Robotic-surgery still requires skilled hands

Dr. Harvey Cushing, one of Harvard’s great neurosurgeons, once remarked,


Dr. Harvey Cushing, one of Harvard’s great neurosurgeons, once remarked, “There is no such thing as minor surgery, but there are a lot of minor surgeons.”

He wanted to drive home the point that you should always be careful about who does your operation. But when Cushing made this remark, he had never heard of robotic-surgery. So what would he say now?

A report in the Journal for Healthcare Quality analyzes complications that occurred during one type of robotic-surgery between the years 2000 and 2012. During that time there were 174 injuries and 71 deaths.

Another study at Johns Hopkins University revealed what has long been suspected, that surgical complications are not always reported in robotic surgery and that reports represent just ‘the tip of the iceberg.’

But, one could make the same remark about non-robotic surgical procedures.

In 1991, Dr. Jacques Perissat at the University of Bordeaux, in France, announced at the World Congress of Surgeons that he had removed a gallbladder (cholecystectomy) using optical instruments through small incisions. This became known as ‘key-hole surgery.’

Now, a large number of operations are done by this method. Many women are saved from hysterectomy when fibroids can be removed by this procedure. Skilled surgeons can even remove a large segment of a cancerous bowel by robotic surgery.

This operative approach has been a great boon for patients. Without a large incision there’s less pain, speedier healing and shorter time in hospital. But there’s a huge difference between opening the abdomen with a scalpel for a direct look at the diseased organ, and performing keyhole surgery.

Harvey Cushing would quickly spot one of the problems with keyhole surgery. Namely, that the term tends to indicate that using tiny incisions also means a simple, uncomplicated way to perform operations. Unfortunately, this is not always the case and small keyhole incisions can be associated with catastrophic complications.

Doctors performing robotic surgery have to become adjusted to an entirely new approach whether removing an appendix or a segment of large bowel.

Rather than holding a scalpel, surgeons watch a video camera while manipulating a variety of grasping, cutting and suturing devices. It’s a vastly different ball game with a steep learning curve.

During this learning curve there’s a greater chance of surgical complication. For example, inserting instruments through the abdominal wall can cause injury to a major blood vessel or bowel even though safeguards are taken.

Keyhole gallbladder surgery over the years has been the source of major complications. The common bile duct is a small tube carrying bile from the liver to the bowel and it’s the one that has been most frequently injured.

If not repaired at the time of surgery it can lead to jaundice and death. In one study that analyzed 613,706 keyhole gallbladder operations, 0.39% suffered this injury.

Dr. Cushing would tell you that before robotic surgery was available, an old dictum held true, that practice makes perfect whether you’re a surgeon or a plumber. For robotic surgery this warning should be made in big red capital letters. I remember well learning quickly to use a scalpel to open an abdomen. My learning experience with keyhole surgery was more prolonged.

Nevertheless, looking at the total picture, there’s no doubt I’d prefer to have my gallbladder removed by robotic surgery.

But I’d agree only if it required removal. Studies show that about 10% of North Americans have gallstones. Today, with the increased use of ultrasound, many gallstones are accidentally discovered during tests to diagnose other conditions. In general, gallstones not causing trouble are best left to the crematorium.

As another Harvard professor once remarked, “Remember, it’s impossible to make a patient feel better who doesn’t have any symptoms.”

Dr. Cushing’s final advice would be to always go to surgery on a first-class ticket. Usually, your family doctor can direct you to the right hands. If not, be sure to do your homework and find a surgeon who has experience in robotic surgery.

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