Robot Wars

rockem robotsThe American Congress of Obstetricians & Gynecologists last week entered the ongoing discussion about the value of robotic surgery, releasing a statement by President James T. Breeden M.D., cautioning about the use of the robot for routine surgeries.

In a previous post, I have noted that the medical evidence does not show a clear benefit from the surgery, in which the surgeon uses a remote console to manipulate robotic arms inserted in the patient.  If it sounds like a video game, that’s exactly how some observers have described it.  The technology is expensive and has a significant learning curve, by some accounts requiring 100 surgeries or more to achieve proficiency.  Numerous complications, often attributed to operator inexperience, have been reported.

The statement from the leading professional organization of women’s health care physicians, noted that, although the robotic approach adds approximately $2000 to the cost of each surgery, “there is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.”  Breedon suggested that established hysterectomy procedures–by vaginal or laparoscopic approach–are safer and cheaper, except perhaps for complicated cancer surgeries.

The robots, which are a significant source of income and prestige for some hospitals and surgeons, quickly fired back.  A group of approximately 30 surgeons issued a rebuttal statement, claiming that the advent of robotic technology “has allowed us to extend a level of quality surgical care to our patients that is exceptionally more diverse and complete than was ever possible with traditional methods of surgery.”  The group was sharply critical of ACOG’s “failure… to embrace the education of Minimally Invasive Surgery.”

Not surprisingly, Intuitive Surgical, the manufacturer of the daVinci robot, wasn’t too pleased either.  The company issued its own statement, claiming that its machine “helps surgeons overcome the limitations of traditional MIS [minimally invasive surgery] techniques to provide patients with a less invasive option and prevent the downstream costs and complications of an open procedure.”  However, the company did acknowledge that the robot wasn’t suitable for all patients or all procedures.

Obviously, both sides have some talking points.  For one surgeon’s assessment of the pros and cons of robot surgery, see here.  What we know as lawyers is that there are a lot of patients out there who were attracted by promises of less pain and faster recovery, but who got exactly the opposite of what they bargained for.

Robotic Surgery… the Rest of the Story

davinci roboticWant to avoid a large surgical incision and scar?  Want to spend the least amount of time in the hospital?  Want the least possible blood loss?  Least amount of pain?  Less narcotic medicine?  Want to recover from surgery as fast as possible?

These are the questions posed by a patient brochure distributed by Intuit Surgical, the manufacturer of the daVinci robot.  The robot is being used to perform a number of different prostate, gynecologic, urologic, cardiac and abdominal surgeries.  The doctor controls the surgical instruments from a console near the operating table.  And for some patients and some doctors, the results are good.   But for other patients, the complications can be extremely severe.

We recently met with a client who had suffered a serious nerve injury after undergoing robotic surgery on his prostate.  During his operation, the machine broke down, the surgery went much longer than planned, and eventually had to be converted to a standard open procedure.  Probably as a result of remaining too long in the surgical position, the man suffered a disabling nerve injury, and cannot work.

There is a growing body of medical literature documenting a number of specific complications of robotic surgery.  These range from nerve injuries and vision loss to brain damage or even death.  Many of these arise from prolonged time on the operating table, which is often attributed to the inexperience of the operating surgeon.  Despite evidence that there is a steep learning curve, requiring as many as 200 surgeries to become proficient, doctors are rushing to sign up patients for the new techology.   In addition, patients with certain medical conditions may be at higher risk for complications with the minimally invasive approach.

Researchers at Johns Hopkins Hospital in Baltimore have expressed concern that hospital websites may be misleading patients by making unproven claims about the safety and effectiveness of the robotic procedure.  Often using content and images provided by the manufacturer, and even providing a direct link to Intuit’s website, hospitals tout the benefits of surgery, overestimating the advantages and largely ignoring the risks.

Hospitals of all sizes are seeking to gain a larger share of the lucrative market in this area.  But especially at smaller hospitals, the volume of procedures may not be sufficient for the surgeons, anesthesiologists and operating teams to develop the expertise needed to use the robot safely and efficiently.   Individual surgeons, feeling pressure to compete with their peers, may rush to perform robotic surgery before they have developed true proficiency.

Despite the obvious appeal of shorter hospital stays and less pain, patients considering robotic surgery should carefully question their surgeons about the actual benefits and the doctor’s own experience with the procedure.  Otherwise, these patients may be trading short-term benefits for devastating long-term consequences.

Read More: Anesthetic considerations for robotic prostatectomy: a review of the literature.

Read More: daVinci Surgery Patient Flyer