July 16, 2013 By 

In 2009, I performed my first robotic operation for pancreatic cancer. Back then, it seemed unimaginable – a futuristic technology that required a great deal of explaining to bewildered patients. Today, robotic liver and pancreatic surgery has become routine in my practice, and many patients actively demand it. Thanks to the lightning speed with which the Internet shares medical advancements, robotics have sped from obscure space technology to mainstream tool, routinely used for urological, gynecological and cardiovascular procedures.

The advantage of robotics is that its complex computer-assisted technology allows translation of a surgeon’s hand movements into corresponding micro-movements of instruments inside the patient’s body. My history as a pilot made this immediately appealing: The fly-by-wire systems resemble those used in the modern fighter jets. A double camera incorporated into robotic visualization allows the physician to see the operative field in 3D, eliminating the limitations of depth perception so common in laparoscopy. The system’s ability to eliminate the doctor’s hand tremor lays path to more precise technique, less bleeding, and ultimately better results.

Many critics argue that the same procedures could nevertheless be successfully performed using conventional laparoscopy. There are other reasons for resistance as well: The learning curve is steep, the training required is intense, and certain cases still have to be initially performed under qualified proctor supervision. Further, there is no question that evidence-based studies and more scientific research is desperately needed to justify new robotics procedures, improve safety, and to allow more widespread support and implementation. These are all valid concerns.

However, for patients there are serious advantages that make me think demand will continue to increase. Patients can, for instance, undergo a heart bypass surgery and valve replacement, and completely avoid the painstaking healing of median sternotomy incision. Those with primary or metastatic liver cancer can have one lobe of the liver removed robotically and be home in 48 hours, letting them start chemotherapy the following week without giving any chance for cancer to relapse. People with pancreatic tumors can experience faster recovery, less overall pain, practically no incidence of incisional hernias, and great cosmetic results.

There’s also something for the surgical safety on our end. As a liver doctor I often operate on patients with hepatitis C. The risk of accidental needle stick and infection or at the very least taking preventive treatment is always looming in my mind. Being separated from the patient at the robotic console significantly reduces these dangers.

Costs are still high. The typical robotic system costs $1.75 million, and when additional modules are purchased, the unit price can be as much as $1.9 million. In addition, maintenance contracts run generally around $150.000 a year. Is this worth the money? The question is complex. Generally, the cost of the average procedure is higher per case than a traditional approach, but the reimbursement rates for robotic procedures are still strong, and the decreased length of stay for patients allows hospitals to make a business case for purchase. In addition, patient satisfaction and hospital reputation come to bear. Hospitals that support robotic programs tend to attract talent in every field and have more developed specialty and ancillary services. These measures – along with proper marketing – can result in more patients coming for treatment and improvement of overall bottom-line.

Robotics is still a new and emerging field, and multiple advancements are on the horizon. I suspect that because several new systems are being developed for general, vascular, and specialty surgery applications, technologies will continue to improve and prices will continue to drop – with great speed. Most tellingly, from my own experiences, those who’ve embraced robotics and passed the initial hurdle of training are rarely looking back.

Dr. Dmitri Alden (Twitter: @LiverSurgeryNY) performs liver and pancreas surgery at Lenox Hill Hospital in New York City. The author of multiple publications on liver and pancreatic surgery, Dr. Alden is a frequent speaker at international forums on the subject of liver, pancreatic, and robotic surgery.


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