When it comes to surgery, less can be more. Smaller incisions mean less cutting. Less cutting means less bleeding, a quicker recovery and less time spent in the hospital.
The trend over the past several decades, assisted by medical technology, has been in the direction of “less”–arthroscopic, laparoscopic, keyhole and other minimally invasive procedures. One of the most recent developments in that trend is robot-assisted surgery.
A human surgeon, as well as a robot, is required, if that eases your mind. And the procedure is usually done under general anesthesia so you are asleep and unaware that a robot may be cutting you open and operating on your internal organs.
The surgeon is sitting at a computer console, however, and he or she is guiding the movements of the robot who performs the surgery with tiny instruments attached to its arms. In some cases, the human part can also be done remotely from virtually any place in the world. In either instance, an assistant surgeon is at the patient’s bedside to monitor what is going on.
It all sounds like science fiction, but it’s rapidly becoming the norm for many procedures. Robot-assisted surgery has now become the most common way of treating prostate cancer, accounting for more than 61 percent of prostatectomies in 2009 compared to only 9 percent in 2003.
Theoretically, the advantages of using a robot are numerous:
• magnified visibility of the surgical site for the human surgeon,
• improved dexterity and range of motion by the robotic arms and
• precise control of surgical instruments through computer technology.
Through the video monitor, the surgeon has a stereoscopic, 3-D image delivered by a tiny camera that has been inserted, along with surgical instruments, through keyhole size incisions.
Ideal for Complex Procedures
The software translates the surgeon’s hand movements to the robotic instruments inside the body, eliminating any time delay or tremor. This kind of precision is ideal for delicate or complex procedures in which it’s necessary to avoid nearby nerves, blood vessels or organs.
Through the flexible joints and tiny instruments of the robot, the surgeon gains dexterity and range of motion, making it possible to operate in tight spaces with small incisions. This, in turn, provides advantages similar to those of laparoscopic and other minimally invasive surgeries–less pain and scarring, lower risk of infections, less blood loss and need for transfusions, faster recovery, shorter hospital stays and quicker return to normal activities.
Aside from prostate surgery, robotic technology is commonly used for colorectal/bowel resection, removal of the thymus gland, bariatric surgery, excision of a kidney mass, gall bladder removal, hysterectomy, lung resections, pediatric surgery and urologic procedures. It may also prove to be helpful for coronary artery bypass surgery, catheter ablation for atrial fibrillation and head and neck surgery.
In practice, research to date has been inconclusive at best. One study, presented at the 27th Annual Congress of the European Association of Urology [February 26, 2012] found that patients getting robot-assisted prostatectomy had fewer post-operative complications, fewer transfusions and shorter hospital stays than patients undergoing open prostatectomy.
The study did not address, however, the complications that matter most to some patients–persistent erectile dysfunction and/or urinary incontinence following the procedure. An earlier study, published in the Journal of the American Medical Association did indeed find a higher rate of these complications.
A meta-analysis of 400 studies published in European Urology [February 24, 2012] found “no good evidence of an overall benefit for one modality over another, and it is uncertain whether minimally invasive surgery, especially robotics, justifies its increased costs and training requirements.”
A study of patients undergoing myomectomy (surgical removal of uterine fibroids) found similar clinical outcomes and complication rates for robotic and traditional laparoscopic procedures when performed by experienced surgical teams. However, the robotic procedures took longer: a mean of 195.1 minutes compared to a mean of 118.3 minutes for laparoscopic surgery. This difference could have been due to the use of barbed sutures in two thirds of the patients undergoing laparoscopic surgery.
Perhaps most discomforting is the 34 percent increase in the number of adverse event reports–from 211 in 2011 to 282 in 2012. That increase prompted the Food and Drug Administration to survey surgeons about their experiences with robot-assisted technology.
This increase came at a time when the number of robotic-assisted procedures was increasing at a 26 percent rate. Many doctors believe that the adverse events can be attributed to the newness of the technology and learning curve issues. A similar increase in adverse event reports occurred during the early evolution of laparoscopic surgery. In both cases, the field of vision is somewhat limited compared to the larger incisions of open surgery.
Although the robotic machines are complex, advocates say, most errors occur because of surgeon error rather than robotic malfunction. Regardless of the method used, the surgeon’s skill and experience are the most important factors in assuring a good outcome.
Primarily because of the smaller incision and quicker recovery, patients like the idea of robotic surgery and often ask for it.
In response to the aggressive marketing and advertising of robot-assisted surgery, the American Congress of Obstetricians and Gynecologists (ACOG) issued a statement [March, 2013] of caution. “While there may be some advantages to the use of robotics in complex hysterectomies,...studies have shown that adding this expensive technology for routine surgical care does not improve patient outcomes. Consequently, there is no good data proving that robotic surgery is even as good as–let alone better–than existing, and far less costly, minimally invasive alternatives.”
A machine costs between $1.5 and $2.2 million, and service contracts run about $14,000 a month. Disposable instruments cost as much as $2,000 per procedure. Theoretically, these costs can be made up in part by reducing the patient’s length of hospital stay and lowering the rate of complications. In practice, it’s most important to have a skilled, highly trained surgical team of humans with extensive experience working with robots.
REFERENCES:
American Congress of Obstetricians and Gynecologists, “Statement on robotic surgery by ACOG President Jhames T. Breeden, M.D.,” March 14, 2013.
Gina Kolata, “Results unproven, robotic surgery wins converts,” New York Times, February 14, 2010.
Jenni Laidman, “Laparoscopic myomectomy faster than robot-assisted surgery,” Medscape Medical News, July 24, 2012.
Albert B. Lowenfels, M.D., “Robot-assisted vs laparoscopic colectomy,” Medscape General Surgery, November 30, 2012.
Becky McCall, “Robotic surgery most common for prostate cancer in the US,” Medscape Medical News, March 1, 2012.
Nick Mulcahy, “Meta-analysis: robotic prostatectomy fares well in short term,” Medscape Medical News, May 2, 2012.
Roxanne Nelson, “Robot-assisted surgery feasible for head and neck cancer,” Medscape Medical News, April 30, 2009.
Carol Peckham, “Is robotic surgery worth its price? An interview with Dr. Joseph Colella,” Medscape General Surgery, June 20, 2013.
“Robotic surgery,” MedlinePlus, updated by Scott Miller, M.D., March 28, 2011.
Gary Schweitzer, “Surgeon blogs that robotic surgery is all hype and no substance,” Evidence-Based Medicine, Medical Devices, July 30, 2011.
Tom Valeo, “Scarless surgery: the benefits and drawbacks of robotic thyroidectomy,” ENT Today, April, 2010.
12/13/2013
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