ChesterCountyMedicine Spring 2018 - 11

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ROBOTIC-ASSISTED
GENERAL SURGERY
BY STEVEN G. FUKUCHI, MD

Infrared fluorescence imaging with the aid of indocyanine green (ICG).
(Firefly is actually a trademarked name.)

Prelude
"Patients don't care about the size of their incisions."
"I can do the operation faster and cheaper."
"Why are you making an easy surgery difficult?"
"That operation is a gimmick and won't last."
Back to the future
In the late 1980s, the above statements were probably heard
throughout hospitals and operating rooms in Pennsylvania and
around the United States with regards to laparoscopic versus
open cholecystectomy. Medical historians credit Dr. Mouret of
Lyons, France, with the first laparoscopic cholecystectomy. The
surgical technique was adopted by surgeons in Paris and, in a
relatively short period of time, was soon being practiced by general
surgeons across the US. In addition to some of the technical
concerns about adopting this new technique, some argued that
laparoscopic cholecystectomy could not be implemented by
surgeons because they didn't have time to train, that it was too
difficult, or that it was too time-consuming. Surgeons and surgical
societies recommended registries and studies to compare open
and laparoscopic techniques. But early on, surgeons observed
shorter hospital lengths of stay, faster recovery, and cosmetic
benefits of laparoscopic cholecystectomy. At the Chester County
Hospital, Dr. George Trajtenberg performed the first laparoscopic
cholecystectomy, only after the hospital created a committee to

investigate the merits of the new technology. Dr. Trajtenberg
believed in laparoscopic surgery so strongly, he bought the
equipment with his own funds to bring laparoscopy to the Chester
County community. And while reviews and meta-analyses of the
two forms of cholecystectomy were ongoing, it wasn't long before
the laparoscopic approach soon became the standard of care.
Robotic-assisted surgery finds itself in the same historical
context as laparoscopy for the modern-day general surgeon.
No patient, and let me repeat this to be completely clear-no
patient-goes to the surgeon with symptomatic gallstones or
biliary tract disease expecting to have an open cholecystectomy
in 2018. This has been true for nearly 30 years. There are
patients, of course, who simply are not candidates for laparoscopic
cholecystectomy, or for whom the surgery may be started in a
minimally invasive fashion but must be converted to an open
procedure. The decision for the best and safest technique is left
to the discretion and expertise of the surgeon based on each
individual situation.
Today, you are likely to find surgeons in two robotic-assisted
surgery camps: believers and skeptics. For the skeptic, I refer you
to the four quotes at the beginning of this article. "Laparoscopic"
and "open" are replaced by "robotic-assisted" and "laparoscopic."
The irony is that many of the surgeons who were pioneers in
laparoscopic surgery-convincing traditional open surgeons of the
benefits of the new technique-are now on the other side of the
coin, weighing in that robotic-assisted surgery does not offer any
benefit over traditional laparoscopic surgery.
Continued on next page >

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