Abstract
Robotic- assisted surgery has revolutionized the surgical practice since its inception and allows surgeons to use minimally invasive techniques in cardiac, urology, and general surgeries. Robotic surgery is quickly becoming an alternative to standard laparoscopic approaches to surgery and especially in the area of urology. Even though the use of robotic- assisted surgery is more advantageous than conventional methods, its use is hinged on the surgical teams training and experiences with it. The study examines the frequency of use of the technique among various surgical teams and their response to its effectiveness.
The research design of the study begins with documentation from agencies that deal with facts on the topic and have put them down in a number of documents, reports, journals and bulletins, textbooks and works of other scholars whether published magazines, written data sources including published and unpublished documents and internet sources among other so as to obtain relevant information. The study also analyzed information obtained from surveys done on demographic trends related to the use of the technique among surgical teams.
The study concluded that the use of robotic assisted surgeries is not so prevalent due to various reasons such as the lack of resources and training opportunities, insufficient remuneration and a general lack of support from hospitals. The study recommends that if these barriers are addressed and mitigated, then robotic- assisted surgeries would become a more conventional and acceptable surgery technique.
Introduction
Robotic- assisted surgery involves the use of various robotic systems in surgical procedures. Surgical techniques have been evolving over the years yet limitations still existed with regards to minimally invasive surgeries. As a result of these limitations, robotic- assisted surgery was developed which helps surgeons when performing open surgeries by enhancing their capabilities and in the performance of minimally invasive surgeries. Robotic- assisted surgeries are performed either through the use of computer control or a direct tele-manipulator. A tele- manipulator uses robotic arms with manipulators and end- effectors that move in line with a surgeon's normal surgical movements while performing a surgery. On the other hand, surgeons can use computers to control the robotic arms and their end- receptors.
Robotic- assisted surgeries afford surgeons a better view as well as better control of their surgical sites and surgical instruments respectively. In effect, the surgeons are able to perform their surgeries with more precision and with smaller incisions and miniaturizations. There is also less pain experienced by the patients in addition to lesser chances of blood loss and consequently, a much quicker recovery time. The robotic- assisted surgery employs the use of techniques that ultimately lead to improved ergonomics as well as countering the flaws, limitations and negative consequences of open surgery techniques used by surgeons.
This study seeks to illustrate that despite the tremendous advantages that the technique offers surgeons performing minimally invasive surgeries, a majority of them still use open surgery techniques. This trend is due to various factors which act as barriers to these surgeons making them opt for open surgery instead of robotic- assisted surgery. This dissertation will seek to highlight the various barriers that surgical teams encounter that hinder them from using the technique and possible remedies for these barriers.
History of Robotic Assisted Surgery
Before embarking on an analysis of surveys carried out on the use of the robotic- assisted surgery technique, it is prudent to the history of the technique and how it evolved and developed over the years. The technique was first used in 1985 when a surgical instrument, the PUMA 560 robotic surgical arm was used by surgeons to perform a very delicate neurosurgical procedure which was, in essence, non- laparoscopic (Samadi). The procedure was successful as the robotic arm allowed for surgical precision. Over the next years, the technique continued to develop till 1990 when the Food and Drug Administration (FDA), approved the AESOP system as the first endoscopic surgical procedure system. The Da Vinci surgery system was approved by the FDA in 2000 as the first robotic surgery system. The da Vinci system had three- dimensional magnification screens that used high- resolution lenses to provide clarity of the operative area (Samadi).
Comparison to Traditional Methods of Surgery
A review of the literature available on robotic- assisted surgeries indicates that opinions differ greatly among surgical teams on the need for the technique. A robotic surgical system costs about $1,390,000 with a disposal supply cost of about $1,500 for every procedure done (Kolata). Aside from the costs, the training period is quite rigorous since the surgeons must operate on about 18 patients, which translates to about 250 surgical procedures before they can claim to have mastered the procedure and become adept to its use (Finkelstein et al., 35-43). In addition, the robotic systems tend to require maintenance often which is quite costly and requires additional consumables like the single- use robotic appliances (Barbash et al., 702). The process of preparation for robotic assisted surgeries is more rigorous that for open surgeries due to the time it takes to prepare the systems and operate them. However, robotic surgeries do reduce the post- operative costs which money can be used by hospitals to offset the acquisition and operating costs of the systems.
According to Hu et al., (1557-1564), the decision on whether to acquire the robotic- assisted surgery systems depends wholly on the hospitals. The hospitals have a lot of factors to consider when deciding whether to acquire the systems or not. Among the deciding factors is the competition between various hospitals to attract doctors as well as patients and support staff. Also, since the aim of most hospitals is the need for surgical volume, they find it difficult to resist the doctors’ preferences even when the returns are not worthwhile. Surgeons on the other hand also feel compelled to be associated with the latest trends in order to remain relevant in the surgical field. This is why Barbash & Glied, (701-704) are of the opinion that a fragmented, as opposed to a centralized form of decision making, is what influences the diffusion of most robotic technology.
Robotic Assisted Surgeries in Urological Procedures
Urological or genitourinary surgery as a branch of medicine focuses on diseases related to the female and male urinary tracts and the reproductive male organs. Urology focuses on diseases of the ureters, kidneys, the male reproductive organs, urethra, adrenal glands and the urinary bladder (Peschel et al., 177-179). According to Dasgupta et al., (723), urology, as a field of medicine has been at the forefront of cutting edge technology including laser- assisted surgeries, laparoscopic and minimally invasive robotic surgeries and other scope guided surgical techniques. The advantages of robotic- assisted surgery in the field of urology which includes increased accuracy in surgical procedures, long- term economic advantages to both the doctors and hospitals and improved quality have urged the use of the technique since the 80's (Stoianovici, 363). Robotic- assisted surgery enable surgeons to perform procedures such as brachytherapy, transurethral resection of prostrates, laparoscopies and percutaneous renal access. According to Guillonneau (103-105), robotic- assisted surgeries are popular with urologists due to their ability to perform surgeries on patients that are more reproducible and that automized gestures that are quite accurate and specific to patients anatomy and illnesses. Robotic- assisted surgery has yielded positive results in the field of urology, especially in the treatment of prostate cancer. The da Vinci system provides enhanced 3D- views that enable the surgeon to have better access to the surgical site, improved dexterity as well as a higher range of motion. The robotic- assisted surgeries are less nerve sparing, quite accurate and less invasive. Consequently, there are fewer complications during surgeries as well as blood loss and it is less jarring to the patients who are able to recover quickly and resume their normal lives (Hemal et al, 39-41).
Medical area is being improved with the technological advances under which robotic-assisted surgeries have been increasing in their numbers on the global scale. Based on the Bertram et al. (1637) in the last decades a minimal invasive revolution has been seen also in the area of urology, but the access and the acceptance of robotic-assisted surgery is variable across the geographical locations. There is still a lack of documentation in the area of the robotic-assisted surgeries, but it is becoming increasingly prevalent. The use of technology, availability and perception differs across countries as well as geographical locations and hospitals (Bertram et al., 1643). The technology is being incorporated and integrated in the minimally invasive urologic surgeries and has been applied for more procedures with gaining more experiences (Bienko et al., 4741). The robotic-assisted surgery is emerging as an alternative to the conventional laparoscopic approaches in the area of urology and is estimated to be at least as effective as conventional methods with various advantages. The use of the technology is connected with the surgical team experiences with it (The Royal Australian College of Surgeons, 98-99).
Analysis
The results of the survey analysis are showing demographic trends where the majority of the participants in our survey were males. A total of 95 participants were included in the survey conducted in the year 2016, among those 89 were males and 7 were females, which is also seen from the Table 1.
Of the all participants the majority of them had the faculty (33) and resident (28) level of training. Among all there were 4 associate consultants, 4 consultants and 17 fellows. This is showing that among all participants, there were 34.7% of the faculty, 29.5% of resident and 17.9% fellow level of training. All the participants were from the United States. The participants were from 49 different hospitals. 11.6 % were from KAMC, 5.3% from KFH and others were dispersed among other hospitals around the country. Of all participants, 45.3% are practicing urology more than ten years, another 28.4% are practicing the urology up to 4 years and there were 26.3% participants that were practicing the urology from 4 to 10 years, which is also shown in the Figure 1. There were 32.6% of participants between 41 and 55 years old, 31.6% were between 31 and 40 years old, 27.4% were between 25 and 30 years old and 8.4% were older than 55 years.
Figure 1 Years of practicing urology
The survey examined the minimal invasive surgery. Out of 95 participants, 52.6% of them – 50 participants have been formally trained in laparoscopic surgery. 45 participants and 47.7% were not. Of those that have been formally trained, the majority and hence 68.4% have not been participating in the laparoscopic surgery or have been practicing it for less than one year. 12 participants and hence 12.6% of participants have been training it for one year, another 7 participants or 7.4% for two years. Further on, there were 2 participants doing it for 3 years, 2 for five years, 4 for eight years and 10 for 3 years. The percentage is similar in the area of formal training in other minimally invasive surgery extra per the formal residency training where 53.7% of them have not and 46.3% have been formally trained. The participants in the survey also in majority in 78.9% have not been formally trained in robot-assisted surgery. From all participants only 21.1% have been formally trained which means only 20 participants, which is shown in the Table 2.
The low number of trained in the robot-assisted surgery is the reason for the lower years of training in robotic-assisted surgery, shown in the Figure 2, where 3 participants have been training it for 10 years, 1 for seven years, one for 3 years, 7 participants for 2 years and 12 participants for 1 year. The majority has not been trained or have been training for less than one year.
Figure 2 Formal years of training robot-assisted surgery
The results of the survey have shown that 48.4% of all participants have participated in less than 50 laparoscopic surgeries as a surgeon or as a 1st assistant. There were 8 participants that have so far never participated in the laparoscopic surgeries. Three of the participants have been participating in this kind of surgery more than 500 times and 19 of them done more than 50 and another 7 more than 250 surgeries. Further on, the majority has not participated in the robot-assisted surgeries as a console surgeon – 63.2%. There were 25.2% of them who have participated as a console surgeon less than 50 times, 5.3% more than 50 times, 4.2% more than 100 times and 2.1% more than 250 times. The majority of the participants – 60% has also never used a surgical robot console at a training course and 40% have used it. Among all participants, 77.9% have never performed robot-assisted radical prostatectomy. From the ones who had there has been performed in majority less than in 50 cases per year. The majority of the participants’ colleges still performed open radical prostatectomy at their institution - 65.3% and there were 34.7% who does not perform it anymore. The performance of laparoscopic radical laparoscopic prostatectomy has in 62% institutions not been performed and in 20% of the institution was still performed. There were 33.7% of participants that believed that the robot-assisted radical prostatectomy is the gold standard, another 12.6% that is better as laparoscopic prostatectomy and 14.7% that is as good as laparoscopic prostatectomy. The support to robot-assisted surgeries are shown with the answer where 73.7% of all included in the survey would recommend to their family members of use robot-assisted surgery in a need of radical prostatectomy. The use of the technology was low as in the areas of cystectomy, where 96.8% have never performed robot-assisted cystectomy and 3.2% already have. 41.1% of the participants believed that the greatest advantage of the robot-assisted radical cystectomy would be in the quality of life and 37.9% in easy performance. The majority of the participants in the survey and hence 80% have never performed robot-assisted radical nephrectomy and 20% have. The result was similar when asked about the partial robot-assisted nephrectomy where 76.8% have not performed it and 23.2% have. All of the robot-assisted surgeries performance data are shown in the Table 5.
There was the highest percentage – 38.9% seen among the participants who believe that they will perform a robot-assisted surgery after they graduate and 14% believed they will never perform it. In majority cases – 71% there has not been new faculty hired to establish a robot-assisted surgical program. The interest for new technology in urology has been shown with expressing the importance of robotic-assisted training in the participants’ career goals, where 47.4% believed it is beneficial and 24.4% that is required, which is shown in the Figure 3. There were 17.9% of those that believed the importance was minimal and 10.5% believed that is not important. 68.4% of participants would pursue a fellowship in robot-assisted surgery if they would be given the opportunity. The majority - 63.3% also believed that taking a few courses would be beneficial to incorporate the robot-assisted surgery into the practice. Identified course that could help were consisting of minimal invasive surgery fellowships (46.3%) and proctorship under the supervision (10.5%). The majority 66.3% of OR does not have a dedicated robot-assistant surgery supported team, which exists in 33.7% departments. Almost a majority - 45.3% expressed that the most significant factor that inhibits the robot-assisted surgery is the need for the system and 38.9% said the administration disinterest and lack of support.
Figure 3 Importance of the robotic-assisted surgical training
Discussion and conclusion
The use of robotic-assisted surgeries have been seen in various fields inside the urology since the introduction of the technology. Based on the Ng and Tam (241) there have been 4000 peer review publication written about the Vinci Surgery of which 46% pertain to urology. The technology has been used in clinically localized prostate cancer and have been increasing in the area of robotic renal and robotic cystectomy surgeries (Ng and Tam, 242), The author shows that despite the popularity and advantages of the technology the robotic surgery does not show any unequivocal evidence of superiority over the traditional laparoscopic surgery. The reasons for that are high maintain and installation costs (Ng and Tam, 248). The interest from the participants was also expressed and the benefits and advantages of the robotic-assisted surgeries were already acknowledged, but the majority of the participants has never assisted in such surgeries, which can be explained by the Ng and Tam (241-248) findings. The results from the survey can also be compared to international level, where similar surveys were conducted. Based on the Bienko et al. (4740) the majority of the surveyed have applied robotic assistance in urological surgery, but 70% of them used the robot only to position and hold laparoscope. The majority of the surgeons surveyed felt that the development of such systems was too expensive for the institution (Bienko et al., 4740). From our survey, it is impossible to find out the reasons for the low usage and training in the robot-assisted surgeries. On the global scale the results were also low since the majority had never sat on a robotic surgical console and around 20% of them have been currently performing robot-assisted surgeries (Bienko et al., 4736). The lower percentage of the use of robot-assisted technology in urology will probably increase in the future. The fact that there was a lower percentage of participants practicing the robotic-assisted surgery can be found also from their level of training. The evolution of the minimally invasive surgery has been seen in various geographical location where there have been longitudinal researches conducted. The hospital resources, lack of training opportunities, lack of support from the hospital or insufficient remuneration will still remain one of the biggest barriers in the increasing the practice of the minimally invasive surgery as well as robotic-assisted surgeries (Chhiv et al., 92-99), which have also been expressed by the participants in our survey conducted.
It is without a doubt that the field of robot- assisted surgery will keep evolving and developing within the coming years. It is therefore recommended for all surgeons to get acquainted with the techniques since the world is fast becoming technological and robot- assisted surgeries will soon become the norm in hospitals and for various procedures regardless of the barriers that are prevalent in the use of the technique. Robot- assisted surgery in its various forms is the future of surgical procedures and should be understood and learned by all surgeons and medical staff
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