Robotic-assisted surgery is being used in an increasing fashion in several areas of surgery. In rectal cancer for example, robotic surgery has better oncological results than laparoscopic surgery. Areas like bariatric surgery, colonic resection, and even hepatic surgery are being performed with robotic assistance. Is this the future? I believe it is. Do we have money for it? I am not sure.
In Portugal robotic is already being increasingly used. It was with great enthusiasm I assisted a webinar last month about robotic surgery organized by “Excelência Robótica” and moderated by Dr. Carlos Vaz (“Hospitais CUF” - Lisbon) and Dr Nuno Figueiredo (“Fundação Champalimaud” - Lisbon). Good lectures about robotics in bariatric surgery, colorectal surgery, abdominal wall hernia and liver surgery were given. Impressive to see the advances in hepatic resection with robotics performed and presented by Prof. Dr. Hugo Pinto Marques from “Hospital Curry-Cabral” in Lisbon. This is the front-line of surgery. Well done.
It is known that robotic surgery makes surgical movements easier to perform and has better oncological results in rectal cancer surgery. Additionally, one important idea and advantage presented by the lecturers of that webinar was the physical benefit for the surgical team. With robotics it is possible to avoid a bad posture during surgery and with that a longer physical and psychological resistance will arise. Will this have impact in the final outcomes? Probably. For me (unfortunately without experience in robotics) the only major disadvantage of robotic-assisted surgery is the price. Will this be overtaken in the future? Hope so.
I believe robotic-assisted surgery is the future. Many procedures can be performed with the help of the robot. Cholecystectomy might be one of them. Since the first laparoscopic cholecystectomy in 1987, the minimally invasive approach become the gold standard. An increase in postoperative complications was reported with the introduction of laparoscopic cholecystectomy. Even though, laparoscopy makes cholecystectomy easier to perform, providing a better visualization of structures because of an easier access. Nowadays it has better outcomes and has decreased costs comparing to open surgery. How about robotic-assisted cholecystectomy?
Dr. Esteban Aguayo et al. from Los Angeles published their results on trends, outcomes and factors associated with the use of robotics in cholecystectomy. They analyzed more than 3 million patients submitted to cholecystectomy in the US because of benign gallbladder disease. Laparoscopy was used in 98,7% of patients while robotics was used on 1,3%. Interesting to see that in 2008 robotics was used in 0,02% and in 2017 3,2% of patients were operated using robotic-assisted surgery. There is an obvious trend to increasing use of robotics (p<0,001).
The authors also analyzed outcomes: mortality, complications, costs. According to their study mortality and postoperative in-hospital days were similar in both laparoscopic cholecystectomy (LC) and robotic cholecystectomy (RC). Interesting to know is that overall complications were more frequent in RC group (15,5% vs 11,7%, p<0,001). However, a greater proportion of patients submitted to RC had greater burden of comorbidities (Tokyo Grade III severity of disease, p<0,001), which may justify the difference. RC was associated with increased costs of treatment, but the “disparity of costs between RC and LC decreased during the study period”.
Overall complications’ rate was higher in RC, including gastrointestinal complications (bowel injury, obstruction, sphincter dysfunction, post-cholecystectomy syndrome). The increased duration of surgery is pointed by the authors as a possible reason for these results. Even though, the difference was only slight. For me it is not easy to understand this difference, and no other factors are pointed by the authors. Why should RC have more complications than LC? Most complications during minimally invasive cholecystectomy occur during trocar placement, and trocars in RC are placed in the same way as LC, I think. Is the lack of expertise in RC the reason for the slight increase in complications? Remember that an increase in complications was reported with the introduction of LC. I do not find any reason why RC should have more complications. This will probably be demystified with more studies.
One interesting idea presented by the authors is the fact that the choice of RC is dependent of both patient and surgeon preferences. Is not this true for all surgical techniques? Should not be the surgeon preference and expertise one important factor for choosing surgical technique? On the other hand, the surgeon should be updated and able to offer the patient with the best surgical treatment. Will this update be possible in worldwide public health-care services? Till now, at least in Portugal, doctors update is entirely supported (payed) by doctors themselves. This must end...
The most important idea from this paper is the increasing use of robotics to treat benign gallbladder diseases. In the US, urban and teaching hospitals are associated with that increase comparing to the rural hospitals. Is this happening in Portugal? Although robotic-assisted surgery is increasing in Portugal (mostly in private hospitals), investment in this new technology is not being made. In fact, Portugal is lacking public investment in health-care service, reason why no robot has been bought by the Portuguese Government. As Dr. Carlos Vaz said last month in the “Excelência Robótica” webinar, Portugal should have a robot in the biggest university hospitals. On the contrary, the only robot available in a Portuguese public hospital has been an offer. Politicians are not investing in health-care service for a long time. They should be ashamed.
In conclusion, I believe robotic-assisted surgery is the future in many fields of surgery. It allows for a good visualization, wider movements, easier to perform several surgical steps, and avoids bad posture of the surgeon (better comfort better results). This report from Los Angeles comparing RC to LC concludes for the same mortality and in-hospital days, but higher complications’ rate. Complications were slightly higher in RC, but patients had more comorbidities. On the other hand, I believe outcomes will be the same as expertise in RC increases. I see no reason why it should be different.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon