Robotic Techniques Show Promise for Pancreatic Procedures

Robotic surgery is continuing to expand its reach, with widespread interest in the technology for endometrial cancer staging and recent exploration of its viability for complex pancreatic resections and reconstructions.

Gynecologic oncologists and pancreatic surgeons aren’t the only ones vying for time with the da Vinci Surgical System (Intuitive Surgical) – the only such system currently on the market. Their experiences, however, offer perspective on some of the key issues – from operative time and cost effectiveness to training needs – that are being raised as robotic technology is adopted.

Photo credit: University of Pittsburgh Medical Center

Pancreatic Surgery

"Robotic-assisted pancreatic resections and reconstructions can be performed safely with postoperative complication rates and fistula formation comparable to results observed with open techniques," according to Dr. Herbert J. Zeh III, and Dr. A. James Moser, codirectors of University of Pittsburgh Medical Center’s pancreatic cancer center, who reported their results with 30 robotic-assisted major pancreatic resections and reconstructions, including 24 pancreaticoduodenectomies (Arch. Surg. 2011:146:256-61).

By now, they said in an interview, they have used a robotic approach for more than 110 major pancreatic resections and reconstructions, including approximately 60 robotic-assisted pancreaticoduodenectomies, or Whipple procedures.

Together with surgeons at the Cleveland Clinic, the Mayo Clinic in Rochester, Minn., and the University of Pisa in Italy, Dr. Moser and Dr. Zeh have pooled outcomes data, and a combined report has been submitted for publication.

"We’ve established comparable safety, and we’re at the point now where our operating times are dropping steadily and we can start to see feasibility and applicability down the road," said Dr. Zeh of the department of surgery at the University of Pittsburgh. "In the next year or two, we’ll start to see whether there are real advantages such as decreased blood loss and better outcomes resulting from a diminished physiologic impact on the patient."

Reductions in postoperative morbidity could make the complex Whipple procedure "less fearsome" for many of the patients with early pancreatic cancer who currently refuse definitive treatment. Robotic surgery might also enable more patients to recover quickly and be well enough to complete chemotherapy, said Dr. Moser of the departments of surgery and cell biology at the university. With the open approach, almost 40%-50% of patients never recover enough to complete their chemotherapy regimens, he said.

Dr. Moser and Dr. Zeh, neither of whom has any financial relationship with Intuitive, began exploring minimally invasive approaches to the Whipple procedure about 2½ years ago. They have been using laparoscopy for distal pancreatectomies since 2001, but were concerned about their ability to take a traditional laparoscopic approach with the Whipple procedure, which involves complex reconstruction.

"The first laparoscopic pancreaticoduodenectomy was described in 1994, and between then and 2010 there were only about 150 cases reported. It didn’t catch on. I think it’s because it takes such a Herculean effort to overcome the limits of the technology [with its two-dimensional imaging and limited range of instrument motion]," said Dr. Zeh.

"We wanted to completely duplicate the open Whipple with a minimally invasive technique without making any compromises or altering any surgical principles because of the limitations of the technology," added Dr. Moser.

Dr. Michael L. Kendrick, who last year published one of the two largest series of totally laparoscopic Whipple procedures, covering 62 patients (Arch. Surg. 2010;145:19-23), maintains that he makes "no alternations or adaptations in surgical principle" with the purely laparoscopic approach, compared with open surgery.

Whether this approach or a robotic-assisted laparoscopic approach is best for patients needing a pancreaticoduodenectomy appears at this time to be "completely the surgeon’s choice" and not driven by any patient characteristics or clinical indications, according to Dr. Kendrick, who chairs the division of gastroenterologic and general surgery at the Mayo Clinic. Proving "any additional clinical advantage of robotic assistance over pure laparoscopy will be very difficult and is unlikely," he said, but "pancreas surgeons may prefer the robotic approach because it is easier to learn and master."

Dr. Kendrick’s experience might be unique. He performed his first laparoscopic Whipple procedure in 2007 and then added the robotic-assisted Whipple to his armamentarium in 2008. To date, he has performed approximately 135 minimally invasive pancreaticoduodenectomies, of which about 30 have been robotically assisted.

The Pittsburgh surgeons, who perform their robotic-assisted Whipple procedures together, place the learning curve for robotic-assisted Whipple at approximately 60 operations – about the same number experts consider necessary with the open approach. While the median operating time in their first reported series of robotic-assisted pancreaticoduodenectomies was almost 9 ½ hours (at least several hours longer than needed for an experienced surgeon to complete an open Whipple), it has steadily dropped to 7-8 hours, they said.

An early laparoscopic Whipple for Dr. Kendrick also took approximately 10 hours, "but within 20-30 cases, it was down to 4 or 5 hours, sometimes 6," he said. "There’s a lower average operative time for laparoscopic Whipple ... but [in the end], is that really an important factor if the patient still gains the benefits of [the minimally invasive surgery]?"

Gynecologic Surgery

In gynecologic oncology, where robotic surgery in recent years has been rapidly embraced as a tool for performing minimally invasive endometrial cancer staging, operating time and cost are factors in an "ongoing debate in over whether robotics provides an advantage over laparoscopy for lymph node dissection," said Dr. James E. Delmore, director of gynecologic oncology for the University of Kansas, Wichita.

At least a half-dozen studies have found that robotic-assisted hysterectomy and lymphadenectomy for endometrial cancer results in significantly shorter hospital stays as well as fewer wound infections and postoperative complications compared with an open approach, according to Dr. Delmore, who has served as a proctor for Intuitive. However, fewer studies have compared all three approaches (robotic assisted, traditional laparoscopy, and open).

"It’s hard to determine and analyze procedure costs in many hospital systems," he said. But "from what we can tell thus far, purely laparoscopic hysterectomy with removal of the lymph nodes is the least expensive approach, followed by robotics and then abdominal."

Such cost differentials were demonstrated in a study comparing the outcomes and cost of endometrial cancer staging performed via traditional laparotomy, standard laparoscopy, and robotic techniques. Dr. Maria C. Bell performed all of the procedures (40 robotic, 40 laparotomy, and 30 laparoscopic) at the Sanford Clinic in Sioux Falls, S.D.

Robotic hysterectomy took about an hour longer to perform than did hysterectomy completed via laparotomy (with no significant difference in operating time, compared with pure laparoscopy), but resulted in the lowest complication rate of the three approaches and the shortest average return to normal activity. Estimated blood loss and average length of stay were both significantly reduced for the robotic cohort, compared with laparotomy, and were comparable to laparoscopy. There were no differences in lymph node retrieval among the three groups (Gyn. Oncol. 2008;111:407-11).

When both direct and indirect costs were considered (including a measure by the Lewin Group of "societal/productivity" costs and the cost of the robot on a 5-year amortization schedule), the total average costs for hysterectomy with staging were $12,943 with laparotomy, $7,569 for standard laparoscopy, and $8,212 for robotic assistance.

The overall decreased cost for robotic surgery was unexpected and could be a result of money "invested up front [being] recouped by less time rounding ... and less time taking care of complications," as well as lower societal costs, wrote Dr. Bell, also of the University of South Dakota, Vermillion.

"I was very surprised that laparotomy was the most costly to the hospital," Dr. Bell said in an interview. (One of the coauthors of the report, Usha Seshadri-Kreaden, is employed by Intuitive, and Dr. Bell is a proctor for Intuitive, but the company did not sponsor the study.)

Other investigators who have compared robotic-assisted and conventional laparoscopic hysterectomies have reported higher per-case hospital costs with the robot. With hysterectomy having surpassed prostatectomy in 2010 as the highest-volume procedure for the da Vinci Surgical System, according to its manufacturer, the value of robotics for routine hysterectomy may well be increasingly scrutinized.

The da Vinci is used to treat more than 90% of endometrial cancer patients at Dr. Bell’s and Dr. Delmore’s institutions, but both surgeons are quick to emphasize the need for more data on outcomes and cost-effectiveness. "The temptation of ‘the patient wants it, so we need to offer it’ needs to be tempered with the question ‘are we making progress doing it?’ " said Dr. Delmore.

Training Needs

Institutions are individually grappling with how best to train residents in robotic-assisted surgery. The University of Kansas model includes an online tutorial, training with inanimate objects, animal lab training, and bedside assistance in real robotic-assisted hysterectomies. Dr. Delmore and his colleagues have a study underway to look at how graduate ob.gyns. use this training.

Within the realm of hepatobiliary and pancreatic surgery, where a minimally invasive approach is younger and where training models for the open Whipple procedure are still deliberated, "there is a dramatic appetite for minimally invasive skills," Dr. Kendrick said. HBP fellows at the Mayo Clinic currently are exposed to minimally invasive surgery, but "our goal over the next 2 years is to incorporate an even more significant focus" on robotics and laparoscopy, he said.

At the University of Pittsburgh, surgical oncology and HBP fellows and residents receive training with the robot in a "dry lab" format, Dr. Moser said. Trainees also can sit during actual cases at a second "teaching console" that is part of the current da Vinci Surgical System.

"We typically teach robotic cholecystectomy and sewing of the duodenojejunostomy during the Whipple procedure and allow them to do these portions of the procedure," Dr. Moser said.

Dr. Kendrick, who said he has no disclosures to make relevant to this article, hopes to see several fellowships established nationwide to address minimally invasive pancreas and liver surgery. However, "we have to be cautious about credentialing and assessing the adequacy of training. There’s a real mortality rate and a major complication rate [with the Whipple procedure] ... We’re trying to make it lower and lower with time, and not go backward."

Robotic surgery is continuing to expand its reach, with widespread interest in the technology for endometrial cancer staging and recent exploration of its viability for complex pancreatic resections and reconstructions.

Gynecologic oncologists and pancreatic surgeons aren’t the only ones vying for time with the da Vinci Surgical System (Intuitive Surgical) – the only such system currently on the market. Their experiences, however, offer perspective on some of the key issues – from operative time and cost effectiveness to training needs – that are being raised as robotic technology is adopted.

Photo credit: University of Pittsburgh Medical Center

Pancreatic Surgery

"Robotic-assisted pancreatic resections and reconstructions can be performed safely with postoperative complication rates and fistula formation comparable to results observed with open techniques," according to Dr. Herbert J. Zeh III, and Dr. A. James Moser, codirectors of University of Pittsburgh Medical Center’s pancreatic cancer center, who reported their results with 30 robotic-assisted major pancreatic resections and reconstructions, including 24 pancreaticoduodenectomies (Arch. Surg. 2011:146:256-61).

By now, they said in an interview, they have used a robotic approach for more than 110 major pancreatic resections and reconstructions, including approximately 60 robotic-assisted pancreaticoduodenectomies, or Whipple procedures.

Together with surgeons at the Cleveland Clinic, the Mayo Clinic in Rochester, Minn., and the University of Pisa in Italy, Dr. Moser and Dr. Zeh have pooled outcomes data, and a combined report has been submitted for publication.

"We’ve established comparable safety, and we’re at the point now where our operating times are dropping steadily and we can start to see feasibility and applicability down the road," said Dr. Zeh of the department of surgery at the University of Pittsburgh. "In the next year or two, we’ll start to see whether there are real advantages such as decreased blood loss and better outcomes resulting from a diminished physiologic impact on the patient."

Reductions in postoperative morbidity could make the complex Whipple procedure "less fearsome" for many of the patients with early pancreatic cancer who currently refuse definitive treatment. Robotic surgery might also enable more patients to recover quickly and be well enough to complete chemotherapy, said Dr. Moser of the departments of surgery and cell biology at the university. With the open approach, almost 40%-50% of patients never recover enough to complete their chemotherapy regimens, he said.

Dr. Moser and Dr. Zeh, neither of whom has any financial relationship with Intuitive, began exploring minimally invasive approaches to the Whipple procedure about 2½ years ago. They have been using laparoscopy for distal pancreatectomies since 2001, but were concerned about their ability to take a traditional laparoscopic approach with the Whipple procedure, which involves complex reconstruction.

"The first laparoscopic pancreaticoduodenectomy was described in 1994, and between then and 2010 there were only about 150 cases reported. It didn’t catch on. I think it’s because it takes such a Herculean effort to overcome the limits of the technology [with its two-dimensional imaging and limited range of instrument motion]," said Dr. Zeh.

"We wanted to completely duplicate the open Whipple with a minimally invasive technique without making any compromises or altering any surgical principles because of the limitations of the technology," added Dr. Moser.

Dr. Michael L. Kendrick, who last year published one of the two largest series of totally laparoscopic Whipple procedures, covering 62 patients (Arch. Surg. 2010;145:19-23), maintains that he makes "no alternations or adaptations in surgical principle" with the purely laparoscopic approach, compared with open surgery.

Whether this approach or a robotic-assisted laparoscopic approach is best for patients needing a pancreaticoduodenectomy appears at this time to be "completely the surgeon’s choice" and not driven by any patient characteristics or clinical indications, according to Dr. Kendrick, who chairs the division of gastroenterologic and general surgery at the Mayo Clinic. Proving "any additional clinical advantage of robotic assistance over pure laparoscopy will be very difficult and is unlikely," he said, but "pancreas surgeons may prefer the robotic approach because it is easier to learn and master."

Dr. Kendrick’s experience might be unique. He performed his first laparoscopic Whipple procedure in 2007 and then added the robotic-assisted Whipple to his armamentarium in 2008. To date, he has performed approximately 135 minimally invasive pancreaticoduodenectomies, of which about 30 have been robotically assisted.

The Pittsburgh surgeons, who perform their robotic-assisted Whipple procedures together, place the learning curve for robotic-assisted Whipple at approximately 60 operations – about the same number experts consider necessary with the open approach. While the median operating time in their first reported series of robotic-assisted pancreaticoduodenectomies was almost 9 ½ hours (at least several hours longer than needed for an experienced surgeon to complete an open Whipple), it has steadily dropped to 7-8 hours, they said.

An early laparoscopic Whipple for Dr. Kendrick also took approximately 10 hours, "but within 20-30 cases, it was down to 4 or 5 hours, sometimes 6," he said. "There’s a lower average operative time for laparoscopic Whipple ... but [in the end], is that really an important factor if the patient still gains the benefits of [the minimally invasive surgery]?"

Gynecologic Surgery

In gynecologic oncology, where robotic surgery in recent years has been rapidly embraced as a tool for performing minimally invasive endometrial cancer staging, operating time and cost are factors in an "ongoing debate in over whether robotics provides an advantage over laparoscopy for lymph node dissection," said Dr. James E. Delmore, director of gynecologic oncology for the University of Kansas, Wichita.

At least a half-dozen studies have found that robotic-assisted hysterectomy and lymphadenectomy for endometrial cancer results in significantly shorter hospital stays as well as fewer wound infections and postoperative complications compared with an open approach, according to Dr. Delmore, who has served as a proctor for Intuitive. However, fewer studies have compared all three approaches (robotic assisted, traditional laparoscopy, and open).

"It’s hard to determine and analyze procedure costs in many hospital systems," he said. But "from what we can tell thus far, purely laparoscopic hysterectomy with removal of the lymph nodes is the least expensive approach, followed by robotics and then abdominal."

Such cost differentials were demonstrated in a study comparing the outcomes and cost of endometrial cancer staging performed via traditional laparotomy, standard laparoscopy, and robotic techniques. Dr. Maria C. Bell performed all of the procedures (40 robotic, 40 laparotomy, and 30 laparoscopic) at the Sanford Clinic in Sioux Falls, S.D.

Robotic hysterectomy took about an hour longer to perform than did hysterectomy completed via laparotomy (with no significant difference in operating time, compared with pure laparoscopy), but resulted in the lowest complication rate of the three approaches and the shortest average return to normal activity. Estimated blood loss and average length of stay were both significantly reduced for the robotic cohort, compared with laparotomy, and were comparable to laparoscopy. There were no differences in lymph node retrieval among the three groups (Gyn. Oncol. 2008;111:407-11).

When both direct and indirect costs were considered (including a measure by the Lewin Group of "societal/productivity" costs and the cost of the robot on a 5-year amortization schedule), the total average costs for hysterectomy with staging were $12,943 with laparotomy, $7,569 for standard laparoscopy, and $8,212 for robotic assistance.

The overall decreased cost for robotic surgery was unexpected and could be a result of money "invested up front [being] recouped by less time rounding ... and less time taking care of complications," as well as lower societal costs, wrote Dr. Bell, also of the University of South Dakota, Vermillion.

"I was very surprised that laparotomy was the most costly to the hospital," Dr. Bell said in an interview. (One of the coauthors of the report, Usha Seshadri-Kreaden, is employed by Intuitive, and Dr. Bell is a proctor for Intuitive, but the company did not sponsor the study.)

Other investigators who have compared robotic-assisted and conventional laparoscopic hysterectomies have reported higher per-case hospital costs with the robot. With hysterectomy having surpassed prostatectomy in 2010 as the highest-volume procedure for the da Vinci Surgical System, according to its manufacturer, the value of robotics for routine hysterectomy may well be increasingly scrutinized.

The da Vinci is used to treat more than 90% of endometrial cancer patients at Dr. Bell’s and Dr. Delmore’s institutions, but both surgeons are quick to emphasize the need for more data on outcomes and cost-effectiveness. "The temptation of ‘the patient wants it, so we need to offer it’ needs to be tempered with the question ‘are we making progress doing it?’ " said Dr. Delmore.

Training Needs

Institutions are individually grappling with how best to train residents in robotic-assisted surgery. The University of Kansas model includes an online tutorial, training with inanimate objects, animal lab training, and bedside assistance in real robotic-assisted hysterectomies. Dr. Delmore and his colleagues have a study underway to look at how graduate ob.gyns. use this training.

Within the realm of hepatobiliary and pancreatic surgery, where a minimally invasive approach is younger and where training models for the open Whipple procedure are still deliberated, "there is a dramatic appetite for minimally invasive skills," Dr. Kendrick said. HBP fellows at the Mayo Clinic currently are exposed to minimally invasive surgery, but "our goal over the next 2 years is to incorporate an even more significant focus" on robotics and laparoscopy, he said.

At the University of Pittsburgh, surgical oncology and HBP fellows and residents receive training with the robot in a "dry lab" format, Dr. Moser said. Trainees also can sit during actual cases at a second "teaching console" that is part of the current da Vinci Surgical System.

"We typically teach robotic cholecystectomy and sewing of the duodenojejunostomy during the Whipple procedure and allow them to do these portions of the procedure," Dr. Moser said.

Dr. Kendrick, who said he has no disclosures to make relevant to this article, hopes to see several fellowships established nationwide to address minimally invasive pancreas and liver surgery. However, "we have to be cautious about credentialing and assessing the adequacy of training. There’s a real mortality rate and a major complication rate [with the Whipple procedure] ... We’re trying to make it lower and lower with time, and not go backward."

Robotic surgery is continuing to expand its reach, with widespread interest in the technology for endometrial cancer staging and recent exploration of its viability for complex pancreatic resections and reconstructions.

Gynecologic oncologists and pancreatic surgeons aren’t the only ones vying for time with the da Vinci Surgical System (Intuitive Surgical) – the only such system currently on the market. Their experiences, however, offer perspective on some of the key issues – from operative time and cost effectiveness to training needs – that are being raised as robotic technology is adopted.

Photo credit: University of Pittsburgh Medical Center

Pancreatic Surgery

"Robotic-assisted pancreatic resections and reconstructions can be performed safely with postoperative complication rates and fistula formation comparable to results observed with open techniques," according to Dr. Herbert J. Zeh III, and Dr. A. James Moser, codirectors of University of Pittsburgh Medical Center’s pancreatic cancer center, who reported their results with 30 robotic-assisted major pancreatic resections and reconstructions, including 24 pancreaticoduodenectomies (Arch. Surg. 2011:146:256-61).

By now, they said in an interview, they have used a robotic approach for more than 110 major pancreatic resections and reconstructions, including approximately 60 robotic-assisted pancreaticoduodenectomies, or Whipple procedures.

Together with surgeons at the Cleveland Clinic, the Mayo Clinic in Rochester, Minn., and the University of Pisa in Italy, Dr. Moser and Dr. Zeh have pooled outcomes data, and a combined report has been submitted for publication.

"We’ve established comparable safety, and we’re at the point now where our operating times are dropping steadily and we can start to see feasibility and applicability down the road," said Dr. Zeh of the department of surgery at the University of Pittsburgh. "In the next year or two, we’ll start to see whether there are real advantages such as decreased blood loss and better outcomes resulting from a diminished physiologic impact on the patient."

Reductions in postoperative morbidity could make the complex Whipple procedure "less fearsome" for many of the patients with early pancreatic cancer who currently refuse definitive treatment. Robotic surgery might also enable more patients to recover quickly and be well enough to complete chemotherapy, said Dr. Moser of the departments of surgery and cell biology at the university. With the open approach, almost 40%-50% of patients never recover enough to complete their chemotherapy regimens, he said.

Dr. Moser and Dr. Zeh, neither of whom has any financial relationship with Intuitive, began exploring minimally invasive approaches to the Whipple procedure about 2½ years ago. They have been using laparoscopy for distal pancreatectomies since 2001, but were concerned about their ability to take a traditional laparoscopic approach with the Whipple procedure, which involves complex reconstruction.

"The first laparoscopic pancreaticoduodenectomy was described in 1994, and between then and 2010 there were only about 150 cases reported. It didn’t catch on. I think it’s because it takes such a Herculean effort to overcome the limits of the technology [with its two-dimensional imaging and limited range of instrument motion]," said Dr. Zeh.

"We wanted to completely duplicate the open Whipple with a minimally invasive technique without making any compromises or altering any surgical principles because of the limitations of the technology," added Dr. Moser.

Dr. Michael L. Kendrick, who last year published one of the two largest series of totally laparoscopic Whipple procedures, covering 62 patients (Arch. Surg. 2010;145:19-23), maintains that he makes "no alternations or adaptations in surgical principle" with the purely laparoscopic approach, compared with open surgery.

Whether this approach or a robotic-assisted laparoscopic approach is best for patients needing a pancreaticoduodenectomy appears at this time to be "completely the surgeon’s choice" and not driven by any patient characteristics or clinical indications, according to Dr. Kendrick, who chairs the division of gastroenterologic and general surgery at the Mayo Clinic. Proving "any additional clinical advantage of robotic assistance over pure laparoscopy will be very difficult and is unlikely," he said, but "pancreas surgeons may prefer the robotic approach because it is easier to learn and master."

Dr. Kendrick’s experience might be unique. He performed his first laparoscopic Whipple procedure in 2007 and then added the robotic-assisted Whipple to his armamentarium in 2008. To date, he has performed approximately 135 minimally invasive pancreaticoduodenectomies, of which about 30 have been robotically assisted.

The Pittsburgh surgeons, who perform their robotic-assisted Whipple procedures together, place the learning curve for robotic-assisted Whipple at approximately 60 operations – about the same number experts consider necessary with the open approach. While the median operating time in their first reported series of robotic-assisted pancreaticoduodenectomies was almost 9 ½ hours (at least several hours longer than needed for an experienced surgeon to complete an open Whipple), it has steadily dropped to 7-8 hours, they said.

An early laparoscopic Whipple for Dr. Kendrick also took approximately 10 hours, "but within 20-30 cases, it was down to 4 or 5 hours, sometimes 6," he said. "There’s a lower average operative time for laparoscopic Whipple ... but [in the end], is that really an important factor if the patient still gains the benefits of [the minimally invasive surgery]?"

Gynecologic Surgery

In gynecologic oncology, where robotic surgery in recent years has been rapidly embraced as a tool for performing minimally invasive endometrial cancer staging, operating time and cost are factors in an "ongoing debate in over whether robotics provides an advantage over laparoscopy for lymph node dissection," said Dr. James E. Delmore, director of gynecologic oncology for the University of Kansas, Wichita.

At least a half-dozen studies have found that robotic-assisted hysterectomy and lymphadenectomy for endometrial cancer results in significantly shorter hospital stays as well as fewer wound infections and postoperative complications compared with an open approach, according to Dr. Delmore, who has served as a proctor for Intuitive. However, fewer studies have compared all three approaches (robotic assisted, traditional laparoscopy, and open).

"It’s hard to determine and analyze procedure costs in many hospital systems," he said. But "from what we can tell thus far, purely laparoscopic hysterectomy with removal of the lymph nodes is the least expensive approach, followed by robotics and then abdominal."

Such cost differentials were demonstrated in a study comparing the outcomes and cost of endometrial cancer staging performed via traditional laparotomy, standard laparoscopy, and robotic techniques. Dr. Maria C. Bell performed all of the procedures (40 robotic, 40 laparotomy, and 30 laparoscopic) at the Sanford Clinic in Sioux Falls, S.D.

Robotic hysterectomy took about an hour longer to perform than did hysterectomy completed via laparotomy (with no significant difference in operating time, compared with pure laparoscopy), but resulted in the lowest complication rate of the three approaches and the shortest average return to normal activity. Estimated blood loss and average length of stay were both significantly reduced for the robotic cohort, compared with laparotomy, and were comparable to laparoscopy. There were no differences in lymph node retrieval among the three groups (Gyn. Oncol. 2008;111:407-11).

When both direct and indirect costs were considered (including a measure by the Lewin Group of "societal/productivity" costs and the cost of the robot on a 5-year amortization schedule), the total average costs for hysterectomy with staging were $12,943 with laparotomy, $7,569 for standard laparoscopy, and $8,212 for robotic assistance.

The overall decreased cost for robotic surgery was unexpected and could be a result of money "invested up front [being] recouped by less time rounding ... and less time taking care of complications," as well as lower societal costs, wrote Dr. Bell, also of the University of South Dakota, Vermillion.

"I was very surprised that laparotomy was the most costly to the hospital," Dr. Bell said in an interview. (One of the coauthors of the report, Usha Seshadri-Kreaden, is employed by Intuitive, and Dr. Bell is a proctor for Intuitive, but the company did not sponsor the study.)

Other investigators who have compared robotic-assisted and conventional laparoscopic hysterectomies have reported higher per-case hospital costs with the robot. With hysterectomy having surpassed prostatectomy in 2010 as the highest-volume procedure for the da Vinci Surgical System, according to its manufacturer, the value of robotics for routine hysterectomy may well be increasingly scrutinized.

The da Vinci is used to treat more than 90% of endometrial cancer patients at Dr. Bell’s and Dr. Delmore’s institutions, but both surgeons are quick to emphasize the need for more data on outcomes and cost-effectiveness. "The temptation of ‘the patient wants it, so we need to offer it’ needs to be tempered with the question ‘are we making progress doing it?’ " said Dr. Delmore.

Training Needs

Institutions are individually grappling with how best to train residents in robotic-assisted surgery. The University of Kansas model includes an online tutorial, training with inanimate objects, animal lab training, and bedside assistance in real robotic-assisted hysterectomies. Dr. Delmore and his colleagues have a study underway to look at how graduate ob.gyns. use this training.

Within the realm of hepatobiliary and pancreatic surgery, where a minimally invasive approach is younger and where training models for the open Whipple procedure are still deliberated, "there is a dramatic appetite for minimally invasive skills," Dr. Kendrick said. HBP fellows at the Mayo Clinic currently are exposed to minimally invasive surgery, but "our goal over the next 2 years is to incorporate an even more significant focus" on robotics and laparoscopy, he said.

At the University of Pittsburgh, surgical oncology and HBP fellows and residents receive training with the robot in a "dry lab" format, Dr. Moser said. Trainees also can sit during actual cases at a second "teaching console" that is part of the current da Vinci Surgical System.

"We typically teach robotic cholecystectomy and sewing of the duodenojejunostomy during the Whipple procedure and allow them to do these portions of the procedure," Dr. Moser said.

Dr. Kendrick, who said he has no disclosures to make relevant to this article, hopes to see several fellowships established nationwide to address minimally invasive pancreas and liver surgery. However, "we have to be cautious about credentialing and assessing the adequacy of training. There’s a real mortality rate and a major complication rate [with the Whipple procedure] ... We’re trying to make it lower and lower with time, and not go backward."