Society of Certified Senior Advisors: Should a Robot Do Your Surgery?

Robotic surgery does have advantages, but they may not be the ones you think it has.

As more and more medical centers are investing the $2 million or so needed for a robotic surgery system in an operating room, patients are often faced with a choice: Should I have my surgery done by a surgeon alone, or in concert with a robot?

A common misconception is that “robotic surgery” involves allowing a pre-programmed robot to carry out a surgical procedure. In fact, a trained surgeon is in control at all times, using a high-definition, 3D camera and miniaturized instruments inserted via one or more small incisions to make intricate moves guided by the surgeon’s hands at a console. The robotic equipment does not “think” on its own at any time.

While robotic technology is not currently used in every situation, it can be employed in the following types of surgery:

Colorectal
General
Gynecologic
Heart
Endometriosis
Head and Neck
Thoracic
Urologic

Traditional surgery is either laparoscopic, performed through small incisions, or open, performed through one large incision. Either way, the surgeon needs room to manipulate instruments with his or her hands. Robotic instruments take up less space, reducing the need to push muscle and tissue aside.

Advantages

Surgical centers cite a long list of advantages to using a robot, starting with more precise surgery due to the enhanced visualization the camera provides, and the range of motion achieved in tight spaces. Surgeons can perform more steps of an operation inside your body, when traditional surgery would have them making a larger incision to work outside of your body. Benefits also include:

Fewer complications during surgery
Reduced risk of infection
Shorter hospital stay
Fewer blood transfusions and less blood loss
Reduced pain during recovery
Quicker recovery
Smaller scars

Disadvantages

The equipment to perform robotic surgery is very expensive, in part because it is dominated in the US by a single company, Intuitive Surgical. Surgeons need special training on the equipment, and robotic surgery fellowships are becoming more common, but these surgeons are limited in number. There are also dangers to the patient, which include:

Your surgeon may need to switch to a large incision and traditional surgery if there are complications. This can include scar tissue from previous surgery.
Nerve damage and compression.
Longer time spent in surgery.
Robotic malfunction. This is extremely rare. There are a variety of safety measures - to prevent this from occurring.

Another downside to robotic surgery is the higher cost. One recent study found an average total hospital cost of $15,319 for patients in a robotic surgery group versus $8,955 for patients getting traditional laparoscopic surgery. However, patients may benefit financially from the reduced cost associated with a shorter hospital stay.

Surgical Outcomes

Robotic surgery is often perceived as “better” than traditional methods. Surgeons often assume that the shorter recovery time and other benefits result in a better outcome for patients. However, according to a recent review of 50 randomized control trials for abdominal and pelvic procedures published in the Annals of Internal Medicine, outcomes for both are nearly identical.

For instance, eight of the reviewed studies listed long-term outcomes of two years or more. Patients died in up to 3 percent of robotic surgeries, up to 5 percent of open procedures, and there were no deaths listed from laparoscopic surgeries. Looking at 39 studies that reported the number of surgeries that required further surgical intervention due to complications, the report found they were needed in up to 9 percent of laparoscopic procedures and in up to 8 percent of robotic surgeries.

“Just because something’s new and fancy doesn’t mean it’s the better technique,” says lead author Naila H. Dhanani, a surgical resident at UC Health in Houston. “Yes, robotic is safe, we’ve proven that. But we haven’t proven it’s better. There were four studies that showed a benefit with robotic surgery, so that’s quite modest. Forty-six showed no difference at all.”

The study may highlight a truism that has long been held. James A. Eastham, chief of urology at Memorial Sloan Kettering Cancer Center and not involved in the study, noted that “it is far more important to select an experienced surgeon with specialization in a particular field rather than picking a technique.”