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.
There are days when laparoscopic surgery is a breeze. The anatomy is perfect. The view is beautiful. Your assistants are thinking three steps ahead of you. In other words, the way surgery happens in your dreams
And then there are days when it isn’t going that way. The anatomy is distorted and confusing. There is bleeding that continuously distort your view. Your assistants are struggling. You are quickly becoming unhappy and want nothing more than for the surgery to be over and the patient to be well.
I have had many of both kinds of days. Over the years I have been operating, I have identified a few things that tend to have happened on the latter kind of days, and hope to pass a few of those things on. So if you find yourself struggling with laparoscopy, consider whether one of these things is going on.
This video demonstrates techniques for resecting infiltrating endometriosis, including dissection of bilateral ureters and pararectal spaces.
For consultation with Dr Fogelson please call Emory University at (404) 778-4416
Copyright 2012 Nicholas Fogelson and http://www.academicobgyn.com
This month I started a fellowship that predominantly involves taking care of women with cancer. Through surgery, chemotherapy, and other medications we do our best to cure or hold back malignancies of many kinds. In these past weeks, I have taken care of several patients who are Jehovah Witnesses, an experience that has been quite interesting.
In most cases, what religion a person subscribes to has little to no impact on their clinical outcome. We have an exception, however, when it comes to a Jehovah’s Witness with cancer. JHW patients to a rule will not accept blood products of any kind, which greatly limits their ability to be effectively treated for cancer. In some cases they cannot have surgery the surgery they need is unsafe without the possibility of blood transfusion. In some cases they cannot take chemotherapy because blood transfusion is required to survive the associated myelosuppression. As surgery and chemotherapy are our two best treatment, they are at a major disadvantage.
When I was a resident, I had a pretty hard opinion about this. I heard a lot of different view on the topic, but the position of one of my attendings resonated best with me. He felt that his job as a physician was to protect the health of his patients, and that if a JHW was dying in front of him he was going to transfuse them whether they liked it or not. He was quite clear about this upfront, and told JHW patients that if they were not happy about this they should find another doctor. He even arranged for attending coverage for emergent issues if need be. He felt that the preventable death of a patient was an emotional trauma he didn’t want to be exposed to, almost as if the patient, through refusal of blood, was exposing him to unnecessary emotional violence. While this was a very hard line, I respected the boldness of it, and that he was being true to his internal values. I held a similar feeling for the first few years of my attendinghood, though I never had to test it until my third year out of residency.
Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.
As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.
I have the pleasure of working with our resident GYN team for several weeks every few months, rounding on their patients and teaching each morning. One of the best parts of this is hearing our medical students present their cases.
Presenting patients is a skill that takes a great deal of time to master. Each student is taught the basic form of a medical presentation at an early ‘age’ – Subjective, Objective, Assessment, and Plan. Each of these bits can be broken down into many subareas, such a Past Medical History or Social History (part of the subjective usually), Chest Exam or Labs (parts of the objective), or individually listed problems (each parts of the assessment and plan.)
This sort of structure is both an aid to great presenting and a hinderance. It helps because it gives the presentation a structure that is easy to follow, and over the years of hearing such presentations the listener has created little boxes in their mind, and had developed the expectation that these boxes will be filled in a specific order. By following this structure, the student fills those boxes and thus creates a structured narrative that fits the listener’s expectations. This can be very functional and efficient. The downside is that if the student follows that structure too tightly, the presentation sounds stilted, like a person reading a spreadsheet. This creates a presentation that is technically correct, but lacks grace.
As I look back over my 10 year career in obstetrics and gynecology, I am sometimes struck at how many things have been discovered in this time period. When I started the origin of pre-eclampsia was unknown, and now we know that it likely originates in an overabundance of a molecule called Soluble FMS-Like Tyrosine Kinase, a competitive inhibitor to natural angiogenesis in the placenta. Ten years ago the origins of cervical dysplasia were still being developed, and now we know that the majority if not the entirety of cervical dysplasia and cancer is due to an infection of Human Papillomavirus, and for all intents and purposes cervical cancer is actually a sexually transmitted disease. We have developed this idea even further, allowing us to use HPV virus detection as part of a screening program for cervical dysplasia and cancer, and even to immunize for HPV infection in young women yet to be exposed.
All of these things amaze me. But to be honest, they also make the practice of obstetrics and gynecology more difficult. We have advanced our understanding to level that is impossible to explain to patients who lack a strong background in science, forcing us to accept simplistic explanations over explanations of how it really works. Let’s use HPV as an example.
I recently had the opportunity to go to the anatomy lab and help the first years go through the pelvic anatomy. What a blast! There is nothing like dissecting a cadaver to tune up one’s surgical anatomy skills, and helping young eager medical students through it is a great experience.
Prior to going into the lab, I spent many hours going through Netter’s atlas to brush up on the anatomy so I could accurately help the medical students. Its amazing what one can learn reviewing what one used to know. Here’s a few examples:
1. The small vessels we like to cut at cesarean have names, and we can avoid them.
Everybody that does cesarean deliveries knows that there are small vessels in the path of entry that sometimes get cut, but not everyone knows what they are called. So for the record, the small vessels in the subcutaneous fat that get cut are superficial epigastrics (most people know this one) and the vessels that sometimes go during the lateral extension of the fascial incision are ascending branches of the deep circumflex iliac artery. One can see that these ascending branches lie between above the transversalis muscle but beneath the obliques, which explains why sometimes taking the fascial layers separately allows one to miss them. I’ve always felt that the routine sacrificing of these vessels was a surgical faux pas, and knowing this anatomy helps one to avoid it.
Junes’s Green Journal had an interesting article on vertical versus transverse skin incisions for emergent cesarean deliveries that seemed worth some comment.
The point of the article was to look at a large retrospective cohort of emergent cesarean deliveries, stratify them by vertical or transverse skin incision, and then look at operative times and patient and fetal outcomes. This dataset was drawn from recorded data from many different centers, as part of the MFMU Network system of studies.