Robotic-Assisted Surgery

[PreMedical1]

I have been trying to understand if the use of robotic-assisted surgical devices (such as the da vinci system) is decreasing, leveling off, or increasing. From what I understand, they have had a pretty positive impact on prostate surgery outcomes. However, in fields like Orthopaedics, they haven't really come through and their use is sort of becoming less prevalent (is what I have heard).

I'm not sure if there is any truth to this. I have also heard they are used in Neurology for more "delicate" procedures, but am not sure how frequently they are actually used.

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[plauto]

my understanding (not based on facts or studies) by what docs say around here is that it's a marketing advantage more than a surgical revolution and it's used very little. They tried to get CT surgery on board and when they used the DaVinci it took them longer to get it set up than to do the actual surgery so that did not fly. Take my MSII opinion for whatever it's worth...

 

[Jolie South]

my understanding (not based on facts or studies) by what docs say around here is that it's a marketing advantage more than a surgical revolution and it's used very little. They tried to get CT surgery on board and when they used the DaVinci it took them longer to get it set up than to do the actual surgery so that did not fly. Take my MSII opinion for whatever it's worth...

It takes no longer than laparoscopic to set up. The ports are set up the same and then the robotic arms are brought in and attached.

ok. . . . It takes 2 minutes longer.

I work with an attending that does all prostates on the DaVinci. Compared to laparoscopic, you get extra degrees of movement, 3 dimensional vision, and no hand tremor. The machine also adjusts the view to different angles and positions the instruments accordingly with no change for the surgeon. Suturing for the surgeon is like suturing in an open field, whereas in laparoscopic procedures, it's awkward and takes extra time.

 

[PreMedical1]

That is interesting. I have read (and again, this might not be very reliable) that it was pretty effective in cardiology, urology (mainly with prostatectomy) and neurology. It seems like there are a fair amount of opposing views on these systems

 

[SLUser11]

I have been trying to understand if the use of robotic-assisted surgical devices (such as the da vinci system) is decreasing, leveling off, or increasing. From what I understand, they have had a pretty positive impact on prostate surgery outcomes. However, in fields like Orthopaedics, they haven't really come through and their use is sort of becoming less prevalent (is what I have heard).

I'm not sure if there is any truth to this. I have also heard they are used in Neurology for more "delicate" procedures, but am not sure how frequently they are actually used.

Robotics are the future. The robot provides multiple technical advantages, and is much more than just a "marketing advantage."

Innovations like NOTES and SILS will take longer to catch on because you are purposefully handicapping yourself and limiting your exposure and dexterity for the sake of a smaller or absent incision. Robotics enhance your dexterity and visualization.

We are using the robot for colons and TMEs. I know one of the guys in town uses it for Nissens, but I don't see a real advantage there, and a guy in KC uses it for everything...fat passes, etc. Usually, POD #1 I make an obligatory joke about how we installed a robotic colon in the patient...I'm still waiting for the day that I don't find it funny.

Anyway, in general and colorectal surgery, we'd be foolish not to learn robotics once given the chance.

 

[PreMedical1]

Robotics are the future. The robot provides multiple technical advantages, and is much more than just a "marketing advantage."

So this might be a little bit of a hard thing to judge, but do you see a need for great advances in these machines/devices? I'm kind of interested in if their technology has sort of "plateaued" and meets the surgeons needs just fine they way they are, or if there will be a lot of upcoming advances (from a technology standpoint). Thanks for all the replies

 

[GregsAnatomy]

We are using the robot for colons and TMEs.

That's great, I can definitely see an advantage with a robotic TME. We have a HPB who is doing robotic distal pancreatectomies pretty regularly here.

 

[plauto]

I am really surprised to see how little it is used in my hospital then . Other than urology, only few people use it here, and very rarely. Anybody out there using it with success for CT surgery?

 

[Pir8DeacDoc]

One of the CT surgeons at my medical school was a pioneer in the use of the robot (Dr Randolph Chitwood). I saw it in the early days and it seemed to be a great addition. Now at my current hospital it's used by the Gyns and Urologists mainly. Though one of our attendings is going to start using it soon for base of tongue tumor surgery, to avoid having to split the mandible for access. It appears to be a great asset, but I don't have any specific data or even any good anecdotal evidence to support that, just what I hear on the street.

 

[Black Surgeon]

I am really surprised to see how little it is used in my hospital then . Other than urology, only few people use it here, and very rarely. Anybody out there using it with success for CT surgery?

Yep, one of our CT attendings does Robotic-assisted MVRs on a regular.

 

[Dr.LeoSpaceman]

I have been trying to understand if the use of robotic-assisted surgical devices (such as the da vinci system) is decreasing, leveling off, or increasing. From what I understand, they have had a pretty positive impact on prostate surgery outcomes. However, in fields like Orthopaedics, they haven't really come through and their use is sort of becoming less prevalent (is what I have heard).

I'm not sure if there is any truth to this. I have also heard they are used in Neurology for more "delicate" procedures, but am not sure how frequently they are actually used.

That's interesting, because I'm fairly sure that use of the robot has not been associated with better outcomes, at least in urology. It does have shorter length of stay, but I'd argue that 2 vs. 3 days is a modest gain. Add in the fact that it takes longer and is much, much more expensive, and the advantage over laparoscopic becomes fairly thin.

Given the concerns with the rising costs of healthcare, I think cost-efficiency is the real issue here.

 

[SLUser11]

So this might be a little bit of a hard thing to judge, but do you see a need for great advances in these machines/devices? I'm kind of interested in if their technology has sort of "plateaued" and meets the surgeons needs just fine they way they are, or if there will be a lot of upcoming advances (from a technology standpoint). Thanks for all the replies

There is plenty of room for improvement with the robots. The most significant one will be the addition of tactile feedback, which is currently missing. Also, the future holds lower-profile/smaller ports and instruments.

They're still working on the invention of that robotic colon, but when it's ready, it's really going to change the way we poop.

That's interesting, because I'm fairly sure that use of the robot has not been associated with better outcomes, at least in urology. It does have shorter length of stay, but I'd argue that 2 vs. 3 days is a modest gain. Add in the fact that it takes longer and is much, much more expensive, and the advantage over laparoscopic becomes fairly thin.

Given the concerns with the rising costs of healthcare, I think cost-efficiency is the real issue here.

It's still pretty early to have long-term follow up on robotic prostates, so most data will be limited, and most experience will be anecdotal, but give it some time. As far as speed goes, several of the urologists in town are scary-fast with the robot, and are easily beating their old open prostate times. Also, an area that is significantly different is blood loss. I don't know how many open prostates you've seen, but they can be a blood bath, and the robotic ones are (anecdotally) much cleaner in that regard.

Also, there are lots of other costs to consider when it comes to complications from the open procedure, but really what studies will be trying to prove first will be that the robotic prostate is not inferior in terms of oncologic outcome, much like the COST trial, etc...the rest of the data will follow that.

Eventually the data will be there, and the costs will possibly equal out, but this is a field that's emotionally charged, and much like the lap chole and the lap appy, the public will demand the procedure before the data is there.

It is very common for us all to resist change, from flowsheets and mandatory CTs to NOTES to bowel preps to something as simple as whether or not a patient needs an NG tube after colon surgery. However, my personal advice is to be one of the first ones on your surgical block that can use the robot...because if you won't do it, other people will, then you'll be behind the curve struggling to keep up as your competitors take all your patients away.....sort of dramatic, but also sort of true....

 

[PreMedical1]

There is plenty of room for improvement with the robots. The most significant one will be the addition of tactile feedback, which is currently missing. Also, the future holds lower-profile/smaller ports and instruments.

From what I have read, there isn't any direct tactile feedback (as in what tissues/organs actually feel like) but there are other ways to compensate - I think they site visual cues and stuff like that. In your opinion, would this force/tactile feedback really make that much of an improvement? Or is it one of those things that just would be nice to have.

It sounds like it would be really, really hard to not have any force feedback, but that must not be true since it's not available right now.

 

[SLUser11]

From what I have read, there isn't any direct tactile feedback (as in what tissues/organs actually feel like) but there are other ways to compensate - I think they site visual cues and stuff like that. In your opinion, would this force/tactile feedback really make that much of an improvement? Or is it one of those things that just would be nice to have.

It sounds like it would be really, really hard to not have any force feedback, but that must not be true since it's not available right now.

It would make a huge difference, and would remove conventional laparoscopy's main advantage. Currently, a big part of the robotic learning curve is learning how to stitch without snapping the suture in half.

An extra-corporeal complication of lack of tactile feedback is that you can beat the hell out of the patient with the robot arms and not really know it.

Anyway, I doubt that I'm the forum expert on robotics. Does anyone else have any input? I admit to having a strong interest in the subject, and I've found it more interesting than other current "cutting edge" technologies. E.g. is SILS (Single Incision Laparoscopic Surgery)...which I think just sucks.

Any time I've done SILS for a gallbag, I really feel like I'm handicapping myself....my instruments are bumping against the camera, my triangulation is compromised, and the cost doesn't seem justified. Also, since it's new and sexy, the staff is more likely to try and take over the case if you struggle at all.

 

[JackADeli]

I noted the OP asked if increasing or decreasing use.....
This is my take:
1. The President visited some fancy med ctr, I think Mayo, got to sit in the console and dry-drive the daVinci.... he reportedly said at that point something like, ~every hospital should have one.
2. It is quite commonly proclaimed one should not have a prostatectomy without daVinci. Yes arguments for and against. But, it is out there and if new urologists are not offering they are loosing work.
3. OB/Gyn is increasingly using it, especially in pelvic cancer cases.
4. ENT is apparently moving into the field... I hear they are actually using it to remove tonsils as a practice run for more complex oral cancers.... The daVinci system actually has high def and 10x magnification.... probably an advantage when working in small delicate spaces like ENT.
5. Apparently use is increasing in Cardiac & Thoracic. Major reputable university med ctrs are now offering additional 1yr superfellowships in robotics..... do a web search if you are interested.

As for operative time and set-up.... set-up is apparently pretty straightforward once you get a feel for it and takes under 8 minutes from what I have seen with uro, ob/gyn, & CT.

Operative time is surgeon dependent. There is nothing intrinsically "slow" moving about the robotics. Apparently, the 10x, high def view causes for lack of better descriptor, "sensory over-load" in the operator. This results in the operator actually moving slower until they get accustomed to view and perspective. I have seen some crawling surgeons and seen some rapid surgeons. Remember, that drop of blood can seem like a "pool welling up" with 10x magnification. But, it is those exceptional optics that also provide such an advantage once one gets their bearings and develops an appreciation for the perspective.

One final note, I hear Mayo or Cleveland Clinic are currently trialing a single port daVinci system. There is a web page video out there somewhere that has an illustration of how it works. The arms and camera come in one port and the arms apparently snake/spider out from the center.

JAD

 

[Pir8DeacDoc]

I noted the OP asked if increasing or decreasing use.....
This is my take:

4. ENT is apparently moving into the field... I hear they are actually using it to remove tonsils as a practice run for more complex oral cancers.... The daVinci system actually has high def and 10x magnification.... probably an advantage when working in small delicate spaces like ENT.

JAD

This is correct. We are actually doing some tonsillectomies next week and will begin base of tongue work soon thereafter to avoid mandible splits for access.

 

[ESU_MD]

No doubt the robot is cool.

As far as robots in CT- in order to do robotic mitrals, you have to know how to do mitral repairs OPEN. By the time alot of surgeons get to this level, its time to retire! Its not all that unusual for someone to make it through a CT training program without EVER personally replacing a mitral, let alone REPAIRING a valve.

I think its funny to see ads looking for surgeons- robotic mitral experience a necessity. where are these guys!?!? europe?

OTOH, everyone coming out of training should be comfortable doing lungs and it would be easy to get motivated to develop a skill set to robotic lobes de novo.

 

[Winged Scapula]

Today in the OR I was discussing the robot with the anesthesiologist. One of his partners had been in a prostatectomy when the patient coded on the table and as I understand it, just getting TO the patient's chest was difficult and resulted in a significant delay (which they suspect contributed or was the cause of the patient's demise). I suppose this is unusual but anyone else hear of it?

 

[SouthernSurgeon]

Today in the OR I was discussing the robot with the anesthesiologist. One of his partners had been in a prostatectomy when the patient coded on the table and as I understand it, just getting TO the patient's chest was difficult and resulted in a significant delay (which they suspect contributed or was the cause of the patient's demise). I suppose this is unusual but anyone else hear of it?

Yes. Patient died at my institution after an intraop complication - took too long to clear the robot out of the way.

 

[surg]

So WS, want to team up and do a robot lumpectomy? Got to be a market for this thing somewhere in breast surgery. We'll through the SLN incision and and the umbilicus, then whack away! Oncoplastics? how about no scars on the breast at all?

 

[SLUser11]

Today in the OR I was discussing the robot with the anesthesiologist. One of his partners had been in a prostatectomy when the patient coded on the table and as I understand it, just getting TO the patient's chest was difficult and resulted in a significant delay (which they suspect contributed or was the cause of the patient's demise). I suppose this is unusual but anyone else hear of it?

Yes. Patient died at my institution after an intraop complication - took too long to clear the robot out of the way.

This is speculation on my part since I wasn't there, but couldn't the robot have also just been the scapegoat in these two situations, especially if the people recounting the story are not big fans of that technology?

I know of lots of situations where surgeons and anesthesia alike would assign complications to something new and different going on that they didn't like or weren't comfortable with.....they'd then use that anecdotal experience to dismiss the technology or technique as altogether unsafe, thinly masking their distaste for change and for having to learn something new.

Really, moving the robot away from the patient shouldn't be hard at all. After removing the instruments from the ports, which is as fast as anything, you should be able to unlock the robot and back it away from the patient.

Of course, with an inexperienced team that is unfamiliar with the equipment, any new procedure can be dangerous....

 

[Winged Scapula]

That's why I was asking.

I've actually *never* seen the DaVinci in use so I had no idea what was involved in moving it away from the patient. I asked a general surgeon later in the day and he said he'd heard the same thing.

So of course its possible that the system was being blamed but I was trying to get a mental picture of why it would take some long to get to the patient and whether this was a real issue.

 

[SLUser11]

That's why I was asking.

I've actually *never* seen the DaVinci in use so I had no idea what was involved in moving it away from the patient. I asked a general surgeon later in the day and he said he'd heard the same thing.

So of course its possible that the system was being blamed but I was trying to get a mental picture of why it would take some long to get to the patient and whether this was a real issue.

I haven't seen enough robot cases to see the technique used, but one thing that experienced surgeons say is that if you run into bleeding, etc, one of the good things about the clutch on the robot is that if you grab something, like a bleeding vessel, then lock it into place, it is not going to move, and you could then open the patient while the robot arm controls the bleeding.

I've attached the robot setup from a recent colectomy. Also, here's a link to a picture I found. The machine itself lies on the free side of the patient (here, on the patient's left). You try to organize the arms so that they don't bump the patient, etc, so they should be able to move away from the body freely in an emergency.


Of course, like I said, just like anything the robot can be dangerous if set up incorrectly or used by an inexperienced team.

 

[SouthernSurgeon]

This is speculation on my part since I wasn't there, but couldn't the robot have also just been the scapegoat in these two situations, especially if the people recounting the story are not big fans of that technology?

Entirely possible. I wasn't there for the case or the (inevitable) M&M conference - this has just become word of mouth lore...

 

[Jolie South]

That's why I was asking.

I've actually *never* seen the DaVinci in use so I had no idea what was involved in moving it away from the patient. I asked a general surgeon later in the day and he said he'd heard the same thing.

So of course its possible that the system was being blamed but I was trying to get a mental picture of why it would take some long to get to the patient and whether this was a real issue.

You could easily remove the arms from the actual instruments inside the trocars in no time.

At that point, I don't see how it'd be different than dealing with complications in a lap procedure.

 

[JackADeli]

EVERY team I have observed in learning to use davinci are specifically taught about rapid de-dock in emergency. The bedside scrubs/assists are clearly instructed on what he/she should do in an emergency to maintain control (i.e. of a bleeder) while robot is rapidly de-docked in controlled manner. That is why there is on-site familiarity training, off-site cadaver training, case observation, on-site proctoring.....
Anything less = untrained.

If you can not "de-dock" the robot rapidly in an emergency, you, your team, or both are not adequately trained in proper and safe use of the robot.... thus, you should not be using it...PERIOD.

...couldn't the robot have also just been the scapegoat in these two situations, especially if the people recounting the story are not big fans of that technology....

Very common

...just like anything the robot can be dangerous if set up incorrectly or used by an inexperienced team.

Agreed

....At that point, I don't see how it'd be different than dealing with complications in a lap procedure.

agreed.

 

[Black Surgeon]

No doubt the robot is cool.
As far as robots in CT- in order to do robotic mitrals, you have to know how to do mitral repairs OPEN. By the time alot of surgeons get to this level, its time to retire! Its not all that unusual for someone to make it through a CT training program without EVER personally replacing a mitral, let alone REPAIRING a valve.
I think its funny to see ads looking for surgeons- robotic mitral experience a necessity. where are these guys!?!? europe?

Like I stated earlier, one of our CTs does robotic MV repairs almost weekly, he also does single coronaries using the robot. The guy is still fairly young (around his 40s). This isn't as unusual as you are making it out to be, especially here in the east coast.

 

[JackADeli]

...As far as robots in CT- in order to do robotic mitrals, you have to know how to do mitral repairs OPEN. By the time alot of surgeons get to this level, its time to retire!...

someone is drinking the old school koolaid that the CT sages are serving. I have seen far too many young CT surgeons do very nice mitral repairs regularly well before age 40... unfortunately, most can share stories about getting that training after fellowship by going to 2-3 day courses to learn what should be taught in fellowship.

...Its not all that unusual for someone to make it through a CT training program without EVER personally replacing a mitral, let alone REPAIRING a valve...

That is unfortunately true in numerous places according to some of the young CT surgeons... it speaks to the poor academic practices of fellowship and has very little to do with robotics. Especially, if, many of these young fresh grads can get an "ah ha" moment and learn to do mitral surgery at a few courses with some pig hearts.... why couldn't they be taught during their formal fellowship, where they have a skilled mentor standing over them and the patient with a TEE probe down the throat to demonstrate the repair in action????

Robotics is a tool... in essence an evolution of laparoscopy. There is no magic. People fear it and senior attendings that wouldn't know the difference between a 30 degree and zero degree scope are terrified.... How many 65 year old "mitral masters" do you know that could do a lap appy or chole?

And, while not a heart surgeon, I have looked at some videos and texts and assisted in numerous CT cases as a resident... I got to tell you that mitrals are not as mystical as the senior folks would have you believe either... especially if you can actually see what they are doing. As an assistant, you stand behind and crain over to see down and under a ledge and marvel at the skill... When someone steps out of your way and you have the direct line of vision... well, the cloud is lifted, the mystery gone, and the stitch almost guides itself....

I don't want to distract this thread from the question about robotics... but your argument of CT is incongruent. You are drawing conclusions from incompetent teaching/training practices/staff and mingling them with a skilled young surgeons ability to learn how to apply new technologies...

 

[Black Surgeon]

Robotics in CT is becoming more and more standard in academia, with VR repairs as one of the more common of the many services offered. Keck, cleveland clinic, carver are the few that come to mind from a google search I did a while ago. Some even over kill it and offer LV leads as one of the options.

Our CT guy tells me that going from lap to the robot is a very smooth and easy transition and states that the former is a lot more difficult to master than the latter. So it isn't too difficult for me to believe that many GS trained young CT guys would be well able to perform the procedure.

Furthermore, I can think of at least two CT servives in private hospitals around my area that offer robotic CT services which include VRs as one of many services.

 

[PreMedical1]

That's a lot of great information, thanks for all the replies. As far as Orthopaedics, which is of course a little different application than CT or Urology, have there been many developments there?

I have heard of devices that are used to I believe align cut-planes and used as like "navigation" to determine where to place implants and such. But it seems like these kind of came and went. I'm not sure if that is really true, and if so, why they never really gained popularity?

It seems like (to an inexperienced person such as myself) those kind of technologies would increase accuracy and stuff like that and make for a better outcome - maybe not really in practice though. Anyhow, just curious why these technologies aren't more popular in Orthopaedics.

 

[JackADeli]

...Our CT guy tells me that going from lap to the robot is a very smooth and easy transition and states that the former is a lot more difficult to master than the latter. So it isn't too difficult for me to believe that many GS trained young CT guys would be well able to perform the procedure...

Got to agree. The issue folks need to understand are what might be possible motivations.... i.e. job security. Numerous senior surgeons over age 45-50 may have very, very limited MIS/scope training/experience. The cardiac market is currently flush with surgeons seeking some scraps. The senior guys have their experience (in traditional techniques) and established reputations. Many have lost their shorts in the economic crash. Many have waited years doing grunge work to get to a senior level and cardiology referral base.... Do you think they want to admit:

a) it doesn't take 1-2 decades after fellowship to become skilled at cardiac valves
b) MIS cardiac and valves can be done safely and with potential benefits for patients.

To admit that while lacking the ability(or interest...) to provide the service is to commit professional suicide. So, community and even university surgeons will spend a good deal of time preaching how "bad" these techniques are and how long it takes to become competent in traditional procedures.... This will stear referral bases to the senior, traditional, "mitral masters".

In the end, it is a business. Unfortunate ethics reality is that numerous physicians throughout all specialties will offer what is best for the patient... at the individual physician's hands. Often, failing to mention alternative therapies, that might be really "best" for the patient but at the hands of another provider..... We have seen this play out with cholecystectomy, appendectomy, gastric bypass, colectomies, Nissens, endovascular therapies, etc......

 

[Black Surgeon]

Got to agree. The issue folks need to understand are what might be possible motivations.... i.e. job security. Numerous senior surgeons over age 45-50 may have very, very limited MIS/scope training/experience. The cardiac market is currently flush with surgeons seeking some scraps. The senior guys have their experience (in traditional techniques) and established reputations. Many have lost their shorts in the economic crash. Many have waited years doing grunge work to get to a senior level and cardiology referral base.... Do you think they want to admit:
a) it doesn't take 1-2 decades after fellowship to become skilled at cardiac valves
b) MIS cardiac and valves can be done safely and with potential benefits for patients.
To admit that while lacking the ability(or interest...) to provide the service is to commit professional suicide. So, community and even university surgeons will spend a good deal of time preaching how these techniques are and how long it takes to become competent in traditional procedures.... This will stear referral bases to the senior, traditional, mitral masters
In the end, it is a business. Unfortunate ethics reality is that numerous physicians throughout all specialties will offer what is best for the patient... at the individual physician's hands. Often, failing to mention alternative therapies, that might be really "best" for the patient but at the hands of another provider..... We have seen this play out with cholecystectomy, appendectomy, gastric bypass, colectomies, Nissens, endovascular therapies, etc......

To add fire to this fuel, the guys at U of Maryland are already doing robotic assited multiple vessel Coronary artery bypass.
It looks like robotics is truly the future of cardiac surgery and those old school guys are on their way out, just in time for the new wave CT surgeons.

 

[Parmax]

I personally think robotics is a great progress for surgery. I first had a chance to try out the first gen. Da Vinci in 2006, and I have used it on and off for two years after completing a course with our team in Italy in 2007. My practice is limited to lap. Gastric Bypass, Sleeve Gastrectomy and Nissens.

1 The robot grants you unbelievable flexibility and field of vision which is crucial for MIS procedures.

2 The setup time is somewhat long, I am yet to have a system running under 45 minutes after the induction of anestesia. Normally it takes 15 minutes to place the ports and the omni lapotract,but with a robot I need minimum 25 more minutes to cover the system, get the arms ready, place the camera etc. this may be due to my team but I don't think they are inefficient, I have heard the same from some other surgeons at SAGES meetings and I am happy not being the only one. But I am sure more experienced centers have shorter times.

3 It is a very easy to learn system although mastering it takes some time. I was suturing in 20 minutes, and I was suturing faster than using an endostitch in 2 hours and way too faster compared to my storz needle driver.

4 in 3 days (18 hours) I was confident that I could use this in any operation without any worry and I was right.

5 you do not need to rely on your assistants for traction and positioning, just hold the stomach and it stays there until you take the control of that arm again, no need to think about the resident moving around.

6 suturing is like music, especially in sleeve gastrectomy, you can invert the staple line and put a second layer for 30 cm's like a breeze, I have seen some people do it conventionally but with the robot you feel like you are Kelvin Higa.

7 unfortunately there are no staplers to use with the robot. ( at least I do not have them). so you still need to staple with the endo-gia gun. If you want to do it yourself you need to get off the console, scrub in, do the stapling and get back to the console. it is inconvenient.

8 I use ligasure for sleeve and ultracision for bypass and nissens, and there are no arms with those tips ( at least I have not seen them), you are limited to coatery.

9 in my experience it is a very good system but I can only use it to secure the long staple line in sleeve, gastro-j in bypass, close the j-j defect in bypass, cloce the petersons defect in bypass, and dissection and stuturing of the crura in nissens.

10 it costs me 3000 more per op. to use the robot.

11 some may disagree to suture over the staple line but I prefer to have a peace of mind the night after the operation so I suture over it or hand sew the anastomoses. considering the time needed to set up the robot I save around 25 minutes per-op. I wonder if it is worth to money or the hassle.

12 thank god I had no complication that required and urgent laparatomy but I do not think you can get in seconds when using the robot. so be sure not to puncture the aorta or the IVC. conventionally I can get in under 45 seconds by lifting the abdomen with towel clamps and cutting through ( we frequently did this after terrorist attacks). but the robot hovers over the patient and you need to dismantle the unit before you can turn in to jack the ripper.

13 in my limited practice I can say it is a very good system but not very efficient to use in general MIS.

14 it is a different story when we are talking about lap. oncologic surgery esp. lap whipple's, I think DaVinci is the master there.

edit:
15 the team gets bored during the op. and they start chatting which sometimes is rather disturbing. you need to find something to keep them on their toes.(without puncturing something)

 

[PreMedical1]

To admit that while lacking the ability(or interest...) to provide the service is to commit professional suicide. So, community and even university surgeons will spend a good deal of time preaching how "bad" these techniques are and how long it takes to become competent in traditional procedures.... This will stear referral bases to the senior, traditional, "mitral masters".

This might be a little over idealistic, but shouldn't there be/isn't there actual data and studies to backup this kind of claim that one is better than the other. I understand that it is new technology and that there won't be longterm, 10 year data, but surely there should be something to back this up? I suppose that data aren't always so clear-cut though, which is a challenge in a lot of different procedures/specialties/fields. This is really more a comment than a question.

 

[JackADeli]

...shouldn't there be/isn't there actual data and studies to backup this kind of claim that one is better than the other. I understand that it is new technology and that there won't be longterm, 10 year data, but surely there should be something to back this up? ...

Short answer is no.
The old guard can point to decades of database data and publications. The new guard as it were, have only small relative numbers. Each year at surgery conferences from OB/gyn, GSurgery, CT, Uro, etc.... presentations are made about individual experience, etc.... But, comparative studies of robotic vs open is limited. There was a Uro study from Europe. Of course, European urologist training paradigm is different then USA.

In the end, patients really drive these technologies ..as the old guard/senior folks retire. Contrary to popular belief, surgeons are as a whole not particularly avangard and pushing any new frontiers or envelopes. They are dependent on consistent outcomes. Contrast that to patients. A patient will be convinced a thyroidectomy without a neck scar is "better".... the surgeons will balk. A patient will be convinced a mini-thorocotomy is better then a sternotomy or as pitched to patients, "splitting your breast bone right down the middle". Sometimes the outcomes are purely what kind of scar the patient wants and has nothing to do with what is inside.

As the old surgery mantra goes something like....you can be a clumsy butcher on the inside but if the incision looks good and the bandage is pristine white, the patient will recognize your exceptional talent.

 

[ESU_MD]

I got to tell you that mitrals are not as mystical as the senior folks would have you believe either... especially if you can actually see what they are doing.

You are very correct- the hardest part of operating on the mitral valve is getting the opportunity to operate on it.
I have been very fortunate to have good mentors who have allowed me to replace mitrals, and even do some simple repairs. Aortic valves ironically are often tougher.

However, I'm still not really aware of how someone can get enough experience in 2-3 years of a standard training program to jump right to the robot. In most groups, the new hire is doing the garbage thoracic cases, maybe some CABG and vascular and a rare valve handed down while the senior partners do all the nice cases.

Outside of a few specialized centers, ct surgery groups arent gonna let their new guy start trying to do robots after going to a few courses. If one is serious about that stuff, you probably need to spend a year of superfellowship and be able to start a program de novo.

 

[ESU_MD]

Sometimes the outcomes are purely what kind of scar the patient wants and has nothing to do with what is inside.

Another interest point I wonder about- do the incisions really matter? A good median sternotomy has a very acceptable complication rate and most people tolerate it much better than thoracotomy, even the mini-thoracotomies.

While I am somewhat fascinated by the robot too, it doesnt really take away from the greatest risks- I think the true morbidity from cardiac cases is from sequelae of the pump, not necessarily the incision(s)
....although I bet someone is trying to do off-pump robots!

 

[Black Surgeon]

....although I bet someone is trying to do off-pump robots!

The guys at Maryland have been doing it multilple vessel CABGs off-pump since 2006:

http://www.umm.edu/news/releases/surgical_robot.htm

Our CT guy does the single coronaries off-pump also and I'm pretty sure all the other programs that employ the robot for such procedures are doing them off pump also. This isn't new. Doing "it" off-pump and thus being "minimally invasive" is the whole point of employing the device in CT surgery.

 

[JackADeli]

...the hardest part of operating on the mitral valve is getting the opportunity to operate on it...

However, I'm still not really aware of how someone can get enough experience in 2-3 years of a standard training program to jump right to the robot...

...If one is serious about that stuff, you probably need to spend a year of superfellowship...

You are correct, if you are actually allowed to see and perform the mitral operation you should be quite competent with a standard procedure open. It is a numbers game and NOT a years game. If you have quality "real" mentors that do volume in mitrals and have you performing them early and frequently, you don't need ten yrs, three yrs, or even two years.

A good modern program with motivated and capable of teaching staff can have you doing open mitrals early. I dare say, a decent resident that understands the straightforward anatomy, could then be progressed to robotics during the same 2-3yr fellowship. The robotics are simply an extension. It provides far better visibility then a sternotomy and leaning over mitral retractor. Again, not magic. It just takes quality attendings interested in progressing surgical practice.... Honestly, how many mitrals does anyone really need to "first assist"/observe before they can throw a stitch on a duran ring or band. It isn't magic and anyone in a program that makes residents actually do the case will be able to do robotics.

The need for additional year of "super-fellowship" is indicative of innadequate primary fellowship using antiquated educational paradigms that is probably wasting fellows time and not actually employing medern training techniques and/or procedures. From the fellows I have spoken with, it is common for senior attendings to step back and determine, "I have two years to take you through parts of the procedure so by your last month I can allow a few skin to skin cases...". In my opinion, fellows should be progressed early and fast. In a high volume place with fellow scrubbed on maybe 2-3 cases a day... he/she should do pieces through the first day or two and be on skin to skin coronies by the end of the week, skin to skin aortic valves by the end of second week, skin to skin CABG & AVR by the third week, and then into mitrals. IMHO, by the end of the first month or two, you should be doing all scrubbed cases skin to skin.

Another interest point I wonder about- do the incisions really matter? A good median sternotomy has a very acceptable complication rate and most people tolerate it much better than thoracotomy, even the mini-thoracotomies.

While I am somewhat fascinated by the robot too, it doesnt really take away from the greatest risks- I think the true morbidity from cardiac cases is from sequelae of the pump, not necessarily the incision(s)
....although I bet someone is trying to do off-pump robots!

So, about incisions, this is what I have heard:
1. Rate of sternal complications may be low over all. They may be higher with osteoporosis and/or diabetes. No sternal wound infection or dehiscence if you never perform sternotomy to begin with... thus low rate vs no rate.
2. thorocotomy better hidden then sternotomy
3. Apparently, like many Asian cultures have social issues with thyroid neck incisions (something about radiation and/or poor genetics); American seniors supposedly have social issues with sternotomy scars. The geriatric community in some parts reportedly view a sternotomy scar as a mark of poor life expectancy and thus the single elderly person with such is less likely to find a new companion.

The robotic coronaries are done off-pump as noted. Though, the research of off or on pump is still contradictary...

Ultimately, we can have philisophical discussions on this all day. But, I believe if you actually go and watch a robot mitral, see the 10x magnification in high def, it will become clear how non-magic it is and why it shouldn't take that much to learn, especially if you had significant laparoscopy in GSurgery. Another thing I have seen, the robot sales guys come in, have the scrub nurses sit at the console, and suture gloves together. The nurses, with zero surgical training all state... "oh, we thought it was hard for DrX to do these cases, but this machine is so easy my kid could do it".

 

[JackADeli]

...The setup time is somewhat long, I am yet to have a system running under 45 minutes after the induction of anestesia....

Not sure what you are doing, but something is not being done right IMHO. In general, the robot should be drapable in under three minutes. Most places I have seen, the robot/arms are draped while the OR set is opened and well before the patient ever arrives in the room. Port placement should be quick. Docking with insertion of first instruments should take under 10 minutes... especially if it is the same case you do regularly. As for your other retractors... again experience and consistency should bring that time way down. 25 minutes... maybe, 45 minutes for an experienced team??? You need to get a good daVinci rep to come in, retrain, and troubleshoot where you are loosing your time. No patient should be getting 45 minutes of extra general anesthesia for "set-up".

If you could get that extra hour of OR/anesthesia time under control, you would start to offset your 3 grand excess costs for usage. In most experienced hands I have seen, the robot adds under 15 minutes to total operative/anesthesia time.

JAD

 

[Parmax]

Not sure what you are doing, but something is not being done right IMHO. In general, the robot should be drapable in under three minutes. Most places I have seen, the robot/arms are draped while the OR set is opened and well before the patient ever arrives in the room. Port placement should be quick. Docking with insertion of first instruments should take under 10 minutes... especially if it is the same case you do regularly. As for your other retractors... again experience and consistency should bring that time way down. 25 minutes... maybe, 45 minutes for an experienced team??? You need to get a good daVinci rep to come in, retrain, and troubleshoot where you are loosing your time. No patient should be getting 45 minutes of extra general anesthesia for "set-up".

If you could get that extra hour of OR/anesthesia time under control, you would start to offset your 3 grand excess costs for usage. In most experienced hands I have seen, the robot adds under 15 minutes to total operative/anesthesia time.

JAD

Hi, as I have written above, it takes 25 minutes more to get a system running compared to conventional laparoscopy. Although the reps claim draping of the unit in 3 mins, I do not think that is easily achievable. I usually take their words with a grain of salt, just like the catalog fuel consumption data of motorcars.

It still is advantageous to use DaVinci as I experience shorter op. times when there is heavy suturing involved but I wonder if it is feasible to use the system in not so advanced procedures such as gastric bypass, sleeve or nissens...

edit: if you drape the unit before you get the patient on the table, there is a high possibility that someone contaminates the system which will require draping again. anyway draping is not the bottle neck but getting the arms in position is.

 

[JackADeli]

...Although the reps claim draping of the unit in 3 mins, I do not think that is easily achievable...

Why not?!? I have been at three different hospitals. I have watched folks drape the arms... It is probably the easiest thing. Draping is really a three minute task. It just isn't that complicated.

...if you drape the unit before you get the patient on the table, there is a high possibility that someone contaminates the system which will require draping again...

I don't know the flow of your room or caliber of your staff. But, what I have seen regularly in most efficient ORs is arms draped before the patient enters. Then a sterile disposable drape sheet draped over the plastic arm drapings to protect against contamination. Folks should not be contaminating sterile draped equipment...PERIOD. Most folks in the hospitals I have visited keep folks out of the room if not attuned to the draping and sterile components of the robotics. If the unusual occurance of a contaminated arm drape,... well a single arm is re-draped in under a minute... cause it is not that complex. It is nothing more then a glorified "sono-site" esq condom sleeve.

Again, I think folks' fear and perception are over-thinking and over-complicating it. Honestly, if someone told me draping a sono-site probe for central line placement added substantial time to a procedure I would be asking why? sono-site = 30 seconds to condom, robot arms = under 3 minutes to condom and "snap-in". I am not OR prep staff. But, as a surgeon, I have taken the opportunity to unskillfully and unpracticed draped the arm... while the OR staff laughed... and I did it on my first try in under 5 minutes.

 

[JackADeli]

See my previous post above...
Again, it's not magic. This how I look at it when considering the reasonable nature of added time to a procedure.

1. draping should add nothing cause should be done as part of room set-up.... can count as 3 minutes added to turn-over for starting a second case. But, usually the arms are draped by one nurse while the scrub is opening the "set"... thus zero added time.
2. Port placement should take as much time as they would for laparoscopy, so really no additional time unless you add extra ports you would not otherwise use in laparoscopy
3. it should take less then one minute to drive up the robot to the patient's side
4. if you do the same procedure over and over again, docking to the same port positions should really take under 5 minutes. You are just snapping the ports into the arm receivers.... again not magic. If your bedside help just can't seem to get the geometry right to snap-in/dock ports quickly, then use double port technique and avoid the problem all together!
5. advancing first instruments should be measured in seconds....

Now, I can't speak to what additional apparatuses you are installing, etc... But, in general, we are talking docking and first instruments in in under 9 minutes.

For application of laparoscopy, robotics, or any other new technologies or variations in old techniques, you need to break down the steps systematically and figure out where the added time is coming from first. Then you need to ask if that added time is justified or represents lack skill/talent/understanding/familiarity/patient variation/etc....

It all comes down to demystifying. If someone tells you technology "x" adds "y" amount of time to a procedure, you should be able to identify where and why that time is added.

Caveat.... I think in cardiac, mitrals in particular, the time added has to do with groin cut-down, canulation, and some sort of coronary sinus catheters or something. Again, the robot component is from what the fellows tell me, not a problem/time consuming aspect.

 

[ESU_MD]

A good modern program with motivated and capable of teaching staff can have you doing open mitrals early.

The need for additional year of "super-fellowship" is indicative of innadequate primary fellowship using antiquated educational paradigms that is probably wasting fellows time and not actually employing medern training techniques and/or procedures.

the problem, at least in CT, is that there are only a handful of these modern programs dedicated to education. Even though I am skeptical about the concept, I think the combined 6 yr programs will probably have the most effective teachers, since they took the time to commit to applying, site review, etc..

As far as preferences though, it will be a very long time before robot or minimally invasive surgery becomes a standard for cardiac. The field cannot even agree that off pump should be a standard tool. In the end, surgical coronary disease is a life-threatening process and no one can be faulted for doing a gold standard, safe on-pump CABG. Much like in general surgery no one would fault someone for doing a colon cancer case via laparotomy.

the super-fellowship argument is very true- I think it also applies to general surgery training as well. Do you really need a superfellowship to do lap colons, or endocrine surgery? No doubt the system is broken. it just depends on where you train.

You do make some compelling arguments for the robot though... I bet you could make alot of money as a consultant for da vinci!

 

[SocialistMD]

I wanted to bring back up the topic of robotic surgery in light of a lecture given by our "main robotic surgeon" the other day. Basically, he admitted that the hospital will always lose $400/case if the robot is being used 100% of the time, more if it is being used less. He stated upfront that a hospital will never recuperate the cost of a robot (due to maintenance contracts, limited reuse of instruments, etc...).

He also showed a slide representing the number of robots in each country/continent. The United States has 1047. Europe (not an individual country, but the entire continent) is next with 270ish.

Let's see...

We are concerned with the rising costs of health care in our country.
We have 5x more robots than any other region in the world.
We lose at least $400 each time we use one.

Does this make any sense?

If you talk to hospital administrators about why they buy them, they will tell you the gain isn't made by use from those who know how to do the laparoscopic equivalent (i.e. prostatectomy), but rather it is when those who only know the open technique use the robot, as the costs reduce when one calculates the expense of an ICU stay eliminated, shorter hospital stay, less blood transfusions, etc... When the robot is compared to the laparoscopic procedure, there is no advantage to the robot with currently performed procedures (the only article I could find didn't show a statistical difference). The problem is, I don't think the "dinosaurs" are the ones using the robot- they continue to do the open procedure they've done for the last 20 years. It is the younger, laparoscopically-trained surgeon that is using the robot- a surgeon whose patients do not see the benefits of having a robot's assistance.

I'm not saying we should abandon what will most likely be the technology of the future, and I do think there are current advantages in the cardiac realm. I just think it is absolutely stupid of us to continue to dig a deeper hole (as surgeons) using something we don't need for a gain that isn't there.

 

[JackADeli]

I wanted to bring back up the topic of robotic surgery in light of a lecture given by our "main robotic surgeon" the other day. Basically, he admitted that the hospital will always lose $400/case if the robot is being used 100% of the time, more if it is being used less...

The "loss" of money is an interesting concept. It depends on how you slice and dice it and also how reimbursement/billing works. Keep in mind that in general the monies paid for a surgical procedure cover pre-op, operation (hosp, anesth, surgeon), and post-op care (hosp, surgeon). That is why they justify lower reimbursement for Lap chole over open chole and lap appy over open. The surgeon is often the one that looses because additional time they put in to do MIS procedures.

...He stated upfront that a hospital will never recuperate the cost of a robot (due to maintenance contracts, limited reuse of instruments, etc...)...

I wouldn't buy that sad tale by the hospitals. They use that to justify and try to contain robotic surgeons income. The truth is, they buy all these robots to make money. It is just as they say about general surgery, "you have to see 10 garbage ED consults to get one good operative consult". Except, those 10 garbage consults still make money for the hospital. A hospital that has a robot has a significant number of patients that show up, use hospital services for work-up/Tx (uro/gyn/onc/cards/radiology/etc...) and then are informed they are not candidates for the robot. However, they are now plugged into that hospital for the ongoing care.

...When the robot is compared to the laparoscopic procedure, there is no advantage to the robot ...It is the younger, laparoscopically-trained surgeon that is using the robot- a surgeon whose patients do not see the benefits of having a robot's assistance.

I'm not saying we should abandon what will most likely be the technology of the future, ...as surgeons... using something we don't need for a gain that isn't there.

Yes, most publications suggest no benefit to patient... and in general not inferior to traditional laparoscopy. The issue from my perspective is... is there a benefit to the surgeon? There is continuing publications of repetitive stress injury/arthritis/etc.. to MIS surgeons. We don't have any data yet. But, the robot situation is ergonomically adjustable and does not strain the surgeon because the patient has difficult habitus or the assistant surgeon heights are different, etc... I would say, yes spend money to save surgeons backs and wrists, etc...

 

[SocialistMD]

I wouldn't buy that sad tale by the hospitals. They use that to justify and try to contain robotic surgeons income. The truth is, they buy all these robots to make money. It is just as they say about general surgery, "you have to see 10 garbage ED consults to get one good operative consult". Except, those 10 garbage consults still make money for the hospital. A hospital that has a robot has a significant number of patients that show up, use hospital services for work-up/Tx (uro/gyn/onc/cards/radiology/etc...) and then are informed they are not candidates for the robot. However, they are now plugged into that hospital for the ongoing care.

That wasn't the hospital; that was the surgeon who said that when asked by one of the residents in the audience how long it takes a hospital to make back the money spent on the robot. The instruments are computerized and "lock-out" at 10 uses (brilliant on the part of Intuitive Surgical), the service costs are annual, etc...

We have 2 robots (a da Vinci S and an Si). We currently use one 100% of the time and one 30% of the time. The one we use 100% of the time loses $400/case, the other loses significantly more. I'm not going to argue those numbers with the guy who uses the robot most in our general surgery department and who is presenting to us to tell of the greatness that is robotic surgery.

I realize it will, in general, bring more patients to the hospital and ultimately bring more money to the hospital, as the hospital wouldn't do it if they weren't making money. However, it doesn't bring more money into the health care system in general. If there were no robot, the patients would still have their operation and it would be done in a way that is cheaper. We are doing operations at higher costs for no added benefits to our patients, and we are doing it more in our country than any other country. That doesn't make sense to me at all.

Having only peripherally played with a robot, I can't comment on the reduction in surgeon strain. Ask me again this time next year...

 

[JackADeli]

...how long it takes a hospital to make back the money spent on the robot. The instruments are computerized and "lock-out" at 10 uses (brilliant on the part of Intuitive Surgical), the service costs are annual, etc...
The one we use 100% of the time loses $400/case, the other loses significantly more...

As you understand based on the next quote, the surgeon is seperating based just on the procedure. That is an artificial and innacurate manner to look at it. But, it is the way the hospital wants the surgeon to look at it. Number of instrument uses has a great deal to do with the FDA allowing ~"disposable" instrument re-usage. Yep, intuitive couldn't have found a more profitable way other then government imposed waste.

...I realize it will, in general, bring more patients to the hospital and ultimately bring more money to the hospital, as the hospital wouldn't do it if they weren't making money. However, it doesn't bring more money into health care in general. ...We are doing operations at higher costs for no added benefits to our patients, and we are doing it more in our country than any other country. That doesn't make sense to me at all.

Yep, the bean counters accross the country know exactly how many additional patients added and associated services sold as a result of the robot presence. That is why small barely making it hopsitals drop $1-2.4 million for a robot instead of other capital expenditures.

Yes, there is higher costs. I am not sure the data is complete as to "no benefit". However, if no benefit to the patient, there may be benefit to the surgeons physical health. As for costs, the loss per case is based on unreal billing/pay systems. The patient does not pay more. In fact, reimbursement is often less then the costs of the equipment. This was the case with early laparoscopy. With time, we have plenty of papers showing patient benefit. However, the costs still remain excessive and are written off.

 

[SocialistMD]

As you understand based on the next quote, the surgeon is seperating based just on the procedure. That is an artificial and innacurate manner to look at it. But, it is the way the hospital wants the surgeon to look at it. Number of instrument uses has a great deal to do with the FDA allowing ~"disposable" instrument re-usage. Yep, intuitive couldn't have found a more profitable way other then government imposed waste.


Yep, the bean counters accross the country know exactly how many additional patients added and associated services sold as a result of the robot presence. That is why small barely making it hopsitals drop $1-2.4 million for a robot instead of other capital expenditures.

I think you are misunderstanding my point; it was never to argue from the hospital perspective, but rather from the health care system of our country. A loss is a loss. Yes, it is financially beneficial to the hospital to have a robot, as they will draw patients who would have had their procedure at community hospital X down the road without a robot. However, to the medical system at large (not just a specific hospital), the patient would have had that procedure with or without a robot. If they don't "qualify" for the robot, then the cost is a wash. If they do have a robotically-assisted procedure, the system is out $400.

As for costs, the loss per case is based on unreal billing/pay systems. The patient does not pay more. In fact, reimbursement is often less then the costs of the equipment.

Exactly. It isn't the patient that eats the cost, it is the system. There is only so much money in the pot. If a hospital with a robot is taking patients who do not have an operation with the robot (thus generating positive revenue) from smaller hospitals, the smaller hospital's profit margin drops, and the hospital with the robot isn't making as much money as they would be with the same number of patients and no robot. Everyone loses financially, maybe not by net dollars, but definitely by dollars/RVU.

Yes, there is higher costs. I am not sure the data is complete as to "no benefit". However, if no benefit to the patient, there may be benefit to the surgeons physical health... This was the case with early laparoscopy. With time, we have plenty of papers showing patient benefit. However, the costs still remain excessive and are written off.

We'll see. I don't think the patient benefits we'll see will be with most of the procedures currently being performed (but rather with the potential uses of the robot; again, I'm not anti-robot, I'm just concerned with the current way we use it in the current state of health care), and I'm not sure future generations of fat-assed surgeons (from sitting at the controls instead of standing at the bedside) will be any better of a trade-off for the carpal tunnel that may or may not be lessened (as the hand controls of the robot require hand movements/positions that remind me a lot of those found with laparoscopic surgery).

 

[JackADeli]

...to the medical system at large ...a robotically-assisted procedure, the system is out $400.
...It isn't the patient that eats the cost, it is the system. There is only so much money in the pot...

Yes, but the system is designed to not allow additional funds to come into it. If you had a system in some respects like India (or elective cosmetic implants).... surgical care is a la carte. You want high end tech, then you pay high end tech costs. Otherwise you get garden variety with standard/traditional scars and care. We have a social justice system in which folks are told they should have access to the most cosmetic apealing and advanced technology surgeries. People cry how unfair it is that they can not afford the expensive robot. So, the "money in the pot" is capped. If folks paid for the more advanced, some would choose to pay more... bringing in more funds into the system. Some would go for the discount. In either case, you decrease any over all losses.

...I'm not anti-robot, I'm just concerned with the current way we use it in the current state of health care, and I'm not sure future generations of fat-assed surgeons....

agreed.