
Robot-assisted surgery associated with longer operating times, higher cost - sirteno
http://med.stanford.edu/news/all-news/2017/10/robot-assisted-surgery-for-kidney-removal-linked-to-longer-times.html
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Cerium
This study is right that for the same operation manual laparoscopic is
currently more efficient than robotic surgery. The issue here is that robotic
surgery does not seek to displace manual laparoscopic surgery- it seeks to
displace open surgery. Example from the article:

>65 percent of patients with kidney tumors that necessitated the removal of
the entire organ underwent an open surgical procedure. About 34 percent had
their kidney removed using a laparoscopic procedure, and only the remaining
1.5 percent of cases

That 1.5 percent is growing by reducing the 65 percent open, not the 34
percent laparoscopic. Surgical robots are able to complete cases where
laparoscopic is not an option due to the complexity. Additionally, they are
able to increase the pool of operable patients. Many patients that are not
candidates for open surgery and have a case that is too complex for
laparoscopic are able to be successfully operated on roboticly.

Disclaimer: I work in this field, and believe that it is going in the right
direction, but do acknowledge that the technology does currently lead to
increased cost and time.

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rcthompson
This reminds me of the time YouTube introduced a more lightweight version of
their video page code and were distraught to find that the average load times
for the lightweight page were drastically higher than the standard page. They
eventually figure out that this was because most of the people switching to
the lightweight page were people on very slow internet connections, since
people on fast internet connections didn't find the video page slow enough to
bother switching.

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SteveGregory
This is the classic Simpson's Paradox

[https://en.wikipedia.org/wiki/Simpson%27s_paradox](https://en.wikipedia.org/wiki/Simpson%27s_paradox)

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dbcurtis
The robots extend the working career of laproscopic surgeons. The training is
long, and their career with traditional laproscopic surgury is limited by the
onset of microtremors, which we all get eventually. The robots contain
adjustable tremor filters, which add 8-10 years to the career of an
experienced surgeon. That is a huge benefit.

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tyingq
Sounds like a win for everyone. A more experienced surgeon without the
downside of age related tremors.

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ekianjo
This falls exactly under the same type of news as:

1905: new "automobile" is slower than a good old horse!

Mature technologies or practices will always have an edge when new
alternatives come, but mature techs dont improve much while the new ones can
only go up. Robots will become faster, be more autonomous, etc and should
drive down costs down the road. Just like digital photography started by being
much worse than film back in the 90s, while beating its performance in most
metrics in 2010s.

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usrusr
Not quite: transportation has always been developed with speed in mind. The
Benz No.1 was a lightweight phaeton, not a roadgoing tractor.

This is quite the opposite of how medical procedures are developed with regard
to cost: there, optimizing for cost is almost considered bad taste, "you can't
put a price on a human life" and all that. Of course everybody knows that a
less expensive procedure would help more people than a more expensive one, but
the whole environment makes it very easy to not think too hard about cost.

High cost of high tech medicine is in no way comparable to the relatively slow
beginning of cars.

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ekianjo
> but the whole environment makes it very easy to not think too hard about
> cost.

I think the opposite is happening right now. These days the FDA requires a
bunch of health outcome metrics to show that your drug makes more financial
sense than your competitors' (patient benefit vs the price you are asking for)
so there is definitely more cost pressure than there ever was. Let's not
forget also that most countries' social security systems around the globe are
completely broke so there will be sooner or later a cost realization.

> High cost of high tech medicine is in no way comparable to the relatively
> slow beginning of cars.

The first cars were not cheap, almost nobody could afford them. We had to wait
for Ford and the T model to see cars that regular folks could afford to buy.
So in terms of analogy, it's not completely wrong: cars were worse in many
regards, and way more expensive than traditional means of transportation at
the time.

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rscho
Judging from the comments, it seems that many people are confused about this.

From what I see in practice: the reasons stated in the OR to choose the robot
amount in most part to increasing the surgeon's comfort. The additional
degrees of freedom in instrument motion, and the stereoscopic vision are very
much appreciated. In addition, believe me when I say that hype is a major
drive. Robots are often presented as "the most advanced technology", and this
resonates with the patient expecting a high level of care and feeling
important. It is true that the robot is sometimes chosen for difficult cases,
but it is a question of reassurance and comfort for the surgeon more than
anything else. Operations being (much) longer is not without consequence on
patient outcome, and no operation done with a robot could not be done without.

Secondly, current robots are absolutely not geared at automation. The surgeon
is in control at all times, and the machine does not perform any preprogrammed
move. Even worse, to my knowledge there is no robot providing haptic feedback
on the market, so that you have to rely on vision for many things which would
normally be done using the sense of touch (tightening sutures, for example).

From the point of view of the anesthesiologist, the whole robot story is
actually a bit sad and seems to add very little for a huge investment in both
money and logistics.

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jpm_sd
All absolutely true. I worked on an orthopedic surgical robot and hospitals
got excited about it ("Advanced!") but surgeons hated it (slow, cumbersome,
reduces "patients fixed per day" metric). Mostly a waste of money.

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roenxi
There are so many factors here that it is difficult to assess the article. The
key for me, which doesn't seem to be discussed, is asking why did the doctors
opt for a slower procedure?

If they have a financial incentive to keep the patient in the operating
theater for longer, that is a problem and needs to be addressed. If they are
slowly learning a new technique (as the article seems to be hinting) that is
normal but interesting. If they are using a more precise technique to bring
complicated cases up to the average outcome, that is praiseworthy and should
be lauded.

This article is interesting regardless, but there isn't enough in it to draw a
conclusion.

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wodenokoto
I went to a symposium on assessing the value and future investment in robotic
surgery a few years ago. Figuring out if it is cheaper or not, than regular
surgery is surprisingly difficult.

For simple procedures, you might ask junior staff to do it with a robot, to
get them training on the robot - compared to sending staff of to seminars,
this is actually cheap, even though it is more expensive than regular surgery.

You might also ask junior doctors to do a slower, more expensive job on a
robot to get their performance up to the same level as expert staff.

And even experienced surgeons might opt for using the somewhat scarce resource
only for difficult cases. So you might end up with the same surgeon, on the
same type of procedure, having a worse track record on the robot, because the
severity of each case is not recorded in the statistic!

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downrightmike
It reduces fatigue, I can see why doctors are opting to use the robots. It
extends how much the Doc can do and do it well. I'd be interested in seeing
the data and how robots impact the day in day out ability to perform
surgeries. It may not be case specific efficient, but on a whole are the
doctors doing better work and more of it?

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MikeTheGreat
The article says "However, the two approaches have comparable patient outcomes
and lengths of hospital stay, the study showed."

So it looks like the answer to the question "are doctors doing better work" is
"No".

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robryk
Not necessarily. This is an observational study, so it might be the case that
robotic surgery is employed in harder cases, which compensates for its
advantages.

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rsingla
A few (potentially useful) additional points:

a) The ability to address more difficult cases is increased with robot-
assisted surgery

b) Ergonomics of the situation should be considered as well for someone who
can go from standing, leaning, or otherwise "on their feet" all the time to
being able to sit and having an armrest.

c) While autonomous robots for complex procedures like this are likely many
decades away for a variety of reasons, it's not unlikely that we'll see
assistive technology for repetitive tasks in the future. In that sense, we are
really at the early stages of the surgical robotics field! (In fact, depending
on what who you talk to, the field is as young as 30 years old)

d) I partially disagree with the notion that a procedure done with the robot
could be done without it

e) Some competitors are emerging onto the scene, such as Senhance by
TransEnterix or Verb Surgical's product, which will progress this technology
even further (if not out of the pure competitiveness of it all).

For those interested in reading more, I would suggest the following articles:

[0] Vitiello V, Lee SL, Cundy TP, Yang GZ. Emerging robotic platforms for
minimally invasive surgery. IEEE reviews in biomedical engineering.
2013;6:111-26.

[1] Lee SL, Lerotic M, Vitiello V, Giannarou S, Kwok KW, Visentini-Scarzanella
M, Yang GZ. From medical images to minimally invasive intervention: Computer
assistance for robotic surgery. Computerized Medical Imaging and Graphics.
2010 Jan 31;34(1):33-45.

[2] Marcus H, Nandi D, Darzi A, Yang GZ. Surgical robotics through a keyhole:
From today's translational barriers to tomorrow's “disappearing” robots. IEEE
Transactions on Biomedical Engineering. 2013 Mar;60(3):674-81.

Disclaimer 1: Have done a few years of research with a surgical robot, so am
biased towards advocating it's use.

Disclaimer 2: I am not from the institutions of the articles I mention.

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wavegeek
Also worth noting that complications and major complications were apparently
lower (20% lower with major complications) with the robots but the study did
not get to the hurdle of statistical significance.

N.B. for people who have no clue about statistics: failure to achieve
statistical significance does not show no effect. In reality this study
suggests that there was a useful effect, but did not conclusively prove it.

This confusion happens so often in medical papers it is almost a meme. A meme
that has killed a lot of people (see e.g. the Vioxx fiasco).

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derekmhewitt
Personally, my main take away from this article was that in 2015 50% of the
patients that had a kidney removed (which would roughly be the other 24k
patients the study didn't comment on) had their kidneys removed via an old
school open incision procedure. Why is that still happening at all?
Laparoscopic procedures are significantly safer for the patient, cheaper and
faster than old school methods, and they have a quicker recovery time, but
just two years ago literally half of the kidney removals performed in these
416 hospitals were using a completely outdated method.

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mrbill
I had this exact surgery (robot-assisted laproscopic complete nephrectomy)
back on September 22nd.

In my case, once the doc got in there, the tumor+kidney was _too big_ and they
had to cut a normal open incision to get it out.

So, I ended up with three tiny laproscopic scars and one big 10" scar.

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PeachPlum
Hmm, there's no mention of error rates / mistakes.

24,000 operations without error is quite possible.

If the robot reduced the chance of catastrophe by 5x (to pluck a figure from
thin air) it may well pay for itself even at an extra $3k per patient.

Would you trade $5k for a 5x reduction in never waking up ?

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marcell
The article claims error rates were comparable:

> However, the two approaches have comparable patient outcomes and lengths of
> hospital stay, the study showed.

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PeachPlum
No real error rates though, as I said, it is easy to imagine none occurred in
just 28k operations.

What if the error rate was (in extremis) 1 death in 50k for non assisted and 1
death in 500k for assisted.

The extra cost might be justified on that basis.

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Judgmentality
Can someone with experience shed some light on the future of this industry? I
think surgical robots are really cool, but I don't know the capabilities or
limitations of the technology. This article only talks about laporoscopic
surgery for removing kidneys, but surely there are many other types of
surgeries - some of which robots excel at and many for which it fails
entirely?

Basically, I'd love for someone knowledgeable to tell me more about the long
term timeline for this technology. How quickly will it grow, and will it
ultimately replace entire types of surgery and transform how we treat people
or continue to be an alternative with no obvious superiority?

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ReallyAnonymous
surgeon here - 15 years - thinking about, but haven't received training to
allow me to use the robot.

I consider myself a moderately advanced laparoscopic surgeon - I do lap
cholecystectomies (gallbladder), laparoscopic hernias, adrenals,
appendectomies, Nissen fundoplications, colons, biopsies.

I think there is a place for robotic surgery, but you have to maintain your
skills to keep using it - at our hospital, robotically certified surgeons have
to do at least 25 robotic cases per year to maintain certification - for my
caseload, I don't think I have more than 10-15 cases that would warrant the
robot so I would basically be taking 10-15 patients to the OR to do their case
robotically in order to maintain my certification.

The advantage of the robot is that it is ridiculously easy to sew vs
laparoscopically. To sew laparoscopically, you have a 2 foot long instrument
holding the needle and trying to sew. For the robot, it follows the movement
of your wrist and hand precisely. It really is amazing technology, but there
is only specific, limited use in my opinion.

For example, for prostatectomies, it is awesome. In open prostatectomies, it's
difficult to see the pudendal nerves and so they are sometimes sacrificed - no
more erections! View is magnified and 3d in robotic. In addition, anastomosing
the bladder back to the urethra happens under the pubic bone so only a limited
number of sutures can be placed in the traditional way, whereas with the
robot, it's a running circular stitch - less urinary leaks with the robot
means less incontinence.

The biggest issue is that in our literature (general surgery) all of the
research papers the last several years regarding the benefits of robotic
surgery are funded by Intuitive Surgical, which leads to bias. It has it's
place, but they are a company and are driven by profit - it behooves them to
get a lot of surgeons trained so that we're all fighting for the robot, so the
hospital feels they have to buy another!

My current status (as told to the rep) "Let's see if Dr. SoAndSo is still
doing robotic surgery in 2 years...."

The only plus is that several other companies are going to be entering the
market soon, so hopefully costs will go down bc now the robots are several
million for one and the instruments are reusable (10 times), but cost $3k.
Just look at ISRG......

\- surgeon

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roel_v
"but haven't received training to allow me to use the robotbut haven't
received training to allow me to use the robot"

What does such training consist of? Is it how to use the robot (like, these
are the menus on the machine, and practice with these joysticks) or are the
procedures different? I guess I'm asking, are robotic operations completely
different from their manual counterparts, or are the 'just' the same except
with the robot doing the moving for you?

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robbintt
I am interested in whether doctors were able to take cases that they normally
don't take.

I do not expect error rates to go down because doctors are already
incentivized to avoid difficult cases.

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shortformblog
It should be noted that robot-assisted surgery is hugely helpful for partial
kidney removal versus the whole thing, as the article states. So the headline
on its own doesn't cover the whole picture here and may even be misleading.

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wavegeek
Figures I've seen show that things are worse for a while and then the robots
are better, after a significant learning curve.

The story acknowledges that this study was done early on so it will have been
affected by the learning curve.

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graeham
Seen similar things, with the effect of learning curve being fairly massive -
particularly for the first 5-10 procedures done. Really understated in the
article for being a fairly major factor.

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aladoc99
Not a surgeon or robot-user, but just by way of example, conventional wisdom
in the medical world is that the best niche for robotically-assisted surgery
is radical prostatectomy for prostate cancer. Conventional wisdom is that the
robot permits better preservation of pelvic nerves, leading to lower rates of
postoperative incontinence. If true, this is well worth a longer, more
expensive procedure.

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rscho
In my center, surgical times went from 2h to a whopping 6h+ for radical
prostatectomy after introduction of the robot. While you are right in that
radical prostatectomy is to my knowledge the only case of demonstrated robot
superiority, fragile patients may suffer from the longer operative times (a
major risk factor for post op complications)

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MrFantastic
Is saving 4 hours worth having to wear diapers for the rest of your life?

Would a damp environment increase risk of skin infection down the line?

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mattkrause
The issue isn't four hours of staff time; it's the added risks to the patient
from four more hours of anesthesia.

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sebringj
If this requires highly trained doctors then of course it will cost more but
it should require less skill overtime until its an automated consultation
where you gently fall asleep, then wake up feeling rested and refreshed with
some minor soreness but not a scar can be found and you go on with your day.

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chiefalchemist
Ok. But over the long term isn't the hope of the robotic method to make the
treatment available to more people, perhaps at hospitals that normally
wouldn't offer such things.

Certainly, as the method is being vetted and perfected that too needs to be
factored into the evaluation?

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atka
How could it be offered at places that don't offer it? The robot is autonomous
it is controlled by a surgeon.

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maxxxxx
In most industries robots make something cheaper. I am confident that the US
health system will find a way to become even more expensive with the help of
robots.

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dguaraglia
How about outcomes? At the end of the day that should be the benchmark we
should use.

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MikeTheGreat
The article says "However, the two approaches have comparable patient outcomes
and lengths of hospital stay, the study showed." So it looks like the answer
to the question "are doctors doing better work" is "No". reply

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readhn
Anesthesiologist friend confirms this.

Robots are nowhere near making a huge impact on outcomes yet.

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zython
Which one would be willing to accept if it would be able to save lives.

