Robotic Surgery: Time to Do Some Soul-searching
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Data continue to be generated related to the use of robotic surgery in gynecology. At the current time, what the future holds for this latest technology within our specialty is anyone's guess. That does not mean, however, that the individual physician should ignore it until the data are conclusive. Indeed, if a clinician had waited to see what role laparoscopic-assisted vaginal hysterectomy played relative to abdominal and vaginal hysterectomy, that individual would still be waiting for the final answers. That impact continues to evolve. Laparoscopic hysterectomy rates have increased from 0.3% in 1990 to almost 12% in 2003. This has, in turn, been accompanied by a reduction in the proportion of abdominal cases and a slight increase in hysterectomies performed vaginally.
The purpose of this article is to provide the thoughtful gynecologic surgeon an opportunity to reflect on how he/she will approach the possible incorporation of what is clearly an innovation that can potentially alter how gynecologic surgery is performed in an individual's practice and/or hospital. As one might expect, the actual performing of the procedure is only the tip of the iceberg, as non-medical factors — be they economic, educational, and ethical — enter into the final decision the clinician will make.
The da Vinci Surgical System was introduced in 1999 and was granted FDA approval for gynecologic surgery in 2005. Both advantages and disadvantages are acknowledged.
Potential advantages of robotic surgery:
- Three-dimensional visualization improves depth perception
- Improved dexterity replicates full range of motion of surgeon's hands
- Increased precision through elimination of physiologic tremors
- Reduced fatigue from surgeon being seated at the console
- Shorter hospital stays using minimally invasive approach
Potential disadvantages of robotic surgery:
- Higher cost, including > $1 million initially, and disposables
- Increased operating time due to equipment set-up time
- Lack of tactile feedback to the surgeon
- Inability to reposition patient after robot arms attached
- Bulkiness of operating system and lack of vaginal access
Potential cases for which the robotic technology is currently appropriate is based upon the experience of others who have published on their respective experiences. Simple hysterectomy is one of the most common procedures and is proposed as an example of a case that is more difficult for a laparoscopic approach, but may be accomplished robotically without having to resort to laparotomy. Myomectomy has also been aided by the robotic approach. Pelvic reconstruction, with particular emphasis on sacrospinous fixation, as well as gynecologic oncology cases, has also been shown to be potential areas in which robotic technology can be beneficial. In tubal reanastomosis, robotic surgery apparently takes longer, but is comparable to mini-laparotomy in terms of hospitalization duration, ectopic pregnancy rates, and pregnancy rates. Convalescence is shorter with robotic surgery.
The impact of robotic surgery has not only clinical aspects, but educational ones as well. Both anecdotal and published data suggest that how residents are trained is already being affected by the technology. At one institution in Michigan, hysterectomy rates for the 18 months prior to the introduction of robotic surgery were compared to the 18 months after; it was found that there was a statistically significant reduction in the rate of laparoscopic-assisted vaginal hysterectomy as well as total abdominal hysterectomy. With fewer traditional cases available to residents, the need for the attending physician to attain a level of comfort with the technique, and minimal meaningful clinical experience for the resident/assistant surgeon, the implications for the training of gynecologic surgeons of the future are obvious.
That being said, the challenge for the education of the individual surgeon who is beyond residency and already in practice is no less daunting. Merely starting to do the procedures without appropriate training and preparation is certainly inappropriate. The education/training of the surgeon should be done in coordination with an operating room team if there is not one already. A mandatory course is available involving dry labs and animal models, but having a proctor present for the first several cases is a must. Initially, patient and case selection are critical to build an appropriate track record and case load. The days required to obtain the education as well as the additional hours required to perform the initial cases before greater expertise is obtained must be looked at carefully for the surgeon to determine whether it is worth the time and effort invested into a technology that he/she may or may not enthusiastically embrace.
The time needed to become educated in the technology and use thereof is not insignificant. As the old saying goes, "Time is money." Will the time invested result in rewards that are of sufficient value? Each clinician will need to answer that for him/herself since the return on investment may or may not take the form of more patients (and implicitly more cases), more peer recognition, more job satisfaction, etc. By the same token, the economic issue for the surgeon may be moot if the hospital chooses not to invest in the technology. Often, multiple specialties together may have to press for this significant capital expenditure.
All surgeons considering becoming a robotic surgeon should certainly ask whether the driving force is truly wanting to deliver better care to the patient or just to "keep up with the Joneses." In some markets, the perception of who the best gynecologic surgeons are is based not on expertise, but on whether they offer the latest surgical approach.
Since there is only one manufacturer, any case done with the robot, is, by definition, done with their machine. This monopoly on the equipment side makes for an interesting dynamic as the technology is being considered. How much is being offered as helpful to the patient and how much is actually a sale? For now, there are precious few data that definitively demonstrate the superiority of the robotic approach over more traditional techniques. In fact, one cannot help but recall the questions raised when laparoscopic-assisted vaginal hysterectomy was sometimes referred to as "a procedure looking for an indication."
Without question, our first priority must be to the welfare of the patient. Are we improving her health? Are we putting her at risk? Is she getting our best? Is she getting full informed consent? Are you prepared to tell her that you've only done it this way a few times?
If the commitment is made to become a robotic surgeon, then it's incumbent upon the clinician to keep up with the robotic literature and attend postgraduate courses and hands-on workshops. A commitment to excellence to this surgical approach is no different from keeping up skills in any other area of practice we participate in, i.e., obstetrics, hormone therapy, health care screening, etc.
So there it is, the challenge to each of us. A final decision is not necessarily needed now, but attention should be paid. The debate is just getting started and each of us is going to have to take sides … eventually. "I've always done it this way" may well be your response to the challenge right now. I encourage you to accept the challenge to start deciding how you feel about it. Will you do it? Will you assist your partners who want to do it? Will your practice designate one partner to be the robotic surgeon? Will you help the hospital make the decision?
You won't know how to answer unless you keep an open mind and an inquiring one at that. We all committed ourselves to lifelong learning when we earned our medical degree. We owe that to each of our patients. The issue of robotic surgery is no exception.
- Robot-Assisted Surgery: ACOG Technology Assessment in Obstetrics and Gynecology. Obstet Gynecol 2009;114:1153-1155.
- Akl M, Magrina JF. Will robots transform gynecologic surgery? Contemp Ob/Gyn 2009;54:26-33.
- Brenot D, Goyert GL. Impact of robotic surgery on obstetric-gynecologic resident training. J Reprod Med 2009;54:675-677.