Robotic surgery and limitations

Abstract

A decade after the approval of the Da Vinci Surgical System (DVSS) by the US Food and Drug Administration (FDA), evidence of its superiority with respect to safety and efficacy for selected types of surgery compared with conventional laparoscopic surgery (CLS) has been accumulated. The potential advantages of the DVSS over CLS include its greater precision, lower error rates, reduced bleeding, shorter hospital stays, more rapid patient recovery, and reduced pain. As a result many surgeons have begun to use the DVSS in daily practice for a wide variety of surgeries, including general, oncological, urological, gynecological, and cardiothoracic [1]. However, because robotic surgery is still in its early stages, comparativeeffectiveness research (CER) evidence is scarce, and costs must be considered in an economical crisis [2], a more critical approach is required [2]. Robotic surgery may not be suitable for specific types of surgical procedures. A paradigm of potential limitations of robotic surgery was published by Scozzari et al. [3] in the February issue of Surgical Endoscopy. Given the difficulties with traditional laparoscopic surgery for morbidly obese patients, the authors thought to use the DVSS to improve the outcomes of these patients. Data from 110 morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass with robot-assisted hand-sewn gastrojejunal anastomosis using the DVSS (DVSS group) were compared with data of 423 patients who underwent standardized CLS group. The patients had a mean weight of 127.5 kg and a mean body mass index (BMI) of 46.7 kg/ m. There were statistically significant differences in favor of the CLS over the DVSS group with respect to the operative time (P \ 0.001) and the cost per patient (P \ 0.001), whereas no differences were found in terms of the intraor postoperative complication rates, revision surgery, or hospital length of stay. The authors concluded that although robot-assisted surgery was safe and intuitive, it did not seem to provide a real advantage over standard laparoscopy in terms of hospital length of stay and complications rates. This study suggests that the use of the DVSS may be indicated for some specific organs and anatomical areas, while it may not be superior to CLS for other disorders and locations. Minimally invasive surgery such as laparoscopyor robot-assisted surgery also has important implications in surgical oncology for a variety of solid tumors. For example, laparoscopic surgery has been the standard approach for colon cancer and promising data have been available for its use in other gastrointestinal cancers, whereas evidence is increasing for the superiority of robotassisted surgery for rectal cancer [4–10]. The age of robotic surgery has dawned and there is still a lot of improvement to be made in the near future. For example, robotic surgery for prostate cancer or rectal cancer is new and has its own learning curve to be overcome. If we remind ourselves of all the debates brought by each new innovative technology, such as laparoscopic surgery, on its first appearance, we believe that further intensive and largescaled studies will answer the upcoming questions about the safety and efficacy of robotic surgery. Translating innovative ideas and concepts into medical practice suggests a key driver to improve health care. However, costs should be considered. A prime paradigm of how costs can drastically be reduced is the competition between biotechnology and pharmaceutical companies and academia regarding next-generation sequencing technology. C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt am Main, Germany e-mail: info@gastricbreastcancer.com