ChesterCountyMedicine Spring 2018 - 13

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Robotic-assisted surgery revolutionized prostatectomy for
the urologist. Laparoscopic prostatectomy was being pioneered
in the late 1990s, but it wasn't until the addition of roboticassistance that urologists could safely and efficiently perform a
prostatectomy using a minimally invasive approach. Gynecology
also saw its surgeons embracing robotic-assisted surgery for
oophorectomy and hysterectomy operations. However, it is
the cost associated with these operations that gives critics of
robotic-assisted surgery the greatest concern over its adoption
in everyday practice. In 2013, Dr. James Breeden, President
of the American Congress of Obstetricians and Gynecologists,
presented a position statement on the use of robotic-assisted
surgery for the specialty:
"The outcome of any surgery is directly associated with
the surgeon's skill. Highly skilled surgeons attain expertise
through years of training and experience. Studies show there
is a learning curve with new surgical technologies, during
which there is an increased complication rate. Expertise with
robotic hysterectomy is limited and varies widely among both
hospitals and surgeons. While there may be some advantages
to the use of robotics in complex hysterectomies, especially for
cancer operations that require extensive surgery and removal
of lymph nodes, studies have shown that adding this expensive
technology for routine surgical care does not improve patient
outcomes. Consequently, there is no good data providing
that robotic hysterectomy is even as good as-let alone
better-than existing, and far less costly, minimally invasive
alternatives."
General surgery is no stranger to the controversies
experienced by urology and gynecology. Any operation that
can be performed laparoscopically can be performed with the
aid of the robot. I would argue that in the right hands, those
operations can be performed more safely and, in the future,
more efficiently. For me, the benefits of robotic-assisted surgery
are clearly the improved dexterity of the instruments, the seven
degrees of freedom, the 3-D imaging, and the complete control
of the operative field.

Before and after views of an incisional hernia repair.

there are cases that I know I would have had to convert to an open
procedure if I was performing it laparoscopically, but because
of the instrumentation and 3-D imaging with a robotic-assisted
approach, I didn't have to.
A case series by Dr. Scott Kelley and his colleagues from
the Division of Colon and Rectal Surgery at the Mayo Clinic
in Rochester, Minnesota demonstrated increased operative
times for their patients undergoing right colon resections for
cancer (over four hours in their first 21 consecutive patients),
and many of the outcomes (complications, length of stay, GI
recovery, and pathology results) were comparable to laparoscopic
outcomes. They were most interested in assessing the ability to
perform a complete mesocolic excision (CME), i.e., lymph node
dissection-a very difficult step of a right colon resection when
continued on next page >

Gallbladder with and without the use of fluorescence imaging
to demonstrate the cystic duct to common bile duct junction.

"One small step for man..."
Randomized controlled studies comparing robotic-assisted
surgery to laparoscopic surgery often demonstrate similar end
points and results, but the investigators often point to the cost/
benefit aspects of robotic-assisted surgery. Similarly, in early
studies comparing laparoscopic surgery to open operations, an
operation performed laparoscopically was always more expensive
than an open procedure, but one of its clear advantages was
the decreased length of stay and savings in the post-op period.
When comparisons are made between robotic-assisted and
laparoscopic surgery the clinical outcomes are often similar, but
the procedure costs still concern critics.
As more robotic-assisted surgery is performed, surgeons
become more proficient and more challenging cases are
completed with a minimally invasive approach. Personally,

SPRING 2018 | CHESTER COUNT Y Medicine 13


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