Priestley Lecture Robotics in Ventral Hernia Repair

Transcription

1 Priestley Lecture Robotics in Ventral Hernia Repair Mike K. Liang Associate Professor of Surgery McGovern Medical School University of Texas at Houston Houston, Texas

2 Disclosures No Financial Conflict of Interest

3 Surgical Approach Guideline When safe and feasible, laparoscopic repair is preferred

4 Onlay (359) Lap (340) Suture (306) Underlay (61) Sublay (397)

5 Recurrence Mesh Location Odds Ratio 95% Credible Probability of Rank Interval being the best Sublay Onlay Ref (1.00) Laparoscopic Underlay Suture SSI Odds Ratio 95% Credible Probability of Rank Interval being the best Laparoscopic Suture Sublay Onlay Ref (1.00) Underlay

6 Poor Adoption Of the 400,000 ventral hernias are repaired Less than one fourth are repaired using a laparoscopic technique!!!

7 Reasons for Poor Adoption Hernia characteristics Large or small defects Adhesions, Old mesh Infections Surgeon preference and experience Outcomes Surgical site occurrence (SSO) Quality of life (QOL)

8 Can Robotics Overcome Barriers Improved surgeon adoption? Lower learning curves? Easier adoption? Advanced techniques? Defect closure Preperitoneal/retrorectus repair Component separation Improved outcomes?

9 Evolution of Mankind

10 Evolution of Surgery

11 LAP VS ROBOT Retrospective review of 215 patients (142 robotic, 73 laparoscopic) 2 large academic medical centers ( ) 10 surgeons

12 LAP VS ROBOT With propensity score matching (48 patients in each group), robotic repair was associated with Improved primary fascial closure (67 vs 77%, p < 0.01) Decreased SSO (18.8 vs 4.2%, p < 0.001) Decreased recurrence (4.2 vs 2.1%, p < 0.01)

13 LAP VS ROBOT Propensity matched analysis of laparoscopic (454 patients) and robotic (177 patients) ventral hernia repair with IPOM technique Lap VHR associated with Shorter operative duration (p<0.05) Increased median length of stay (1 vs 0 days) More surgical site occurrence (SSO) (14 vs 5 %) No long term outcomes reported 40 surgeons performed robot cases, 79 surgeons performed laparoscopic cases, 19 performed both

14 LAP VS ROBOT Single center review ( ) 103 LVHR, 53 Robotic retromuscular repair Robotic VHR associated with Higher rate of fascial closure (96.2 vs 50.5%) More component separation (43.4%) Longer operative times (245 vs 122 minutes) More seromas (47.2 vs 16.5%) Shorter length of stay (1 vs 2 days) No long term outcomes reported

15 Lap versus Robot Analysis of Vizient database (Jan September 2015) 46,799 patients (39,505 open, 6,829 lap, 465 robot)

16 RETROMUSCULAR REPAIR 38 robotic TAR vs 76 open TAR 2 institutions Large hernia width (13.5 cm) Robotic surgery associated with Longer operative time (299 vs 211 minutes, p<0.001) Lower EBL (49 vs 139 ml, p<0.001) Less systemic complications (0 vs 17.1%, p=0.026) (UTI, pneumonia, PE, DVT, prolonged ileus (>5 days)) Shorter hospital LOS (1.3 vs 6 days, p<0.001)

17 RETROMUSCULAR REPAIR Single center, retrospective review ( ) 76 open VHR vs 26 robot VHR 90 day follow up (i.e no long term outcomes) Robotic VHR Longer operative time (365 vs 287 minutes, p<0.01) Lower morbidity (19 vs 39.2%, p=0.09) Shorter median hospital LOS (3 vs 6 days)

18 RETROMUSCULAR REPAIR , propensity matching comparison of open and robotic retromuscular VHR 333 patients; 2:1 match (111 robot, 222 open) Robotic associated with Longer operative times More surgical site occurrences Shorter hospital length of (2 vs 3 days, p<0.001) Open operations 39 surgeons, Robot operations 14 surgeons

19 Ready for Prime Time?

20 Horton, editor in chief of Lancet, 2015 The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.

21 Biomedical research, Believe it or not? Scientific American Why Most Published Science Studies Are Wrong The Economists Lies, Dammed Lies, and Medical Science The Atlantic Why Almost Everything You Hear About Medicine Is Wrong Newsweek When Studies Are Wrong: A Coda New York Times

22 Current Practice in Hernia Surgery Surgical Need New Technology Higher quality study shows no benefit OR harm Industry Sponsored Case Series Proliferation of use Recommended by experts

23 Current Practice in Hernia Surgery Surgical Need New Technology Higher quality study shows no benefit OR disadvantage Industry Sponsored Case Series Proliferation of use Recommended by experts

24 How Can We Do It Better? Surgical Need New Technology Post Plans on Clinicaltrials.gov D I S S E M I N A T I O N Large RCT Small (n=10-50) RCT Initial Assessment in 1-10 patients

25 High Quality Robotic RCT None Exist Ongoing RCT Cleveland Clinic, Enrollment 2017, NCT COI, Intuitive Greenville Health System, Enrollment 2017, NCT COI, None reported UT Health, Enrollment 2018, NCT COI, None reported

26 Robotics in Other Specialties Specialty/ Author/Year Organ Colorectal Change 2015 Ramage 2015 Zarak 2015 Included Studies Level 1,2,3 Level 2,3 Level 1,2,3 Overall Increased Cost Risk of Bias High High High Foregut Yao 2014 Level 1 Low = No Objective Clinical Benefit Gastric Liao 2013 Level 2, 3 High + Pancreas Authors Huang Report 2016 Subjective Level 2, 3 High Benefit = Urologic (Bias Wilson or unmeasured 2015 Level 1 benefit?) Low = Uterus Albright 2016 Level 1, 2 Moderate = Verdict =/+ = =/+

27 Non-Evidenced Based Discussion RCT needed, we re running one What do I think about robotics

28 Legend of John Henry

29 Legend of John Henry

30 Legend of John Henry

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33 Limitations of Robotics Currently Access Requires lots of space Requires mm ports (5% hernia rate at 2 years) Significant torque on tissue at port sites Makes easy things harder Takes longer Specialized team

34 Limitations of Robotics Currently Excessive Surgery Unnecessary dissection Unnecessary component separation (CS) NSQIP N=34,541 Width: Unknown CS: 501 (1.6%) AHS QC N=3,924 Width (mean): 5 6±5 CS: 1690 (43.1%)

35 Where Does Robotics Help Makes hard things easier Wristed motion (suturing, dissecting) Improve visualization Retract yourself, 3 arms Potential for improvement

36 Preperitoneal flap.mov

37 Role of Robotics In Future Robotics in surgery is future Multiple companies developing surgical robotic assistants At some point, robotics will surpass even the most highly skilled minimally invasive surgeons

38 Conclusions Currently, no high quality studies support use of robotics in VHR Inevitable this line of technology is the future of surgery But, right now, skilled laparoscopic surgeons are better than robotics platform High quality studies and refinement of the technology are needed