For a balanced argument, I have listed two opposing points of view, the first one is mine, and the second is that of my good friend and colleague, Dr Abid Qazi, one of the best pediatric surgeons I have ever worked with.
My point of view:
Robotic surgery is a trendy topic currently. In almost every scientific meeting I attend, there are few presentations about it. It is also a frequently asked question by families. In this post I'm going to give my own take on robotic surgery in my specialty.
First, I'd like to declare that I do not currently do robotic surgery. I have been in centres where the robot was available to me, and I have taken some steps towards getting privileges to use it, but I never had it offered to patients as an option.
Second, I'd like to dispel a myth about robotic surgery. The surgery is not done by the robot. It is done by the surgeon who then controls the robot. Imagine using a robotic arm to hold a fork that you then use for eating. The arm has no ability to move on its own. It simply copies your hand movement. This would be a good analogy to robotic surgery in its current status.
If this is starting to sound like a massive hassle to you, then you are right! Why implement such an expensive machine to do a simple task that you can do perfectly yourself? It would be such a waste of time and resources. It might be useful to a person who is incapacitated, but not to a normally functioning adult. You would not get in a Ferrari to travel a distance of 5 meters; walking would be easier, cheaper, and quicker.
You do not expect your surgeon to be physically impaired and rightly so. For the majority of surgical procedures done by a competent surgeon, the robot is a waste of time and resources for no demonstrable benefit. This will explain why a good majority of practicing surgeons have not taken it up. There is currently no evidence that the robot offers increased functionality compared to traditional laparoscopy, unless the surgeon finds using traditional laparoscopy challenging.
Also, when it comes to children, there is an important drawback to using robotics. The laparoscopic port of the Da Vinci console is 8 mm. When I do laparoscopy on children, I usually use 3 mm instruments. The instrument will need an incision that is 1.5 times its diameter for easy insertion. This is a significant difference, especially when multiple ports are being used. For a standard 3 ports procedure, the total sum of “robotic” incisions will be over 4 cm! If I’m using 3 mm incision, the sum total is around 1.5 cm. If you compare the total sum of robotic incisions to open surgery, you may find no difference at all.
I feel that most surgeons and institutions promoting robotic surgery currently are mainly doing it to make them look “cool”, as a marketing tool and because it is trendy. This is not necessarily a bad thing, but I don’t think they are quite forthcoming about the lack of evidence of benefits to patients as they should be. If you are considering robotic surgery, you should ask your surgeon how it is better for you as a patient or parent of a patient. I have seen “robotic” surgeons converting to traditional laparoscopy whenever things got tough during robotic surgery. This made me skeptical of the robot functionality. Does it really enhance the surgeon?
Not to be misunderstood, I think one day the robot will be routinely utilized. However, for this to become beneficial, a significant reduction in cost and instrument size needs to happen. This will have to be coupled with a significant decrease in my ability to do traditional laparoscopic procedures. I like to think that my ability is actually increasing with increasing experience.
In summary, robotic surgery is trendy but does not offer any real advantage for the vast majority of procedures, especially in children. In its current status it has important drawbacks mainly with cost and instrument size.
Dr Abid Qazi point of view:
Paediatric robotic surgery was inaugurated almost in parallel with adult robotic surgery in the first decade of the new millennium. Like any other field of life, some surgeons took this on welcomingly and the others remained sceptic. I had the opportunity to be one of the very first surgeons who were motivated with what robotic surgery can do in comparison to conventional laparoscopic surgery. I witnessed first-hand, since 2006, the successful use of the robot in paediatric surgery in as little as 5 kg child.
Like laparoscopic surgery, which had been denied by older generation of surgeons, both in adult and paediatric world, putting up resistance from the sceptics, robotic surgery has evolved over years. Currently available paediatric laparoscopic equipment is specifically designed and manufactured for neonatal size, and some specific conditions, for example, use of 3mm pyloric spreader for pyloric stenosis and the 5mm auto stapler. I am certain, in due course, we will see the same evolution in robotics surgery.
Major advantages of robotic surgery are its 3-dimensional vision, the wide-angled view, and the intuitive wrist movement of the tip of instruments which overcomes the difficulty faced in conventional laparoscopic surgery. This is exactly why the learning curve is quite steep in robotic surgery when compared to the learning of conventional laparoscopic surgery. I would also say that in fact robotic surgery is a direct extension of open surgery and cannot be compared to conventional laparoscopic surgery. It has additional advantages of immense convenience for the surgeon being seated and head is rested over the console which allows several hours of surgery without any physical exhaustion. Additionally, for aging surgeons but with significant number of years of experience and wisdom, the robot has the ability to ignore hand tremors and perform only the desired movement. This is a significant benefit for the patient as well as the health system, especially where active training of surgeons is instituted.
The high running cost of robotic surgery is also a myth. The actual increased costs can be easily balanced by the decreased length of stay and improved surgical outcomes. Over the coming years, it is expected, when larger proportions of surgeons are using the technique and an increasing number of hospitals have robotic surgery available, the cost will be evenly distributed. It is also expected that in due course the size of individual instruments will also decrease with the more refined robots being available on the market. Over the last three decades, we have already witnessed the size of the robot being reduced from a humongous giant, difficult to move in the operating theatre to the easily movable newer versions. In conclusion, I am certain that despite the significant scepticism, Paediatric robotic surgery is here to stay and will improve further in its gadgetry and clinical applications. It is also pertinent to say that like laparoscopic surgery, the surgeon must choose the application of the technique purely to benefit the patient and any surgical skill or gadgetry must not be used for self-glorification of the individual surgeon.
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