Nailing Down the Numbers Surrounding Robotic Surgery

Ryan Black
FEBRUARY 26, 2018
data analytics, population health, robotic surgery da vinci, da vinci system black box, da vinci surgery studies, hcanews

Leonardo da Vinci spent the end of his life dissecting cadavers, trying to figure out what makes humans feel, react, and survive. It was the coda of a lifelong obsession with human design and function, which also birthed what some consider the first automated technology. Now, Intuitive Surgical’s groundbreaking da Vinci robotic surgery device bears the innovator’s name, because of both his early invention and deep interest in human anatomy.

But the modern machine contains little of the humanity that the original Renaissance man so idealized: With its 4 sleek, imposing arms, the surgical tool resembles a spider. The robot’s applicability varies across specialties; although it has become the standard of care for some procedures, it has yet to make a dent in others. At more than $1 million, da Vinci robotic surgical devices carry a high cost that is compounded by 6-figure annual required maintenance contracts. Even so, they have managed to enter thousands of American hospitals. Intuitive Surgical also released a “value minded” version of the device in 2017, designed to spur further adoption.

Some say the da Vinci expands the ways that surgeons can do their work, eliminating the inevitable tremor of a human’s hand and adding multidimensional views of the procedure. They also argue that it has the potential to create standardization and precision that the field has never seen before. Critics say the device merely adds time at the expense of touch and that claims of true comparative supremacy have not been validated.

What matters most, however, is what the data suggest.

The General Surgeon

At first, Joel Horovitz, MD, was enthusiastic about robotic surgery. When the machines began to enter operating rooms, Intuitive established a training center at East Carolina University in Greenville, where Horovitz practiced on the first iteration of the da Vinci. Afterward, he began using the machine in some procedures but eventually gave up due to the added “hassle,” he said.

A general surgeon at Maimonides Medical Center in Brooklyn, New York, Horovitz describes himself as a skeptic of the machines. It’s not that he doesn’t recognize their benefits, like the lack of tremor and the multiple views. It’s that he doubts the evidence base that surround them.

Randomized controlled trials can’t be done with surgery the way they are with drugs. An investigator, for example, can’t in good conscience give a person a placebo surgery. Still, Horovitz compares the efforts of robotic surgery machine makers to those of pharmaceutical companies. “Almost all the articles that have been written about the supremacy of the robot have been by researchers paid by Intuitive,” he said, citing a 2015 literature review that found spin in over 80% of published studies on robotic surgery between 1992 and 2014. 

According to Horovitz, “superb salesmanship” has led to the adoption of robotic surgery, more so than any proven benefit. It also involves another financial opportunity for Intuitive—selling its multiview console.

“No one is going to go back now and start doing comparative effectiveness trials when they’ve already invested $2.5 million dollars in a robot and they have a $100,000 per year maintenance contract,” Horovitz said. “It’s just too damn expensive to do that.”

He also thinks that the robots make it harder to train future surgeons, extending the learning curve. Rather than observing and slowly increasing their participation, as in open or laparoscopic surgery, residents simply stand by the bedside with nothing to do as the surgeon manipulates the robotic arms. 

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