How can robot-assisted surgery provide value for money?

A systematic review on the effectiveness of robot-assisted minimally invasive gastrectomy

BACKGROUND

Robot-assisted minimally invasive gastrectomy (RAMIG) is increasingly used as a surgical approach for gastric cancer. This study assessed the effectiveness of RAMIG and studied which stages of the IDEAL-framework (1 = Idea, 2A = Development, 2B = Exploration, 3 = Assessment, 4 = Long-term follow-up) were followed.

METHODS

The Cochrane Library, Embase, Pubmed, and Web of Science were searched for studies on RAMIG up to January 2023. Data collection included the IDEAL-stage, demographics, number of participants, and study design. For randomized controlled trials (RCTs) and long-term studies, data on intra-, postoperative, and oncologic outcomes, survival, and costs of RAMIG were collected and summarized.

RESULTS

Of the 114 included studies, none reported the IDEAL-stage. After full-text reading, 18 (16%) studies were considered IDEAL-2A, 75 (66%) IDEAL-2B, 4 (4%) IDEAL-3, and 17 (15%) IDEAL-4. The IDEAL-stages were followed sequentially (2A-4), with IDEAL-2A studies still ongoing. IDEAL-3 RCTs showed lower overall complications (8.5-9.2% RAMIG versus 17.6-19.3% laparoscopic total/subtotal gastrectomy), equal 30-day mortality (0%), and equal length of hospital stay for RAMIG (mean 5.7-8.5 days RAMIG versus 6.4-8.2 days open/laparoscopic total/subtotal gastrectomy). Lymph node yield was similar across techniques, but RAMIG incurred significantly higher costs than laparoscopic total/subtotal gastrectomy ($13,423-15,262 versus $10,165-10,945). IDEAL-4 studies showed similar or improved overall/disease-free survival for RAMIG.

CONCLUSION

During worldwide RAMIG implementation, the IDEAL-framework was followed in sequential order. IDEAL-3 and 4 long-term studies showed that RAMIG is similar or even better to conventional surgery in terms of hospital stay, lymph node yield, and overall/disease-free survival. In addition, RAMIG showed reduced postoperative complication rates, despite higher costs.

Behind the pattern: General surgery residsent autonomy in robotic surgery

Objective

Robotic surgery is increasingly utilized and common in general surgery training programs. This study sought to better understand the factors that influence resident operative autonomy in robotic surgery. We hypothesized that resident seniority, surgeon work experience, surgeon robotic-assisted surgery (RAS) case volume, and procedure type influence general surgery residents' opportunities for autonomy in RAS as measured by percentage of resident individual console time (ICT).

Methods

General surgery resident ICT data for robotic cholecystectomy (RC), inguinal hernia (RIH), and ventral hernia (RVH) operations performed on the dual-console Da Vinci surgical robotic system between July 2019 and June 2021 were extracted. Cases with postgraduate year (PGY) 2-5 residents participating as a console surgeon were included. A sequential explanatory mixed-methods approach was undertaken to explore the ICT results and we conducted secondary qualitative interviews with surgeons. Descriptive statistics and thematic analysis were applied.

Results

Resident ICT data from 420 robotic cases (IH 200, RC 121, and VH 99) performed by 20 junior residents (PGY2-3), 18 senior residents (PGY4-5), and 9 attending surgeons were extracted. The average ICT per case was 26.8 % for junior residents and 42.4 % for senior residents. Compared to early-career surgeons, surgeons with over 10 years' work experience gave less ICT to junior (18.2 % vs. 32.0 %) and senior residents (33.9 % vs. 56.6 %) respectively. Surgeons' RAS case volume had no correlation with resident ICT (r = 0.003, p = 0.0003). On average, residents had the most ICT in RC (45.8 %), followed by RIH (36.7 %) and RVH (28.6 %). Interviews with surgeons revealed two potential reasons for these resident ICT patterns: 1) Surgeon assessment of resident training year/experience influenced decisions to grant ICT; 2) Surgeons' perceived operative time pressure inversely affected resident ICT.

Conclusions

This study suggests resident ICT/autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, but not related to surgeon RAS case volume. Design and implementation of an effective robotic training program must consider the external pressures at conflict with increased resident operative autonomy and seek to mitigate them.

Robot-assisted surgery in thoracic and visceral indications: an updated systematic review

BACKGROUND

In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery.

METHODS

We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1.

RESULTS

For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting.

CONCLUSION

In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment.

Robotic surgery: public perceptions and current misconceptions

Whilst surgeons and robotic companies are key stakeholders involved in the adoption of robotic assisted surgery (RS), the public's role is overlooked. However, given that patients hold ultimate power over their healthcare decisions, public acceptance of RS is crucial. Therefore, this study aims to identify public understanding, opinions, and misconceptions about RS. An online questionnaire distributed between February and May 2021 ascertained the views of UK adults on RS. The themes of questions included familiarity, experience and comfort with RS, opinions on its ethical implications, and the impact of factual information provided to the participant. The data were evaluated using thematic and statistical analysis, including assessing for statistical differences in age, gender, education level, and presence in the medical field. Overall, 216 responses were analysed. Participants were relatively uninformed about RS, with a median knowledge score of 4.00(2.00-6.00) on a 10-point Likert scale. Fears surrounding increased risk, reduced precision and technological failure were identified, alongside misconceptions about its autonomous nature. However, providing factual information in the survey about RS statistically increased participant comfort (p = < 0.0001). Most (61.8%) participants believed robot manufacturers were responsible for malfunctions, but doctors were held accountable more by older, less educated, and non-medical participants. Our findings suggest that there is limited public understanding of RS. The numerous common misconceptions identified present a major barrier to the widespread acceptance of RS, since inaccurate fears about its nature could discourage potential patients from engaging with robotic procedures.