Johns Hopkins University
Publication Date: January 1, 2015
Robotic-assisted surgery used to be an imaginative component of science fiction; however, as is often the case, one generation’s version of science fiction has evolved into scientific fact. In 2007 there were a total of 80,000 robotic-assisted surgeries, hereby referred to as RAS, compared to 205,000 in 2010 (Barbash et al. 2010) —and the trend has continued through 2014. A study by Lanfranco et al. termed a robotic surgery unit “in essence the entry fee into marketing an institution’s surgical specialties as ‘the most advanced.’” (Lanfranco et al. 2004) RAS is routinely discussed with patients concerning a variety of surgeries, with the ultimate aim of faster recovery rates and lower risks of infection. Unfortunately, there are monetary and pragmatic disadvantages of RAS for routine surgeries, even in comparison to conventionally laparoscopic surgical interventions; because of these disadvantages, many patients should be urged to decline RAS in surgeries that are considered more routine, in which costs of RAS may outweigh potential advantages. Regardless, the issue is certainly not cut-and-dry; for more complex surgeries, patients would be best advised to use RAS, especially in instances in which evidence points to shorter recovery times.
Many think of robotics as synonymous with automation. In the case of RAS, however, the surgeon is in complete control of the device via a console. The robot itself, according to Intuitive Surgical Inc., the maker of the DaVinci surgical robot, is a large machine composed of multiple robotic arms with parts to suit several surgeries, including electrocauterization tools, an endoscopic camera, and devices capable of operating dexterically similarly to a human hand. The surgeon operates through voice command, foot petals, and hand levers that translate the surgeon’s movements into mechanical motion. This motion may then be scaled to any desired force ratio, thus allowing the surgeon to more delicately perform precise operations.
Minimally invasive laparoscopic surgery is an excellent way for a patient to shorten recovery times, but it has its disadvantages—the aim of RAS is to eliminate the complications brought about by human error in these manual procedures. Even the most well-trained surgeons are physiologically imperfect, with natural tremors, the fulcrum effect, limited degrees of motion, compromised dexterity in laparoscopic procedures, etc. (Lanfranco et al., 2004). RAS seeks to eliminate these issues by enhancing vision, improving dexterity, enabling the surgeon to scale motions to his or her desire, and eliminating tremors (Lanfranco et al., 2004). In addition, the surgeon can sit comfortably throughout the procedure instead of having to maneuver his or her body to get the correct angle with an instrument, providing for greater surgical precision. It is clear that RAS accomplishes its goal of resolving negative aspects of manual laparoscopic procedures.
Even after improving traditional techniques, RAS should not be used for routine surgeries, because of the lack of research documenting long-term results, the extremely high cost of RAS, and other disadvantages for both the patient and hospital systems. On average, the cost of a robotic surgery unit costs between 1 million and 2.5 million USD, making it difficult for the average hospital to obtain a unit (Andrews, 2013). As the NIH admits, “almost no long-term follow up studies have been performed” to compare results to conventional methods (Lanfranco et al., 2004). According to Barbash and colleagues, RAS increases the cost of the average surgery by $3,200, but “evidence suggests that despite the short-term benefits, robotic technology may not have improved patient outcomes or quality of life in the long run” (Barbash et al., 2010). Therefore, logic would dictate that it would not make sense for a patient to travel to one of the relatively few hospitals with RAS capability to pay extra money for a surgery that may or may not improve long-term outcome for routine surgeries.
Patients should, however, invest in RAS for more complex surgeries. Barbash et al. argue: “In the case of procedures that had previously been performed as open surgery…some of the new costs will be offset by reductions in post-operative hospital costs and by productivity gains if patients recover more rapidly and can return to work and other activities sooner.” (Barbash et al., 2010). RAS has also opened the door to surgeries that were previously impossible to conduct using laparoscopic methods. For example, RAS has developed capabilities for minimally invasive cardiac surgery (Prasad et al., 2001). Pediatric surgery has also historically been outside the reach of minimally invasive technology because of obvious issues arising from the small size of the patient; once again, RAS allows pediatric laparoscopic surgery to be “technically feasible” even in infants, shown by procedures conducted successfully on piglets (Lanfranco et al., 2004; Hollands et al., 2001).
Looking ahead to the future, RAS has extremely exciting potential applications. Telesurgery is in its infancy, but it can potentially allow for a surgeon to operate on a patient from hundreds of miles away over a secure network using RAS; teaching new surgeons could be made easier by allowing surgeons to simulate surgeries within the robotic system; surgical movements could be tracked to show a surgeon ways to improve the procedure, and artificial intelligence could make suggestions to the surgeon concerning the next move; patient scans and imaging technologies could be incorporated into the robot to allow the surgeon to access a wealth of patient information while operating… truly, the limitations of this technology are only subject to the limitations of human ingenuity.
Outlining the potential RAS possesses also brings about its greatest downfall: it is a new field. Unfortunately, more research must be done in order to recommend it fully for every procedure, and it is too expensive to provide care for the masses. For patients today, informed consent is absolutely critical before they undertake RAS; they must fully understand the costs, benefits, and potential risks involved therein. Even so, for complex surgeries and new technologies, RAS is at the cutting edge of precision, and serves as an excellent alternative option to open and often debilitating operations.
1) Barbash, G. I., & Glied, S. A. (2010). New technology and health care costs—the case of robot-assisted surgery. New England Journal of Medicine, 363(8), 701-704.
2) Lanfranco, A. R., Castellanos, A. E., Desai, J. P., & Meyers, W. C. (2004). Robotic surgery: a current perspective. Annals of surgery, 239(1), 14.
3) Andrews, M. (2013, April 23). Questions Arise about Robotic Surgery’s Cost, Effectiveness. . Retrieved July 31, 2014, from http://www.kaiserhealthnews.org/features/insuring-your-health/2013/042313-michelle-andrews-robotic-surgery.aspx
4) Prasad SM, Ducko CT, Stephenson ER, et al. Perspective clinical trial of robotically assisted endoscopic coronary grafting with 1 year follow-up. Surg. 2001;233:725-732.
5) Hollands CM, Dixey LN. Technical assessment of porcine enteroenterostomy performed with Zeus robotic technology. J Pediatr Surg. 2001; 36:1231-1233.
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