The Enid News and Eagle, Enid, OK

January 3, 2014

Next big innovation: Is it robot surgery?

By Judy Rupp, columnist
Enid News and Eagle

ENID, Okla. — 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, and the procedure is usually done under general anesthesia, so you are unaware that a robot may be cutting you open. 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. An assistant surgeon is at the patient’s bedside to monitor what is going on.    

Theoretically, the advantages of using a robot are numerous. 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.    

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 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.    

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. The technology is also used commonly 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 [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.    

However, the study did not address 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 [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 and were more costly.    

Perhaps most discomfiting 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. Many doctors believe that the adverse events can be attributed to the newness of the technology and learning curve issues.    

Although the robotic machines are complex, advocates say, most errors occur because of surgeon error rather than robotic malfunction.

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.”

Regardless of the method used, doctors agree that the most important factors in assuring a good outcome are the surgeon’s skill and experience.

Rupp is a certified information and referral specialist on aging for NODA Area Agency on Aging. Contact her at 237-2236.