Academic OB/GYN

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.

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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.