Surgical responsibility and robot-assisted laparoscopic surgery

There is an interesting editorial just published on line in the Journal of Urology and written by Prof. Joseph Smith of Vanderbilt University. Unfortunately, because it is an editorial, there is no abstract, and the text is only accessible if you are a subscriber to the journal.

As regular readers will be aware, there has been a lot of noise in the media about risks for side effects and complications associated with use of the da Vinci robot, and the U.S. Food and Drug Administration has instituted an investigation of reports of such side effects and complications. The aggressive promotion of the technology by the manufacturer has also been brought into question.

In his editorial, Prof. Smith is at some pains to point out that at the end of the day it is the individual surgeon — not the equipment manufacturer nor the place where s/he works — that has the responsibility for deciding whether (a) s/he wants to use this technology in surgical practice and (b) whether s/he is sufficiently skilled and experienced with the technology to be able to use it appropriately. We hope that the Journal of Urology will forgive us for passing on the following quotations from the article that seem particularly important to our readers:

The robot does what the surgeon tells it to do by hand movements. It is a computer controlled mechanical arm. Although technical problems with the da Vinci robot occur occasionally, complications from surgery are, for the most part, those created by the surgeon. The robot does not go haywire and start cutting into adjacent structures. The operating surgeon is responsible for the surgical result.

Claims are made that Intuitive promoted use of the robot by aggressive marketing to hospitals and individual surgeons. Is anyone surprised by this? One would expect a device maker to promote its business. Another criticism is that Intuitive did not ensure that practitioners were adequately trained. Surely, one would hope that it is not the responsibility of an industry representative to teach a surgeon how to perform a particular operation.

… it is the surgeon’s conscience that should be the primary determinant of whether he or she is qualified to perform a particular operation. All surgeons become better with experience but only one can be the best in the world at a particular operation (although many may make that claim!). That is not the standard. The patient trusts that the surgeon is not unduly influenced by financial or practice considerations and possesses the necessary skills to perform an operation competently. An almost sacred covenant exists between a surgeon and a patient.

In a prior article on this topic, The “New” Prostate Cancer InfoLink had noted that

… we need to distinguish very carefully between any real problems that may be associated with the technology and problems resulting from inadequate training and experience in the use of this technology by surgeons (and perhaps by those responsible for maintenance of the equipment at specific institutions).

It appears that Prof. Smith, at least, is in considerable agreement with us. And no one who knows him would suggest that Prof. Smith was anything other than a highly dedicated surgeon. We would go one step further and suggest that the “almost sacred” trust that does indeed exist between a surgeon (or any other doctor) and his or her patient has been under a lot of stress over the past 20 years or so. Perhaps we all need some re-education about what that trust entails — for physicians, for other healthcare professionals, and for patients too.

8 Responses

  1. Another insightful piece from The “New” PCILink. The last paragraph of Prof. Smith’s missive beginning with, “it is the surgeon’s conscience …” should be read by every prostate cancer urologist in the country. He is exactly correct. An entire article could be written about that last paragraph.

    Patients are usually left out of the loop when it comes to understanding physician competence and professional experience. At what point in time does the urology community subscribe to peer review and published data results for all to see?

  2. Let me make two remarks. First, concerning the second paragraph, why should it not be at least *part* of a robot’s producer [I’m changing the terminology] to instruct surgeons who intend to use the device? Prof. Smith gives us no argument. Second, the same lack of argument is found in the third paragraph’s first sentence. Who knows what Prof Smith means by ‘conscience.’? Belief that he/she has had enough experience? Belief that he/she’s been paid off enough to use the machine come what may? Until these two points are further explained, this is quite unhelpful.

  3. Dear George:

    In the full article (which I can’t simply copy and paste to this site because of copyright restrictions), Prof. Smith addresses both of the issues you ask about in significantly more detail than is represented by the brief quotes above. If you want to read the article, ask your library to get you a copy. You can’t just “damn the article” without reading it.

  4. Dear Sitemaster,

    I tried but first found nothing and then found two candidates for online urology journals. Then I gave up and wrote my contribution. Now, since the writer does address these issues then you should have said so, or have given a summary. Without that the three texts are not only unhelpful, but elucidated1 found them insightful, especially the third text, which lacking expansion is cognitively empty. Note that I’m assuming that elucidated1 did not see the full article. If he or she did, then I’m wrong.

  5. Dear George:

    I have absolutely no idea what “three texts” you are referring to. There is only one version of Dr. Smith’s text that I am aware of. To be able to read it you need to be able to access the Journal of Urology. And it would have been quite impossible to “summarize” what is already a highly condensed editorial comment that makes a series of carefully constructed observations in 2 pages.

    My goal was to bring the article to people’s attention, not to try to replicate it.

  6. I used the word “text” because at least one of the selections above is not a full paragraph. I tried to think up some better phrase, but anything I came up with was in my opinion unwieldy. I’ll try again later, to see if I can find the full text. Unless I typed wrongly, the library doesn’t subscribe to a source of that name. It does though to something called The Internet Journal of Urology and one other with a similar name. Give me time.

  7. Oh … I see, you were referring to the “extracts” or “quotations” I had given from the original article.

    The Journal of Urology is one of the core urology journals world wide, so I can’t believe a good medical library wouldn’t have it available.


  8. Dear Sitemaster,

    No wonder I could not access that journal with my account. The library has a computer problem. Business as usual here.

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