Robotic Surgery's Applications Expanding


SAN DIEGO — When precision matters, robotic surgery offers visual features that are “unparalleled by any other laparoscopic or open operation,” William E. Kelley Jr., M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

But cost and patient benefits need to be considered before adopting robotic surgery on a widespread basis in any surgical discipline, advised Dr. Kelley, a general surgeon who practices in Richmond, Va.

Dr. Kelley, who chairs the society's special interest group committee on robotic surgery, considers the term to be an unfortunate one. “Robotic surgery is not performed by robots, which are independently operated, pre-programmed machines … This is computer-enhanced minimally invasive surgery. It's truly three-dimensional, and it's under the surgeon's control.”

Computer-enhanced surgery has been used for the last 10-12 years in orthopedic surgery for drilling the femoral shaft with a precision that is “about 10 times” better than that achievable by a surgeon without computer assistance,” he said.

In addition, the devices are equipped with electronic filtering, “which means no matter how late the surgeon's been up, no matter how many cups of coffee the surgeon's had that day, and no matter how many operations [he's] done, there is zero tremor in the instrument,” Dr. Kelley said.

The devices also have motion scaling, “so the very forced movement of the surgeon's hand can become translated into a very fine motion at the incident tip,” he explained. “There's forearm support, and it's a 3-D magnifying field with six degrees of freedom: up-down, side-to-side, in and out, rotation, pitch, and yaw.”

Traditional surgery cannot achieve the flexibility of the instrumentation. “The movements are simultaneous and fluid. It's direct and intuitive. It also conveys true ambidexterity to almost any surgeon within minutes of sitting down at the instrument,” he said.

In gynecology, most applications have been limited to infertility surgery for tuboplasty and tubal reanastomosis, although some centers use robots for laparoscopically assisted vaginal hysterectomy.

“Gynecologic experience has been relatively varied,” he said. “We're at the safety and efficacy stage. Operating time, costs of start-up, and learning curves are higher with robotics, but those [factors] are expected to decrease with time.”

In general surgery, robotic systems have enhanced laparoscopic Heller myotomy, esophagectomy, pancreatectomy, pyloroplasty when performed at the time of antireflux surgery, and fashioning the posterior suture lines of Toupet fundoplication. Dr. Kelley likened the technology's use in general surgery to “where we were in 1990 with laparoscopic surgery.”

In vascular surgery, experience is growing with robot-assisted laparoscopic aortofemoral bypass and laparoscopic aortic aneurysmectomy. Dr. Kelley described one 54-year-old with a failed iliac stent that he treated with robot-assisted aortofemoral bypass. The patient stayed in the hospital for 2.5 days and was golfing at 2 weeks.

Cardiothoracic applications are “the most spectacular examples” of robotic surgery, with uses for mitral valve replacement and coronary artery bypass graft (CABG).

Robotic surgery is associated with shortened hospital stays and rapid resumption of normal activities. Consider sternotomy and minimally invasive surgery: Would you rather wait a month before being able to drive a car or have no postoperative driving restrictions?

The medical literature documents a clear length of stay advantage in vascular procedures, prostatectomy, and cardiac procedures, he said.

From the hospital's perspective, the first hospital in a community to offer robotic surgery can garner “huge media exposure,” but the associated costs can be hard to recoup.

The reduced need for operating personnel in certain cases and the shorter hospital stays will cover some costs, but “that's not going to make a $1.3 million instrument cheaper,” he acknowledged.

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