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Robotic Surgery: the “Laser” of the 21st Century?

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Article from Generalsurgerynews.com December 3, 2012

An OR nurse with 40 years of experience told me that she thinks robotic surgery might go the way of the laser.

Like many good observations, it is simple and I wonder why I didn’t think of it myself. The fact that I didn’t think of it won’t stop me from running with it though.

Laparoscopic surgery was introduced in the United States in 1989. Before then, gynecologists had used laparoscopes to peek into the abdomen for diagnostic purposes and tie some tubes, but removal of organs had not been done much. General surgeons didn’t use laparoscopy at all.

Some intrepid surgeons in Europe started performing laparoscopic cholecystectomies and the technique rapidly spread to the US. The rest is history.

But there is a forgotten chapter of the story. In 1990, surgeons in the US were scrambling to take courses in laparoscopic cholecystectomy. It was hard to find a course that had openings. Many were sponsored by a company that made a YAG laser and the operation was originally called “laparoscopic laser cholecystectomy.”

Most surgeons abandoned the laser fairly quickly because it did not stop bleeding as well as old-fashioned cautery. Its use made the surgery take longer and result in an occasional unusual complication. The latter occurred because, unlike electrocautery which generally only burns the tissue that it touches, the laser beam kept going until it reached some tissue to burn. That something could have been the duodenum, liver or the diaphragm.

Now we have robotic surgery. So far for cholecystectomy at least, single-incision robotic cholecystectomy takes longer, is more difficult to do and may or may not be more painful than the standard 4-port laparoscopic procedure. Although touted as producing a better cosmetic result, proof that the larger umbilical incision is cosmetically better than the extra 5 mm incisions, which are usually not a concern for the average patient, is lacking. Postoperative hernia at the umbilical incision is also more common with robotic single-incision surgery.

Similar to the unusual complications seen with the laser, when robotic surgery goes bad, it really goes bad. So far, robotic cholecystectomy complications are not being reported in the literature but one hears rumors. Certainly, some unusual things have happened with robotic surgery of other organs.

There is a lawsuit based on malfunction of the robot which resulted in what the plaintiff is saying was an unnecessary conversion to open surgery.

A patient’s family successfully sued a surgeon for causing a duodenal injury during a robotic splenectomy. The patient died. It is unclear how that could have happened since the two organs are not really very closed to each other.

A woman in New Hampshire had both ureters severed during a robotic hysterectomy.

Another suit claims that the robot arms are poorly insulated which caused injuries to the intestine and an artery leading to the death of a 24-year-old woman after a hysterectomy.

The frenzy to buy robots continues but some warning signs are in the wind. I hear that a gynecology society is about to publish a position statement which will say that the use of the robot adds time and expense to procedures without impacting outcomes at all.

A big difference between the laser and the robot is cost. If I recall correctly the laser was about $100K while the robot goes for $1.5-2M plus a yearly maintenance contract of $150K plus disposables of up to $2K for every case.

Time will tell if, like the laser, the robot will end up sitting in a corner as an expensive place to hang lead aprons.

References:

Robot malfunction

Splenectomy case

Bilateral ureter injuries

Burns to intestine and artery

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 325,000 page views, and he has over 4000 followers on Twitter.

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