The case for robotic-assisted hysterectomy
In this era of cost containment, it is imperative that surgical innovation thrive. Where would all specialties involved in minimally invasive surgery be if surgical pioneer and visionary Professor Kurt Semm were not allowed to perform early operative laparoscopic cases in Kiel, Germany? As chronicled by his associate, Professor Lisolette Mettler, in the July-September 2003 NewsScope of the AAGL, "Kurt endured much resistance, including a request for him to undergo a brain scan to rule out brain damage when attempting to introduce operative laparoscopy; the laughter of general surgeons when he recommended laparoscopic cholecystectomy in the late 1970s; a call for suspension by the president of the German Surgical Society after a 1981 lecture on laparoscopic appendectomy; and rejection of a paper on laparoscopic appendectomy to the American Journal of Obstetrics & Gynecology as unethical." Where would the cholecystectomy market be if general surgeons headed the randomized controlled trial of open vs. laparoscopic cholecystectomy published in Lancet in 1996 (Lancet 1996;347:989-94)? The study concluded that the open procedure was superior because there was no difference in hospital stay or recovery, compared with the laparoscopic route. Where would minimally invasive gynecologic surgery be if our specialty fell in line behind Dr. Roy Pitkin, then president of ACOG, who in 1992 entitled an editorial in Obstetrics & Gynecology "Operative Laparoscopy: Surgical Advance or Technical Gimmick?" (Obstet. Gynecol. 1992;79:441-2). In this editorial he questioned operative laparoscopy on the following:
• How does one separate technical feasibility from therapeutic appropriateness?
• What is the nature of "quality assurance"?
• How can appropriate credentialing criteria be established for procedures not taught in residency and for which no present member of the medical staff can claim experience?
• To what extent are these procedures "experimental," requiring review by an institutional body charged with protection of human subjects, and how should truly informed consent be obtained?
• What about fees? When the procedure is not part of established clinical care, is it ethical to charge for professional services?
Dr. Pitkin concluded by commenting, "Our approach to evaluation of these newer surgical techniques is not something of which we can be proud." Many of these same concerns are currently being voiced by those who do not see the brilliant potential of robotics in gynecologic surgery.
Eighteen years later, in a subsequent editorial (Obstet. Gynecol. 2010;115:890-1), Dr. Pitkin acknowledged that "A substantial body of evidence has accumulated in the recent years to support the laparoscopic approach to various gynecologic operations. ... From this extensive literature, it is now clear that many, if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches."
Dr. Pitkin and his coauthor, Dr. William Parker, then go on to discuss the issue of cost, "All health care financial studies are complicated by inconsistencies and uncertainties regarding the meaning of cost. ... Increase in operating time with laparoscopic surgery and disposable instruments are offset, by decreased charges reflecting shortened postoperative hospital stays. If a societal cost that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater."
Just as it is imperative that our surgical specialty must remain innovative, we must remember, as can be learned with Dr. Pitkin’s two editorials, that scientific evidence behind the innovation takes time. The fact that, in its infancy, robotic assisted surgery has enabled more gynecologic surgeons to perform minimally invasive surgery for more patients cannot be denied. As seen by the JAMA article, even early on, it can be performed safely and effectively. Data collected in the final decade of the 20th century and the first decade of the 21st have enabled operative laparoscopy to enter mainstream surgical care. One can foresee, with the accumulation of knowledge and experience, that robotics will have a similar – if not even greater – role within our specialty. We must learn from William Shakespeare, who provided Marc Anthony the words, "I have come to bury Caesar, not to praise him." We must not come here to bury robotic assisted surgery, but to praise it!
Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy, and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill; and the medical editor of this column. Dr. Miller has received grants from Intuitive Surgical Inc. He also has served as a consultant for and served on the speakers bureau for Intuitive.
