Robots in theatre: tomorrow’s world?
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6624 (Published 18 October 2011) Cite this as: BMJ 2011;343:d6624
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From the perspective of Scotland's only high-volume laparoscopic
prostatectomy centre (150 cases per year) we agree with the comments made
by Professor Neal, that even the staunchest laparoscopic urologists would
like to use a robot. Although outcomes from high-volume surgeons working
in centres of excellence are broadly similar regardless of the surgical
technique used for radical prostatectomy, Professor Neal indicates that in
his view performing the definitive comparative trial will now be extremely
difficult. It is clear that as a minimum the robotic approach offers the
reduced blood loss and shortened hospital stay obtained with the
laparoscopic approach (over open prostatectomy) whilst undoubtedly
shortening the surgical learning curve usually observed for this
technique. It also seems likely that robotic surgery also offers reduced
wear-and-tear on the surgeons, thus increasing productivity. That said, we
would point out that a strong background in laparoscopic surgery is vital,
because the default position in the event of robotic equipment failure
should be a laparoscopic prostatectomy rather than the open approach.
Another benefit to the widespread introduction of a robot for urological
surgery would be its application to other urological operations such as
partial nephrectomy, which is the gold standard for excision of renal
tumours of up to 7cm, bringing the benefits of a minimally invasive
surgical approach to a greater number of patients with renal cancer.
We also concur with the comment that the greatest drawback to robotic
surgery is cost. There are currently no da Vinci robotic surgical systems
in Scotland, compared with approximately 25 in England and 25 on Manhattan
Island. Indeed the Scottish Government have indicated that no NHS Board
may commit to a robotic surgical programme until the results of an NHS
NIHR Health Technology Assessment comparing robot assisted laparoscopic
prostatectomy to those of laparoscopic radical prostatectomy have been
published (this is expected in February/March 2012). If the HTA report is
in favour of robotic assisted radical prostatectomy in high volume
centres, then arguably Scotland is well-placed to develop and implement a
well-thought out national strategy for robot assisted surgery thus
avoiding the economic pitfalls associated with allowing the 'market' to
drive development as has happened elsewhere.
Competing interests: Members of a centre with a desire to introduce robotic assisted prostatectomy
Missing the Robotic Revolution
As a junior doctor planning on applying for core surgical training in
the next month or two, I read the article on robotic surgery with
excitement and also trepidation [1].
It seems that enthusiasm for robotic surgery has not dampened since
the mid nineties [2,3] but I wonder what implications it has for current
and future surgical trainees? I have been lucky enough to observe open,
laparascopic and da Vince-aided colorectal procedures and have certainly
felt that robotic surgery, while not yet perfected, is the future. I think
it is safe to say that robotic procedures will become the standard of
care, replacing open and traditional laparascopic techniques. Where does
this leave young surgical trainees starting on their career now? Spending
the next seven years learning techniques which are likely to become
obsolete within their lifetime will leave most trainees stuck between two
stools, too junior not to be affected by the robotic revolution yet too
old to ride the robotic wave without having to retrain. Those that follow
us will no doubt be riding that wave, but I fear that my peers and I will
be left treading water in between generations.
I suspect this is nothing new, there were the same issues when
laparoscopic surgery replaced many laparotomies, but while everyone is
getting excited about robots in theatre, I wonder whether I have chosen
the wrong decade to start my surgical training.
1. Watts G. Remote Control. BMJ 2011;343:D6624
2. Wickham J E A. Future Developments. BMJ 1994;308:193-6
3. Buckingham R A, Buckingham R O. Robots in operating theatres. BMJ
1995;311:1479-82
Tiarnan Magos
Foundation Year 2
Whittington NHS Trust
tiarnan.magos@nhs.net
Competing interests: No competing interests