By Sid Schwab
Herald columnist
To benefit humanity, and from the goodness of my liberal, bleeding heart, I answer medical questions on some websites. Of late, many concern “robotic” surgery, about which it’s apparent there’s much misinformation. As it happens, the FDA just warned surgeons to stop going crazy with what they’re doing using robots. So let’s talk about it.
For general surgeons, robotic surgery is laparoscopy, but cooler. The laparoscopy revolution happened well after I finished my surgical training, so I took courses later. The first, for laparoscopic gallbladder removal, was sponsored by a laser manufacturer; in fact, the procedure was originally called “Laser Laparoscopic Cholecystectomy.” We practiced on pigs (sorry), using both lasers and standard electrocautery. Seeing no advantage to the laser, I asked the sales-guy why anyone should spend fifty grand (back then) on the device. “Because,” he replied, “If people hear you’re not using one, they’ll go elsewhere.” Ah.
In hospitals across the land, those lasers now gather dust, after recognition that, for most operations for which they were purchased and advertised, there was no added benefit. It’s unlikely surgical robots will become electrified dust-bunnies, but, for now, their value is familiarly controversial: multiple studies have found no improvement in outcomes, whereas operative costs increased by several thousand dollars. (Robots cost millions. Attachments add more.) That FDA missive was occasioned by surgeons using robots for mastectomy, raising concerns, because of a more restricted view, about leaving critical tissue behind. Having done many mastectomies, I’m concerned, too.
Evidently, lots of civilians believe robots do the operating, employing extraordinary artificial intelligence. They ask if my profession is threatened, if surgery is better done by robots than humans. So, here’s the deal:
Robotic surgery was conceived as a way for military surgeons to operate on soldiers near the battlefield, but remotely, from behind the lines. (Not so, of course, for the medics who’d be installing the instruments.) Mechanical arms would move the instruments, controlled from anywhere, wirelessly, even across the internet.
My analogy: You’re being driven somewhere. The driver is your surgeon; the car is the operating room. With traditional open surgery, the driver sits up front, her hands on the wheel, gearshift, operating all controls directly, looking out the windshield to see the road.
With laparoscopic surgery, the driver is in the back seat, controlling the wheel, etc., with long tools, and instead of looking out the window, he’s looking at an image sent from a maneuverable camera on the front of the car to a TV screen, giving a closer, changeable view. Also, it’s a minicar.
In robotic surgery, servos, grabbers, whirring motors, are attached to the controls. That marvelous mass of machinery is being operated by your driver, who’s nowhere to be seen; ensconced, rather, at a console, in the garage, at home, or, truer to the surgery analogy, in a trailer being pulled behind the car, in case of mechanical trouble. She’s got fingers in all sorts of moveable gadgets, her head in a booth at the front of which is a TV screen. The controls of the car are moved by the attachments, but only in response to your driver’s every action, including verbal commands. It’s laparoscopy by remote control and with more agile instruments. The “robot” itself, though, is stupid. Acrobatic, yes. But dumb as a gallstone.
Robot-assisted abdominal surgery ramped up with prostatectomy and hysterectomy. Surgeons like the view they get, and the un-anatomical movements that are possible using their brilliantly engineered tools. And it’s fun. Because medicine in the U.S. is a commercial, competitive enterprise, doctors — and especially hospitals — trumpet their use of robotics. As with lasers, patients are impressed, convinced it’s even more “non-invasive” and less dangerous than laparoscopy alone. Futuristic. Magical. Cutting edge, one might say.
Now, “robots” are employed in ever more complex operations. Also, simple ones: gallbladder removal, hernia repair, for example, adding complexity (setting them up is a big deal). Better results have yet to be demonstrated, compared to standard laparoscopy. Greater expense remains the only consistent finding. But robots market really well.
Occasionally, robots have been used as imagined, by surgeons remote from the operative location. Having a world-renowned expert available from afar to “do” your operation is rightly appealing. In other situations? We’ll see. No matter what, though, there’s no thinking robot involved. Tender and variable tissues still need human minds.
We’re not even at the R2-D2 stage, let alone C-3PO.
Email Sid Schwab at columnsid@gmail.com.
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