BY GRANT MERCER – Sixteen years ago, the Food and Drug Administration (FDA) approved the nation’s first robotic surgical system. Named after a Renaissance master, the da Vinci system promised a revolutionary breakthrough just as its name implied — a revolutionary breakthrough reflective of the marriage between art and science. Then-FDA Commissioner Jane Henney predicted that the da Vinci would be the “first step in the development of new robotic technology that will change the practice of surgery.” Commissioner Henney’s prophecy has come true, as more than half of today’s prostate, gynecological and gallbladder operations are now performed robotically.
In robotic surgery, the surgeon makes a small incision, often no longer than a half inch, and inserts a laparoscope — a tiny, lighted 3D camera — into the opening. After clipping surgical instruments onto the three pencil-thin robotic arms hovering over the patient, the surgeon takes his or her spot, not standing by the patient’s side, but rather seated at a computer console. Resembling a high-tech video game, the console is equipped with foot pedals and hand controllers designed to mimic the surgeon’s hand, wrist and finger movements. The controls allow an extensive range of motion and greater precision while the instruments perform complex procedures that would have been far more difficult and invasive using traditional methods. The 3D laparoscope gives a high resolution view of the surgical field, illuminating and magnifying every nuance of the body.
The robotic system does not replace the surgeon’s skills, but enhances them. Should the surgeon’s hands tire and tremble during an hours-long operation, the computer automatically smooths out the motion, giving each movement a virtual stillness. If the surgical area is in a tight space, like the back of the throat, the high-definition magnified image allows the surgeon to better see his or her way around the surrounding tissue.
Robotic surgery provides numerous benefits over traditional open operations, including faster recovery time (with smaller cuts, healing time shrinks from the usual four to six weeks to a measly one to two weeks); smaller scars, a definite cosmetic benefit when operations must be performed on more visible areas of the body and decreased costs for both patient and hospital due to lesser blood loss and a shorter stay.
However, like all medical procedures, there are downsides to robotic surgical technology. To begin with, the time to perform a robotic surgery is usually longer than traditional methods, increasing the time the patient stays under anesthesia with its potential risks. Additional physician training is also required to utilize a robotic system. While most traditional surgical techniques require a year-long fellowship to master, certification on the da Vinci varies widely by hospital. At some facilities, certification can be obtained in as little as three surgical sessions while other hospitals require up to 100 procedures before declaring a surgeon certified. This non-standardized training could lead to unequal skills among surgeons, leaving patients struggling to decipher their surgeon’s true expertise on a robotic system. Additionally, mid-operation tech glitches are always a possibility. Should the broadband signal be lost, the screen suddenly fade to black or the instruments simply fail to operate as promised, the surgeon must be capable of performing the operation by traditional methods. Space is also an issue — robotic surgical systems can be quite large, taking up a great deal of room in an operating room already crowded with a gurney, anesthesia equipment and medical personnel.
In the early 2000’s, hospitals, eager to be recognized as technology leaders, began touting their da Vinci capability on billboards, in magazines and on their websites. One billboard emblazoned with a surgeon’s face boasted that robotic-assisted surgery had made him famous. Another hospital’s billboard promised that the da Vinci system transformed lives. One more featured a man happily fly-fishing as he exclaimed, “When I was diagnosed with prostate cancer, I chose da Vinci. So should you!”
This direct-to-consumer marketing push has driven the number of robotic surgeries from 1,000 operations in 2001 to over half a million annually in the U.S., with patients often demanding the robotic-assisted surgery. Today, over 25% of all American hospitals offer a da Vinci system, according to the American Hospital Association. Fortune magazine noted that up to one third of all surgeries will likely be performed by a robot within the next five years.
Hospitals justify the $2 million cost of a robotic system as a means to bring more patients through their glass doors instead of those of their competitors’, according to a Wall Street Journal survey. Dr. Eric Genden, a surgeon at New York’s Mount Sinai Hospital, observed that, “Patients will go to someone who has the robot because it’s been marketed so much,” also noting that, “This is a beautiful illustration of how American medicine and the patients tend to become enamored of technology without ever really asking the question, ‘What are we getting for the technology?”
A July 2016 study published in the British medical journal, The Lancet, described the results of a 250-surgery trial, comparing robot-assisted surgery to a traditional version. The researchers concluded that the outcomes of both surgery types had similar outcomes, with the overall skill of the surgeon being the main determining factor of success. The research team wrote that they would, “encourage patients to choose an experienced surgeon they trust, rather than a specific surgical approach.” Nearly two decades after the introduction and now widespread adoption of robotic surgery, it is interesting that the first comprehensive study comparing these two types of surgeries finds little discernible outcomes.
The da Vinci system has enjoyed a virtual monopoly on robotic surgical systems. While the system is now on its fourth iteration, Dr. Vince Loudone of Memorial Sloan Kettering Medical Center noted that, “There are no other true competitors in the field at this time. Even though we are 16 years into this technology, we haven’t seen the innovative breakthroughs that would come from having other players in the field.”
In the world of medicine, novelty should not be automatically equated with progress.
Robot-assisted surgical systems should be considered an enhancement of the surgeon’s skills, not a replacement of human performance. Robotic surgery may someday evolve to being the gold standard of all surgical procedures, but there is still work to be done. As of now, an experienced surgeon is where you’ll want to turn in times of need.