BJOG Debate: Robotic surgery
AGAINST: Robotic surgery has no advantages over conventional laparoscopic surgery THOMAS IND, CONSULTANT GYNAECOLOGICAL SURGEON, UK
.................................................................................................................................................................. The DaVinci robot is a technology designed to improve on laparoscopic surgery using rigid, counterintuitive, and straight instruments (straight stick surgery). The robot has wristed instruments allowing the surgeon to work around corners. Furthermore, it removes the fulcrum effect of straight stick surgery and eliminates the surgeon’s tremor amplified by straight sticks. It is not surprising that in the laboratory, the learning curve of an exercise is shorter (Rashid TGK et al. Int J Med Robot 2010;6:306–10), the ergonomics superior (Balasubramani LM et al. J Robot Surg 2011;5:137–40), and outcomes better (Haider JN et al. J Gynecol Surg 2013;29:287–91). The introduction of new surgical technologies is fraught with problems. We never learn from history. The manufacturers have been accused of over-exaggerating efficacy, over-charging, and marketing direct to patients. This has encouraged naysayers to highlight complications and to make equally unfounded criticisms. Using the robot for many gynaecological cases is akin to admitting a patient to intensive care for blood pressure measurement but it does have a sensible and balanced position in gynaecological practice.
ª 2014 Royal College of Obstetricians and Gynaecologists
One example of its value lies in surgery for endometrial cancer. For one Canadian unit, the introduction of robotics resulted in fewer open procedures, less blood loss, decreased length of stay, reduced complications, and lower costs (Lau SV et al. Obstet Gynecol 2012;119:717– 24). What cannot be denied was the value for that institution and the motion that there is ‘no’ advantage must be rejected outright. In my own hospital we have also undertaken a service evaluation project that has shown similar results and we are currently in the process of preparing an article on this. Again, these benefits refute the adage of ‘no advantage’. Much has been made of the perceived increased costs of robotics over straight stick surgery. Many papers have not analysed cases by intention to treat or factored in the high proportion of cases having laparotomy (the most expensive route). The best evidence available suggests that DaVinci utilisation lowers the proportion of patients having open surgery for endometrial cancer, which is why overall costs are cheaper in Lau’s and other studies. Furthermore, conversion rates are probably halved compared with straight stick (Boggess JFG et al.
Am J Obstet Gynecol 2008;199:360). Calls for randomised controlled studies forget that surgery is not a drug that can be prescribed and utilised uniformly by all surgeons. A better comparison would be to look at whole services with or without the resource of robotic surgery. In that setting, the best evidence available suggests that outcomes are improved for endometrial cancer when the DaVinci robot is available. A rational argument is required to find a sensible place for new technology in clinical practice. The introduction of all laparoscopic surgery has been set back two decades by extreme claims and counter claims. Today, most surgery for endometrial cancer is performed by laparotomy in spite of clear evidence against open surgery. Clearly, there is a role and an advantage for robotics in some patients with endometrial cancer.
Disclosure of interests
In 2007 I received 2 days of training funded by Intuitive. I am a member of council of the British and Irish Association of Robotic Gynaecological Surgeons (BIARGS). &
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AGAINST: Robotic surgery has no advantages over conventional laparoscopic surgery THOMAS IND, CONSULTANT GYNAECOLOGICAL SURGEON, UK
.................................................................................................................................................................. The DaVinci robot is a technology designed to improve on laparoscopic surgery using rigid, counterintuitive, and straight instruments (straight stick surgery). The robot has wristed instruments allowing the surgeon to work around corners. Furthermore, it removes the fulcrum effect of straight stick surgery and eliminates the surgeon’s tremor amplified by straight sticks. It is not surprising that in the laboratory, the learning curve of an exercise is shorter (Rashid TGK et al. Int J Med Robot 2010;6:306–10), the ergonomics superior (Balasubramani LM et al. J Robot Surg 2011;5:137–40), and outcomes better (Haider JN et al. J Gynecol Surg 2013;29:287–91). The introduction of new surgical technologies is fraught with problems. We never learn from history. The manufacturers have been accused of over-exaggerating efficacy, over-charging, and marketing direct to patients. This has encouraged naysayers to highlight complications and to make equally unfounded criticisms. Using the robot for many gynaecological cases is akin to admitting a patient to intensive care for blood pressure measurement but it does have a sensible and balanced position in gynaecological practice.
ª 2014 Royal College of Obstetricians and Gynaecologists
One example of its value lies in surgery for endometrial cancer. For one Canadian unit, the introduction of robotics resulted in fewer open procedures, less blood loss, decreased length of stay, reduced complications, and lower costs (Lau SV et al. Obstet Gynecol 2012;119:717– 24). What cannot be denied was the value for that institution and the motion that there is ‘no’ advantage must be rejected outright. In my own hospital we have also undertaken a service evaluation project that has shown similar results and we are currently in the process of preparing an article on this. Again, these benefits refute the adage of ‘no advantage’. Much has been made of the perceived increased costs of robotics over straight stick surgery. Many papers have not analysed cases by intention to treat or factored in the high proportion of cases having laparotomy (the most expensive route). The best evidence available suggests that DaVinci utilisation lowers the proportion of patients having open surgery for endometrial cancer, which is why overall costs are cheaper in Lau’s and other studies. Furthermore, conversion rates are probably halved compared with straight stick (Boggess JFG et al.
Am J Obstet Gynecol 2008;199:360). Calls for randomised controlled studies forget that surgery is not a drug that can be prescribed and utilised uniformly by all surgeons. A better comparison would be to look at whole services with or without the resource of robotic surgery. In that setting, the best evidence available suggests that outcomes are improved for endometrial cancer when the DaVinci robot is available. A rational argument is required to find a sensible place for new technology in clinical practice. The introduction of all laparoscopic surgery has been set back two decades by extreme claims and counter claims. Today, most surgery for endometrial cancer is performed by laparotomy in spite of clear evidence against open surgery. Clearly, there is a role and an advantage for robotics in some patients with endometrial cancer.
Disclosure of interests
In 2007 I received 2 days of training funded by Intuitive. I am a member of council of the British and Irish Association of Robotic Gynaecological Surgeons (BIARGS). &
1555
