery is better for GYN and colon surgeries simply because of their increased precision and accessibility to small spaces.”

“Robots are sexy, the media covers it like it’s the next best thing since sliced bread, and advantages may or may not be earth-shattering. Since when has that ever stopped a sale?”

“If you’re a surgeon: would you rather stand uncomfortably over a patient for 2-3 hours, trying to manage laparoscopic instruments? Or would you rather sit comfortably at a console and feel like you’re playing a surgery video game? It isn’t about outcomes. Plus, robots are cool to patients.”

So, before I plunge into the limitations of the robot let me begin with a brief story. Some years ago, I sat in on a Hot Topics debate at the Academic Surgical Congress. The hot topic: Laparoscopy versus robotic surgery.

For the surgically naïve, laparoscopy is the surgeon standing next to the patient, directly handling long, skinny instruments that are passed through tiny incisions into the patient to perform the surgery.

Robotic surgery involves the surgeon sitting at a console in the corner of the room remotely operating a $2.5 million machine that in turn handles the not-so-skinny instruments that are introduced through small incision to perform surgery.

Laparoscopy is hard on a surgeon’s body, but all surgery, in general, is hard on a surgeon’s body. Robotic surgery is easier on the surgeon’s body.

The debate was rather one-sided. The majority of surgeons felt that the robot was of minimal value. The other side put up the typical arguments: “All technologies have to start somewhere. Remember the first mobile phones and bulky they were and how much they cost?” and “The costs will go down as the technology improves and is more widely used.”

The robot was introduced in 2000. Unlike the cell phone, it has not evolved into a better, sleeker technology and it sure as hell isn’t cheaper. Back then, the robot cost one million dollars, not the 2.5 million it costs today. And the technology has not accelerated at the rate of Moore’s law. It remains a bulky, cumbersome technology looking for an application.

I agreed with the audience consensus that the robot is of little utility, but I pointed out that we are not making ergonomically designed patients, tables or surgeons. And until we come up with some better ergonomic solutions, surgeons will continue to accumulate back, neck, shoulder, elbow and hip injuries at alarming rates. It is estimated that more than 60 percent of surgeons are nursing a chronic skeletal injury by 50 years of age. The robot represents an attempt to address the ergonomic crisis in surgery.

So, with that let’s look at the cons of the robot through the three comments above:

The first comment assumes the robot will result in better outcomes. And the JAMA data demonstrates that this assumption is incorrect. If there were an advantage in precision or getting into small spaces, it would show up in the data. I can’t speak for GYN surgery, but in colorectal surgery, the major complication is the bowel leaking from where it is reconnected. And there is increasing evidence that a leak from where the bowel is reconnected has more to do with the bacteria in your intestine and the enzymes they secrete than it does with precision in dissection.

The second comment is spot on. Robotic surgery companies have sold the health care organizations on the “sexy” without any evidence of increased benefit proportional to cost.

The third comment nails the point about ergonomics, but the author is completely misguided or mistaken. Health care is entirely about outcomes. In the rapidly evolving environment of value-based medicine (outcome per cost) the robot loses.

One little thing that does not get mentioned is that in addition to the initial cost of purchase, hospitals pay an annual six-figure maintenance fee to the company. So after ten years, the initial cost of the purchase has doubled.

There are other hidden costs as well:

Room setup and room breakdown: This is much longer for robotic cases and one minute of OR time at my institution cost about $106.

Reprocessing a robot: this takes at a minimum of four-and-a-half hours of labor. Usually, it is more like seven to nine hours. When you consider most good reprocessing techs can reprocess the instruments from three cases in an hour, they can turn over instruments for 13 other ORs in the same time it takes to reprocess one robotic case in one OR. This becomes a huge sink in terms of OR efficiency and operating costs.

And finally …

Instrument amortization. Break an arm or an attachment, add $40K to your six-figure bill for the year. In contrast, a high-quality laparoscopic instrument will cost around $1K to replace.

To be sure we need ergonomic solutions for surgeons. Maybe we need to think and train more like athletes from the very beginning when we enter residency. Maybe someone can invent a better OR table. Or maybe we need an exoskeleton to help position and rest our bodies better during surgery. Whatever solution, it must demonstrate value by improving results, reducing cost or doing both.

Peter F. Nichol is chief medical officer, Medaware Systems.

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