The dangers of robotic surgery

Tuesday, April 04, 2017 Stef dela Cruz, MD 0 Comments

“Gone [are the times when] surgeons had no choice but to open up patients,” said Dr. Michael Dennis dela Paz, currently part of a minimally-invasive surgery program in the Philippines. We have come to rely heavily on technology and robots, even in matters of life and death.

robotics surgeryUsing robots in surgery: an accident waiting to happen?

While moving forward in the field of surgery may require robotics, it is not without its drawbacks. How dangerous is robotic-assisted surgery exactly?


Why we like robots in surgery

“Through minimally-invasive surgery, we [have a] less harmful approach to abdominal, thoracic, gynecologic, urologic, neurologic, solid organ, orthopedic, and many [other types of surgery]. Studies have shown it is beneficial with less post-operative pain, faster recovery, and superior cosmetic outcome, hence the better quality of life of patients.”

A more recent type of minimally-invasive surgery is robot-assisted surgery, often nicknamed robotic surgery, which uses a DaVinci Machine to perform complex procedures with more precision, flexibility, and control than is possible with conventional techniques.

“The advantage of this modality is that the machine filters [a surgeon’s] tremors, so movement becomes smoother and finer. The [machine] has all the freedom of movement of [a surgeon’s hand] – it’s as if you are operating with your actual hands, unlike in laparoscopy where [you can only go] up, down, left, right, and rotate.”

“In contrast to laparoscopy where there is just one lens, robotic surgery uses two lenses to give you a three-dimensional view of the operative field,” said Dr. Julius Cajucom, head of The Medical City (TMC) Robotics Surgery Program.

“There is wrist movement, unlike in laparoscopic surgery. This will be very useful for obese patients and also in procedures that involve tight or narrow spaces, such as the pelvic cavity,” said Dr. Cajucom.

What would have been an incision several inches long could be as small as 1.5 centimeters, with the help of robots.


Why we don’t like robots in surgery


As is the case with all novel tech applications, robot-assisted surgery has its drawbacks and limitations. “Not all patients are [good] candidates for this surgery. Not all surgeons are skilled [to do it],” said Dr. dela Paz.

“In general, minimally-invasive surgery was initially not [well-accepted] even in countries where it originated because of the new skills it required. You have to operate indirectly using instruments, [which have] a lot of limitations: Without haptic feedback, you can’t feel what you’re doing.

“There was no formal training at the time, so most of those who tried it gained their insight through observership or short-course workshops. When they used the modality initially, they had a lot of significant complications, such as iatrogenic injuries for patients, and ergonomics-related hand and body pain for surgeons.”

“Adverse events include technical issues, such as when the instrument isn’t working properly, and burns,” said Dr. Kristine Katimbang, a gynecologic surgeon at TMC.

The cost of robotic surgery is also one of the most compelling reasons why people might not enjoy its benefits: It is about two to three times more expensive than traditional surgery. “Compared to open surgery, there’s a big difference [in terms of cost],” said Dr. Katimbang. “It’s just like laparoscopic surgery when it first started. We are hearing the same comments now about robotic surgery, about how it’s really expensive.”

But is it worth it? “There are no direct studies about costs, but just consider the costs of pain management, hospitalization, and infusion [in traditional surgery],” said Dr. Enrique Ian Lorenzo, a urologist specializing in laparoscopic and robotic surgery.


Burden of proof

According to a 2015 statement by the Committee on Gynecologic Practice of the Society of Gynecologic Surgeons, recent trends in robotic surgery, especially in gynecology, are not supported by evidence.

The American Urogynecologic Society supports the above committee opinion.

Existing literature does not indicate any definite benefit in terms of disease outcome and patient safety. Studies abound but because they are mostly observational or retrospective, they do not provide solid evidence to support the shift towards robotic technology in surgery.

“I tend to agree with [the statement] but it has to be looked at in context,” said Dr. Francisco Roxas, chairman of the Department of Surgery at TMC. “For instance, hysterectomy can be done via open, laparoscopic, vaginal, and robotic surgery. If you were to compare experts on all these, you might not see a difference. But you might notice scars, adhesions, hernias, and pain [in traditional procedures] that you wouldn't see in small incisions.”

“With robotics, at least it will feel like [surgeons] are operating with their hands. I can’t see surgeons doing the same thing in minimally-invasive surgery without robotics.”

DaVinci surgeryThe DaVinci Machine: a feat of technology… and the topic of much controversy in surgery.

While some doctors demand proof, others grant robots the benefit of the doubt. After all, optimism provides hope in progress.

However, skepticism – including the demand for proof that comes with it – elevates medicine to a higher standard.

In a field grounded on science, evidence defines the endgame. As we wait for substantial proof, we cross our fingers and pray that man’s trust in robots during surgery is justified, just like we do when we’re watching a Terminator flick.

In case you haven’t read Part I:
Why robots rule the world (of surgery)

Stef dela CruzAbout the blogger
Stef dela Cruz is a vegan doctor and writer. She received the 2013 Award for Health Media from the Department of Health. She is the editor of The Manila Bulletin's Animal Scene Magazine. Get in touch if you want to invite her as a speaker!