Tuesday, July 8, 2008

Robots in medicine

Sometimes I feel like an old man. Hey--no snickering back there. When I trained in my residency the laparoscope was just gaining general acceptance in gynecological surgery. Even in the 4 years that I was training, the indications for using the scope expanded dramatically, as we became more comfortable with its use, and in hand with technological advances in lenses and other equipment.

It was about 10 years or so ago that the laparoscopically assisted hysterectomy became widespread. The "advance" that it promised was shorter hospital stays, and less discomfort to the patient. It certainly has shortened hospital stays; most patients undergoing LAH go home within 24 hours. But, most traditional hysterectomy patients go home in 24-36 hours anyways (gone are the days of the 4-5 day post-operative hospital stays for the majority of surgeries). And, I think for the most part, scope patients have less post-op pain for shorter durations of time, and usually return to work sooner.

There is a cost, or course. Most of the equipment used in laparoscopic surgeries is disposable, and hence quite costly. And scope procedures take considerably longer to perform compared to the traditional, "open" procedures. So a lot of the cost advantages are offset by the increased operating costs and times. Most studies in general do show a slight advantage overall for laparoscopic surgeries compared to traditional methods, but the advantage for the most part is small.

Of course, MD's (including gyn surgeons) love technology, and the race has been ferocious in coming up with new laparoscopic devices and increasingly complex procedures to do with them. The latest "advance" in gyn surgery is the use of robots to assist the surgeon. With the da Vinci system, the surgeon sits at a console outside of the OR, viewing the operative field through a viewer attached to a remotely controlled set of "robotic" surgical instruments. This article summarizes the experience of 20 patients in Ohio who underwent a radical hysterectomy for early stage cervical cancers. A radical hysterectomy as the name implies involves a significantly more extensive dissection of the pelvic tissues, and in general takes a bit more operative time; where a regular, old-fashioned hysterectomy takes about 30-45 minutes to do, a radical hysterectomy done via the "open" method (with traditional abdominal incisions) takes anywhere from 2-3 hours.

In this study, the median operative time was 6.5 hours, more than double the usual operating time. The study authors congratulated themselves in getting that time down to 4.5 hours for the last 5 cases (although I suspect that the "learning curve" is a bit steeper than that). Still, I don't really see a great advantage here. The article specifically mentions two advantages. One is the system uses some sort of dual-lens scope which "provides vivid 3-dimensional images." You know, I've got a dual-lens system that I've been using for over 48 years; even with some corrective optical devices, I think my system works pretty darn good. The other advantage they mention is some sort of articulation at the tip of the microinstruments that "serve the same function of the human wrist." But that's not really an advantage, serving the "same function." The authors do grudgingly acknowledge that there are no studies showing that robotic surgery is superior to laparoscopic surgery. So what's the point? "We believe that the goal of robotic surgery is to perform the same procedure laparoscopically that would have been performed during laparotomy."

I remember at one laparoscopic conference I attended, a "learned" professor solemnly intoned, "Just because you can see something through the laparoscope, doesn't mean you have to operate on it through the laparoscope." Alas, I am afraid his advice goes unheeded.

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