YES – Robotics Holds Promise for Surgery’s Future
Robotic surgery offers some real advantages over laparoscopic techniques in the abdominal area, but so far it has been difficult to prove the clinical benefits and cost-effectiveness of robotic systems.
It will likely take some time before there is ample evidence to show that robotic procedures produce better outcomes. And it may take even longer before the price tag on these systems comes down to earth.
Dr. Mark A. Talamini
But most surgeons will agree that there are real benefits to using robotic systems. As laparoscopic surgeons, we lost our tactile feedback, our three-dimensional visibility, wrist degrees of freedom, and even a comfortable operating posture. Robotic surgery can give a lot of that back.
The vivid, three-dimensional visibility of the robotic system is like nothing else that I’ve seen to date. Robotic systems also return the ability to get behind tissues. And these systems offer a more comfortable posture. Unfortunately, there are no gains in tactile feedback, and it may even be a little worse.
More than 40% of prostatectomies are now being done using the robotic da Vinci system – yet, for the most part, urologic surgeons weren’t even doing laparoscopic surgery before this device came along. But this device is very well suited for that particular operation. Similarly, robotic techniques are making inroads in colorectal pelvic surgery and esophageal surgery.
Robotic technology improves our ability to precisely manipulate tissue, minimize tissue trauma, improve visibility, and reduce surgeon fatigue. But how do you put a value on these improvements? We have a serious cost problem in American health care, and because surgical technology is expensive, we must continue to try to find ways to measure and assess advanced technologies.
Imagine that I took a superb open surgeon and put Crisco on his glasses. Then, instead of handing him a pair of his favorite 6-inch Metzenbaum scissors, I gave him a pair that was a foot-and-a-half long. Would that great surgeon still be able to get his Whipple operation done? Of course. And he would do it well because he’s a great surgeon. But I’m equally sure that same excellent surgeon would rather be able to see the way he likes and use instruments that can get the job done more effectively. To me, that’s a little bit like what robotics can give to surgeons.
I’m not ready to say that robotic surgery is the future for our field. It’s a good fit for specific procedures, but not for all. However, using computer technology and advanced imaging to improve what we do for patients is absolutely the future of surgery – and the current generation of robotic devices is the very beginning of that revolution.
Dr. Talamini is Professor and Chairman of the Department of Surgery at the University of California, San Diego. He is a pioneer in minimally invasive abdominal surgery and specializes in robotic surgery.
NO – A Question of Value
It’s true that robotic-assisted surgery has given us back some of the advantages we lost with the move to laparoscopic surgery. We have gained back the degrees of freedom. The three-dimensional vision that we lost has been restored. We can put surgeons in a more comfortable position while operating.
But there aren’t any data that show beyond a doubt that robotic-assisted surgery results in decisively better patient outcomes – especially in abdominal operations, for which there is currently no indication.
Dr. Nathaniel J. Soper
The heart of the matter is value – which we can see as an equation of quality divided by outcomes and costs. With robotic surgery, the quality is generally equivalent or goes down slightly, but the cost goes up – a lot.
The question of value even arises in prostate surgery, the robotic procedure with the largest body of clinical data.
A 2009 study of 2,600 men who underwent minimally invasive or robotic radical prostatectomy is a case in point. The laparoscopic group had a shorter length of stay as well as fewer blood transfusions, respiratory complications, and surgical complications. Men who had the robot-assisted surgery were more likely have to genitourinary complications, to become incontinent, and to experience erectile dysfunction (JAMA 2009;302:1557-64).
The New England Journal of Medicine also looked at the cost issue. At a price tag of more than $2 million, the robot added about $1,600-$3,200 to the cost of every procedure – without any increase in reimbursement (N. Engl. J. Med. 2010;363:701-4).
Let’s look at outcomes specifically in abdominal procedures. One recent study examined robotic and laparoscopic liver resection in 29 patients. Patients who underwent the robotic procedure had more ICU admissions, more minor complications, and longer hospital stays. In addition, the robotic surgery cost almost $5,000 more (J. Gastrointest. Surg. 2012;16:2233-8).