At this year’s ESCP meeting in Milan, Dr Steven Wexner from Cleveland Clinic Florida discussed the current controversies in robotic colorectal surgery. We talked to Dr Wexner about the procedures limitations, the lack evidence to support its widespread adoption and its possible educational practicalities…
“I do not believe that robotic colorectal surgery confers any advantage to my patients,” began Dr Wexner. “I have had over 25 years’ experience with laparoscopic minimally invasive colorectal surgery. So, if I am operating on a patient with rectal cancer, I perform it laparoscopically using only three or occasionally four ports. To do the same procedure robotically, I would need a minimum of five ports. The same procedure is also much more cost-effective and much quicker laparoscopically, compared to the robotic procedure.” “Moreover we know by our own peer reviewed published data, our oncologic parameters are significantly better by laparosopy than by laparotomy.”
He said that the vast majority of the evidence demonstrates that laparoscopic surgery is clearly the gold standard procedure compared with robotic or open surgery. Although he stated that robotic surgery confers no advantages over laparoscopic procedures, he acknowledges robotic surgery in the hands of some surgeons can result in better oncologic outcomes than those surgeons can offer their patients by either laparotomy or laparoscopy.
Nevertheless, Dr Wexner added that the evidence shows no difference in outcomes between robotic surgery and laparoscopy. Indeed, according to the literature the two main differences between the procedures are cost and operative time, both in favour of the laparoscopic approach.
Why robotic surgery?
“So why do surgeons perform robotic procedures? The first is market share, surgeons feel that if they do not offer robotic surgery they will lose patients and if they wish to maintain or develop their practices, they feel they must learn to perform surgery with this technology; that is an individual choice for each surgeon to make,” he explained. “The second reason is that surgeons who are not comfortable with, not educated in, or not adept at performing laparoscopic pelvic procedures, use robotic surgery as a means of transitioning from the open to the minimally-invasive approach.”
As well as allowing, surgeons who have difficulty in mastering a laparoscopic pelvic dissection, to offer their patients in minimally-invasive approach, the robotic approach does confer some potential benefits such as improved visualisation with the 3D imaging.
However, Dr Wexner cited a study by a study by Park et al. (Surgical Endoscopy. Is a robotic system really better than the three-dimensional laparoscopic system in terms of suturing performance?), which looked at suturing robotically vs 3D vs 2D laparoscopic suturing in operators with different levels of experience. It showed that the novices (<20 cases) failed to complete the task with 2D or 3D laparoscopy, but all of them completed the task with the robot. In comparison, the intermediate group (20-99 cases) completed the task equally well and equally quickly with 3D laparoscopy and the robot. The experts (>100 cases) completed the task equally well regardless of instrument, but their times were much faster with 3D laparoscopy.
He noted that numerous studies in Europe and the US have reported that outcomes from rectal cancer surgery are better in high volume centres, in the hands of high volume surgeons. A paper by Delaney et al. (Journal of the American College of Surgeons. Short-Term Outcomes for Robotic Colorectal Surgery by Provider Volume), found that lower-volume hospitals, at which the majority of robotic procedures were performed, were generating more complications, longer hospital lengths of stay and higher costs of care.
“So, what we have is an undesirable paradox: robotic surgery has made it easier for a group of surgeons who are not performing a high number of open or laparoscopic rectal cancer procedures to perform robotic rectal cancer operatons. In theory, the increased availability of minimally invasive surgery should be good for their patients. However, conversely, because these surgeons are doing a limited number of rectal cancer operations, the patient may not be deriving the same benefit as they would having an open, robotic or laparoscopic procedure performed by a high volume rectal cancer surgeon. Yes, the surgeon can do it more easily, but should the low volume surgeon be doing it at all? Not according to numerous recent publications from both the EU and the USA. It is indeed an interesting ethical dilemma.”
The proponents of robotic surgery claim that it has a lower conversion rate (vs laparoscopic surgery) as compared to open repair. But the ROLARR (Robotic vs. Laparoscopic Resection for Rectal Cancer) multi-centre, international, randomised clinical trial assessed this very question - with the primary endpoint being the rate of conversion to open surgery. The study did not find any statistically significant advantages that favoured robotic total mesorectal excision and it failed to demonstrate any statistically significant advantage relative to conversion rate in either overall or subgroup analysis.
“If we look at the literature, at the studies, none of them show an advantage for robotic surgery over laparoscopic surgery. And again, the only consistency that the research shows is that robotic surgery costs more and takes longer.”
Cost
Cost is a crucial issue as every study across the world, according to Dr Wexner, has shown that it is significantly more expensive to perform these procedures robotically. He cited Dr Michael Stamos’ published data from the National Inpatient Survey (Moghadamyeghaneh Z, Phelan M, Smith BR, Stamos MJ. Disease of the colon and rectum. Outcomes of Open, Laparoscopic, and Robotic Abdominoperineal Resections in Patients With Rectal Cancer), which showed when compared to laparoscopy, robotic rectal cancer surgery was US$25,000 per case more expensive (including all costs).
“Now, when you multiple that added cost by 45,000 rectal cancers - and if we did them all robotically – it equates to approximately US$1.2 billion extra each year spent treating rectal cancer in the USA; the added cost in Euros in the EU may be even higher. I think that is hard to justify. In the end, it is gaining a share of the market, but it is costing more money. It’s an interesting business model.”
In order for robotic colorectal surgery to be more widely adopted, Dr Wexner believes that the procedure would have to have at least equal outcomes at reduced operative and hospitalisation costs or same costs but better outcomes in terms of recurrence and or complications, adding that these results would be “a compelling argument.”
“We are now seeing the emergence of 3D laparoscopy system with several companies such as Karl Storz and Olympus Medical, in the market. It could be that robotic surgery becomes a valuable educational platform as a trainee console. So as an educational platform, I can see the benefits.”
He rejects the arguments that the significant additional cost of the robotic platform is justifiable because the operative method is more ergonomically beneficial for the surgeon who can sit at a console as opposed to standing and looking at a monitor.
“That allegation may be true, but I don’t think healthcare systems around the world are keen to pay considerable additional amounts of money so that surgeons can be more comfortable!”
He understands the genuine fear among surgeons that they could be left behind if they don’t learn the robotic techniques needed to attract patients, adding that it’s a very strong motivating force that should not be underestimated. On the other hand, he has many colleagues who did learn the robotic procedures and who stopped because their patients were not gaining an advantage and they were incurring a significant extra cost.
“Each individual surgeon has to have independent appraisal of his or her results. We all need external auditing so we know what procedures and techniques we do best. If someone does open TME surgery best – that’s the way they should be performing - and it’s the same for laparoscopic and robotic TME procedures. But, the patient has to know these data. Ours have been published in public domain and show a significant oncologic benefit to laparoscopic versus open TME including a 25% greater lymph node yield with the laparoscopic approach (Boutros M, Hippalgaonkar N, Silva E, Allende D, Wexner SD, Berho M. Disease of the colon and rectum. Laparoscopic resection of rectal cancer results in higher lymph node yield and better short-term outcomes than open surgery: a large single-center comparative study.). The mistake occurs when a surgeon knows they are better at laparoscopy but performs robotic procedures because they do not want to lose patients. A surgeon must be honest with his or her results. For me, patients should pick the surgeon who is the best for their procedure of choice, not a surgeon who ‘can’ do their procedure robotically.
He remembers when the first laparoscopic colorectal procedures were carried out in 1991, and straight away surgeons were seeing lower rates of hospital stay, reduced wound infection rates, fewer complications, less post-operative pain, more rapid recovery, patients eating sooner, going to the toilet sooner - across the board improvements. Even though the new laparoscopic approach did cost more than a laparotomy, he said there was a general acceptance that as the surgeon’s laparoscopic skills improved (as well as improvements in the technology), patient’s outcomes would also improve.
“But, we have not witnessed the same improvements with the robotic platform as compared to laparoscopy but we may see more patients offered minimally-invasive surgery. The world literature is very much in consensus that robotic procedures are not superior to laparoscopic procedures,” he concluded.