Thursday, October 18, 2007

Domo Arigato (Mr. Roboto)

(With apologies to Styx fans)

Thank you very much, Mr. Roboto
Until the day we meet again
Thank you very much, Mr. Roboto
I want to know your secret
I want to know your secret too, Mr. Roboto, and I think I have discovered at least a part of it.

There is a tremendous amount of interest, excitement, and speculation revolving around the da Vinci surgical system. It is a fascinating piece of engineering, designed to allow minimally invasive approaches to a variety of surgical procedures. Predominantly, the use of "the robot" has been limited to cardiac and prostate surgeries, though a whole host of bright surgeons are trying to expand its applications. Plus, it looks cool --- sort of like the ED-209 with longer arms.

Separated at Birth?

I have had the opportunity to watch robot-assisted laparoscopic prostatectomy and mitral valve surgery (you can view a video on their web site), and the technology is truly impressive. Well, I'm no technophobe, so what role might Mr. Roboto play in general surgery? Will I get to play with this cool ~$1.5 million device? I'm not so sure.

A little background is in order. Laparoscopic, minimally invasive general surgery procedures have gradually gained traction in the past 15-20 years. Initially limited to simple surgeries such as cholecystectomy and appendectomy, we have seen significant advances in instumentation that now allow general surgeons to perform more complex procedures --- my practice includes laparoscopic colectomy, gastric bypass, splenectomy, Nissen fundoplication, and Heller myotomy, along with the less complex procedures noted previously. Better instruments that allow safe dissection and division of tissues, such as the Harmonic Scalpel and LigaSure, along with better endoscopic stapling devices have make most of this possible. Additionally, it is critical to be facile with laparoscopic suturing; what we routinely perform in an "open" procedure can be tedious and difficult with long instruments and a 2-dimensional video system.

The robotic system allows a surgeon to have instruments that mimic their hand movements to a very great degree. This permits the surgeon to replicate open surgery techniques using minimal access, particularly with suturing. There are some procedures that are "suture-intense," in a fashion, that have been performed with good success using the robot --- prostatectomy and mitral valve surgery are good examples --- that were not generally feasible with conventional laparoscopic instruments.

For most general surgical procedures, however, our current instruments are more than up to the task, and adding the setup time and complexity of the robot may not provide significant improvements in the things that matter most --- outcomes, OR time, and cost. This has been shown in a number of articles, including two in the most recent volume of Surgical Endoscopy. The first, entitled Robotic versus laparoscopic colectomy, comes from the Univ. of Illinois and compared 30 consecutive robotic and 27 consecutive non-robotic laparoscopic colon resections (emphasis is mine):

Conclusions The comparison groups were similar. The robotic cases were significantly longer for right colectomies because of the intracorporeal anastomosis instead of the extracorporeal anastomosis performed in the laparoscopy cases. Every cost category was higher for the robotic cases. The right colectomies showed significant increases in total OR cost, OR personnel cost, OR supply cost, and OR time cost. The sigmoid colectomies had significant increases in OR personnel cost and OR supply cost. The total hospital cost was higher for the robotic groups, but the difference was not statistically significant.
Additionally, though the difference was not statistically significant, the robotic cases averaged about 35 minutes longer --- however, the authors did not factor the lengthy robot set-up time in this analysis, which is critical when multiple procedures need to be performed in an OR on a given day.

The second study, while more favorable in some ways to the robotic approach, reached a similar conclusion. Entitled Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized trial, this Romanian study compared forty patients randomized between the two approaches. Interestingly, their robot set-up time was fairly short, compared to an average of 30-45 minutes in other studies, but their operative time was shorter with the robot. Despite a trend towards a slightly faster procedure, using the robot was more expensive and no differences in outcome were found:
Conclusion In comparison with CLF, operative time can be shorter for RALF if performed by an experienced team. However, costs are higher and short-term outcome is similar. Thus, RALF can not be favoured over CLF regarding perioperative outcome.
Well crap! A cool new toy, here at my hospital, and I can't find a good reason to play with it! Why aren't the results any better in general surgery, like they are in cardiac and urologic surgery? There are a two fairly obvious reasons.
[1] We are already pretty efficient at minimally invasive general surgical procedures, with good outcomes, so a huge change would be needed to see significant improvement
[2] The robot excels at procedures requiring a large amount of suturing. We already have great laparoscopic stapling devices that have eliminated the need for extensive laparoscopic suturing. Even in a laparoscopic fundoplication, I will only be placing and tying about 6-7 sutures.
We also need to be aware of the dollars and cents --- these are expensive toys, and hospitals are unlikely to have several of them laying around for every surgical specialty to use. It makes the most sense to me for them to be utilized for those patients who will gain the maximal potential benefit from them. For now, that appears to be certain cardiac surgery and prostatectomy patients.

Oh, well, maybe I can find something else to toy around with in the OR. I wonder if they'll let me play with the Midas Rex....?