Home > Gynecology > My Take on the Recent Robotics Kerfuffle

My Take on the Recent Robotics Kerfuffle

This month ACOG released a statement on Robotic Surgery, generally negative towards the development. They propose that robotics does not offer a proven advantage in benign gynecologic surgery, and increases cost.

Per the statement “If most women undergoing hysterectomy for benign conditions each year chose a vaginal or laparoscopic procedure—rather than TAH or robotic hysterectomy—performed by skilled and experienced surgeons, pain and recovery times would be reduced while providing dramatic savings to our health care system. Conversely, an estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.”

This morning a large cadre of minimally invasive surgeons released a statement of response, accusing ACOG of not being supportive of minimally invasive techniques and misinterpreting the data on robotics.

Here’s my take on the issue:

I am a surgeon that focuses on minimally invasive techniques and gets a lot of referrals for difficult cases.  I’ve been doing robotics for about two years now, and have done enough cases (over 100) that I feel like I can make a pretty objective assessment of its utility in what I do.

As Intuitive Surgical will be happy to tell anyone that listens, robotics has quite a few advantages.

The ability of the robot to move with wrist-like motions allows laparoscopic maneuvers that are difficult if not impossible with straight stick laparoscopy. This allows one to do surgery in very small delicate areas that are much harder to address traditionally.

The vision allowed by the robot is far superior to traditional laparoscopic vision, for 4 reasons: 1) image fidelity is better than most traditional equipment 2) 3D vision allows one to see relationships between structures far better 3) the screen is so close to your face that it fills your whole field of view, creating an immersive “I am the robot” experience and 4) you control the camera and don’t have to depend on your assistant to show you what you want to see.

The ability to pass energy through both primary instruments creates a surgical flow that is difficult to match with traditional instruments. The fact that one can cauterize every surface that is cut tends to lead to bloodless surgery. This can be done traditionally as well, but its a bit more difficult to achieve the same result.

Long laparoscopic surgeries require a surgeon to stand in a way that is eventually painful to the back and legs. Robotics is quite comfortable for the surgeon, as he is sitting in a ergonomically superior position.

All of this together allows one to tackle much more difficult cases than one might have tackled with straight stick, such as stage IV endometriosis with obliterated cul-de-sacs, huge uteruses, or cases that require extensive suturing. As such, robotics has the potential to turn cases that otherwise would have been abdominal cases into laparoscopic cases.

There is potential to do surgeries through a single site using the robot, which is a cosmetic advantage over multiple port surgeries.

And here is the downside:

The robot is a tremendously complicated piece of equipment that requires a very skilled team to operate efficiently.  Without that team, the use of the robot adds a huge layer of complexity to a surgery.  With that team, it still slows things down.   While one may be able to do the operative portion faster, the setup time for the room and and early part of the surgery is significant and will slow most cases down overall.   A ideal team may mitigate this completely, but such a team I have never seen in an academic center.

The robot is extremely expensive, both to buy and to maintain.  It costs between 1.5 and 2 million dollars, and several hundred thousand dollars a year for a service contract.

One usually needs more port sites to do robotics than traditional laparoscopy.

The robot breaks down from time to time, sometimes in the middle of a surgery.  While these problems inevitably get resolved, it is a remarkably unpleasant experience for all involved.  A two million dollar machine with a two hundred thousand dollar a year service contract should not break down at all.

The robot is sold and serviced by a company that does not have an objective view of their own technology.  They aggressively market their product directly to patients, and even more so to the robot trained surgeons.  They do not seem to see the reality of their product, which is that it is very useful for a subset of laparoscopic surgeries and a hinderance to another subset.  They prefer to think about it as an improvement to all laparoscopic surgery, which it clearly is not.


My feeling is that ACOG’s statement is a response to the tremendous proliferation of robotics throughout benign gynecologic surgery without a clear evidence base to suggest that this level of use can be justified.  I agree with that part.   A lot of surgeons are using robotics to complete cases that could have been done via traditional laparoscopy or vaginal surgery, which is not right.   The entire point of the robot was to convert open surgeries to laparoscopic surgeries, but in benign gynecology it is being used for far more than that.  This drives up costs at minimal to no benefit to patients.

Some argue that robotics allows a surgeon who is not a particularly skilled laparoscopist to do more difficult laparoscopic surgeries.  I think this is true, but at the same time I am not sure that is a good thing.  Surgery is done best when it is done by people that do a lot of it.  If one does a lot of laparoscopy, one gets good at doing a lot of things with or without the robot.  At that point many mild to moderate difficulty laparoscopic surgery is most easily done without the robot.

Right now my hospital has two robots at one center and is about to buy a second at our other site.  The drive to have multiple robots is because of demand for time on the robot.  While this seems appropriate, I have to ask myself whether these marginal cases that justify a second machine actually cases that require robotics to be completed laparoscopically.   If not, then the cost is not very justifiable.

I love working with the robot, and get a real feeling of accomplishment when I am able to complete a robotic case that I know I never would have been able to do through traditional methods without a laparotomy.  I have done many of those.  But having done over 100 robotic cases, a 10 week size hysterectomy done robotically does not give me that sense of accomplishment.  I get that sense of accomplishment by doing that case vaginally or via traditional laparoscopic surgery, being out of the room in two hours and with far less expensive toys.

Categories: Gynecology
  1. April 12, 2013 at 5:52 am

    Dr. Fogelson, I enjoyed your post and I agree with meny of your points. It sounds like we have about the same level of experience on the robot although I am likely older and have more abdominal/vaginal experience. From my perspective, the robot is an emerging technology that if nurtured properly could completely overtake all but the most simple diagnostic/adnexal laparoscopic surgery. If an economy of scale develops, whereby the cost of the robot and it’s reposables comes down and the utilization and effeciency of robotic surgery goes up, eventually there will be an equilibrium point that we can all live with. As an enabling technology, I believe the robot can offer more women a minimally invasive procedure and that the goal should be less than 2% abdominal/10%vaginal/ the remainder robotic. Depending on the population served of course. Douglas Krell MD

  2. August 5, 2013 at 5:27 pm

    For newest news you have to go to see world wide web and on web I found this web site as a finest website for hottest

  3. November 14, 2013 at 10:40 pm

    It’s genuinely very complex in this full of activity life to listen news on TV, so I only
    use world wide web for that reason, and obtain the
    most up-to-date news.

  4. November 22, 2013 at 10:26 pm


  5. March 18, 2014 at 7:15 pm

    I am really enjoying the theme/design of your web site.
    Do you ever run into any browser compatibility
    problems? A handful of my blog visitors have complained about my blog not
    working correctly in Explorer but looks great in Chrome.

    Do you have any tips to help fix this problem?

  6. August 19, 2014 at 8:21 am

    Great beat ! I would like to apprentice while you amend your site, how
    can i subscribe for a blog site? The account helped me a acceptable deal.
    I had been a little bit acquainted of this your broadcast provided bright clear

  7. rid
    August 20, 2014 at 10:02 am

    I’ve been exploring for a bit for any high-quality articles
    or blog posts on this kind of area . Exploring in Yahoo I eventually stumbled upon this website.
    Studying this info So i am happy to convey that I’ve a very good uncanny feeling I came upon just what
    I needed. I such a lot definitely will make certain to do not disregard this site and provides it a look regularly.

  8. August 25, 2014 at 3:02 pm

    What’s up i am kavin, its my first occasion to commenting anywhere, when i read this article
    i thought i could also create comment due to this brilliant post.

  9. August 26, 2014 at 9:25 pm

    Superb, what a webpage it is! This webpage presents helpful facts to us, keep it up.

  10. August 29, 2014 at 4:04 pm

    hello!,I really like your writing so much! share we keep up a correspondence more about your article on AOL?
    I need a specialist in this area to resolve my problem.
    May be that is you! Looking forward to see you.

  11. September 6, 2014 at 1:53 pm

    Howdy! This is my 1st comment here so I just wanted to give a quick shout out
    and tell you I really enjoy reading through your
    articles. Can you recommend any other blogs/websites/forums that go over the same topics?
    Many thanks!

  12. September 15, 2014 at 12:35 am

    Good site you have here.. It’s hard to find good quality writing like yours nowadays.
    I seriously appreciate people like you! Take care!!

  13. September 22, 2014 at 10:58 pm

    Having read this I thought it was rather enlightening.
    I appreciate you taking the time and energy to put this content
    together. I once again find myself personally spending a lot
    of time both reading and commenting. But so what, it was
    still worth it!

  14. September 26, 2014 at 4:34 am

    There are norestrictions on ovulation symptoms where to hang the curtains for you just give
    them the right shade of wood. Regular ovulation symptoms custom made curtains are the best idea.
    Purchasing curtains online make it easier to find.
    Made to order curtains make it easy to find something that fits.
    The procedure for measuring a bay window or alcove are a
    way to save on your electric or fuel bill.

  15. October 7, 2014 at 10:43 pm

    When there are a couple is dead set on a
    daily basis, you need to know the basics of fertility is to make a
    baby girl is truly a motivating process. The Whelan MethodTo make matters more confusing,
    the desire to balance a family consisting of children of only
    boys or girls, how to conceive a girl with many couples trying
    to conceive should take their temperature.

  16. June 26, 2015 at 4:39 am

    Event planners are professionals who take everything into account while planning an event.

    Unfortunately, there are some people out there that are just trying to take your money, and they will set up
    a contest with a paid entry, and then there will never actually
    be a winner. Team competitions are another way to build fun into employee referrals.

  1. March 24, 2013 at 8:38 am

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s


Get every new post delivered to your Inbox.

Join 121 other followers

%d bloggers like this: