A Guiding Hand
Robots are showing up in ever more surgical suites. But they're better suited for some operations than others
Research shows that the first hospital in a geographic market to get a robot generally sees a handsome payoff. "There's a huge halo effect for the first hospital," says Giri Venkatraman, who oversees surgical services research for Sg2. "They get a huge increase in volume, both in patients in general and in patients who want the prostate procedure." Competitive pressure sometimes spurs other hospitals in the area to invest in a robot as well, says Venkatraman.
Why should patients care about a hospital's business strategy? With any new surgical technology or procedure, there's a learning curve. The more experienced the surgeon, the better the outcome is likely to be. Each hospital sets its own credentialing requirements for surgeons to perform robotic surgery. But many surgeons agree that to become comfortable and efficient at performing a robotic procedure often takes 30 or more operations. To become skilled enough to save nerves may take much longer. "The finesse part takes at least a couple hundred cases," says Ash Tewari, director of robotic prostatectomy for New York-Presbyterian/Weill Cornell, who operated on John Lynch and has performed some 1,400 robotic prostatectomies.
Do your homework. There are other questions to ask when considering robotic surgery. In addition to how many times a surgeon has performed a particular procedure, find out how many times the procedure itself has been performed at the hospital, says Jihad Kaouk, codirector of robotic urological surgery at the Cleveland Clinic. "I wouldn't go to a surgeon who just started doing robotics for a new procedure," he says. "There are just too many variables." It's always a good idea to talk to previous patients as well.
Although many procedures can safely be performed robotically, most surgeons agree that certain operations don't warrant such cutting-edge intervention. Repairing hernias and removing gallbladders, appendixes, or ovaries with benign conditions generally fall into this category of straightforward laparascopic operations for which the robot is overqualified. And although a few procedures can be performed in older children, at this time the da Vinci's instruments generally aren't small enough to be used in children under 5 or in fetal surgery, says Michael Klein, surgeon in chief at the Children's Hospital of Michigan in Detroit.
Shorter recovery. Some patients choose robotic surgery because they believe it offers the quickest way to get back on their feet. When Kris Zellmann was considering gastric bypass surgery, the time factor was critical. The 32-year-old bookkeeper couldn't afford the eight- to 10-week recovery period of a standard operation. She decided to have the procedure done robotically at the Hackensack University Medical Center and was back to work in nearly half that time.
Insurance is another factor. Although Zellmann's health insurer approved her robotic surgery without questioning it, coverage isn't always assured. Lynch says his insurer denied coverage for his prostatectomy because the procedure is considered experimental. He is appealing the decision. A study published in 2004 in the Journal of Urology found that open prostatectomies were about $1,700 less expensive than robotic ones, and nearly $500 less expensive than laparascopic ones. Even though patients' hospital stays are about two days shorter with robotic surgery than open procedures, the equipment itself is so expensive that it offsets the savings. Some hospitals absorb the added expense, but before signing on for robotic surgery, make sure you understand what your insurer will cover.
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