Robotic assisted surgery has seen an explosion since it was first introduced about 20 years ago with over 4 million procedures performed. Although minimally invasive laparoscopic surgery has been around longer, certain limitations existed within this field. Laparoscopic surgical instruments lack wristed movement, essentially forcing surgeons to operate with chop sticks. The effect was difficulty performing certain procedures and working at difficult angles. Robotic surgery allows wristed action of the instruments, better optics (depth perception), surgeon control of the camera, and better ergonomics. While there is not any significant change in long term outcomes, there are studies suggesting decreased pain and shorter hospital stays.
As a resident, I was not trained in robotic general surgery even though the OB/GYN and Urology residents used it routinely. I began to see the potential uses early in my career and began my training and early adoption of the techniques. Over the last 4 years, I have performed over 450 robotic surgeries ranging from hernias, colon resection, splenectomy, adrenalectomy, and stomach. I still use traditional laparoscopic technique at some of the hospitals where I practice because no robotics is available. While robotics is a great platform, it is not perfect.
Rural hospitals and outpatient surgical centers have not gone the route of acquiring robotic platforms. The console and robot cost well over 1 million dollars and yearly maintenance contracts can cost hundreds of thousands of dollars. In a time of limited healthcare dollars, hospitals don’t always have the resources available for a robotics program. There is no increased compensation for performing a procedure robotically. However, most larger hospitals and all major hospitals have adopted robotic surgical platforms for their surgical departments.
Patient selection is always a critical component in determining which surgical platform to use to perform a surgery. Patients with higher BMI’s tend to be great candidates for robotic surgery. This surgical population can make laparoscopic surgery more complex due to poor equipment maneuvering and surgeon discomfort. Robotics helps overcome this with the wristed action of the instruments and surgeon comfort at the console. However, low BMI patients are not always great candidates for robotic surgery because of the need to space out the instruments appropriately and avoid arm collision. Also, patients undergoing surgery may require additional tools to be used in their surgery. Robotics allows the use ICG dye to help identify critical bile duct structures during difficult gallbladder surgeries. Also, the ICG dye can be used to assess blood flow while performing colon resections and anastomosis. While most surgeries due not require these advanced tools, they can prove pivotal in difficult operations.
Technology has allowed vast advancement in surgical options for surgeons and their patients. Which platform to use depends on surgeon training and preference as well as patient’s choice. Experience and comfort with robotics is necessary to achieve optimal outcomes. The quick adoption of robotics into general surgery has been much faster than laparoscopic. At its peak, laparoscopic inguinal hernia repair was only being used about 33% of the time compared with open surgery. Where technology takes us next and what the next generation of surgery will look like is anybody’s guess. However, I am sure it will be exciting to see what comes next.
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