Discussion as to whether Australia should follow suit is alive and well. A debate at the recent Australasian Gynaecological End-o-s-copy and Surgery Society’s (AGES) annual scientific meeting discussed “that robot-assisted laparoscopy will replace conventional laparoscopy”.
The affirmative team gleefully derided its opponent for attempting to deny the robot its rightful place as the future of surgery in Australia. The opposition indignantly — and correctly — pointed out the lack of robust clinical data to justify the robot’s cost. The audience voted overwhelmingly in favour of the robot… but were they voting on the likely future of surgery in Australia, or the brazen, though entertaining, crowing of the robot zealots?
The FDA approved the da Vinci Surgical System in 2000 and the parent company, Intuitive Surgical, is now a booming multi-billion dollar company. There are more than 2100 surgical robots in clinical use in the US with more than 5000 surgeons accredited to perform robot-assisted surgery over the last 15 years. In Australia there are currently 21 robots (four in public hospitals) and about 150 accredited robotic surgeons.
One of the most common robotic procedures is benign hysterectomy, essentially a robot-assisted laparoscopic procedure.
Indeed, the uptake of robotic hysterectomy in the US has been nothing short of spectacular, increasing from 0.25% in 2005 to more than 30% in 2013. It is now more commonly performed than each of the abdominal, vaginal and conventional laparoscopic routes. The increase in robotic hysterectomy has been largely at the expense of total abdominal hysterectomy (TAH).
Despite this promising trend away from laparotomy, a statement on robotic surgery by the American Congress of Obstetricians and Gynecologists (2013) concluded “there is no good data proving that robotic hysterectomy is even as good as — let alone better — than existing, and far less costly, minimally invasive alternatives” (namely vaginal hysterectomy [VH] and total laparoscopic hysterectomy [TLH]).
The accepted advantages of VH and TLH over TAH include smaller incision(s), reduced postoperative pain, shorter hospital stay and quicker recovery, with an associated reduction in hospital costs. These advantages can also be ascribed to the robotic hysterectomy. But, at about $2 million per robot, annual maintenance costs of $200,000 and instrument fees of $2000 per hysterectomy, what advantages does robotic surgery offer to justify this cost?
There is no question the surgical robot is a magnificent technology, the console providing an exquisite view of the surgical field, magnified x10 and in high-definition 3D stereoscopic vision.
The wrist and finger gestures of the surgeon at the console are faithfully reproduced by robotic-controlled instruments within the patient’s abdomen. Surgeon tremor is essentially eliminated, and the surgeon can perform complex surgeries while seated comfortably at the console. But for benign hysterectomy in Australia, are these advantages enough?
Furthermore, the robot is a surgical tool and, despite its advantages, its utilisation cannot be considered in any way a replacement for established surgical training.
Addressing this issue, RANZCOG’s Position Statement on Robot-Assisted Surgery (2013) concludes “gynaecologists should not perform robotic-assisted surgery until they have reached appropriate skill levels in advanced operative laparoscopy”.
The Australian ‘surgical herd’ is nervous about the almost inevitable arrival of the robot. Whether it can be afforded and also improve clinical outcomes are different matters altogether!