Robotic Surgery: the US Perspective

Transcription

1 Robotic Surgery: the US Perspective Meagan Costedio MD FACS FASCRS November 10 th, 2017 Disclosures None 1

2 Advantages Actual Enhanced dexterity and precision 3-dimensional vision Intuitive instrument manipulation Enhanced primary surgeon control Tremor elimination Ergonomics for the surgeon Theoretical Decreased conversion rate Improved hemostasis Improved Accuracy of TME Improved sexual/urinary function Disadvantages $ COST $ Increased operative time Loss of tactile feedback Inability to reposition table Inadequate data??safety?? 2

3 Real Benefit Ergonomic Outcomes Surgeon wore EMG electrodes during 13 laparoscopic and 5 robotic procedures Mean maximum voluntary contraction measured in bilateral deltoid, biceps, triceps and the trapezius B/L deltoid, biceps, triceps significantly elevated activation in laparoscopic procedures Unsure of clinical significance to surgeon Sihni AM, et al. Ergonomic Analysis of Robot-Assisted and Traditional Laparoscopic Procedures. Surg Endosc Dec;28(12):

4 Survival Lim DR, Bae SU, Hur H, Min BS, Baik, Lee KY, Kim NK. Long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision of mid low rectal cancer following neoadjuvant chemoradiation therapy. Surg Endo. April 2017, 31(4) Conversion Rashid L, Neighorn C, Bastawrous A. Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg 2017 May; 213(5):

5 Valverde A, Boawquen N, Oberlin O, Svrech M, Flejou J, Sezeur A, Mosnier H, Houdart R, Lupinacci, R. Robotic versus laparoscopic rectal resection for sphincter-saving surgery: pathological and short-term outcomes in a single-center analysis of 130 consecutive patients. Surg Endosc Mar 7. Gorgun E, Ozben V, Costedio M, Stocchi L, Kalady M, Remzi F. Robotic vs. Conventional Laparoscopy in Rectal Cancer Surgery in Obese Patients. Colo Dis ,

6 Conversion Conversion Gorgun E, Ozben V, Costedio M, Stocchi L, Kalady M, Remzi F. Robotic vs. Conventional Laparoscopy in Rectal Cancer Surgery in Obese Patients. Colo Dis , Conversion Jayne D, Pigazzi A, Marshall J, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoes resection for rectal cancer: The ROLARR Randomized Clinical Trial. JAMA 2017 Oct 24;318 (16):

7 Functional Outcomes Paneleimonitis S, Ahmed J, Ramachandra M, Faroog M, Harper M, Parvaiz A. Urogenital function in robotic vs laparoscopic rectal cancer surgery: a comparative study. Int J Colorectal Dis Feb;32(2): Cost Rashid L, Neighorn C, Bastawrous A. Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg 2017 May; 213(5):

8 COST Silva-Velazco J, Dietz DW, Stocchi L, Costedio M, Gorgun E, Kalady MF, Kessler H, Lavery IC, Remzi FH. Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy. Ann Surg May;265(5): COST 8

9 Robotic Trends Damle A, Damle RN, Flahive JM, et al. Diffusion of technology: Trends in roboticassisted colorectal surgery. Am J Surg Mar 21. epub. Marketing Wright JD, Tergas AI, Hou JY. Effect of Regional Hospital Competition and Hospital Financial Status on the Use of Robotic-Assisted Surgery. JAMA Surg. 2016: 151(7):

10 Innovations 10

11 Conclusions Robotics have significant surgeon benefits There are no proven significant PATIENT benefits? decreased conversion rate in obese males Hospital benefits Innovation and Marketing WE NEED COMPETITION IN THIS INDUSTRY TO OFFSET COST!! The right operation is the technique that the operating surgeon feels most comfortable with Questions? 11

12 SI Robotic LAR Techniques: IMA/IMV, Splenic flexure 8mm - #3 5mm Asst port 12mm - Camera 8mm - #2 #1 Scissors w/ monopolar #2 Cadiere Forceps #3 Fenestrated bipolar Asst Bowel grasper / suction 8mm - #1 SI Robotic LAR Techniques: Side Dock 12

13 SI Robotic LAR Techniques: Side Dock SI Robotic LAR Techniques: IMA/IMV, Splenic flexure 13

14 SI Robotic LAR Techniques: Pelvis 5mm Asst Rt 8mm Asst -Lt 8mm - #1 12mm - Camera 8mm - #3 8mm - #2 #1 Scissors w/ monopolar #2 Fenestrated Bipolar #3 Cadiere Asst Lt Bowel grasper / Needle driver Asst Rt - Suction SI Robotic LAR Techniques: Pelvis 14

15 XI Robotic LAR 15

16 XI Port Placement 16

17 XI Docked 17