Over the last three decades, surgery has slowly but steadily evolved towards a minimally invasive technique. The standard of care for appendicitis now involves creating three half-inch incisions and using a laparoscopic technique to remove the appendix. This technique uses a camera to see inside the body via a large screen. Instruments that are over a foot long are used. Sufficient research has shown that this minimally invasive technique leads to significantly faster recovery, better pain control, smaller scars, and wound infections, without compromising the ultimate goal of the surgery.
More recently, the minimally invasive approach has expanded to include a robotic approach. Despite its astronomical $2 million cost, robotic surgical systems have grown in popularity. Robotic surgery uses the same principles as laparoscopic surgery, in that small incisions, a camera, and long instruments are used to perform the operation. Instead of standing near the patient, the surgeon is in a different part of the room, at a “console” that allows them to use their hands and feet to control the arms of the robot. At the bedside, an octopus-like machine with surgical arms translates the surgeon’s moves into moves inside the patient’s body. At the patient’s bedside is often a technician, a physician assistant, or a resident who is in charge of exchanging instruments.
The positive aspects of robotic surgery are that it allows surgeons to operate in difficult to reach spaces such as deep in the pelvis or under the diaphragm. Because the arms of the robot allow flexion and extension in ways that laparoscopic instruments are not capable of, the robot allows surgeons to have the equivalent of wrists on the instruments when placing stitches or dissecting. The robot has all the advantages of laparoscopic surgery such as small incisions and fast healing time. Another important advantage of the robot is the ergonomics of the operating surgeon. Instead of standing next to the patient in a very uncomfortable position, the surgeon now spends the entire time sitting down with the back and neck straight. Because the robot can translate any gentle movement into a strong grip, the surgeon’s arms do not tire out from having to use their own strength to retract tissue. Most importantly, the robot does not operate on the patient; the surgeon does. The robot does not have a mind of its own, and every move it makes is under the control of the surgeon. In a way, the robot is simply an extension of the surgeon’s arms.
The negative aspects of the robot are the ones that we feel are not openly discussed with patients. From the console, the surgeon can see and move the robot arms, but does not receive any tactile feedback. This means that a surgeon may unintentionally pull or rip tissues without realizing it. Every move feels like air in the surgeon’s hands. When a small vessel bleeds, the surgeon would normally apply pressure with a sponge and would receive tactile feedback in their hands, knowing exactly how hard to push. With the robot, that pressure could be too light or too strong. Although, while using the robot, one can see the ripping effects of tissue if the grasp is too strong, the surgeon will not actually know if they cut through a vessel unless they see bleeding. This brings up the next point of dangerous mistakes. Surgery is not risk-free, and sometimes minimally invasive techniques cannot safely be used to perform an operation. If a large vessel is injured and there is life-threatening bleeding, converting a laparoscopic surgery to an open one that allows for easy access to address the issue is a matter of seconds to minutes. The robot, on the other hand, is attached to the patient and undocking it can take several minutes, a short delay that could mean life or death.
Another very important aspect of robotic surgery that is often overlooked is the time it takes to perform an operation. Placing and adjusting the ports, docking the robot so that it is appropriately attached to the patient, and fighting the limitations that it poses on the angles from which the surgeon can work can nearly double the length of an operation. For example, an open groin hernia repair may be done safely in 30 in 45 minutes, sometimes under conscious sedation like a colonoscopy. Laparoscopic and robotic surgery always require general anesthesia with a breathing tube. Laparoscopic surgery for the same hernia might take 1.5 to 2 hours. A robotic repair of the same hernia takes 2 to 3 hours. These times, of course, differ between different surgeons and the complexity of the operation. But in general, the robotic surgeries are significantly longer than their counterparts. While an hour might not make a difference, for complex oncology cases, a robotic surgery might take 14 hours compared to the 8 hours for laparoscopic surgery or 6 hours for open surgery. There is strong evidence to show that time under general anesthesia is associated with increased mortality and morbidity, such as deep venous thrombosis, pneumonia, prolonged intubation after surgery, and pulmonary embolism.
However, time is not hard only on the patient, but also on the surgeon and the team. Needless to say, on the 13th hour of sitting in the dark at a cold console far away from the patient, the surgeon and team will be quite tired, and sometimes that means by the time the critical part of the operation occurs the same attention to detail and vigilance that was present 10 hours prior is no longer there. Finally, from an economic standpoint, and in a country with one of the highest costs for medical care per capita, it is hard to argue the added operative time for robotic surgery and subsequent increased surgical costs is beneficial even when outcomes are equivocal. Numerous studies have shown that the results of robotic surgery as far as achieving the goal of surgery (e.g., fixing the hernia, taking the tumor out) are similar. Pain has been sometimes noted to be higher in robotic surgery because of the torque that the robot places on the tissue. Most importantly, there are no studies that show that robotic surgery is superior to laparoscopic surgery.
When patients consent for surgery, the discussion revolves around the choice of open versus minimally invasive technique. The latter is often overlooked as laparoscopic or robotic without further details. While the robot represents the new “sexy surgery,” it is in many cases, a marketing strategy that allows for higher billing and increased patient recruitment. Despite presenting the surgery as minimally invasive, the choice between laparoscopic and robotic surgery should be a deliberate one and made with an understanding of the significant benefits and drawbacks that each technique poses – because, at the end of the day, an operation is a lot more than just about the length of the scar.
The author is an anonymous physician.
Image credit: Shutterstock.com