Robotic Surgery: Buyer Beware?

Robotic surgery is the hot new trend at many hospitals.  Heavily marketed, robotic surgeries promise to decrease bleeding risk, shorten length of hospital stay and decrease pain compared to more traditional laparoscopic surgical procedures.  But do these new operating systems perform as promised?  How should nurse practitioners advise their patients considering robotic surgical procedures?

As a nurse practitioner, you won't be the one sitting behind the controls of a $1.4 million robot performing surgery with remote-controlled arms meanwhile sitting on the opposite side of the room of your patient.  This new hands-off surgical technique is becoming increasingly popular among surgeons and hospitals.  It promises improved outcomes and decreased pain compare to more traditional laparoscopic surgeries.  Robotic surgeries are expensive so hospitals who have invested in these surgical devices heavily market robotic surgeries hoping to maximize use of their pricey equipment.  This year, the FDA has called into question the safety and efficacy of robotic surgery.  There are a few things nurse practitioners need to know about the safety and efficacy of these novel robotic procedures.

Does Robotic Surgery Improve Outcomes?

Last month, the Journal of the American Medical Association compared the outcomes of over 264,000 women who had received either a laparoscopic or robotic hysterectomy between 2007 and 2010.  Despite the lofty claims of robotic surgery device manufacturer's, researchers found very little difference in overall outcomes between the two groups of women.  The two groups showed no difference in the rate of blood transfusion although robotic surgery reportedly causes less bleeding than laparoscopic methods.  Robotic surgery slightly decreased hospital stay for some women; 80 percent of robotic surgery patients left the hospital less than 2 days after the procedure compared with 75 percent of women undergoing laparoscopic surgeries.  Overall, minimal difference in outcome was demonstrated among patients receiving costly robotic surgeries.

Is Robotic Surgery Safer than Laparoscopic Surgery?

Maybe robotic surgery doesn't confer significantly improved outcomes compared to laparoscopic techniques, but is it inherently safer?  The FDA has recently received an increase in the number of reported complications as a result of robotic procedures.  It is still unclear if this is related to the higher number of patients undergoing robotic surgeries, surgeon incompetence or a reflection of problems with robotic systems themselves.  Reports of damage to other internal organs such as the bladder and bowel during robotic surgery as well as claims that pieces of the robotic instrument have fallen off into patients have been filed.  The FDA states the number of reports filed is small compared to the number of robotic procedures preformed, yet enough reports have been filed to spark a formal investigation.  Results of this investigation are pending.

As with many new medical developments, standards regulating training of surgeons operating robotic devices have not been created.  No one knows just how many procedures surgeons must perform before they become proficient at operating these complex devices.  Surgeons who have experience with the device say it takes anywhere from 50 to 200 surgeries before becoming proficient performing robotic surgeries.

Urologist Vipul Patel who reports he has operated on more than 4,000 patients via robot, more than anyone else in the world, says:

"I don't think there's an exact number of cases needed to become an expert.  It's probably around 50 or 100 cases to have a basic proficiency, but that has nothing to do with outcomes.  If you have low expectations, that number is probably sufficient.  If you have higher expectations, you're going to want a surgeon who has done more."

Surgical associations are reluctant to enact regulations surrounding standards for training and education in robotic surgeries.  For now, hospitals determine which of their physicians are qualified to perform these complex procedures.

Should You Recommend Robotic Surgery to Your Patients?

Urologist Dr. Vipul Patel's quote, "If you have low expectations, that number [50 to 100 surgeries] is probably sufficient" left a bad taste in my mouth towards robotic surgery.  Who enters a consultation with a surgeon with low expectations, or even seeking adequacy?  No, I demand excellence in anyone operating on myself, my family or my patients.  Advise caution among your patients considering robotic surgery.  It is imperative they know the exact number of robotic procedures their surgeon has preformed.  Unless this number is well into the hundred's, I would seriously reconsider undergoing a robotic surgical procedure.  Given the lack of standardized training for surgeons performing robotic surgeries, patients may be putting themselves at risk in the hands of an inexperienced, or less experienced surgeon.

For the average $2,189 in extra cost per operation the patient incurs with robotic surgery it seems all they get is higher risk compared to more traditional methods with little to no benefit.  Until safety and training regulations are standardized for robotic surgery and the cost of these technical procedures decreases or it offers improved outcomes, I will stick with advising the more traditional laparoscopic surgery route. 


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Quick Update: March 15, 2013 the American College of Obstetrics and Gynecology released a statement recommending against robotic surgery as the method for hysterectomy. 

Erin Tolbert