From Open to MIS: Robotic Surgery Enables Surgeons to Do More With Less

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Since the introduction of robotic surgery, many advanced laparoscopists—myself included—have argued that robotic surgery is unjustifiable. The increased costs, longer operative times, and lack of any data showing significant improvements in clinical outcomes with robotic surgery have allowed us stay within our laparoscopic comfort zone and state that we are helping to contain costs.1–3 Whereas it is convenient to compare these 2 minimally invasive approaches, such comparisons fail to account for more complex cases that are not generally amenable to standard laparoscopy for most surgeons. Although we have been skeptical of the benefits of robotic surgery when comparing apples to apples, perhaps we ought to be comparing apples to oranges.
In this article, Dr Carbonell and his colleagues have shown that robotic retromuscular ventral hernia repair was associated with a decrease in length of stay compared with an open approach.4 This finding is both statistically significant, and also clinically relevant. The decreased length of stay likely reflects a decrease in perioperative pain associated with the robotic approach. Additionally, although it did not reach statistical significance, the robotic approach was associated with a 50% decrease in surgical site infection. This is not an entirely surprising finding given that previous studies comparing laparoscopic and open ventral hernia repair have shown significant decreases in wound morbidity associated with laparoscopy.5 This is not the only study that has shown the benefits of robotic surgery compared with open approaches for complex operations. Peng et al6 have previously shown that robotic pancreaticoduodenectomy was associated with a significant decrease in overall complication rate, surgical site infection, and margin positivity compared to open pancreaticoduodenectomy.
It is also worth noting that the data analyzed in this paper came from multiple surgeons practicing in a variety of clinical settings. Unlike most randomized controlled trials that restrict patients from entry due to a variety of inclusion and exclusion criteria, this study accurately represents real world surgery. The Americas Hernia Society Quality Collaborative has also found that robotic surgery is associated with a significant increase in fascial closure rate compared with laparoscopy during ventral hernia repair.7 Although the clinical significance of this is unclear, it again shows that robotic platform enables surgeons to perform complex maneuvers that are not easily performed with standard laparoscopy.
It is difficult to predict what the future of minimally invasive surgery will look like. Advancements in optics, haptics, wristed laparoscopic instrumentation, and robotics will continue to drive our field forward and allow surgeons to perform increasingly complex operations through increasingly smaller incisions. While we must continue to compare these advanced techniques to our surgical gold standards, we should also strive to utilize these advances in innovative ways for the betterment of our patients as Carbonell et al have done here.
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