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Oh, robot!

November 2, 2012

A large spider-like contraption hovers over the patient.  A bored-looking resident holds a camera steady inside the patients abdomen.  An even more bored scrub nurse stands by.  A mostly comatose anesthesiologist sits in a 1-square-foot area of space back in a corner.  The surgeon is…. where?… oh, over there playing video games.  Yes ladies and gentlemen, robotic surgery appears here to stay. From prostatectomies to hysterectomies to salpingo-ophorectomies, more and more abdominal surgery is being done this way.  Essentially what happens is just like laparoscopic surgery, where the surgery is done thru a couple of small incisions in your belly into which a camera and instruments are inserted to do the surgery.  Except in this case the “robotic” part is that the instruments are controlled remotely in an atari-like video console by the surgeon.  The robot does not actually do the surgery.  It’s like a remote controlled car.  The car isn’t doing the driving.

DaVinci, one of the major manufacturers of these robots, wants to convince you that this is the greatest thing since power steering.  I’m going to use prostatectomy (removal of the prostate) as an example since most of the robot work was originally in this procedure.  The DaVinci website makes a number of claims about the fabulousness of it’s system: “DaVinci surgeons achieve better cancer control, lower positive margin rates, faster return of erectile function, shorter hospital stay, less blood loss, lower complication rate, lower risk of wound infection, less pain and faster recovery”  among other wonders.  It even has a list of scholarly publications to prove it.  Of course, there are just as many publications that say the opposite.  A few examples:  a study at Vanderbilt found no difference in pain scores between open, laparoscopic, and robotic techiques.  Return of continence studies are similarly mixed.  Journals such as Reviews in Urology and Journal of Clinical Oncology have published studies that are equivocal at best on things like recovery of potency and general quality of life scores.  Some of it is just whooey, like lower blood loss and lower risk of wound infection.  In fact, with robotic surgery you have 5 or 6 little holes in your belly at the end, whereas with laparoscopic surgery you have 3.  More holes = more things to get infected.

There is also the cost.  A robot system costs 1.2 million dollars.  1.2 million.  Think of how much primary care we could do with that kind of money.  My institution has two such systems.  The annual maintenance cost is above $100,000.  The per case cost for instruments is $1,500.  The whole procedure costs at least $1000 more than other methods and takes twice as long.

Please do not be fooled.   Robotic surgery may some day be found to be better by some measures, but 1.2 million dollars better?

 

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