Friday, February 22, 2013

Robotic Hysterectomy: Everybody's Doing It!

A cohort study done by Columbia University evaluating the rise of robotic hysterectomy from 2007-2010 had some pretty breathtaking findings.

Use of robotically assisted hysterectomy increased from 0.5% in 2007 to 9.5% of all hysterectomies in 2010. During the same time period, laparoscopic hysterectomy rates increased from 24.3% to 30.5%. Three years after the first robotic procedure at hospitals where robotically assisted hysterectomy was performed, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies.... In a propensity score–matched analysis, the overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%).......Total costs associated with robotically assisted hysterectomy were $2189 (95% CI, $2030-$2349) more per case than for laparoscopic hysterectomy.

So here we have an exponential rise in robotic hysterectomy over a relatively short period of time without any tangible benefit to the patient.  Will anything come out of this?  Or will hospitals across the country continue to advertise their very own robotic programs on highway billboards and quarterly mailings?  

In a nutshell, this is the very essence of why healthcare costs are spiralling out of control.  We never hesitate to implement the "latest hot innovation" no matter how expensive it is, no matter how little it improves the quality of care.  When a nation collectively decides to treat health care provision as just another commodity-- as a good to market and sell, a source of pure profit--- then it has embarked on a course of fiscal and moral bankruptcy.

Full disclosure:
I have gone through the credentialing and training process for the DaVinci robot and have now done a small series of robotic assisted laparoscopic procedures.  My motivation for doing so is multi factorial.  One, the robot is quite nice.  The technical improvements compared with straight stick laparoscopy are sometimes quite extraordinary.  (Although, for the majority of general surgery cases, these benefits are irrelevant/extraneous).  The ability to articulate the end of the instrument like a human wrist adds a layer of dexterity and elegance that one just cannot get from straight laparoscopy.  So, two, I didn't want to end up like one of those old school surgeons who decided that laparoscopy was a "fad" back in the nineties and then were quickly relegated to irrelevance once the technique became the standard of care.  Three, I don't like to judge things without first experiencing them myself.  Four, the application to single site surgery makes intuitive sense to me in so far as the improved coordination gained by the robot sticks offsets the awkwardness of pushing three instruments through a single access port.   

At this point in the game, I think the robot does have a future role, albeit a limited one, in general surgery.  If the costs can be controlled (single payer anyone?) then I see a real potential in using the robot for single site colon/bowel/even gallbladder surgery. Situationally, I can see it evolving into the standard technique for rectal surgery, hiatal hernia repairs, and complex pancreatic/biliary surgery.



Joseph Sucher, MD FACS said...

I agree on all points.

Anonymous said...

The FDA is starting to probe hospitals to determine the rise of incident reports for the da Vinci. It also may put women at greater risk for bad outcomes.
“Player Piano” Robotic Surgeries Put Women’s Lives At Risk