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Wednesday / December 13.

Is there a future for robot-assisted surgery?

There was a fascinating article in the Wall Street Journal recently on robot-assisted surgery. It reported the results of two articles published in the Journal of the American Medical Association (JAMA) that demonstrated that robot-assisted surgery, on average, cost more and took longer without achieving superior results to laparoscopic surgery.

For the surgically naïve, laparoscopy is the surgeon standing next to the patient, directly handling long skinny instruments that are passed through tiny incisions into the patient to perform the surgery. Robot-assisted surgery involves the surgeon sitting at a console in the corner of the room remotely operating a $2.5 million machine that in turn handles the not so skinny instruments that are introduced through a small incision to perform surgery.

My LinkedIn account lit up with the publication of this article. Here are a few comments that came through:

“I’ve come to assume that robotic surgery is better for GYN and colon surgeries simply because of their increased precision and accessibility to small spaces.”

“Robots are sexy, the media covers it like it’s the next best thing since sliced bread, and advantages may or may not be earth-shattering. Since when has that ever stopped a sale?”

“If you’re a surgeon: would you rather stand uncomfortably over a patient for 2-3 hours, trying to manage laparoscopic instruments? Or would you rather sit comfortably at a console and feel like you’re playing a surgery video game? It isn’t about outcomes. Plus, robots are cool to patients.”

The robot represents an attempt to address the ergonomic crisis in surgery

Before I plunge into the limitations of the robot let me begin with a brief story. A number of years ago I sat in on a “Hot Topics” debate at the Academic Surgical Congress. The hot topic: Laparoscopy versus robot-assisted surgery.

Laparoscopy is hard on a surgeon’s body. But all surgery, in general, is hard on a surgeon’s body. So, yes, robot-assisted surgery is easier on the surgeon’s body.

Interestingly, the debate was rather one-sided. The majority of surgeons felt that the robot was of minimal value while the minority put up the typical arguments: “All technologies have to start somewhere. Remember the first mobile phones and how bulky they were and how much they cost?” and “The costs will go down as the technology improves and is more widely used.”

The robot was introduced in the year 2000. Unlike the cell phone, it has not evolved into a better, sleeker technology and it sure isn’t cheaper. Back then the robot cost one million dollars, not the 2.5 million it costs today. In addition to the initial cost of purchase, hospitals pay an annual six-figure maintenance fee to the manufacturer. So, after ten years the initial cost of the purchase has doubled.

And the technology has not accelerated at the rate of Moore’s law. It remains a bulky, cumbersome technology looking for an application.

I agreed with the majority consensus that the robot is of little utility, but I pointed out that we are not making better ergonomically designed patients, operating room tables, or surgeons. And until we come up with some better ergonomic solutions, surgeons will continue to accumulate back, neck, shoulder, elbow and hip injuries at alarming rates. It is estimated that more than 60% of surgeons are nursing a chronic skeletal injury by age 50.

Now, let’s look at the robot through the three comments above:

The first comment assumes that the robot will result in better outcomes. JAMA data demonstrate that this assumption is incorrect. If there were an advantage in improving precision or getting into small spaces it would show up in the data. I can’t speak for GYN surgery, but in colorectal surgery the major complication is the bowel leaking from where it is reconnected. And there is increasing evidence that a leak from where the bowel is reconnected has more to do with the bacteria in your intestine and the enzymes they secrete than it does with precision in dissection.

The second comment is spot on.

Robot-assisted surgery companies have sold the healthcare organizations on the sexy without any evidence of increased benefit proportional to cost.

The third comment nails the point about ergonomics, but the author is completely misguided or mistaken. Healthcare is entirely about outcomes. In the rapidly evolving environment of value-based medicine (outcome per cost) the robot loses.

There are other hidden costs as well

Room set up and room breakdown: This takes much longer for robotic cases. One minute of OR time at my institution costs about $106.

Reprocessing a robot: This takes at a minimum 4.5 hours of labor. Usually it is more like 7 to 9 hours. When you consider most good reprocessing techs can reprocess instruments from three cases in the span of one hour, they can turn over instruments for 13 other ORs in the same time it takes to reprocess one robotic case in one OR. This becomes a huge sink in terms of OR efficiency and operating costs.

Instrument amortization: Break a robot’s arm or an attachment, add $40K to your six-figure bill for the year. In contrast, a high-quality laparoscopic instrument will cost a fraction of this to replace.

And finally

To be sure we need ergonomic solutions for surgeons. Maybe we need to think and train more like athletes from the very beginning when we enter residency, maybe someone can invent a better OR table, or maybe we need an exoskeleton to help position and rest our bodies better during surgery. Whatever solution, it must achieve something the robot has completely failed to do: demonstrate value by improving results and reducing cost.

 

This article was originally published on medawaresystems.com.