Robotics in Bariatric Surgery: Is the Hype Justified?

| April 1, 2020

 by RANA C. PULLATT, MD, MS, MRCS, FACS, FASMBS, and BENJAMIN L. WHITE, MD

Dr. Pullatt is Professor of Surgery and Clinical Director Bariatric & Robotic Surgery at Medical University of South Carolina, as well as Director, Bariatric Surgery VISN-7 in Charleston, South Carolina. Dr. White is a Chief Resident in General Surgery at the Medical University of South Carolina in Charleston, South Carolina.

FUNDING: No funding was provided.

DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.

ABSTRACT: The scope and breadth of robotics continues to grow, particularly in general surgery. There is still considerable debate regarding its utility in bariatrics and surgery of the foregut. Despite the many advantages conferred by the robot, the learning curve, team dynamics, and economics of robotic surgery preclude its widespread adoption. Less common, though perhaps more viable, arguments in its favor include reduced surgeon stress and improved ergonomics, the dynamic challenges of training new surgeons, and the promise of surgical telepresence. Robotic surgery is here to
stay and bariatric surgeons need to continue to explore applications for it, as competition amongst manufacturers should eventually lead to economic viability.

KEYWORDS: Robotic, surgery, bariatric, foregut

Bariatric Times. 2020;17(4):14–15.

My interest in robotics stemmed from the largely egotistical fact that as a bariatric surgeon, I consider myself as the top dog in minimally invasive surgery in my hospital ecosystem. However, there was an amazing machine in the corner of the room that other specialties used and could not stop bragging about. I invested time in mastering this machine several years ago and subsequently set up a structured robotic training curriculum for residents in my program. This article is the musings of a “straight sticks” laparoscopic surgeon who has embraced robotic surgery, with some reservations. To put these musings into perspective, I still do a significant amount of laparoscopic surgery, including laparoscopic duodenal switch in high body mass index (BMI) patients with straight sticks.

No subject in our field is as much of a lightning rod as robotics is in bariatric surgery. Debates regarding the indications, benefits, and costs have existed since the inception and earliest adoption of the first iteration of our modern robotic system in the early 2000s. In every meeting I attend, I witness impassioned, frustrated surgeons on both sides of the fence trying to convince each other the worth or folly of using the robot. The most often-quoted reservations against the robot are the increased time for docking and added time for the procedure.1,2 These are both byproducts of a steep learning curve associated with using the robot as a surgeon, and probably more significantly, the team dynamics that are required for implementing a robotic surgery program. These disappear after the learning curve is met.3,4 Procedures can be done just as efficiently, or in some cases better, with the robot once the team is adept in its preparation and use.5,6 The elephant in the room, and far and away the sharpest criticism, is the increased cost of doing the procedure robotically.7-10 In response to this criticism, we see proponents start indulging in funny math and economic gymnastics to prove the worth of the robot. I think at this point, we all have to honestly acknowledge the fact that the robot adds significant costs to the procedure. If the cost of the robot is amortized over procedures, there is without doubt a significantly increased cost of performing the procedure robotically, even without accounting for the cost of the disposables used during the procedure, which can be significant. Robotic instruments, with the exception of the clip applicator and the stapler, are limited to 10 uses. Notably, robotic energy devices do not add significant cost compared to energy devices used during laparoscopic procedures. In response to robotic proponents who say that laparoscopic equipment is not amortized, while this might be true, I would contend that the best laparoscopic towers are 1/20th the cost of a robotic system and do not incur the significant annual maintenance contract that the robotic system requires to keep it functioning well.11-13

So, why do hospitals buy in to the robot at all? One defensible position is there are specialties in every hospital that simply cannot do certain procedures in their field in a minimally invasive fashion without the robot. This alone makes the capital cost of the robot a necessity. Another reason, and one that robotic manufacturers have taken extensive advantage of, is that robotics is “sexy” and is good for marketing a hospital in its local ecosystem. Effective marketing brings in new patients, increases market share, and justifies the cost of the robot. In many instances, the robot serves as a gateway technology to get patients bought into the hospital’s ecosystem, and the hospital subsequently benefits from the downstream revenue of patient from ancillary services and subsequent hospitalizations. However, I do sincerely believe the biggest benefit the robot offers is for the operating surgeon. It is perhaps a relic of our masochistic training over the years in medical school and surgical residency that it in our mind, it almost lessens us as surgeons if we accept that we physically need the robot. Operating every day on high BMI patients, frequently requiring the application of significant torque, puts a lot of stress on our bodies. It is a fact that we suffer significant work-related injuries,14-17 and we endure them as the “self-sacrificing martyrs” we are trained to be. I personally use the robot to decompress my operating schedule. At the end of the day, I feel less worn out, and these sentiments are echoed by many of the surgeons who have embraced robotics. A revisional case like a Nissen takedown or bariatric conversion becomes less mentally stressful, physically taxing, and suddenly it doesn’t matter if it is the last case of the day.

Additionally, we have to look at the generational change that we are dealing with in training programs. We are training millennials, and their strengths don’t align with our generation’s strengths. We have to train them during residency within the stringent Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour work week restrictions. Perhaps the robot is the way to go to train these young surgeons in doing safe operations.18-20 We also have to acknowledge that all bariatric surgery fellowships are not created equal. With the increase in the number of sleeves being done, and the reduction in anastomotic procedures, maybe robotics would be a safer pathway for younger surgeons doing an anastomotic procedure.21 The duodenal switch operation in a high BMI patient is a technically challenging operation and is perhaps another surgery where we will see robotics being embraced. Obviously, revisional surgery is the area where the robot would be most useful, even for experienced laparoscopic surgeons.

It has been 34 years since Eric Mühe performed the first laparoscopic cholecystectomy and ushered the era of laparoscopic surgery. We as surgeons made the difficult jump of retraining ourselves from open surgery to laparoscopic surgery. At that time, if robotic surgery were available, I believe nobody would have retrained themselves to laparoscopy, as it is inherently unnatural transitioning from a three-dimensional wristed space to a two-dimensional straight stick space. Perhaps the natural order of things would be that over time, and when robotic surgery becomes more economically viable, it will replace standard laparoscopic surgery. Perhaps laparoscopic surgery was always meant to be a transitional technology.

Computer-assisted surgery is here to stay. Anyone who has bet against the computer in the last 30 years in any field has lost; it would be a Luddite mentality to maintain that our field will be insulated from this revolution. We have to acknowledge that the market leaders in robotic surgery, Intuitive Corporation (Huntsville, Alabama) has a product that is well above anything else that the competition has to offer and has done exceptionally
well in training surgeons and offering them resources. It would be great to see some real competition in this field to drive down prices to make it economically more viable. Cheap imitations and systems straddling laparoscopy and robotics have thus far failed to secure any real foothold.22 For the robotics companies, the biggest barrier to sustained growth in a field like ours, populated by talented and well-trained laparoscopic surgeons, is cost. The economics of robotics simply has to get better, especially with the cost of the disposables, to see large-scale adoption in bariatric surgery. The leading robotic company says 10 uses for a disposable instrument. In my travels outside the country, I have often witnessed robotics being used in price-sensitive markets, and most times the increased cost of doing a procedure robotically is transferred to the patient directly with a tiered pricing system for laparoscopic and robotic procedures. There have also been instances where the surgeons have told me that they rig the robot by not undraping or removing instruments for several procedures through the day, and by doing so, they are able to get 50 uses out of an instrument, which helps them greatly reduce the cost of the procedure. These solutions obviously would not work in our country due to sterility and ethical standards, but it also points to the fact that perhaps these instruments could be used many more times than what is regulated by the manufacturer. The new stapling system that Intuitive Corporation has launched for the Xi system is a step in the right direction as far as competitive pricing is concerned.

The future for robotic surgery is exciting. We already see technological advances in computer-assisted surgery helping us determine tissue viability using imaging while performing surgery. Haptics is being built into these systems that could help us measure anastomotic tension in quantifiable terms, which could make a difference clinically. Of course, the real potential, which is already being exploited in Canada, is telementoring using computer-assisted systems. All of us as bariatric surgeons have made terrible mistakes in the operating room as young surgeons. Some of us have partners who can help mentor and bail us out. We have to recognize that outside the ivory towers of our institutes, there exist surgeons in small community hospitals who do not have that kind of help. They might need the assistance of the robot to make up for not having the plethora of residents, students, and surgical assistants that we do to deliver quality surgical care that our patients desperately need, and in those centers, the robot makes perfect economic sense in delivering quality care.

The Concord was an amazing and equally “sexy” technology, designed to cut the travel time for transatlantic flights by more than half. Ultimately, it failed for economic reasons. The robot companies might do well to remember that. They possess a disruptive technology that, if they price right, could capture the entire market.

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