Seduction By Robot

Seduction by robot??? Sounds strange does it not? But that is exactly what appears to be happening at a hospital near you. Perhaps you have not yet heard of the da Vinci Surgical System. However, I can assure you, your hospital administrators have, as have the surgeons who practice in your area. What is it? When did it arrive on the scene? And, perhaps, most importantly, why should you care?

Originally launched in January of 1999 by Intuitive Surgical, The da Vinci Surgical System is described by its creators as “a sophisticated robotic platform designed to enable complex surgery using a minimally invasive approach. The da Vinci System consists of an ergonomic surgeon’s console, a patient-side cart with four interactive robotic arms, a high-performance 3D HD vision system and proprietary Endowrist instruments. Powered by state-of-the-art robotic technology, the da Vinci System is designed to scale, filter, and seamlessly translate the surgeon’s hand movements into more precise movements of the Endowrist instruments. The net result is an intuitive interface with breakthrough surgical capabilities.”

Wow! Sounds great, does it not? Sign me up! As a surgeon, I cannot wait to place my hands on one of these things. What patient would not want their surgery to have this technology incorporated into their procedure? “Seamlessly translate the surgeon’s hand movements into more precise movements, state-of-the-art, breakthrough surgical capabilities.” Seems like a no-brainer, right? Hospitals around the nation and the world seem to think so. And they have snatched these robots up in a “We don’t want to be left out” frenzy. Many surgeons have also been eager to jump on board. However, wait a tick. Let us take a closer look.

There exist several potential issues with this device as well as issues with how it has been marketed. Some of these include the cost of the device, monthly maintenance costs, significantly increased operative times, steep learning curve, increased complications and, at least in one area, presentation of the robot as the least invasive approach when a lesser invasive procedure is available. These potential problems deserve a closer look.

Consistently, the cost of the da Vinci Surgical System is reported to be $1-1.2 million. A hospital administrator recently informed me that the monthly maintenance for the system is in the neighborhood of $10,000.00. That is a significant amount of money. Add to that the enormous cost of training in terms of both time and money, and we are talking about an even larger sum. This is something of which any hospital system that acquires one of these robots will be acutely aware. This presents one of the issues I have found most concerning surrounding this device, more specifically, its marketing.

Several times over the last year I have received and read advertisements with invitations for people in neighboring communities to attend a meeting or dinner to learn about a new minimally invasive procedure available for hysterectomy. This, in and of it itself, poses no problem. However, the slant presented appeared to be that this new technology (read robot) was less invasive than “traditional” hysterectomy. This is where the problems arise.

There can be no argument that the LEAST invasive hysterectomy is a vaginal hysterectomy. The vaginal hysterectomy has also consistently proven to be the safest in terms of dangerous complications like ureteral injury. However, the purpose of these meetings is to “inform” people of this less (read, least) invasive option of robotic hysterectomy. A more skeptical assessment might be that these meetings intend on “selling” prospective hysterectomy patients on the idea that this robot offers the least invasive approach to hysterectomy.

Let us not forget, these da Vinci systems are extremely expensive and it appears from these marketing efforts, that these hospital systems are looking to drum-up business to help cover their costs. If, in so doing, they are deliberately misleading patients that the robot offers the LEAST invasive option for hysterectomy, then it is at a minimum wrong, and at worse, potentially assault and battery.

But let us back-up for a moment. Let us examine potential issues with this da Vinci Surgical System craze in more general terms. When news began making its rounds in surgical circles about this device and as most of us watched procedures being performed “robot-assisted”, there was one comment heard time and time again. That comment was that the system seemed to be a “technology looking for an application.” In other words, yes, this is an interesting, fancy machine, but it really had not been able to demonstrate a benefit in any particular area of surgery that could come close to justifying its enormous costs. Keep in mind that these costs consist of much more than the cost of the machine itself and its monthly maintenance costs (which we have seen are substantial), but the enormous costs in terms of increased surgical times, increased anesthesia costs and increased costs of surgical training.

These are some of the costs speaking in financial terms. Potential personal costs to the patient include increased operative times, increased time under anesthesia and the potential for increased operative risks and injury. More on this in a moment.

When I first began learning about robotic assisted surgery, the one area where they felt they could definitively state that there existed a significant proven benefit to the patient when robotic-assisted surgery was employed was in the area of a radical prostatectomy. There existed decreased risk of erectile dysfunction and other morbidity and the surgeons apparently really raved about the benefits of robot-assistance with this procedure. Radical prostatectomy is way out of my area of expertise but it certainly sounded reasonable to me at the time and I was pleased to hear they had a truly beneficial application for the technology. However, recently when speaking to a urology colleague about the incidence of complications in robot-assisted surgery he informed me that his colleagues were beginning to question this benefit and some of their contemporary literature was refuting it, as well.

It was during this conversation that I was discussing another of the potential issues with this robot-assisted surgery, that is of complications and what is more concerning, unrecognized complications. Any surgeon will tell you that if you operate enough, eventually, you will have complications. There is no way around it. It is part of surgical medicine. The best, most gifted surgeons in the world have surgical complications. One strives, as a surgeon, to minimize complications through thorough training, proper preparation, careful surgical technique and vigilance. Even with all of these things sometimes complications will occur. When they do occur, you, as a surgeon, want to recognize that a complication has occurred and address it appropriately and timely thus minimizing the impact it has on the patient.

We have already mentioned that the learning curve for physician training with the da Vinci system is very steep and time-consuming. It is one of the few, if not only, products on the market of which I can think that charges the surgeon a fee to learn how to use its product. The system itself is very hands-on and labor intensive not only for the surgeon but for the operating room personnel, as well. It only makes sense, that depending on where any given surgeon is on that curve, the potential for complications may increase. The discussion I was having with this urologic colleague stemmed from a patient recently referred to me following a robot-assisted gynecologic procedure during which the patient sustained injuries to her bladder and ureter. The ureteral injury was unrecognized at the time of surgery. This colleague discussed with me the increasing number of robot-assisted surgical injuries that he is seeing in his practice, as well.

There are numerous surgical fields that are attempting to incorporate robot-assisted procedures into their practice. I have read some reports from cardiovascular physicians and oncologists who report enjoying using the da Vinci Surgical System and feel it has benefits in their field. You can read many of these posted on the company’s website (perhaps, not the most objective source). As I have no expertise in those fields I am not qualified to opine. Where I can voice concern is in my own area of expertise in how this technology is being employed in gynecology. I recently had a conversation with a gynecologic oncologist who was planning to use the robot in a benign gynecologic case, not because the robot offered any particular benefit to the patient, but simply because he wished to use the robot. Never mind the aforementioned increased cost to the patient and our medical system but also the increased operative and anesthesia times and potential risks. This is concerning.

When discussing increased operative times, we are not talking about 20-30 minutes. Unfortunately, doubling, tripling and even quadrupling of operative times is common. Approximately 3 years ago when returning from a medical conference I was discussing the pros and cons with one of the more experienced “robotic” surgeons in my area. He stated that, at the time, a case that might require 45 minutes for him to complete with traditional laparoscopy might require 2.5 to 3 hours with the robot. He reported that he did not mind the increased operative time because he really enjoyed robotic surgery. And this, he reported, was a significant improvement over the initial increase in operative times. He explained that one could expect even longer times when first learning the system. Is this reasonable? Is this acceptable in the field of gynecology, or in any field for that matter? Does the end justify the means? When is this the best approach? Most cost-effective? Safest? Is it ever any of those things or does it offer all those things and more? The answers to these questions are certainly not clear and require further evaluation, at a minimum.

There are often numerous choices in the approach a surgeon uses to perform a procedure. Some surgeons are trained in multiple approaches to the same procedure, others perhaps only one. Numerous factors go in to deciding on which procedure is most appropriate. Factors include surgeon’s skill, patient factors such as their health, size, or organ size, as in hysterectomies. Never should a more invasive procedure be chosen simply because a physician finds it to be more “fun” or “interesting.” Additionally, a procedure should never be chosen because it is a part of an efficient marketing machine. I was caught a little off-guard the first time I saw a physician advertising themselves as a “robotic surgeon.” Does that sound like a good thing? I know what they are trying to say/advertise. But does anyone truly want a “robotic” surgeon? Not me. I want a skilled surgeon who has the ability, adaptability and fluidity to adjust their approach as the case requires, not plod aimlessly forward in robotic fashion without regard to the circumstances of the specific case. This is clearly not what they mean, but it sounds a little odd.

The most appropriate procedure should always be the least-invasive procedure that can be safely performed in a particular surgeon’s hands at a given surgical facility.

I am not saying that there does not or never will exist a place in medicine for robot-assisted surgery. I personally know many well-respected surgeons who are using the product and believe it offers a benefit in their hands. I am simply saying that in a world with an increasingly scarce healthcare dollar we should tap the brakes a bit and determine if this or any other technology is appropriate for any given medical field. And whether it truly offers a cost-effective benefit to our patients without increasing their risks.