The use of robots in bariatric surgery—evaluating the evidence before being glamoured by new technology

Dear Readers:

I just read a New York Times editorial on robotic surgery. I am glad someone has the courage to speak up and call everyone’s attention to the use of robots in surgery. The New York Times article comments on the widespread use of robots in prostatectomies and that there is a lack of evidence that this approach is indeed beneficial or detrimental to patients’ health. The New York Times article cites a national study of Medicare patients from 2003 to 2007 (authored by Dr. Jim C. Hu of Brigham and Women’s Hospital and published last October in The Journal of the American Medical Association), which reviewed 6,899 men who had surgery with a robot and 1,938 who had laparoscopic surgery.

Though this study had several flaws (e.g., patients were not randomly assigned to have one type of surgery or another; laparoscopic operations done without a robot were included with the robot-assisted ones), it is, in my opinion, a good indicator of what robotic surgery is all about. This study is the only one that compares a largely robot-assisted surgery group with a group that did not have a robot to assist the surgeon. In conclusion, this study reported that laparoscopic, robotic-assisted surgery patients had shorter hospital stays, lower transfusion rates, and fewer respiratory and surgical complications. But the patients in that group also had more incontinence and impotence. What the authors fail to emphasize is that all the advantages reported in the laparoscopic, robotic-assisted group are mainly due to the laparoscopic approach and not the robot. When it really comes down to whether the robots enabled average surgeons to get better urethra anastomosis and spare nerves, the results were poor, with more impotence and more incontinence.

Frankly, I am stunned that a group of surgeons, in conjunction with the industry, has taken advantage of aggressive marketing, public ignorance, and the desperation of hospital administrators panicked by the current economy in order to make a financial profit without the scientific evidence that use of robotic technology has a benefit for our patients. Even more surprising is that despite the lack of evidence, these surgeons and members of the industry keep promoting robotic use.

New technology can lead to big advances, which can justify extra costs. But sometimes use of technology will spread long before surgeons know whether or not it is worthwhile. It is true, to some degree, that a robot can reach places human hands cannot. It is also true that for some surgeons who lack the dexterity to perform surgery with a laparoscope the robot will enable them to perform difficult tasks. However, it has come to my attention that the surgeons who are actually using robots are terrific technicians and do a faster job without the robots. In addition, it is well documented in the literature that robotic surgery sometimes takes twice as long, is more expensive, and has minimal, if any, advantage to the patient over surgery without robots.  So the question I am asking myself is why are they using robots? Should we be doing this at any cost?

With drugs, the United States Food and Drug Administration requires extensive studies to be carried out in order to determine safety and efficacy. We surgeons are free to innovate, and few of us would argue against surgery can being held to the same standards as drugs. Evaluating technology is not easy, and often, it seems, surgeons become enthusiasts without rigorous studies ever being done.

As the above-mentioned situations illustrate, patients may end up making life-changing decisions that are based on marketing or the biased surgeon’s choice, not on the scientific evidence. During these advanced times when optoelectronic instrumentation has revolutionized surgery and more and more gadgets are being developed, I welcome the concept of “surgical innovation committees” in addition to each center’s internal review board (IRB) so that we can better evaluate the current standards and decide how and if a new technology will be safe and cost effective when introduced to our practices.

And now, allow me to discuss this month’s Bariatric Times. This issue of Bariatric Times has an article that deals with post-surgery weight regain due to anastomotic and pouch enlargement after gastric bypass. Endoscopic suturing and adjustable banding are suggested as possible treatment options in order to induce restriction and weight loss.

The problem of weight regain and failure after bariatric surgery, specifically gastric bypass, is a serious one. There is a lot we need to understand in order to better identify those patients who will fail and will need a reoperation or a reintervention. Valid questions that need answers are the following: At what point do we consider a bypass as failed? How much weight should a patient regain before we consider reintervention? Are the current treatment strategies, such as pouch trimming, banding, and endoscopic suturing, valid options? Should we lengthen the limbs and increase the malabsorptive component of the operation? I am sure you will be impressed with the information presented in this article, and I hope you will give it serious thought before implementing any of this into your practices. We also have a number of other excellent articles this month that I hope you enjoy.

I hope I get a chance to see you later this month in Las Vegas at the annual meeting of the American Society for Metabolic and Bariatric Surgery. Have a safe trip and enjoy the meeting.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

Tags: Dr. Raul Rosenthal

Category: Editorial Message, Past Articles