The recent SAGES 2016 in Boston included a debate on robotically assisted hernia repairs, chaired by Brian Jacob and David Earl. It was interesting to see how gastrointestinal (GI) surgery is split into two camps when it comes to the use of advanced enabling technologies such as the Da Vinci robot.
What is driving this scepticism, bearing in mind the commercial success of Da Vinci and the fact that it is estimated that the majority of hospitals have already invested in purchasing one? Sceptics are not impressed, primarily for three reasons:
Cost does not justify its use in routine operations such as hernia repair
The total cost for a hernia repair laparoscopically is limited by the use of relatively cheap tools. However, the capital expenses for the Da Vinci robot can reach $2 million. This is on top of a typical service contract which will set you back up to $180,000. The actual running of an operation is not getting cheaper either, as the use of consumables adds another $1-2,000 for each hernia repair.
Robots should make operations faster not slower
Surgeons who have tried hernia repair using the Da Vinci have reported that their operations take longer than standard procedures. This is primarily driven by the complexity of the system, which was not developed specifically for operations like this. For example, the OR team may require to change the position of the instrument midway through the operation – and this adds extra user steps which are not required during a simple laparoscopic procedure.
The data is not there yet
Surgeons are very sceptical about the perceived improved patient outcomes related to the use of the Da Vinci system – and, in particular, about how these are communicated in order to convince the surgical community of the value it adds to hernia repair. There is only limited data published in peer-reviewed journals on the value such approaches offer. On top of this, there are thousands of videos on social media sites, such as YouTube, building a story – which lacks any scientific merit, according to the sceptics – of great success. As expected, none of these videos provides comparative information on:
- Trauma resulting from simple laparoscopic and robotically assisted operations – what are the incidences of seromas and haematomas in each case, for example?
- Patient outcomes from the two procedures
Not many will argue with the perception that GI surgery of the future will involve, to a greater extent, the use of robotic systems like the Da Vinci. However, like with any new technology, it will require time to refine their use and achieve maximum performance. The wider adoption of robotically assisted hernia repairs will be helped by systems which are developed around the requirements of GI surgeons, as it is difficult to foresee one robotic system – like the Da Vinci – being good at everything for everyone. In any case, the biggest promoter of robotic systems will be the users themselves – and the data that provides evidence of the benefits they offer to patients.