Who needs a robot — and why?

To put the answer to this question at its very simplest — You don’t. Your surgeon may!

When Is a Robot Not a Robot?

In the early days of laparoscopic radical prostatectomy (LRP), no one used what is now referred to as a “surgical robot.” They did use (and some specialists continue to use) equipment that facilitates the manipulation of surgeon-directed camera-holders at a distance. Indeed Guilloneau et al. referred to such equipment as a “robot” in their original description of LRP (see figure on left).

The commercial names of these systems include

  • the Aesop® Endoscope Positioner
  • LapMan® (a “dynamic laparoscope driver”) made by Medsys
  • EndoAssist® (a “robotic camera manipulator”) made by Prosurgics

However, the difference between this camera-manipulative equipment and the type of “robotic” surgical equipment widely used today is considerable. The da Vinci® Surgical System, which is the system used not only to carry out most “robotic” laparoscopic radical prostatectomies (RALPs) but many other forms of laparoscopic surgery, is a truly “remote” operating system. The surgeon sits at a console across the room from the patient on the operating table, and manipulates every camera and surgical tool through three or four “arms.”

Apparently, however, even Intuitive Surgical, the makers of the da Vinci Surgical System, aren’t entirely happy about their system being called a “robot.” Here is the answer to the question, “Is this robotic surgery?” that is given on their web site:

Devices for “robotic surgery” are designed to perform entirely autonomous movements after being programmed by a surgeon. The da Vinci Surgical System is a computer-enhanced system that interposes a computer between the surgeon’s hands and the tips of micro-instruments. The system replicates the surgeon’s movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way or perform any type of surgical maneuver. Sometimes, however, the general term “robotic surgery” is used to refer to our technology.

Detailed information about this equipment is available on the manufacturer’s web site (but do remember that all information on the manufacturer’s web site is a form of advertising and is designed to help sell this equipment to hospitals and surgeons).

Thus, the first thing you need to understand if you decide to have a RALP is that it is not really going to be “robotic surgery.” A real live surgeon is still going to operate on you in real time … and a good thing too because each patient is very different from the one before!

Is a RALP “Better” than a “Non-robotic” LRP?

There is absolutely no evidence that this is the case.

In fact, what really appears to be the case is that it is easier to learn to do LRPs using the da Vinci equipment than it is to learn without. The following quotations are taken from from two of the few publications that appear to have made a serious attempt to compare the clinical value of the two techniques:

RALP appears to offer a significant benefit to the laparoscopically naïve surgeon with respect to learning curve when compared to LRP. This, however, comes at an increased cost (see Rozet et al.)

and

… the lessons we have learned to date suggest that it is the skill of the surgeon that determines outcome, regardless of whether or not the operation is performed by [a non-robotic] open or robotic laparoscopic technique (see Nosnik et al.)

Given the relative prevalence of the da Vinci system, it is now almost inevitable that the vast majority of surgeons learning to carry out LRPs today will in fact learn to do RALPs rather than classic LRPs.

The second thing you need to remember is one we have repeated (and will continue to repeat) over and over on this web site. It’s not the gizmos that matter, it is the skill of the individual physician or team using the gizmos that you really have to be concerned about! The American Cancer Society makes the same point in their booklet, “QuickFACTS on Prostate Cancer.”

So Why Has “Robotic” Surgery Become So Popular?

Three simple reasons:

  • If you are a young surgeon (or even a certain type of older surgeon), the da Vinci system is very cool. It’s kinda like being able to drive a Porsche instead of a Toyota. And many surgeons (like many of the rest of us) are very suceptible to cool toys.
  • Assuming that Rozet et al. are correct, and it is indeed easier to learn to do laparoscopic surgery with this equipment, then that in itself is a crucial reason for the popularity. Why would you want to make acquiring this skill any harder than it has to be?
  • And third, great marketing! Intuitive Surgical set out to make the da Vinci Surgical System the laparoscopic operating technology that no hospital and no surgeon could live without! In many cases they have succeeded.

So here’s the last thing you need to bear in mind. Driving a Porsche well at high speed requires a high degree of skill as a driver. Most people just don’t have that level of driving skill. Caveat emptor! (which, for those who missed Latin in high school, means “Let the buyer beware!”)

Content on this page last reviewed and updated May 23, 2008.
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