« POINT & COUNTERPOINT »
Is the hype surrounding robotic surgery for treating some cancers legitimate, or are opinions influenced by over-eager sales teams? Read one side of the argument below and then click here to read an opposing opinion from Dan Neel. Read more
As a surgical oncologist who performs a large volume of colorectal surgery, I have adapted to robotic resections in select situations. I do not feel there is a role for this technique for standard colon resections, as both right and left colectomies can be performed using standard laparoscopic techniques, with fewer incisions than the robot and with a decreased cost. That being said, there is no doubt that robotic resections have increased in urologic oncology, gynecologic oncology, thoracic oncology, and surgical oncology. As technology for single incision surgery improves, trends in robotic general surgery will likely increase.
In my experience, I have found a subjective benefit in patients with low rectal cancers requiring a total mesorectal excision with either a low anterior resection or an abdominoperineal resection.The robotic instruments definitely provide improved dexterity, with increased degree of motion and articulation over standard laparoscopic instruments.The improved visualization provides increased fine dissection in the pelvis and improved visualization of the pelvic nerves.
Jeffrey M. Farma, MD
There are, of course, limitations as described in the article. However, there is the constant balance of technique, technology, safety, and cost in surgery. Are the robotic era and arguments supporting the technology the same as laparoscopic arguments that occurred in the 1980s? With any new technology there clearly has to be safety oversight and one must rely on the confidence and decision-making of the surgeon. The technology does not compensate for poor decision-making or operative skills. At high-volume centers there is little increased time with a robotic procedure as compared to laparoscopic or open resections once you have moved past the learning curve phase. The cost of the system is an ongoing issue; as with any new technology, with increased competition in the field and time, the costs should continue to decrease. That being said, with the increasing cost of health care, it has yet to be determined where robotic surgery will ultimately end up.
Having been trained on the robot and having dealt with local sales representatives, I have not received or seen any luxury treatments or aggressive tactics. Like all sales representatives for any surgical companies, they are interested in surgeons trying out their newest instruments and technology. Regarding the liability of the cases, it is unclear to me if this is misuse of the technology or related to understanding, adequate training, and appropriate use of the technology by the surgeon.
In terms of outcomes related to robotic colorectal surgery, there have been no large randomized trials to date. Currently, published research is either retrospective or prospective single-institution studies. ACOSOG Z6051, which has almost completed accrual, will help to answer the oncologic equivalency of minimally invasive surgery (laparoscopic and robotic) for rectal cancer compared with open proctectomy. I feel that the robot provides instrumentation that is more instinctual, the operative position is more comfortable, and the visualization is improved. There needs be more research into the long-term outcomes and quality of life in patients who have undergone robotic resection in all disciplines. With all of the changes in health care, there will be continued scrutiny of all technological and medical advances balanced with the cost of care and overall outcomes for patients, and this is not unique to robotic surgery.
Read an opposing opinion from Dan Neel in the Point portion of this Point & Counterpoint.