What exactly is robotic surgery?
We are selective when applying robotic assistance in bariatric surgery. Lowering cost for patients and surgeons’ preference to operate with conventional laparoscopy for bariatric surgery are the major reasons at our institution.
From a technical standpoint alone, I prefer minimizing the complexity of setting up my cases and relying less on equipment. As a minimalist when it comes to cost and improving efficiency, I prefer conventional laparoscopy. Unlike the pelvis, operating near the hiatus only requires about a 30 degree conical workspace which can be easily achieved with trocars placed a handbreadth apart to facilitate hand sewing or additional two handed dissection. Additionally, robot trocars are 7mm in size and additional ports will need to be placed for staplers which pass through a 12mm trocar. One can still achieve a high level of haptic feedback with the simplest laparoscopic instrument and much faster hand motion without signal delay which is not substantial with the robot but still significant. This is also true not only for tissue manipulation and dissection but also with camera driving which is only static during a robotic operation.
Although the robot offers potential application benefits such as less surgeon fatigue and improved ergonomics, it comes so at the expense of time for the vast majority of robotic surgeons. A laparoscopic band or sleeve takes about an hour and a linear stapled hand-sewn gastric bypass takes about twice that for actual operating time with a novice resident surgeon assistant. I do see potential for the solo surgeon with inadequate help in need of a third hand in order to operate but then this would be negated by the reliance of having a skilled person to remain scrubbed to pass suture, staplers, sponges, etc into the abdomen.
Given the substantial initial cost over $1 million to purchase the robot without any difference in reimbursement for the same procedure, I do not see much of a change in surgeons’ choice to continue laparoscopic bariatric surgery without the robot due to reasons of efficiency and cost. The robot is a great idea however with limited application in bariatrics. I’m unsure that this luxury will make me a faster surgeon or a better surgeon. We should all find ways to innovate and to be safer and more cost-effective surgeons however, I find that if the wheel spins fast enough, there’s no point in reinventing it.