Highlighter Session: Robotic Surgery Trends and Recommendations for Slowing Their Roll

Adoption of robotic surgery has been rapid and enthusiastic. Here are some takeaways from a closer look at the trends.

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In operating rooms at hospitals around the country, robots have been rolled out and are used to assist in a wide variety of general surgery procedures.

Kyle Sheetz, a general surgery resident at Michigan Medicine, recently published a paper in JAMA Network Open on the trends, and the takeaways are highlighter-worthy.

Here are a few trends that stuck out during a read of the paper.

Adoption rapid, and data is lacking

"Recent work suggests that the United States now performs more robotic surgery than any other country in teh world, although overall trends in other specialties (eg, urology) toward greater use of robotic surgery have been present for years.9 Based on robotic device manufacturers' financial statements, procedure volumes exceeded 600 000 in 2017, with the largest and fastest growing contributor being the field of general surgery.9 This finding suggests that the clinical footprint for robotic surgery will continue to increase as it has for more than a decade already. However, accurate data on how robotic surgery is being applied in contemporary practice is lacking."

Data from the Michigan Surgical Quality Collaborative (MSQC), in which 73 Michigan hospitals participate, showed rapid adoption of robotic surgery during the reporting period for the study. The MSQC data is abstracted directly from medical charts as opposed to extracted from claims data, so the study’s estimates have a high degree of accuracy.

With exponential growth anticipated, a lack of data on how the new robotic surgical practices are being applied highlights the need for more study.

More robots, more expense

"Robotic surgery continues to diffuse across an increasingly broad range of surgical procedures. However, concerns have been raised that robotic surgery is more costly 1,2 and may be no more effective3,4 than other established operative approaches, such as traditional laparoscopic minimally invasive and open surgery. With respect to costs, for example, robotic surgery has been associated with episode costs as much as 25% higher compared with laparoscopic surgery. There are also concerns about the rapid growth of robotic surgery in areas with limited evidence to support its use and little theoretical benefit or clinical rationale (eg, inguinal hernia repair)."

Replacing human hands with robotic ones doesn’t necessarily correlate with lower costs. It’s a consideration for patients and providers when other viable options with similar or better outcomes exist.

Established procedures are being displaced

"We also demonstrate that increasing use of robotic surgery changed existing trends toward greater use of laparoscopic surgery. For many common and low-risk procedures, such as cholescystectomy, conventional laparoscopic surgery is already the accepted standard of care. Laparoscopic approaches are also less expensive and can be performed by most general surgeons without robotics.18 This situation highlights a questionable trend: robotic surgery is replacing conventional laparoscopic approaches for procedures that may not be complex enough to warrant the consideration of an advanced, expensive, and unproven minimally invasive platform."

While the study saw a significant uptick in the adoption of robotic surgery for all general surgery procedures among participating hospitals, the replacement rate of robotic surgery for laparoscopic surgery stood out.

Sometimes less safe

"For example, randomized clinical trials have failed to demonstrate the benefits of robotic surgery over other approaches in the treatment of rectal cancer12 and have shown even potentially worse outcomes in procedures for cervical cancer.4 Observational studies that compared robotic surgery with more established laparoscopic or open approaches have also failed to demonstrate superior outcomes after inguinal hernia repair,8 kidney resections,1 colectomy,13-16 or cholecystectomy.7 The discrepancy between the ongoing rapid adoption of robotic surgery and unclear clinical benefit highlights why accurate information on how it is being applied in contemporary surgical practice is necessary."

Are clinicians and systems falling for the siren song of robots despite a lack of evidence that they’re providing better outcomes—and in light of evidence that they can sometimes provide worse outcomes? Maybe. They’re only human.

More oversight and more data needed for patient safety

"This study suggests that regulators and the surgical community can take additional steps to monitor the ongoing diffusion of robotic surgery and ensure that this trend does not lead to diminished patient safety. Because accurate data are necessary to inform the creation of appropriate safeguards, the FDA and the Centers for Medicare & Medicaid Services should consider providing coverage for robotic surgery with provisions for evidence development.19"

Surgeons currently have wide discretion when it comes to using robotic surgery for procedures. An FDA warning and prior studies show that such discretionary use may place patients at risk for poor outcomes. More engagement from the FDA and insurers could help fill the holes that exist in data and help both patients and providers make better informed decisions about robotic-assisted surgery.

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By Colleen Stone

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