Surgical procedures performed using a robot are sometimes marketed as the “best” form of surgery. But a recent review of 50 randomized controlled trials comparing robotic-assisted surgery to conventional methods of abdominal or pelvic procedures suggests that while there may be some benefits to robotic surgery, all the benefits over other approaches are modest.
Robotic surgery is performed by surgeons, not robots. But instead of conventional hand tools used in laparoscopic surgery, which involve small incisions, and open surgery, where the surgeon enters the body through a large incision, the doctor uses a machine. The surgeon remotely controls the machine’s instruments using joysticks and foot controls while viewing the surgical site through a high-definition monitor that provides a three-dimensional view of the procedure.
Some surgeons believe that these robots allow for greater precision during surgery, a shorter recovery time and overall better clinical outcomes for patients. But the review found that the compared results of the robotic and conventional procedures showed little difference in many respects.
For example, in 39 studies reporting the incidence of complications requiring further surgical intervention, up to 9 percent of conventional laparoscopies led to such problems, but so did as many as 8 percent of robotic surgeries. In studies of gastrointestinal surgery, life-threatening complications ranged from 0 to 2 percent for robotic-assisted surgery, from 0 to 3 percent for laparoscopy, and from 1 to 4 percent for open surgeries. The findings were published in Annals of Internal Medicine.
For various reasons, robot-assisted or laparoscopic surgeries sometimes don’t work and the surgeon has to switch to open surgery. In total, this happened up to 8 percent of the time in robotic surgeries and up to 12 percent in laparoscopies. In urologic and gynecological surgeries, there was virtually no difference between robotic-assisted surgery and laparoscopies in the number of surgeries that had to be switched to open procedures.
In eight of the reviewed studies, long-term results of at least two years were reported and they found that mortality rates for all three techniques were comparable. Patients died in up to 3 percent of robotic surgeries and 5 percent of open surgeries. There were no deaths from laparoscopic procedures.
The researchers did find some time differences between the procedures. In short, robot-assisted operations generally take longer. In studies of gynecological robotic surgery, the duration ranged up to 265 minutes, compared with maximums of 226 minutes for laparoscopy and 187 for open procedures. In both urologic and colorectal surgeries, robot-assisted surgeries consistently took longer than comparable laparoscopic and open surgeries.
The lead author, Dr. Naila H. Dhanani, a surgical resident at UT Health in Houston, said there is no reason for a patient to choose robotic surgery over other modes.
“Just because something is new and fancy doesn’t mean it’s the better technique,” she said. “Yes, robotics is safe, we have proven that. But we haven’t proven it’s better. There were four studies that showed a benefit to robotic surgery, so that’s pretty modest. Forty-six showed no difference at all.”
dr. James A. Eastham, chief of urology at Memorial Sloan Kettering Cancer Center, who was not involved in the study, agreed.
“No one will contradict the primary conclusions,” he said. “The intraoperative complications and postoperative outcomes are similar regardless of the surgical approach. It is much more important to select an experienced surgeon who specializes in a particular field than to choose a technique.”
But there are certainly practical benefits to the surgeon. Operations can take hours and conventional procedures require the surgeon to stand, bend, twist and turn to position the instruments correctly. Not so with a robotic procedure.
“There’s this ergonomic advantage,” said Dr. Gerard M. Doherty, chief surgeon at Brigham and Women’s Hospital in Boston, who did not participate in the study. “We move the robot’s arms while sitting comfortably. I have a surgeon who told me it would extend his career by a decade.”
But robotic surgery is more expensive than other methods. The initial cost of the machines, the disposable instruments they require, the contracts to maintain the devices, and the extra time spent in operating theaters make them so expensive that many hospitals cannot use them. The average initial cost of a robotic installation is approximately $2 million.
Even in large healthcare centers, robots have their limitations. “We have 64 operating rooms and only four of them have robots,” said Dr. doherty.
One company, Intuitive Surgery, which makes the da Vinci robots, has such a dominant market presence in the United States that they have essentially no competition, and this could be a factor in keeping prices high. But maybe there will be more competition.
“I’ve seen robots made by other companies,” said Dr. doherty. “Everyone hopes that if someone can introduce a new platform, prices will come down. But we’ve been saying that for ten years. Intuitively has been quite aggressive in keeping their market going.”
Anyway, according to Dr. Eastham is the future of surgery robotic. “Despite the lack of evidence that robotics is ‘better’ than real laparoscopy or open surgery,” he said, “there is no doubt that the shift to robotics has already taken place in the US.”