Single-Incision and Robotic Surgery: Medical Breakthrough or Marketing Ploy?

A recently published article (Reuters Health, July 18) appears under the headline: “Single-Incision Approach Yields No Benefit in Laparoscopic Gallbladder Surgery.”

Authors of the article, a group of surgeons from the University of Leicester in England, looked at 49 studies involving 2,336 patients who underwent single-incision laparoscopic cholecystectomy (SILC). Based on their study the researchers concluded, “Outcomes from systematic reviews rather than market research must guide decisions about surgical procedures if we are to ensure that surgical progress is not dictated by commercial and industrial interests.”

Upon reviewing the article (http://www.medscape.com/viewarticle/767710?src=mp&spon=14), my colleagues and I enjoyed a healthy conversation about the potential merits of newer procedures, such as single-incision laparoscopic surgery and robotic surgery. The following captures some of our thoughts:

Dr. Michael Kelly: The results of the study come as no surprise and lend more support to my suspicion that many single-site and robotic-assisted surgeries are just another way to perform the operation. They are useful techniques and often enable some surgeons to operate in a minimally invasive fashion. Premier surgeons use these techniques safely, but I do not believe that they can be presented as superior, safer or better than the standard laparoscopic approach. So far, there is no good data to support these kinds of statements in general surgery, just anecdotal experience. Terms such as “painless” and “incisionless” are industry-driven and misleading.

That’s why discussions like this are beneficial to our practice and our patients. While currently there is insufficient data for patients to provide informed consent, we can share information from surgeons in our practice who are regularly performing these procedures.

Dr. Mark Colquitt: Having had the experience of nearly 100 robotic gastric bypasses under my belt, I can honestly say that, if possible, I will never go back to older laparoscopic methods. Currently greater than 90 percent of our gastric bypasses are done robotically. The patients tend to do better – less pain, no nausea and early mobility. More often than not we are sending patients home within 24 hours. We were never able to do that before. From a personal standpoint, doing robotic surgery is probably the most fun I’ve had in the operating room. Ergonomically, there is very little strain on your neck and back, and at the end of a long day you feel rested.

Dr. David Harrell: I agree, Mark. I wouldn’t want to go back to laparoscopic Nissens [a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia]. The dexterity, vision and ergonomics are far superior. I am able to repair and wrap much more securely because I can place sutures where I physically couldn’t laparoscopically. Also, don’t discount single-incision laparoscopic cholecystectomies. I agree they are not for most patients, but for the body-conscious patient it is amazing to have no visible scar. The key is that it can be done safely and practically with good triangulation and excellent vision of the critical view.

The bottom line is this: Newer isn’t necessarily better, nor is it necessarily worse. The key is for patient and physician to have a frank discussion, weigh the pros and cons, and move forward with the best interest of the patient in mind.

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