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Anthony Burdo

Professor L. Healey

Research in Disciplines

December 11, 2007

Premature Robotic Surgery: Putting Patients and Professionals at

Risk

Robotic Surgery has reached one of the highest peaks of interest for

scientists, surgeons, and the general public today. The focus of much

acclaim and attention in the medical field, robotic surgery allows a surgeon

from a console to operate on a patient via the use of a high-tech camera and

arms which can be manipulated as needed. Current applications of this

technology include advanced cardiac surgery, gastrointestinal surgery,

gynecology, neurosurgery, orthopedics, pediatrics, and urology. Robotic

surgery, although already in use, raises controversy over the practicality,

safety, and cost effectiveness of the technology, and whether or not it is

truly the best option for the patient. With regard to improving patient care

and providing the technology for healthcare professionals to do so, there are

many limitations and obstacles to overcome before robotic surgery systems

should be integrated into the medical field. The future of robotic surgery

technology promises to greatly improve upon current surgical methods and

techniques. At this time, however, robotic surgery is still a novel concept

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and the availability of long-term results regarding the success of operative

procedures is limited. Statistics show that such success may be hindered for

several reasons. [Based on research, analysis, and case studies it can be

concluded that for the majority of procedures currently performed using

robotic surgery, long term post-op success rates of patient outcomes are still

unclear, patients’ physical needs are not being adequately met, the robotic

surgery systems themselves are unsuitable for surgeons to use, many

surgeons are incapable of operating such technology, the costs to the patient

and providing institution are exorbitantly high and unnecessary, the

uncertainty with regard to litigation procedures and the violation of patient

integrity make robotic surgery technology an impractical resource for both

patients and healthcare professionals alike,].

With the introduction of robotic surgery techniques to the medical field,

there have been a variety of case studies which analyze patient outcomes

after undergoing operative procedures. While the large majority of cases

observed that have utilized robotic surgery systems have been successful, it

should be noted that these studies have not monitored long term post

operative success rates. In a case study at the Innsbruck Medical University

in Austria, only 5% of procedures utilizing the da Vinci ® robot were

unsuccessful; however these patients experienced major bleeding and

collateral tissue damage by robotic instruments, there was a complete

system failure, and there were four reported post-op wound infections

(Bodner 676). Similarly, a study of pediatric patients at St. James’s

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University Hospital showed a 6% complication rate with regard to mechanical

failures, faulty system signals, and malfunction of instruments (Najmaldin

200). Johannes Bodner in, The da Vinci Robotic System For General Surgical

Applications: A Critical Interim Appraisal, responds to one such case study

and explains that “various general surgical procedures have proved feasible

and safe when performed with the da Vinci ® robot” (Bodner 674). However,

these statistics for operative complications in robotic surgery compare to the

national average of 4% using conventional methods, and thus further

challenge the efficacy of robotic surgery techniques (Gazella). While the

cause for concern may appear to be minimal, these studies blatantly suggest

that robotic surgery is not meeting patients’ physical needs. In fact, the

observed malfunctions, although infrequent, demonstrate the need for

further research and improvement before robotic surgery can be utilized. It

is clear that these limitations must be resolved as the complications pose a

major threat to patient well being. While the rate of failure appears to be

minimal, the unpredictable system malfunctions that occur in current

applications of robotic surgery, and the effects thereof, put all patients who

utilize robotic surgery at an unnecessary risk.

In comparison to conventional surgery methods, there are additional

shortcomings of robotic surgery which directly affect the patient. One issue

of concern is the extensive operating time. The robotic systems are

designed to work on small areas of the body; however, many procedures

require a surgeon to operate on two or more subdivisions of the body (Taylor

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4). For example, robotic surgery has become highly used in operations on

the abdominal cavity. The robotic systems are designed to work on one

quadrant at a time when most surgeries require operating on at least two

(Taylor 5). Because of this, the robotic systems must be readjusted and

recalibrated over the course of the surgery. The dissembling and repeated

docking of robotic machinery significantly adds to the total operating time.

This not only adds a factor of increased costs to the patient and medical

facility, but necessitates a patient to be unconscious for a longer period of

time while putting more pressure on the surgeon to work quickly and

effectively (Taylor 4). The bulkiness of the robotic systems in use also poses

a threat to patient safety. The space occupied above and around the patient

creates issues regarding anesthetic safety in that rapid access to the patient

in the event of a cardiopulmonary collapse is difficult (Taylor 4). This also

creates a risk regarding sterilization procedures and prevention of infection.

The sheer size of the machinery makes it very difficult to sterilize completely,

which poses a direct threat to a patient’s well being during surgery. This

problem has added to the increased incidence of postoperative wound

infections utilizing robotic surgery methods.

A particular concern regarding the application of robotic surgery is that

the technology in use is inadequately designed for practical use in complex

procedures. Therefore, surgeons may not be equipped to operate such

technology efficiently and effectively. The devices in use have shown to limit

surgeons’ dexterity and maneuverability when operating on patients.

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Additionally, “lack of tactile and force feedback to the surgeon” is another

major problem which may inhibit the surgeon’s ability to operate successfully

(Morris 2). Communication amongst the operating staff utilizing the robotic

surgery systems also seems to be an issue; while the majority of the staff

may be present in the operating facility, the actual operating surgeon may

be quite distant from the procedure taking place (Hashizume S332).

Anthony Lanfranco, in Robotic Surgery: A Current Perspective, notes that in

fact, there have been some improvements on these “ergonomic limitations,”

but the technology is still in flux (16-17). It seems that many surgeons may

be ill equipped to handle technology that creates so many impedances. With

the inability to gain a hands-on feel for what is happening to a patient on the

operating table, it is very easy to make an error that may not be immediately

apparent to the surgeon. Additionally, the limited maneuverability may

prohibit the surgeon from gaining access to certain regions of the patient’s

body. Finally, the lack of communication may prevent the operating surgeon

from conveying vital patient information to the surgical staff and vice versa.

These limitations of robotic surgery pose a major threat to a patient’s safety,

and further indicate the need for improvement to robotic surgery technology

and techniques.

Rory McCloy, in Virtual Reality in Surgery, argues that “healthcare

professionals over the age of 30 are regarded as the lost generation with

regard to informational technology” (3). Perhaps the surgeons who are

currently utilizing robotic surgery technology are at a disadvantage due to

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inadequate exposure to advanced computer guided technology. In an

interview with pediatric urologist, Dr. Craig Peters, he explains that there is a

mere “two day training session to learn the robot” (Robotic). The problem, it

seems, is that healthcare professionals today are not adequately prepared to

operate the current robotic surgery systems. While robotic technology is

expected to play an increasingly important role in the future of surgical

training, a survey in 2002 showed that 80% of medical students did not have

a robotic training program in their institutions and 77% of their universities

did not plan on incorporating one (Morris 3). Additionally, while there is

some training available for current and future healthcare professionals, the

enhancement and further development of these programs may take up to

ten years (McCloy 4). Without the proper training and preparation to utilize

robotic surgery systems, we cannot expect to arrive at a generation of

technologically adept surgeons that will be prepared to utilize technology

beyond their control. Furthermore, because there is merely a fraction of the

surgeon population that will become proficient in utilizing surgical robots, it is

unrealistic to anticipate the improvement of the technology in the near

future. Many changes must still be made to the technology and training

programs to provide the safest and most practical surgical options for both

patients and professionals.

Robotic surgery raises an issue regarding the practicality of such

technology and whether or not it truly meets the patients’ overall needs.

One issue of great discussion is that of the costs to the providing medical
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institution and the patient. Regions of the country that generate the most

medical need are often supplied with the least financial resources for medical

care. With a purchase cost of around $1.2 million, “a surgical robot is too

expensive for places where it is most needed” (Morris 2). Additionally,

maintenance costs can be up to $100,000 per year. Therefore, it goes

without saying that many medical institutions have not integrated robotic

technology systems into their facilities because the costs are just too high.

We can not expect to advance or improve upon robotic surgery if the

technology is unaffordable. While the costs of the actual robotic components

may fall in the future, the costs of continuous updates in software and

enhancement technology may actually be prohibitive as well (Lanfranco 18).

With such a great cost to the medical community, those expenses are

inevitably passed on to the patient.

A recent survey of procedural costs per patient revealed that on

average, robotic procedures were approximately one and a half times the

cost of the conventional equivalent (Bodner 677). In a society where quality

medical care is preceded by a price tag, Richard Deyo, in Hope or Hype,

states that patients “deserve their money’s worth for these treatments, and

their health may depend on them” (272). The physical risks of robotic

surgery are, by themselves, a cause for alarm; the patient should not have to

worry about whether or not they can afford an essential surgery. In terms of

practicality, it seems that this emerging technology has “primarily been

driven by the market” (Lanfranco 1). As many insurance companies

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throughout the country still do not offer coverage for robotic surgery, it is

evident that the patient is subject to inflated costs at the discretion of the

industry (Bodner 2). Furthermore, robotic surgery, in its current state, is

primarily used in minor and simplistic procedures, rendering the exorbitant

costs unnecessary (Lanfranco 3). Patients must consider whether or not they

will be willing to pay such great prices to utilize risky and error-prone

technology.

While robotic surgery techniques have been in use for several years

now, there still have not been many regulations set on the litigation

procedures and who exactly is responsible if something goes awry during a

procedure. According to T. McLean, in The Complexity of Litigation

Associated with Robotic Surgery and Cybersurgery, there is a much greater

risk of liability for the medical community and robotics industry than in

conventional methods because of the increased possibilities of things that

could go wrong (5). In other words, while the technology may be

maneuvered and controlled by the surgeon, the patient may have the option

to pursue action against the hospital and maker of the robotics system,

depending on what goes wrong. The current restriction on a malpractice suit

against a surgeon is set at $1 million, but there really is no limit as to how

much the industry or hospital can be sued (McLean 6). Additionally, the

question of whether or not the surgeon is responsible raises an inquiry

regarding the effectiveness of the technology itself. In an interview with

cardiology surgeon, Dr. Pedro del Nido, he explains that, “if it [the robotic
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system] failed because I was misusing it than obviously it is my fault. If it

failed because of some defect in the design or the production than it is the

company’s fault” (Robotic). However, this subject of liability may not be so

clear cut. The subject of faultiness in the maneuverability and dexterity of

the machines, introduced previously, may pose an additional obstacle in

deciding exactly what went wrong in a particular malpractice case. While the

surgeon may be protected by a $1 million limit, the hospitals and industry

that pursue robotic surgery are at great risk of going bankrupt in the

litigation proceedings that may occur (McLean 8). This not only puts

pressure on the operating surgeon, but may potentially slow the progress of

robotic surgery.

According to Roy Porter, in The Greatest Benefit to Mankind, “modern

medicine has become synonymous with complex infrastructures, professional

organizations, government departments, international agencies and

corporate finance” (668). His theory of medicalization proposes that our

society has been overtaken by the medical field with regard to dependency

and limited patient integrity (Porter 669). In other words, because the

medical community plays such a significant role in the infrastructure of our

lives, most of us place full trust and confidence in medical professionals, and

are therefore subject to being unknowledgeable and unaware when it comes

to our health. With regard to robotic surgery, it would seem that this market

driven technology has become so overly promoted by the industry to the

point where society and the medical community has placed full confidence in
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its effectiveness when in fact, the technology is still error- prone. Patients

need to be more aware of the risks and consequences of undergoing a

robotic surgery procedure before society can make any sort of progress with

this technology. Simply put, patients have the right to know about what

failures and complications have been observed with the use of robotic

surgery, and what this may mean for them if they decide to undergo such a

procedure. Porter makes the argument that the politicization of medicine

has created a concern over who is really making the decisions with regard to

our health (699). Before we can further pursue applications of robotic

surgery, patients must realize that they are accountable for their health, and

it is their responsibility to decline robotic surgery if they cannot place 100%

of their trust in it.

The future of robotic surgery technology promises to revolutionize the

medical field. However, robotic surgery today has acquired a somewhat

premature claim to fame as there are still many limitations and setbacks to

overcome before this technology is safe and practical for the patients and

healthcare professionals that utilize it. Research on current applications of

this technology reveals a small percentage of mechanical, ergonomic, and

operative failures which, although seemingly marginal, can pose serious

threats to the lives of patients undergoing robotic surgery procedures. The

lack of training programs is also a cause for concern as the amount of

healthcare professionals trained to use robotic surgery technology is not

expected to keep up with the surge of medical technology in the future.

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Additionally, the ergonomic setbacks of current robotic surgery systems

present a major limitation to all healthcare professionals who use them.

Moreover, the price tag set on robotic surgery technology restricts both the

medical community and patients from pursuing it and improving upon it. It is

just not cost effective at this point. Furthermore, the litigation procedures

and issues of responsibility are undefined, and put a great deal of pressure

on the surgeon, industry, and patient. Finally, patients’ vulnerable integrity

and unawareness with regard to their health and safety are a cause for

concern as we approach the future of robotic surgery. At this time, due to

the obstacles currently posed to the patient and surgeon and the deficiency

of long term results, research suggests that robotic surgery is an impractical

resource for the medical community and patients alike.

Works Cited

Bodner Johannes, Florian Augustin, Heinz Wykypiel, John Fish, Gilbert

Muehlmann, Gerold Wetscher, and Thomas Schmid. “The Da Vinci

Robotic System For General Surgical Applications: A Critical Interim

Appraisal.” Swiss Medical Weekly. 135 (2005). 19 Oct. 2007.

http://www.smw.ch/dfe/set_archiv.asp?target=2005/45/smw-11022.

Deyo, Richard A. Hope or Hype: The Obsession With Medical Advances and

the

High Cost of False Promises. New York: American Management

Association, 2005.
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Gazella, Katie. “Obese Patients Run Higher Risk of Post-Operative

Complications, U-M Study Finds.” University of Michigan Health

System. 13 March 2007. 14 Nov. 2007

http://www.med.umich.edu/opm/newspage/2007/obesesurgery.

htm

Hashizume, Makoto and Kouji Tsugawa. “Robotic Surgery and Cancer: the

Present State, Problems and Future Vision.” Japanese Journal of Clinical

Oncology. 34 (2004). 19 Oct. 2007.

http://jjco.oxfordjournals.org/cgi/content/abstract/34/5/227.

Lanfranco, Anthony R., et al. “Robotic Surgery: A Current Perspective.”

Annals of

Surgery. 239.1 (2004). 5 Oct. 2007

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmedid=1

4685095

McCloy, Rory. “Virtual Reality in Surgery.” British Medical Journal. 323

(2001).

11 Oct. 2007

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&

artid=1121442

McLean T. “The Complexity of Litigation Associated with Robotic Surgery and

Cybersurgery.” International Journal of Medical Robotics and Computer

Assisted Surgery. 3.23 (2007). 12 Nov. 2007.

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Morris, Bishoy. “Robotic Surgery: Applications, Limitations, and Impact on

Surgical

Education.” Medscape General Medicine. 7.3 (2005). 11 Oct. 2007

<http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez

&artid=1681689>

Najmaldin, A., and B. Antao. “Early Experience of Tele-Robotic Surgery in

Children.” International Journal of Medical Robotics and Computer

Assisted

Surgery. 3.3 (2007). 22 Oct. 2007.

http://www3.interscience.wiley.com/cgibin/issn?DESCRIPTOR=PRINTISS

N&VALUE=1478-5951.

Porter, Roy. Selections from The Greatest Benefit To Mankind. New York:

W.W.

Norton & Co., 1997. 668-718. ISBN 0393046346

Robotic Surgery. Brown University. 9 April 2005.

http://biomed.brown.edu/Courses/BI108/BI108_2005_Groups/04/timelin

e.html

Taylor, G.W. and D.G. Jayne. “Robotic Applications in Abdominal Surgery:

Their

Limitations and Future Development.” The International Journal of

Medical Robotics and Computer Assisted Surgery. 3.0 (2007). 5 Oct.

2007. <http://www3.interscience.wiley.com/cgi-bin/jtoc/112094293>.
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