Doctors grapple with the value of robotic surgery

SPRINGFIELD, Mo. (AP) — Wanda Ackerman of Billings was the first patient at St. John's to undergo surgery with what has been billed as a state-of-the-art $1.6 million robotic surgical system called the da Vinci.

Ackerman, now 50, had a hysterectomy three years ago through four small incisions in her abdomen. Her surgeon, Dr. Kent Burk, sat at a console, maneuvering the controls of the robot to do the surgery.

"I was up taking a shower the very next day," Ackerman said. "Within three weeks, I was back to normal. It was the perfect surgery for me. Perfect."

Such testimonials touted by hospital marketing staffs are common for the da Vinci system, named after the Italian artist who painted Mona Lisa and studied anatomy. The system is used in more than 1,100 hospitals in the United States, including 29 in Missouri.

Dozens of patients in southwest Missouri eager to have the high-tech surgery traveled to other hospitals hours away before St. John's and CoxHealth got state approval in 2008 to buy their da Vincis.

But some researchers have questioned whether the outcomes of robotic surgery are any better than conventional surgery and whether using the robotic systems are justified given the increased cost.

"It symbolizes everything that is wrong with American health care," said Dr. Marty Makary, an associate professor of surgery and public health at the Johns Hopkins University School of Medicine in Baltimore.

Some studies suggest improved outcomes, especially in shorter hospital stays and less blood loss, according to an article in the March issue of Medical Care.

Other studies suggest that there isn't a benefit compared with other types of surgery or there's a detriment, according to the Medical Care article. Researchers also say the price of the robot may be pushing hospitals to do more surgeries on people who may not need it.

"There's strong incentive for hospitals to use the robot once it's acquired because it's very expensive to try to recoup their investment," said Dr. Danil Makarov, an assistant professor of urology and health policy at the New York University School of Medicine. "Are we treating a lot of patients who don't need surgery in the first place? We don't know."

Research has also suggested that the machine may have a high learning curve. At least one lawsuit involving robotic surgery has been filed in Greene County.

Carolyn Hedrick of Aurora, whose husband Donnie Hedrick, 66, died in October 2009 after prostate surgery, sued Cox, Ferrell-Duncan Clinic and Dr. Howard Follis.

The suit, which is pending, alleges that the surgery perforated Hedrick's small bowel but that Follis didn't realize this.

CoxHealth officials declined to discuss the lawsuit.

"We are very sorry for the family's loss and extend our sincerest condolences," said hospital spokeswoman Stacy Fender. "Unfortunately, due to pending litigation, we are unable to comment further."

A spokesman for the California manufacturer, Intuitive Surgical Inc., and doctors at St. John's and CoxHealth who frequently do the surgeries said the robot allows surgeons to operate with preciseness they couldn't achieve before.

"It brings tools to the surgeons' hands that we've never had access to before," said Dr. Thomas Shultz, an obstetrician affiliated with CoxHealth who has performed more than 320 hysterectomies with robotic surgery. Shultz has changed the pain medication he gives his patients, which allows him to send them home the same day as surgery.

The 6-foot-5 surgeon, once a forward on the Glendale High School basketball team, called robotic surgery "a game changer" like the three-point basket that revolutionized how basketball was played. He said the instruments inside the patient, which can be moved 270 degrees, are similar to having a wrist in the patient's pelvis.

"It's like having mini-me wristed instruments," Shultz said. "That brings me a degree of safety I could never have before."

The view of the patient is magnified up to 10 times through cameras. Doctors lose their sense of touch when operating with robotic controls, but they said they learn to compensate with visual cues such as watching how the tissue moves.

"You actually learn to feel with your eyes," said Dr. Eric Guilliams, a urologist at St. John's who frequently uses the robot to perform prostate surgery.

Men who undergo surgery for prostate cancer to remove the prostate gland and some of the tissue around it often have problems urinating and having erections. It is unclear whether patients who have robotic surgery suffer these problems less or the same as patients who undergo conventional surgery. About 86 percent of American men who had surgery for prostate cancer in 2009 had robotic surgery.

Makarov, the New York University assistant professor, and other researchers found that hospitals that buy robotic surgery systems did more prostate operations. Hospitals without the robots did fewer of the operations.

"Is doing more surgery good or bad?" Makarov asked. "We don't know."

Doctors at St. John's who perform prostate surgery said whether robotic surgery is performed varies, depending on the patient.

"Not everyone who walks in the office is going to get a robotic procedure," said Dr. Mark Walterskirchen, a urologist.

Walterskirchen said prostate cancer patients at St. John's who had robotic surgery did better than patients who underwent other types of surgery when doctors looked at whether cancer cells were found at the edges of the removed tumor. If cancer cells are found near the edge, the patient may be at increased risk for cancer recurrence.

"If it was me," Walterskirchen said, "there is no doubt I would have it robotic."


Information from: Springfield News-Leader, http://www.news-leader.com

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