Enough with the Anti-Robot Rhetoric!
The following is a letter to the editor of General Surgery News from our very own David Coster, MD, FACS, FASMBS. This letter has been reprinted here with the express consent of the author. The original letter can be found here.
As a surgeon and early adopter of robotic surgery some 10 years ago, I am having an increasing problem in tolerating the rhetoric of the invented controversy over “laparoscopic” versus robotic surgery. In our hospital, robotics is used around the clock and on weekends as needed. All OR staff know how to do the setup, and it is used judiciously for appropriate cases, of which we have now done thousands in general surgery.
"Robotic surgery “is” laparoscopic surgery, but with a better set of instruments. So what is the basis of any argument against using a better tool?"
The robot is a laparoscopic technology that allows the surgeon to control each instrument; there is no longer any need for a “camera operator” or an assistant to hold something. There is no reason to expect that robotic laparoscopic surgery would be any “better” than regular laparoscopic surgery in regard to the usual outcomes. It doesn’t have to be; it only has to be as good.
Where robotic surgery “is” better—and demonstrably so—is in cases that could otherwise not be done by minimally invasive techniques, that is, the most complex types of surgery that one could only hope to perform laparoscopically and those procedures that eventually are converted from regular laparoscopic to open because the laparoscopic technology does not offer the range necessary to complete the case successfully. Here there is a clear advantage to robotic surgery, but no one is bothering to talk about it.
You cannot tell me that successfully avoiding open surgery is of no benefit to the patient. In my practice, I do a lot of complex procedures in patients who have had many other operations, and it is in this patient population that the robotic approach really shines. In addition, robotics offers advantages for the surgeon in every possible way: visibility, exposure, technique, ease of use and comfort for the operator. Since when does the surgeon experience not count as a “measurable outcome” for comparison? Being better for the surgeon is no small thing, as this has never occurred in the past with any new technologies. One can see things better, and often things that would have gone unnoticed with regular laparoscopy; one can manipulate better and perform the operation with more finesse and less tissue damage; one can be more certain of the quality of their work when using robotic technology.
Robotic laparoscopic surgery is still laparoscopic surgery, but with a better tool. It’s time for surgeons to stop setting the bar at whether or not patient outcomes are better, as all they have to be is the same. Why? Because the process for the surgeon, for once, is better. No longer does one have to suffer to complete a laparoscopic operation; rather, it can be completed with ease, aplomb and a certainty of perfection that was previously not possible.
"Those who think robotic surgery is going to go away are wrong."
Many of us do nearly all of our procedures these days robotically, and we have a much nicer day as a result. The costs will go down as the approach becomes the norm, as it inevitably will. As with the controversy of laparoscopy versus open surgery in the 80s and 90s, this controversy of laparoscopy versus robotic laparoscopy is tied to the fear of being left behind. I would suggest a healthier approach to robotics is simply to add it to your skill set so you have it when you need it for difficult cases where such technology is not just a perk but a requirement.
David Coster, MD, FACS, FASMBS