Robot-assisted surgery associated with longer operating times, higher cost | Hacker News Reader

Robot-assisted surgery associated with longer operating times, higher cost

med.stanford.edu

139 pointssirteno62 comments

This study is right that for the same operation manual laparoscopic is currently more efficient than robotic surgery. The issue here is that robotic surgery does not seek to displace manual laparoscopic surgery- it seeks to displace open surgery. Example from the article:

>65 percent of patients with kidney tumors that necessitated the removal of the entire organ underwent an open surgical procedure. About 34 percent had their kidney removed using a laparoscopic procedure, and only the remaining 1.5 percent of cases

That 1.5 percent is growing by reducing the 65 percent open, not the 34 percent laparoscopic. Surgical robots are able to complete cases where laparoscopic is not an option due to the complexity. Additionally, they are able to increase the pool of operable patients. Many patients that are not candidates for open surgery and have a case that is too complex for laparoscopic are able to be successfully operated on roboticly.

Disclaimer: I work in this field, and believe that it is going in the right direction, but do acknowledge that the technology does currently lead to increased cost and time.

I agree when I was in the royal free renal ward (London UK) one of the guys in the bed next to me was in his mid 80's and had robot surgery to remove a problem kidney - his doctor had told him that he was the oldest patient in the UK to have this op I suspect that the older style of surgery might not have been possible.

Could be that, or the doctor trusting the machine to do the job, the availability at the hospital, etc.

Actually the royal free is one of the leading hospitals in the UK for transplants - as this 80+ guy was the oldest patient they had performed this op on.

This reminds me of the time YouTube introduced a more lightweight version of their video page code and were distraught to find that the average load times for the lightweight page were drastically higher than the standard page. They eventually figure out that this was because most of the people switching to the lightweight page were people on very slow internet connections, since people on fast internet connections didn't find the video page slow enough to bother switching.

This is the classic Simpson's Paradox

https://en.wikipedia.org/wiki/Simpson%27s_paradox

AFAIK it was even more drastic. People were timing out before the change. It went not from slow -> quick but from unreachable to reachable.

But this article and research is about laparoscopic surgery vs robot assisted laparoscopic surgery. If a case is too complex for manual laparoscopic does the robot assistance suddenly make it operable? It seems like we aren't quite to the point where robot assistance (in laparoscopic surgery) would make a procedure less complex.

"The issue here is that robotic surgery does not seek to displace manual laparoscopic surgery- it seeks to displace open surgery. "

Yes, it makes a proportion of cases that would have required open surgery amenable to laparoscopic surgery.

The robots extend the working career of laproscopic surgeons. The training is long, and their career with traditional laproscopic surgury is limited by the onset of microtremors, which we all get eventually. The robots contain adjustable tremor filters, which add 8-10 years to the career of an experienced surgeon. That is a huge benefit.

Sounds like a win for everyone. A more experienced surgeon without the downside of age related tremors.

This falls exactly under the same type of news as:

1905: new "automobile" is slower than a good old horse!

Mature technologies or practices will always have an edge when new alternatives come, but mature techs dont improve much while the new ones can only go up. Robots will become faster, be more autonomous, etc and should drive down costs down the road. Just like digital photography started by being much worse than film back in the 90s, while beating its performance in most metrics in 2010s.

Not quite: transportation has always been developed with speed in mind. The Benz No.1 was a lightweight phaeton, not a roadgoing tractor.

This is quite the opposite of how medical procedures are developed with regard to cost: there, optimizing for cost is almost considered bad taste, "you can't put a price on a human life" and all that. Of course everybody knows that a less expensive procedure would help more people than a more expensive one, but the whole environment makes it very easy to not think too hard about cost.

High cost of high tech medicine is in no way comparable to the relatively slow beginning of cars.

> but the whole environment makes it very easy to not think too hard about cost.

I think the opposite is happening right now. These days the FDA requires a bunch of health outcome metrics to show that your drug makes more financial sense than your competitors' (patient benefit vs the price you are asking for) so there is definitely more cost pressure than there ever was. Let's not forget also that most countries' social security systems around the globe are completely broke so there will be sooner or later a cost realization.

> High cost of high tech medicine is in no way comparable to the relatively slow beginning of cars.

The first cars were not cheap, almost nobody could afford them. We had to wait for Ford and the T model to see cars that regular folks could afford to buy. So in terms of analogy, it's not completely wrong: cars were worse in many regards, and way more expensive than traditional means of transportation at the time.

Judging from the comments, it seems that many people are confused about this.

From what I see in practice: the reasons stated in the OR to choose the robot amount in most part to increasing the surgeon's comfort. The additional degrees of freedom in instrument motion, and the stereoscopic vision are very much appreciated. In addition, believe me when I say that hype is a major drive. Robots are often presented as "the most advanced technology", and this resonates with the patient expecting a high level of care and feeling important. It is true that the robot is sometimes chosen for difficult cases, but it is a question of reassurance and comfort for the surgeon more than anything else. Operations being (much) longer is not without consequence on patient outcome, and no operation done with a robot could not be done without.

Secondly, current robots are absolutely not geared at automation. The surgeon is in control at all times, and the machine does not perform any preprogrammed move. Even worse, to my knowledge there is no robot providing haptic feedback on the market, so that you have to rely on vision for many things which would normally be done using the sense of touch (tightening sutures, for example).

From the point of view of the anesthesiologist, the whole robot story is actually a bit sad and seems to add very little for a huge investment in both money and logistics.

All absolutely true. I worked on an orthopedic surgical robot and hospitals got excited about it ("Advanced!") but surgeons hated it (slow, cumbersome, reduces "patients fixed per day" metric). Mostly a waste of money.

> there is no robot providing haptic feedback on the market

So like driving an old car with power steering that has zero road feel.

Great.

There are so many factors here that it is difficult to assess the article. The key for me, which doesn't seem to be discussed, is asking why did the doctors opt for a slower procedure?

If they have a financial incentive to keep the patient in the operating theater for longer, that is a problem and needs to be addressed. If they are slowly learning a new technique (as the article seems to be hinting) that is normal but interesting. If they are using a more precise technique to bring complicated cases up to the average outcome, that is praiseworthy and should be lauded.

This article is interesting regardless, but there isn't enough in it to draw a conclusion.

I went to a symposium on assessing the value and future investment in robotic surgery a few years ago. Figuring out if it is cheaper or not, than regular surgery is surprisingly difficult.

For simple procedures, you might ask junior staff to do it with a robot, to get them training on the robot - compared to sending staff of to seminars, this is actually cheap, even though it is more expensive than regular surgery.

You might also ask junior doctors to do a slower, more expensive job on a robot to get their performance up to the same level as expert staff.

And even experienced surgeons might opt for using the somewhat scarce resource only for difficult cases. So you might end up with the same surgeon, on the same type of procedure, having a worse track record on the robot, because the severity of each case is not recorded in the statistic!

Probably less invasive surgery has less side effects and better outcomes

It reduces fatigue, I can see why doctors are opting to use the robots. It extends how much the Doc can do and do it well. I'd be interested in seeing the data and how robots impact the day in day out ability to perform surgeries. It may not be case specific efficient, but on a whole are the doctors doing better work and more of it?

I definitely agree. Not to mention that there is a limit to what a human surgeon is capable of without some sort of augmentation. If this technology is going to improve it needs to be used in the field.

The article says "However, the two approaches have comparable patient outcomes and lengths of hospital stay, the study showed."

So it looks like the answer to the question "are doctors doing better work" is "No".

The answer to "are the patients doing better?" is no. "Is the doctors efficiency outside the surgery more?" is what the parent seems to be asking. There might be confounding variables like the doctors experience level coming into play. Are less experienced doctors more likely to use robotic surgery and still produce results that a more experienced doctor does?

Also, robots might get faster one we better understand them and that can be applied to all robots. Each humans will have to be trained individually and knowledge transfer might not be the same i.e. each human doctor starts as amateur vs robots.

I'm just playing devils advocate here.

https://jamanetwork.com/journals/jama/article-abstract/26582...

Not necessarily. This is an observational study, so it might be the case that robotic surgery is employed in harder cases, which compensates for its advantages.

In response to "are the doctors doing [...] more of it?":

The article also said "Robot-assisted laparoscopic surgery to remove a patient’s entire kidney requires slightly longer operating times"

I'm guessing that if the operating times are longer than the doctors can't do more work because the Operating Rooms are still in use.

And that's not even thinking about the possible safety and/or legal requirements that might exist, such as "any active, ongoing surgery must have a doctor actively overseeing it, at all times".

Robotic surgery is not autonomous. The surgeon is in complete control and provides the only decision making input into the surgery.

Also, doesn't the robot approach enable off-site doctors to perform the procedure?

No. None of the current systems enable that, since a surgeon needs to be ready to take over if the system becomes unavailable due to some failure.

Indeed! From what I know of prior research, the latency issues with regards to remote control of these robotic systems was unlikely to ever reach clinical use but has been explored to a small degree.

A few (potentially useful) additional points:

a) The ability to address more difficult cases is increased with robot-assisted surgery

b) Ergonomics of the situation should be considered as well for someone who can go from standing, leaning, or otherwise "on their feet" all the time to being able to sit and having an armrest.

c) While autonomous robots for complex procedures like this are likely many decades away for a variety of reasons, it's not unlikely that we'll see assistive technology for repetitive tasks in the future. In that sense, we are really at the early stages of the surgical robotics field! (In fact, depending on what who you talk to, the field is as young as 30 years old)

d) I partially disagree with the notion that a procedure done with the robot could be done without it

e) Some competitors are emerging onto the scene, such as Senhance by TransEnterix or Verb Surgical's product, which will progress this technology even further (if not out of the pure competitiveness of it all).

For those interested in reading more, I would suggest the following articles:

[0] Vitiello V, Lee SL, Cundy TP, Yang GZ. Emerging robotic platforms for minimally invasive surgery. IEEE reviews in biomedical engineering. 2013;6:111-26.

[1] Lee SL, Lerotic M, Vitiello V, Giannarou S, Kwok KW, Visentini-Scarzanella M, Yang GZ. From medical images to minimally invasive intervention: Computer assistance for robotic surgery. Computerized Medical Imaging and Graphics. 2010 Jan 31;34(1):33-45.

[2] Marcus H, Nandi D, Darzi A, Yang GZ. Surgical robotics through a keyhole: From today's translational barriers to tomorrow's “disappearing” robots. IEEE Transactions on Biomedical Engineering. 2013 Mar;60(3):674-81.

Disclaimer 1: Have done a few years of research with a surgical robot, so am biased towards advocating it's use.

Disclaimer 2: I am not from the institutions of the articles I mention.

Also worth noting that complications and major complications were apparently lower (20% lower with major complications) with the robots but the study did not get to the hurdle of statistical significance.

N.B. for people who have no clue about statistics: failure to achieve statistical significance does not show no effect. In reality this study suggests that there was a useful effect, but did not conclusively prove it.

This confusion happens so often in medical papers it is almost a meme. A meme that has killed a lot of people (see e.g. the Vioxx fiasco).

Personally, my main take away from this article was that in 2015 50% of the patients that had a kidney removed (which would roughly be the other 24k patients the study didn't comment on) had their kidneys removed via an old school open incision procedure. Why is that still happening at all? Laparoscopic procedures are significantly safer for the patient, cheaper and faster than old school methods, and they have a quicker recovery time, but just two years ago literally half of the kidney removals performed in these 416 hospitals were using a completely outdated method.

I had this exact surgery (robot-assisted laproscopic complete nephrectomy) back on September 22nd.

In my case, once the doc got in there, the tumor+kidney was too big and they had to cut a normal open incision to get it out.

So, I ended up with three tiny laproscopic scars and one big 10" scar.

Hmm, there's no mention of error rates / mistakes.

24,000 operations without error is quite possible.

If the robot reduced the chance of catastrophe by 5x (to pluck a figure from thin air) it may well pay for itself even at an extra $3k per patient.

Would you trade $5k for a 5x reduction in never waking up ?

The article claims error rates were comparable:

> However, the two approaches have comparable patient outcomes and lengths of hospital stay, the study showed.

No real error rates though, as I said, it is easy to imagine none occurred in just 28k operations.

What if the error rate was (in extremis) 1 death in 50k for non assisted and 1 death in 500k for assisted.

The extra cost might be justified on that basis.

They said the outcomes are comparable.

I think what PeachPlum is saying is that the words "the outcomes are comparable" has already injected an interpretation into the data, which, if not revealed in the article, is difficult to agree with.

You are right in that it looks like the robots had a lower incidence of major complications but the P value was short of "statistical significance" (i.e. 0.05) so it was not considered proven. This is a long way from saying "there was no difference".

surgeon here - the "robot" is not a robot - you 100% control the instruments. It just allows the instruments to mimic the movements of your hands inside the body, without the big incisions. I've sent patients with lymph nodes between the vena cava and the portal(not the game)vein to robotic surgeons bc the robot can be more precise than me laparoscopically

> It just allows the instruments to mimic the movements of your hands

So it's more of a waldo[1] than a robot.

[1]: https://en.m.wikipedia.org/wiki/Remote_manipulator

Can someone with experience shed some light on the future of this industry? I think surgical robots are really cool, but I don't know the capabilities or limitations of the technology. This article only talks about laporoscopic surgery for removing kidneys, but surely there are many other types of surgeries - some of which robots excel at and many for which it fails entirely?

Basically, I'd love for someone knowledgeable to tell me more about the long term timeline for this technology. How quickly will it grow, and will it ultimately replace entire types of surgery and transform how we treat people or continue to be an alternative with no obvious superiority?

surgeon here - 15 years - thinking about, but haven't received training to allow me to use the robot.

I consider myself a moderately advanced laparoscopic surgeon - I do lap cholecystectomies (gallbladder), laparoscopic hernias, adrenals, appendectomies, Nissen fundoplications, colons, biopsies.

I think there is a place for robotic surgery, but you have to maintain your skills to keep using it - at our hospital, robotically certified surgeons have to do at least 25 robotic cases per year to maintain certification - for my caseload, I don't think I have more than 10-15 cases that would warrant the robot so I would basically be taking 10-15 patients to the OR to do their case robotically in order to maintain my certification.

The advantage of the robot is that it is ridiculously easy to sew vs laparoscopically. To sew laparoscopically, you have a 2 foot long instrument holding the needle and trying to sew. For the robot, it follows the movement of your wrist and hand precisely. It really is amazing technology, but there is only specific, limited use in my opinion.

For example, for prostatectomies, it is awesome. In open prostatectomies, it's difficult to see the pudendal nerves and so they are sometimes sacrificed - no more erections! View is magnified and 3d in robotic. In addition, anastomosing the bladder back to the urethra happens under the pubic bone so only a limited number of sutures can be placed in the traditional way, whereas with the robot, it's a running circular stitch - less urinary leaks with the robot means less incontinence.

The biggest issue is that in our literature (general surgery) all of the research papers the last several years regarding the benefits of robotic surgery are funded by Intuitive Surgical, which leads to bias. It has it's place, but they are a company and are driven by profit - it behooves them to get a lot of surgeons trained so that we're all fighting for the robot, so the hospital feels they have to buy another!

My current status (as told to the rep) "Let's see if Dr. SoAndSo is still doing robotic surgery in 2 years...."

The only plus is that several other companies are going to be entering the market soon, so hopefully costs will go down bc now the robots are several million for one and the instruments are reusable (10 times), but cost $3k. Just look at ISRG......

- surgeon

"but haven't received training to allow me to use the robotbut haven't received training to allow me to use the robot"

What does such training consist of? Is it how to use the robot (like, these are the menus on the machine, and practice with these joysticks) or are the procedures different? I guess I'm asking, are robotic operations completely different from their manual counterparts, or are the 'just' the same except with the robot doing the moving for you?

Medical robotics is a growing industry, led by growth in laparoscopic and cardiac surgeries. There are many types of robotics in that term but focusing on surgical settings, the applications are broad and include cardiac, gastrointestinal, orthopedic, neuro, ear-nose-throat, urology, and probably more I've missed. The latest market estimate I've read was estimating a $2.71B market in 2015, expected to grow to $5.4B in 2021.

Some companies in this field would be Intuitive Surgical, Think Surgical, Titan Medical, Mazor Robotics, Medtronic, Siemens, etc. Needless to say, it is my opinion this is a growing and persistent industry.

It won't be as rapid growth as the smartphone or web development, given the regulatory and heavy capital investment requirements for a new hospital or clinic to get a system, but it will be growing. The lag between an innovative feature to clinically acceptable product is multiple years after all!

I am interested in whether doctors were able to take cases that they normally don't take.

I do not expect error rates to go down because doctors are already incentivized to avoid difficult cases.

It should be noted that robot-assisted surgery is hugely helpful for partial kidney removal versus the whole thing, as the article states. So the headline on its own doesn't cover the whole picture here and may even be misleading.

Figures I've seen show that things are worse for a while and then the robots are better, after a significant learning curve.

The story acknowledges that this study was done early on so it will have been affected by the learning curve.

Seen similar things, with the effect of learning curve being fairly massive - particularly for the first 5-10 procedures done. Really understated in the article for being a fairly major factor.

Not a surgeon or robot-user, but just by way of example, conventional wisdom in the medical world is that the best niche for robotically-assisted surgery is radical prostatectomy for prostate cancer. Conventional wisdom is that the robot permits better preservation of pelvic nerves, leading to lower rates of postoperative incontinence. If true, this is well worth a longer, more expensive procedure.

In my center, surgical times went from 2h to a whopping 6h+ for radical prostatectomy after introduction of the robot. While you are right in that radical prostatectomy is to my knowledge the only case of demonstrated robot superiority, fragile patients may suffer from the longer operative times (a major risk factor for post op complications)

Is saving 4 hours worth having to wear diapers for the rest of your life?

Would a damp environment increase risk of skin infection down the line?

The issue isn't four hours of staff time; it's the added risks to the patient from four more hours of anesthesia.

If this requires highly trained doctors then of course it will cost more but it should require less skill overtime until its an automated consultation where you gently fall asleep, then wake up feeling rested and refreshed with some minor soreness but not a scar can be found and you go on with your day.

Ok. But over the long term isn't the hope of the robotic method to make the treatment available to more people, perhaps at hospitals that normally wouldn't offer such things.

Certainly, as the method is being vetted and perfected that too needs to be factored into the evaluation?

How could it be offered at places that don't offer it? The robot is autonomous it is controlled by a surgeon.

In most industries robots make something cheaper. I am confident that the US health system will find a way to become even more expensive with the help of robots.

How about outcomes? At the end of the day that should be the benchmark we should use.

The article says "However, the two approaches have comparable patient outcomes and lengths of hospital stay, the study showed." So it looks like the answer to the question "are doctors doing better work" is "No". reply

Anesthesiologist friend confirms this.

Robots are nowhere near making a huge impact on outcomes yet.

Which one would be willing to accept if it would be able to save lives.

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