You may have heard or read about a recent report comparing robotic hysterectomy to non-robotic methods (USA Today, Huffington Post, Today Show, etc.). The headlines varied but the message in each was similar to USA Today’s “Robot-assisted hysterectomies booming, but better?” The story that the major media were reporting is based on the results of a recent study published this week in Journal of the American Medical Association (JAMA). We would like to offer our patients a little clarification about the criticism of robotic surgery contained in the JAMA article.
The study, from the Columbia University College of Physicians and Surgeons, questioned the advantage of robotic hysterectomy, but only compared with procedures known as Total Laparoscopic Hysterectomy, Laparoscopic Subtotal Hysterectomy, or Laparoscopic-assisted Vaginal Hysterectomy. These are all minimally-invasive surgeries. The researchers found no significant difference in how quickly patients recovered or the number of surgical complications between the robotic and laparoscopic hysterectomies. If the procedures are equally safe and recovery times are similar, they conclude that physicians should prefer the laparoscopic hysterectomy because it is cheaper.
In our practice, we strongly prefer the robotic hysterectomy. The robot and the laparoscope are similar instruments because they both allow the surgeon to work through very small incisions in the abdomen. But the laparoscope is a hand-held instrument. It does not have a bendable “wrist” like the robotic instrument. It cannot give the surgeon a 3-D view inside the abdomen. Being a hand-held instrument, it cannot control very tiny movements as precisely as the robot. In short, the robot is much easier to use.
We are not insensitive to rising healthcare cost and its effect on society (public health considerations), but—as private-practice physicians—our first goal is to achieve the best outcome for our individual patients. That includes using the least-invasive surgery possible. Although laparoscopic technology has been available for over two decades, as recently as 2007, over half of all hysterectomies were still performed through a large incision in the abdomen. Why? The laparoscopic approach is either extremely difficult or impossible in many situations.
I understand this based on my experience as a teaching faculty member at UAB and, in the past few years, as I have taught other surgeons to use the robot. Physicians master the robotic hysterectomy more easily and are more confident to use it. I believe this is what drives the “boom” in robotic surgery, rather than another possibility suggested by the JAMA study—heavy marketing of the robot.
While the national trend toward minimally-invasive procedures is growing, abdominal hysterectomy still represents about 40% of all hysterectomies. At Sparks & Favor, (with excellent support from Brookwood Women’s Medical Center) we made an early decision that the robot offered a major breakthrough in women’s surgery, We are now able to offer a minimally-invasive procedure to around 90% of our patients who undergo a hysterectomy. Many of these are women who, because of large uterine fibroids, previous cesarean delivery, other abdominal surgery, or a very thick abdominal wall, would have required abdominal surgery.
The research study only measured the surgery’s cost to providers (the government or insurance companies). It did not estimate the cost savings to an individual woman who goes back to work up to a month sooner. True, laparoscopic hysterectomies are also minimally-invasive. Women recover and return to their normal activities quickly. But let me re-emphasize that before the robot, not many women were getting minimally-invasive hysterectomies.
Some health policy experts have suggested that the money spent on very expensive technology might be better spent to train physicians to use the laparoscope. I don’t agree. Like all new technologies the robotic surgery costs will decrease as surgeons become more efficient and robot manufacturers begin to compete in the marketplace. Residency programs need to concentrate on training excellent robotic surgeons, because there will always be situations where the laparoscope just can’t do the job. The robot is here to stay.