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Almost every anesthesiologist in America has experience with surgery using the da Vinci robot system. Is robot surgery a miraculous futuristic device that advances surgery to a higher plain? Or is it an expensive gadget for hospitals and surgeons to market and attract potential patients?
To answer these questions let’s first review some history. Until the 1990s most abdominal surgery was done through an open incision. To remove a gall bladder or an appendix, the surgeon made an incision into the abdomen, inserted his hands and instruments, cut out the tissue under direct vision, and then sewed the abdomen together again. A gall bladder incision might be five inches long. An appendix incision might be 2½ inches long. The surgical times were short—a private practice surgeon could complete an open gall bladder surgery in 30 – 40 minutes, or an open appendectomy in 20 – 25 minutes. A disadvantage was that the patient had pain from the incision, and the recovery time was days to weeks before the patient could return to normal activities.
Enter laparoscopy, a true major advance in surgery. The first video laparoscopic gall bladder resection (cholecystectomy) was performed in 1987. A quantum advance occurred in the 1990s when video laparoscopic surgery became widespread. Laparoscopy required only small incisions in the abdomen, through which slender instruments were inserted. The interior of the abdomen was insufflated (blown up like a balloon) and one of the slender instruments held a camera. The image of the inside of the abdomen was visualized on a video screen while the surgeon manipulated instruments seen on that two-dimensional view. My colleague and Stanford clinical faculty member Camran Nezhat, the author of multiple textbooks on the topic, was a leading pioneer in the development of video laparoscopy. Laparoscopic surgery took longer than open surgery—a laparoscopic gall bladder or laparoscopic appendectomy usually lasted about twice as long as an open surgery—but the significant advantage was the lack of a painful open incision, which led to significantly less postoperative pain and a shorter postoperative recovery time. Many patients could be discharged the same day as their surgery, and most returned to normal activities sooner than if they had open surgery. Video laparoscopy surgical equipment and the longer operating times were increased expenses, but the advantages of outpatient surgery and quicker recovery made the new technique the standard of care for many surgeries within the abdomen.
Anesthesia for laparoscopy was similar to the anesthetic for open abdominal surgery. Patients were asleep and paralyzed, and their breathing is done by a ventilator. The laparoscopy patient had a tense abdomen—it was essentially a balloon full of carbon dioxide—that usually required smaller volume breaths from the ventilator, but in most ways the two anesthetics were alike.
Using the da Vinci robot for abdominal surgery is an extension of laparoscopic techniques, but the instruments are connected to robot arms rather than held by surgeons. The da Vinci surgeon sits at a console in the corner of the operating room, with his back to the patient and his face in a 3-D viewer, which gives a high-definition, magnified view of the surgical site. Assistant surgeon(s) and techs stand at the patient’s side, watch the surgery on video screens, and assist during the operation. The surgeon manipulates handles on the da Vinci device, which move the instruments within the patient’s body. The three-dimensional view within the abdomen is superior to a two-dimensional view on a video screen. I’ve personally had the opportunity to look through the 3-D viewer into the abdomen, and it’s a remarkable phenomenon. It’s as if you were a microscopic insect inside the patient, and looking around at the intestines, liver, arteries and veins that surround you. Another touted advantage of the robot is the ability for the surgeon to make precise movements via the robot’s mechanism.
The non-profit SRI (Stanford Research Institute) developed the early da Vinci system in the late 1980s with funding from the National Institutes of Health. The system was thought to have promise in allowing surgeons to operate remotely on surgeons wounded on battlefields. (When you read on you’ll realize how improbable this application would be.)
In the 1990s, John Freund negotiated an option to acquire SRI’s intellectual property, and started a company named Intuitive Surgical Devices, Inc. The company’s prototype was ready for clinical testing in 1997. In 2000 the Federal Drug Administration (FDA) approved use of the da Vinci Surgical System for laparoscopic surgery, and Intuitive raised $46 million in an initial public offering. One year later the FDA approved use of the system for prostate surgery. In subsequent years the FDA approved the system for thoracoscopic surgery, cardiac procedures, and gynecologic procedures.
The da Vinci Surgical System spread slowly at first. Sixty hospitals in the United States used the system in 2002, but this number grew to 431 hospitals by 2014. Approximately 1,500 United States hospitals now have the da Vinci Surgical System, according to Modern Healthcare. The system costs approximately $2 million, and there are costs for maintenance and for the non-reusable instruments held by the arms during surgery. A robotic surgery generally costs anywhere from $3,000 to $6,000 more than traditional laparoscopic surgery. In 2016 Healthline wrote, “To justify its price — roughly 10 times that of a traditional laparoscopic surgery — da Vinci would need to do a lot better overall.”
For abdominal surgery, use of the robot is as follows: The assembled robot is draped in sterile plastic and positioned distant to the patient, while the anesthesiologist induces general anesthesia and inserts an endotracheal breathing tube into the patient’s windpipe. The circulating nurse then preps the patient’s abdomen with antiseptic solution and the scrub tech surrounds the patient’s abdomen with sterile drapes. The surgeons insert a trocar to inflate the abdomen with carbon dioxide gas, and then make the incisions required for the insertion of the instruments into the patient’s body. When the robot is finally moved in over the patient and the instruments are connected to the robot arms, the anesthesiologist has limited access to the patient’s head, neck, and chest, due to the size, breadth and girth of the robot. The anesthesiologist’s station is within 4 – 6 feet of the patient’s head. At least one surgical assistant and one scrub tech stand at the patient’s side throughout the surgery. At a university teaching hospital, this number could be significantly greater.
The anesthetic for robotic abdominal surgery is no different than the technique for laparoscopy, except for one important feature. Robotic surgeries take longer than the same surgery done via traditional laparoscopy—a fact that makes most robotic procedures tedious for anesthesia personnel. Robot surgeries take up more of an operating room’s most precious resource—time. Hospital operating room resources—nurses, techs, orderlies, and administrative staff—are paid by the hour. Longer surgeries mean longer staffing hours and greater expense.
Do anesthesiologists prefer, enjoy, or feel challenged by these robotic surgery cases? In a word—no. There is little that is unique or challenging after one has done a few of these cases. In general anesthesiologists prefer surgery that is fast, efficient, safe, and effective.
What does the world’s medical literature have to say about robotic surgery? When I entered the keywords “robot surgery, 2019” into the Pubmed search engine today, I discovered 1,248 papers published on robot surgery in the first 11 months of 2019. This is an exceptionally large number of publications. Robot surgery is a hot topic in the community of academic surgery. Multiple surgical specialties, including general, gynecology, cardiac, thoracic, cancer, and head and neck surgeons, are writing about their experiences with the da Vinci robot. You’ll find individual case reports, series of cases, meta-analyses, and comparison of current outcomes/complications to historical controls.
Pertinent studies include the following:
Gall bladder surgery: In a 2019 study in the American Journal of Surgery, a national databank review of gall bladder resections (cholecystectomy) showed that the direct cost of robotic cholecystectomy was significantly higher than laparoscopic cholecystectomy, with no added benefit. The conclusion of the study was that “routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.”
Prostatectomy: A randomized controlled trial compared robotic surgery with open surgery for patients with localized prostate cancer, and showed that both robotic and open surgery achieved similar results in terms of key quality of life indicators at three months.
Kidney surgery: A study published in the Journal of the American Medical Association (JAMA) showed the percentage of radical nephrectomies using the robot increased from 1.5% in 2003 to 27.0% in 2015. There were no significant differences between robot-assisted vs laparoscopic radical nephrectomy in major postoperative complications. The robot-assisted procedures had both longer operating times and higher direct hospital costs.
Gynecology: The mortality in benign minimally invasive gynecologic surgery was low, and the mortality for laparoscopic vs robotic approaches was similar.
Rectal surgery: A JAMA publication showed that for patients with rectal carcinoma, robot-assisted laparoscopic surgery did not significantly reduce the risk of conversion to open laparotomy, when compared with conventional laparoscopic surgery. These findings suggested that robot-assisted laparoscopic surgery did not confer an advantage in rectal cancer resection.
What will be the future direction of robotic surgery? Currently Intuitive Surgical and the da Vinci Surgical System have a monopoly. No other company has any significant market share. In 2017 Intuitive Surgical had $3.12 billion in total revenue, with a net income of $660 million. Their stock price is currently $549/share, up 300% from $178/share in January of 2016. The volume of robotic surgeries continues despite a paucity of published data that robotic surgery is any better. The cost of these procedures is high, and most hospitals are losing money on robot cases. Hospital executives seem to see the robot as a loss leader. No administrator wants to lead an old-fashioned hospital that doesn’t have a robot, while their competitor hospital across town is advertising robotic surgery on the side of buses traveling down Main Street.
Robotic surgery is a technology looking for a reason to exist, and a solution looking for a problem. Robotic surgery is not nearly the advance that laparoscopy was. Technology is pervasive and is changing healthcare. Enter any hospital today and you’ll see doctors and nurses peering into computer screens. They are pointing, clicking, entering information, and typing in findings on their patients. Where are the patients? Often they’re looking at the backs of these same doctors and nurses who are sitting at the computer terminals. Medicine, as I was taught in the 20th Century, was a profession dedicated to caring for and healing people. Modern medicine is increasingly pushing the hands of doctors and nurses toward keyboards and gadgets.
The surgeon with his face in a robot console’s 3-D viewer, while his back is to his patient, is a powerful metaphor for the technologic trend in medical care. I believe patients want to see our faces, and we need to look into their eyes. I doubt that great American physicians from our past—William Osler, Harvey Cushing, the Mayo Brothers, or Norm Shumway—would be fans of robotic surgery.
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Hopefully readers of the article will read the whole thing to see the waste of money robotic surgery is. Surgeons however hold the hospitals hostage by saying if you don’t get a robot we will go elsewhere. One example of how we are wasting money in America