by Renee Euchner
As a freelance writer, I came to Minimally Invasive Surgery Week (Reston, VA, August 28–31) with an agenda. My basic goal was to interview at least 25 surgeons and get their take on where robotics was heading.
I needed to confirm that robotics was stabilizing in the urology arena; check with gynecologists about any jitters over past negative publicity; probe general surgeons about the latest issues with robotic cholecystectomies (Was single-site laparoscopic surgery more effective? What about resultant hernias?); find out where general surgery was heading next; try to corner thoracic and cardiovascular surgeons to see how robotics was working on their end of the body; query pediatricians about future robotic possibilities; explore concerns about and adjustments to current robotic training programs; and determine if robotics did indeed reduce hospital stays. I was interested in any new techniques, adaptations, thoughts. (For clarity, in this article laparoscopic refers to both lap and endoscopic procedures, and robotic refers to surgery with the daVinci. It is understood that robotic surgeons also do lap surgery.
Returning home, I was asked about my “take-aways.” My head was spinning. I had talked with 32 surgeons, and if time allowed, I would have talked to more. All of you were very gracious with your time, and I promised you anonymity, which I will continue to honor in this short article.
I reported to my coworkers that robotics was considered by some as a staple for prostatectomies, and the growth rate in that discipline seemed to have stabilized. Gynecologists were busy catering to women who did not want scars showing outside of their bikini lines. Concerns about negative publicity? They were already moving on to single-incision lap and robotic hysterectomies.
General surgeons had mixed thoughts on robotic cholecystectomies, but their patients were also scar conscious. A single-site lap surgery took less than an hour, and the patient went home the same day. How could you improve on that? On the other hand, robotics would be ergonomically better for the surgeon whose patient had a high body mass index (BMI). Resultant hernias? Maybe, but the jury was still out. General surgeons reported positive robotic experiences for colorectal and other deep pelvic surgeries, especially using Novadaq’s Firefly fluorescence, an imaging system approved in 2011 for use with the daVinci.
To my regret, the cardiac surgeon reports were mixed. Hands down, I would take a few scars between my ribs over a cracked sternum any day, and I know I’m not alone in this. However, patients aren’t recovering as quickly as expected following robotic mitral valve replacement. The possible glitch—the patient still requires a cardiac bypass pump, thereby complicating recovery. To add to the disappointment, I was told that nearly 500 U.S. cardiac surgeons were trained on robotics in the past few years, but currently only 20 cardiac surgeons continue to use the robotic device. Inadequate training, mixed patient results, and the varied nature of heart problems were cited as barriers. On the positive side, thoracic surgeons were quite pleased with robotic results for lung surgery, especially for lung cancer. The combination of Firefly fluorescence and daVinci’s magnification allowed surgeons to more successful remove affected lymph nodes, possibly leading to higher recovery rates.
Understandably, pediatricians currently have limited use for the large robotic instruments, and they are patiently awaiting Intuitive Surgical’s smaller torques.
Lastly, enhanced robotic training is being taken seriously by Intuitive, resident programs across the country, and almost everyone with whom I talked. Intuitive is working with at least one surgical group to start a new intense robotic fellowship for hepatopancreaticobiliary (PBH) surgery, and fellowships in other disciplines are opening up. More than 93% of all surgery residents reported having some type of robotic experience, and several talked about the robotic training steps required to move “to the next level.” Several sessions were devoted to improving clinician robotic training, and the rooms were not empty.
Robotics has truly evolved in its short six-year existence. But what stood out for me at this conference, more than any other conference in the past, was the overall acceptance of robotics as an extension of laparoscopic surgery rather than as its replacement. Robotics is no longer a threat to lap surgeons, as it was in 2007, when rumors abound that lap surgeons had to get on the bandwagon or give up surgery. Or in 2009, when very proficient lap surgeons were hesitantly sticking their head in a console and slowly, so slowly, trying to build new skills to keep up with the next generation. Or even as late as spring 2013, when lap surgeons were defensively pointing at negative robotic media reports and when one robotic surgeon—with a straight face—expressed concern that robotics was being designed to eliminate expensive surgeons. (That surgeon didn’t go so far as to say it was a government conspiracy, but there were implications.)
Fast forward five months later—MIS Week, August 2013—and everyone has settled down a bit. Lap and robotic surgeons acknowledge that there will always be a need for open surgery; it is not a lost art. They are now sitting side-by-side, discussing the same surgery, listening to each other’s experiences, and reviewing pros and cons of robotic and lap surgery with an open mind and an open heart. Their agendas definitely mesh: They want the most efficacious and cost-effective surgery for their patients.
Further experience and additional data are needed to determine the best surgery for various procedures. This does not mean a daVinci in every operating room. But it may mean, when applicable, referring a patient to a robotic center with robotic-dedicated surgeons. This does not mean that hospitals should continue receiving only laparoscopic reimbursement for a more costly robotic procedure. But it may mean updating the diagnostic related group (DRG) coding so that hospitals receive appropriate reimbursement for necessary robotic procedures. And this does not mean that insurance companies need to pick up the tab for an expensive scar-minimizing procedure. But it may mean that patients acknowledge responsibility for some of their choices. Let’s keep the dialogue moving forward.
Renee Euchner is a freelance medical writer living in Northern California. She may be contacted at email@example.com.