Robotic vascular surgery: Ready for prime time?

When we examine the data presented by the authors of this paper closely, we see vast differences between the group I patients (bypasses for aortoiliac occlusive disease) and the group II patients (repair of aortoiliac aneurysms). In the occlusive group (group I), the operative time averaged 194 minutes. However, in the aneurysm group, the surgical repair of an aneurysm took over 4 hours. Another broad discrepancy between groups I and II is evident in examining cross-clamp time. In the occlusive group, the cross-clamp was 37 minutes; however, aneurysm patients required 93 minutes of cross-clamp to complete the proximal anastomosis. Similar disparities are seen in mean blood loss. Patients with occlusive disease lost an average of 320 mL of blood, while aneurysm patients lost 1,210 mL

Dr. Mark A. Adelman

The authors have been clever in combining these two groups as a single cohort.

However, I might argue that by segregating the groups, we might find that occlusive disease is well treated with robotically assisted surgery, but aneurysm repair should be left to open or endovascular techniques.

In addition to the data disparities, there are several practical limitations to performing robotic aortic surgery. Learning robotic techniques requires significant additional surgical training that is typically not within the skill set of a vascular surgeon. Who will devote the time and resources toward training vascular surgeons? Presently, there are increased hardware and operating room times associated with robotic-assisted surgeries. Because of the bulkiness of the robotic system and need for space for mechanical arms, large operating rooms must be utilized to perform robotic procedures.

Although I have not performed robotic surgery, I understand the tactile feedback, or haptics are significantly reduced when operating with the robot. Lastly, during this era of value-based medicine, is robotic surgery too expensive? The current cost of a robot approaches $2 million, and robotic arms have a limited life expectancy.

In summary, the authors have not demonstrated that this procedure is safe in aneurysm patients, or generalizable across all vascular surgeons given the lack of training paradigm. Further, robotic procedures are probably not cost effective in this very cost-sensitive health care environment. When I was training under Dr. Frank Cole Spencer in general surgery, he was fond of saying “just because you can teach a dog to ride a bicycle, it does not mean that you should.” As Dr. Juan Parodi will remind us, if the technology becomes more affordable, and changes significantly, we must all remain open minded. But currently, this technology is not yet ready for prime time. In its current state, this dog will not be learning to ride this robotic bike.

Dr. Mark A. Adelman is the Frank J. Veith, MD Professor, chief of vascular and endovascular surgery, and vice chair for strategy and business development, department of surgery, NYU Langone Medical Center, New York.

When we examine the data presented by the authors of this paper closely, we see vast differences between the group I patients (bypasses for aortoiliac occlusive disease) and the group II patients (repair of aortoiliac aneurysms). In the occlusive group (group I), the operative time averaged 194 minutes. However, in the aneurysm group, the surgical repair of an aneurysm took over 4 hours. Another broad discrepancy between groups I and II is evident in examining cross-clamp time. In the occlusive group, the cross-clamp was 37 minutes; however, aneurysm patients required 93 minutes of cross-clamp to complete the proximal anastomosis. Similar disparities are seen in mean blood loss. Patients with occlusive disease lost an average of 320 mL of blood, while aneurysm patients lost 1,210 mL

Dr. Mark A. Adelman

The authors have been clever in combining these two groups as a single cohort.

However, I might argue that by segregating the groups, we might find that occlusive disease is well treated with robotically assisted surgery, but aneurysm repair should be left to open or endovascular techniques.

In addition to the data disparities, there are several practical limitations to performing robotic aortic surgery. Learning robotic techniques requires significant additional surgical training that is typically not within the skill set of a vascular surgeon. Who will devote the time and resources toward training vascular surgeons? Presently, there are increased hardware and operating room times associated with robotic-assisted surgeries. Because of the bulkiness of the robotic system and need for space for mechanical arms, large operating rooms must be utilized to perform robotic procedures.

Although I have not performed robotic surgery, I understand the tactile feedback, or haptics are significantly reduced when operating with the robot. Lastly, during this era of value-based medicine, is robotic surgery too expensive? The current cost of a robot approaches $2 million, and robotic arms have a limited life expectancy.

In summary, the authors have not demonstrated that this procedure is safe in aneurysm patients, or generalizable across all vascular surgeons given the lack of training paradigm. Further, robotic procedures are probably not cost effective in this very cost-sensitive health care environment. When I was training under Dr. Frank Cole Spencer in general surgery, he was fond of saying “just because you can teach a dog to ride a bicycle, it does not mean that you should.” As Dr. Juan Parodi will remind us, if the technology becomes more affordable, and changes significantly, we must all remain open minded. But currently, this technology is not yet ready for prime time. In its current state, this dog will not be learning to ride this robotic bike.

Dr. Mark A. Adelman is the Frank J. Veith, MD Professor, chief of vascular and endovascular surgery, and vice chair for strategy and business development, department of surgery, NYU Langone Medical Center, New York.

When we examine the data presented by the authors of this paper closely, we see vast differences between the group I patients (bypasses for aortoiliac occlusive disease) and the group II patients (repair of aortoiliac aneurysms). In the occlusive group (group I), the operative time averaged 194 minutes. However, in the aneurysm group, the surgical repair of an aneurysm took over 4 hours. Another broad discrepancy between groups I and II is evident in examining cross-clamp time. In the occlusive group, the cross-clamp was 37 minutes; however, aneurysm patients required 93 minutes of cross-clamp to complete the proximal anastomosis. Similar disparities are seen in mean blood loss. Patients with occlusive disease lost an average of 320 mL of blood, while aneurysm patients lost 1,210 mL

Dr. Mark A. Adelman

The authors have been clever in combining these two groups as a single cohort.

However, I might argue that by segregating the groups, we might find that occlusive disease is well treated with robotically assisted surgery, but aneurysm repair should be left to open or endovascular techniques.

In addition to the data disparities, there are several practical limitations to performing robotic aortic surgery. Learning robotic techniques requires significant additional surgical training that is typically not within the skill set of a vascular surgeon. Who will devote the time and resources toward training vascular surgeons? Presently, there are increased hardware and operating room times associated with robotic-assisted surgeries. Because of the bulkiness of the robotic system and need for space for mechanical arms, large operating rooms must be utilized to perform robotic procedures.

Although I have not performed robotic surgery, I understand the tactile feedback, or haptics are significantly reduced when operating with the robot. Lastly, during this era of value-based medicine, is robotic surgery too expensive? The current cost of a robot approaches $2 million, and robotic arms have a limited life expectancy.

In summary, the authors have not demonstrated that this procedure is safe in aneurysm patients, or generalizable across all vascular surgeons given the lack of training paradigm. Further, robotic procedures are probably not cost effective in this very cost-sensitive health care environment. When I was training under Dr. Frank Cole Spencer in general surgery, he was fond of saying “just because you can teach a dog to ride a bicycle, it does not mean that you should.” As Dr. Juan Parodi will remind us, if the technology becomes more affordable, and changes significantly, we must all remain open minded. But currently, this technology is not yet ready for prime time. In its current state, this dog will not be learning to ride this robotic bike.

Dr. Mark A. Adelman is the Frank J. Veith, MD Professor, chief of vascular and endovascular surgery, and vice chair for strategy and business development, department of surgery, NYU Langone Medical Center, New York.