BJOG Debate: Robotic surgery
FOR: Robotic surgery has no advantages over conventional laparoscopic surgery JON EINARSSON, DIRECTOR OF MINIMALLY INVASIVE GYNECOLOGIC SURGERY, BRIGHAM AND WOMEN’S HOSPITAL, ASSOCIATE PROFESSOR OF OB/GYN HARVARD MEDICAL SCHOOL, USA
.................................................................................................................................................................. Robotic surgery has enjoyed rapid adoption since the 2005 FDA approval for use in gynaecology. A recent article by Wright et al. found that in 2010 the traditional laparoscopic approach accounted for 30% of all hysterectomies, while 10% were performed with robotic assistance; today, robotic hysterectomy is the most commonly performed robotic procedure worldwide (Wright et al., JAMA 2013;309:689–98.). Clearly, the introduction of robotic surgery has significantly affected our field in a relatively short time and it is worth exploring whether this adoption is beneficial for patients, physicians and the healthcare system. Available evidence suggests that compared with conventional laparoscopy, robotic surgery offers no patient benefits. This is clearly outlined in a recent AAGL position statement (AAGL Advancing Minimally Invasive Gynecology Worldwide, J Minim Invasive Gynecol 2013;20:2–9) as well as a Cochrane review published in 2012(Liu H et al., Cochrane Database Syst Rev 2012;2:CD008978). Early robotic adopters claimed reduced postoperative pain due to pivoting of the robotic arms and ‘more precise’ dissection but this has not been supported by evidence. In fact, a randomised trial comparing laparoscopic an-
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drobotic sacrocolpopexy found significantly higher pain scores in the robotic group (Paraiso MF et al., Obstet Gynecol 2011;118:1005–13). While there are challenges in designing surgical studies, mainly due to surgeon bias, the available evidence has a consistent theme as described above. Secondly, although the robot is marketed as ‘enabling’ technology, the learning curve for robotic surgery can be prolonged and surgeons have to acquire a lot of new tasks such as docking and managing when away from the patient’s bedside. There is no convincing evidence that clinical use of robotic surgery enables surgeons to move faster or more safely through the learning curve of a certain procedure when compared with traditional laparoscopic surgery. At my institution we perform approximately 1100 hysterectomies per year and we were able to change the main mode of access from predominantly abdominal (70%) to predominantly laparoscopic (60%) without use of the robot. Thirdly, robotic surgery is more costly. For example, each robotic hysterectomy costs $2000–3000 more than a traditional laparoscopic hysterectomy. A recent review in the New England Journal of Medicine concluded that if
robotic surgery were to replace conventional surgery for all surgical procedures, the additional cost would be more than $2.5 billion every year (Barbash GI, et al., N Engl J Med 2010;363:701–4). Therefore, the growth of robotic surgery is not sustainable in the current medico-economic environment. The robotic surgery debate has unveiled a major deficit in our surgical field; low surgical volumes. High volume surgeons have better outcomes, and it may be challenging for low volume surgeons to sustain the learning curve for new procedures. We need surgical guidelines that limit the performance of advanced gynecologic procedures to surgeons with the necessary skills and experience to perform them safely. In summary, laparoscopic surgery offers safe and cost-effective outcomes in experienced hands. In the near future, gynaecologic surgery may migrate towards high volume providers who are able to provide patients with safer and more cost-effective surgical care. This transition, as well as the ongoing changes in our cost environment, may significantly dampen further growth of robotic surgery.
Disclosure of interests None to declare. &
ª 2014 Royal College of Obstetricians and Gynaecologists
FOR: Robotic surgery has no advantages over conventional laparoscopic surgery JON EINARSSON, DIRECTOR OF MINIMALLY INVASIVE GYNECOLOGIC SURGERY, BRIGHAM AND WOMEN’S HOSPITAL, ASSOCIATE PROFESSOR OF OB/GYN HARVARD MEDICAL SCHOOL, USA
.................................................................................................................................................................. Robotic surgery has enjoyed rapid adoption since the 2005 FDA approval for use in gynaecology. A recent article by Wright et al. found that in 2010 the traditional laparoscopic approach accounted for 30% of all hysterectomies, while 10% were performed with robotic assistance; today, robotic hysterectomy is the most commonly performed robotic procedure worldwide (Wright et al., JAMA 2013;309:689–98.). Clearly, the introduction of robotic surgery has significantly affected our field in a relatively short time and it is worth exploring whether this adoption is beneficial for patients, physicians and the healthcare system. Available evidence suggests that compared with conventional laparoscopy, robotic surgery offers no patient benefits. This is clearly outlined in a recent AAGL position statement (AAGL Advancing Minimally Invasive Gynecology Worldwide, J Minim Invasive Gynecol 2013;20:2–9) as well as a Cochrane review published in 2012(Liu H et al., Cochrane Database Syst Rev 2012;2:CD008978). Early robotic adopters claimed reduced postoperative pain due to pivoting of the robotic arms and ‘more precise’ dissection but this has not been supported by evidence. In fact, a randomised trial comparing laparoscopic an-
1554
drobotic sacrocolpopexy found significantly higher pain scores in the robotic group (Paraiso MF et al., Obstet Gynecol 2011;118:1005–13). While there are challenges in designing surgical studies, mainly due to surgeon bias, the available evidence has a consistent theme as described above. Secondly, although the robot is marketed as ‘enabling’ technology, the learning curve for robotic surgery can be prolonged and surgeons have to acquire a lot of new tasks such as docking and managing when away from the patient’s bedside. There is no convincing evidence that clinical use of robotic surgery enables surgeons to move faster or more safely through the learning curve of a certain procedure when compared with traditional laparoscopic surgery. At my institution we perform approximately 1100 hysterectomies per year and we were able to change the main mode of access from predominantly abdominal (70%) to predominantly laparoscopic (60%) without use of the robot. Thirdly, robotic surgery is more costly. For example, each robotic hysterectomy costs $2000–3000 more than a traditional laparoscopic hysterectomy. A recent review in the New England Journal of Medicine concluded that if
robotic surgery were to replace conventional surgery for all surgical procedures, the additional cost would be more than $2.5 billion every year (Barbash GI, et al., N Engl J Med 2010;363:701–4). Therefore, the growth of robotic surgery is not sustainable in the current medico-economic environment. The robotic surgery debate has unveiled a major deficit in our surgical field; low surgical volumes. High volume surgeons have better outcomes, and it may be challenging for low volume surgeons to sustain the learning curve for new procedures. We need surgical guidelines that limit the performance of advanced gynecologic procedures to surgeons with the necessary skills and experience to perform them safely. In summary, laparoscopic surgery offers safe and cost-effective outcomes in experienced hands. In the near future, gynaecologic surgery may migrate towards high volume providers who are able to provide patients with safer and more cost-effective surgical care. This transition, as well as the ongoing changes in our cost environment, may significantly dampen further growth of robotic surgery.
Disclosure of interests None to declare. &
ª 2014 Royal College of Obstetricians and Gynaecologists
