The Future is Robot!

Apr 23, 2024

Minimally invasive surgery (MIS) is accepted as being superior to traditional open surgery.

There are several large meta-analyses of randomised trials, demonstrating a more rapid return to normal activity, reduced incidence of persistent pain, reduced hospital stays etc. More recently robot-assisted surgery has been widely adopted, particularly in the USA. 

It was the 1999 that saw the da Vinci Surgical System by Intuitive Surgical. The da Vinci system revolutionised MIS by offering enhanced precision and dexterity to surgeons. Initially used in urology with robotic prostatectomy being the gold standard and in fact the training is in cooperated into their curriculum. The Lancet Oncology in 2018 compared robotic-assisted radical prostatectomy with open radical prostatectomy and reported lower rates of urinary incontinence and erectile dysfunction in patients who underwent robotic surgery, highlighting the benefits of robotic techniques for urological procedures. Robotic platforms have now grown at a faster rate have rolled over to essentially most surgical specialties, from gynaecology, colorectal, orthopaedics, cardiothoracic to general and upper gi.

It has gained great traction in abdominal wall hernia repairs. Available meta-analyses of trials comparing robot-assisted repair have suggested possible superiority of robot-assisted approach, with some meta-analyses reporting reduced conversion rates (Solaini, J Robot Surg 2021; Mohan, Hernia, 2021), reduced rates of bowel injury (Thomas, Hernia 2022), or reduced recurrence rates (Goettman, J Minim Access Surg 2020) when compared to laparoscopic hernia surgery.  These studies cite the more precise and stable visualisation platform, precision of dissection, and added instrument dexterity as factors which may contribute to these differences in outcome. For incisional and large ventral hernias, the current traditional open approach requires a full laparotomy.  The avoidance of this means that a robot-assisted approach can be quicker, less painful, and avoids the need for additional adjuncts such as epidural anaesthesia or post-operative vacuum drains. Reported outcomes for large series of robotic ventral/incisional hernias include a typical length of stay of 1 day (Santos, Surg Endosc 2021), and skin-to-skin operative times of <90 min (Kudsi, Ann Surg 2022).

The benefit to surgeons.

• Ensure ergonomics,
• Magnified 3D vision, improving visualisation of critical structures, leading to reduced damage to surrounding tissues and in some cases improved functional outcomes.
• Perfect, shake free and faithful replication of movements.
• Surgeons control their own vision and have incredible fine control and there is no loss of finger/hand fine control due to use of proximal muscles.
• Better accessibility to difficult areas for conventional laparoscopic approach. A systematic review and meta-analysis published in the Journal of the American Medical Association (JAMA) in 2017 compared outcomes of robotic-assisted hysterectomy with laparoscopic and open hysterectomy and found that robotic surgery was associated with lower rates of complications and shorter hospital stays.

There are some benefits to patients.

• There is evidence suggests that patients undergoing robotic surgery experience faster recovery times, reduced postoperative pain, and improved quality of life compared to those undergoing open surgery. The minimally invasive nature of robotic procedures contributes to these favourable outcomes. A study published in JAMA Surgery in 2021 evaluated patient-reported outcomes following robotic-assisted vs. open surgery for colorectal cancer and found that patients who underwent robotic surgery reported better physical and emotional well-being, as well as improved functional status during the recovery period.
• In colorectal fewer stomas formed, in some case fewer anastomotic leaks. A meta-analysis published in the Journal of Robotic Surgery in 2020 compared robotic-assisted surgery with laparoscopic surgery in colorectal cancer patients and found that robotic surgery resulted in lower conversion rates to open surgery, shorter hospital stays, and fewer postoperative complications.

These all sound great especially in high volume, larger population areas such as USA, UK, South Korea, and Europe, however there is a lot of potential and growing for Australia to do. Currently robot is available at a lot of private hospitals, but a very limited public hospitals to a very limited surgical speciality. Having robotically trained in the UK in the field of esophago-gastric surgery, performing robotic oesophagectomies, gastric resections and bariatrics, I can see first-hand the greater advantage and the immense growth within the 12 months with the growing numbers of NHS hospitals purchasing robots. Since returning and proctoring/teaching other surgeons, I can also see the growing numbers of Australian surgeons taking up robotics in their speciality and skills. It is no secret that cost is a major factor into accessibility, however with the growing trend of more surgeons using it, the competition in different robotic platforms driving the cost down, more evidence coming out showing the effectiveness, it is only a matter of time that this exciting robotic evolution will play a vital role in advancing surgical care and improving patient experiences.

Dr Anik Sarkar, MBBS FRACS

General surgery - Upper GI, Bariatric Surgery

Wollongong Day Surgery Consulting Suites

Level 3, Suite 3

354-358 Crown Street

Wollongong NSW 2500

P: 1300 372 645
F: 02 4504 0232

E: reception@draniksarkar.com.au