Robotic vascular surgery: Ready for prime time?

Key clinical point: Robotic-assisted vascular surgery procedures appeared safe and provided benefits in speed and simplicity for vascular anastomoses.

Major finding: A total of 298 (96.1%) cases were successfully completed robotically, with a 30-day mortality of 0.3% and two (0.6%) late prosthetic infections seen.

Data source: A prospective study was performed assessing 310 robotic-assisted vascular procedures.

Disclosures: The authors reported that they had no disclosures.

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Not ready for prime time

When we examine the data presented by the authors of this paper closely, we see vast differences between the group I patients (bypasses for aortoiliac occlusive disease) and the group II patients (repair of aortoiliac aneurysms). In the occlusive group (group I), the operative time averaged 194 minutes. However, in the aneurysm group, the surgical repair of an aneurysm took over 4 hours. Another broad discrepancy between groups I and II is evident in examining cross-clamp time. In the occlusive group, the cross-clamp was 37 minutes; however, aneurysm patients required 93 minutes of cross-clamp to complete the proximal anastomosis. Similar disparities are seen in mean blood loss. Patients with occlusive disease lost an average of 320 mL of blood, while aneurysm patients lost 1,210 mL

Dr. Mark A. Adelman

The authors have been clever in combining these two groups as a single cohort.

However, I might argue that by segregating the groups, we might find that occlusive disease is well treated with robotically assisted surgery, but aneurysm repair should be left to open or endovascular techniques.

In addition to the data disparities, there are several practical limitations to performing robotic aortic surgery. Learning robotic techniques requires significant additional surgical training that is typically not within the skill set of a vascular surgeon. Who will devote the time and resources toward training vascular surgeons? Presently, there are increased hardware and operating room times associated with robotic-assisted surgeries. Because of the bulkiness of the robotic system and need for space for mechanical arms, large operating rooms must be utilized to perform robotic procedures.

Although I have not performed robotic surgery, I understand the tactile feedback, or haptics are significantly reduced when operating with the robot. Lastly, during this era of value-based medicine, is robotic surgery too expensive? The current cost of a robot approaches $2 million, and robotic arms have a limited life expectancy.

In summary, the authors have not demonstrated that this procedure is safe in aneurysm patients, or generalizable across all vascular surgeons given the lack of training paradigm. Further, robotic procedures are probably not cost effective in this very cost-sensitive health care environment. When I was training under Dr. Frank Cole Spencer in general surgery, he was fond of saying “just because you can teach a dog to ride a bicycle, it does not mean that you should.” As Dr. Juan Parodi will remind us, if the technology becomes more affordable, and changes significantly, we must all remain open minded. But currently, this technology is not yet ready for prime time. In its current state, this dog will not be learning to ride this robotic bike.

Dr. Mark A. Adelman is the Frank J. Veith, MD Professor, chief of vascular and endovascular surgery, and vice chair for strategy and business development, department of surgery, NYU Langone Medical Center, New York.




A single-center experience using the da Vinci robotic system to perform vascular procedures demonstrated the safety and feasibility of this technique in different areas of vascular surgery.

Dr. Petr Štádler and his colleagues at the No Homolce Hospital in Prague reported on 310 robotic-assisted vascular procedures performed between November 2005 and May 2014 with the aid of the da Vinci system. They concluded that robotic-assisted vascular procedures added to the speed and relative simplicity of construction of vascular anastomoses.

The patient cohort had procedures consisting of 224 robotic occlusive disease treatments (group 1), 65 robotic aorto-illiac aneurysm surgeries (group II), and 21 other robotic procedures (group III) as reported online in the European Journal of Vascular and Endovascular Surgery (2016. doi: 10.1016/j.ejvs.2016.02.016).

A total of 298 cases (96.1%) were successfully completed robotically, with conversion required in 10 cases; 2 patients were inoperable. The overall 30-day mortality rate was 0.3% for the entire cohort, and only two (0.6%) late prosthetic infections were seen. The median operating time was 204 min, the median anastomosis time was 29 min, and median blood loss was 571 mL.

In comparing groups I and II, group I required an operative time of 194 min, compared with 253 min in group II. Mean aortic cross-clamp time was 37 min in group I and 93 min in group II, while the mean blood loss was greater in group II (1,210 mL) as compared with group 1 (320 mL).

“The robotic system provides a real opportunity for minimally invasive surgery in the field of vascular surgery ... with all its advantages. Robotic AAA [abdominal aortic aneurysm] and aortofemoral bypass represent the standard operations in vascular surgery and they are not only possible, but safe and effective,” said Dr. Štádler and his colleagues. They added, however, that “further randomized studies are needed to ensure its benefits and the cost-effectiveness of robotic vascular surgery, compared with open and laparoscopic repair.”

Dr, Štádler and his colleagues reported that they had no disclosures.

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