In medical school, I watched a robot remove a woman’s uterus. The machine reminded me of a spider, but its arms held scissors, forceps, and a tissue grasper. The surgeon operating the machine made a few centimetre-long incisions in the patient’s skin and placed the instruments, along with a small camera, inside her body. Then, she moved to the other side of the room and controlled the robot’s movements using a video-game-like console. To my untrained eye, it was like watching science fiction.
Not long ago, doctors used robots mainly for gynecologic and urologic surgeries, but over the past decade robots have become popular for all kinds of operations. Now we use them for surgeries on the head and neck, the heart, the digestive system, and more. In the field of general surgery, which focusses on abdominal operations, the number of robotic procedures rose more than fivefold between 2011 and 2013.
It’s easy to see the appeal. Traditional open procedures typically involve big incisions; robotic surgeries leave impressively small scars. The use of robots has been linked to less blood loss, less pain after surgery, and faster recovery. Laparoscopy, an older form of minimally invasive surgery in which the instruments are attached to long poles that a surgeon holds outside the body, can also deliver these benefits, but some doctors have found that robotic surgery is easier to master, since laparoscopic instruments can be difficult to maneuver in small spaces like the pelvis.
Still, there’s a lot that robots can’t do. They don’t guarantee better outcomes. For patients who need surgery to treat cancer, a robotic approach doesn’t necessarily provide more effective treatment; many studies suggest that laparoscopy and open surgery offer similar rates of disease recurrence and survival. Nor do robots improve surgeons’ skills. Dr. Julio Garcia-Aguilar, who is the chief of the colorectal service at Memorial Sloan-Kettering Cancer Center, in New York, and who performs robotic surgery, told me that the proficiency of the surgeon matters more than the approach. “I’d rather have short-term discomfort and long-term benefits with a good open surgeon than less pain this week and the tumor back in a year,” he said.
There are also risks associated with using a robot. In March, 2013, the Massachusetts Board of Registration in Medicine issued an advisory to the state’s physicians after receiving reports of “patient complications associated with robot-assisted surgery.” Surgeons who are inexperienced with robots take longer to operate; a procedure that could be completed in two hours using an older technique might take eight with a robot. The more time patients spend strapped to the operating table, the greater the chance of nerve damage.
Then there’s the price: a robot typically costs millions of dollars, and each procedure also requires costly disposable equipment. A study published last year in the Journal of the American Medical Association compared robotic and laparoscopic uterus removals at more than four hundred hospitals, and found that the robotic procedures cost more than two thousand dollars more per surgery (with no improvement in the rate of complications).
“Rest assured, we waste just as much money as everyone else,” a department chairman joked when he informed me that his hospital owned two robots. A study published in January in the Annals of Surgery reported that hospitals are more likely to acquire robots if other hospitals in their immediate vicinity have them. Many hospitals, faced with the pressure to compete with high-tech programs, are advertising robots aggressively—on billboards, on YouTube, even at baseball games. Some may be overselling the benefits of the technology. Researchers at Johns Hopkins University analyzed the Web sites of four hundred U.S. hospitals and, in a study published in the Journal for Healthcare Quality, reported that the majority of sites claimed that robotic surgery offered an “overall better outcome,” and a third of the sites touted “improved cancer control.” (None of the Web sites mentioned risks.) A study by researchers at Columbia University investigated the marketing of robotic gynecological procedures and found that many hospital Web sites described robotic surgery as the “most effective treatment.”
Jason Wright, who worked on the Columbia University study and is the chief of gynecologic oncology at the university, told me that many claims made about robotic surgery aren’t based on clinical evidence. “When you see an ad for a drug on television, the claims that are made have to be backed up by scientific data,” he said. “There’s not the same level of scrutiny for devices.”
There is no standardized process for deciding whether surgeons qualify to perform robotic surgery. Hospitals set their own criteria. To help insure a baseline of skill, some surgical societies have recommended the use of proctors—experienced robotic surgeons who supervise procedures and provide help—until trainees can operate with the robot independently. But it’s up to the hospitals to adopt and enforce these requirements. The New York Times reported last year that when representatives of Intuitive Surgical, the company that manufactures the robot, pressured hospitals “to ease the training path for busy surgeons, to increase use of the equipment and to drive sales,” some hospital officials agreed to consider cutting back on the requirements. Geoff Curtis, a spokesman for Intuitive Surgical, told me by e-mail, “It is the hospital's responsibility to credential and privilege the surgeon and determine the nature and extent of observation, training and proctoring necessary.”
The introduction of any new technology comes with tension, of course. “The discussions today are very similar to the ones we had twenty years ago with laparoscopy,” Garcia-Aguilar said. It takes time for surgeons to master a new technique, for regulation to catch up, and for patients to learn their options. The newest tool isn’t always the right tool. Novelty must give way to familiarity. And all surgery, by whatever means, remains a human enterprise. “I don’t think there’s anything magical about the robot,” Garcia-Aguilar said.
Rena Xu is a resident physician at Massachusetts General Hospital, in Boston.
Photograph: Xinhua/eyevine/Redux.
