Help or Hoopla?: Surgical robots can benefit otolaryngology

The large, roadside billboards advertised robotic surgery in bright, bold colors, something that struck David Eibling, MD, professor of otolaryngology at the University of Pittsburgh, as “fundamentally wrong.” Hospitals and physicians “should not be offering robotic surgery as a draw for patients,” said Dr. Eibling, who noticed the billboards while traveling through Florida earlier this year, “but rather as a potential tool to benefit the care of the patient.”

The role of robotics in health care, and health care advertising, is a hotly debated topic. In a recent New York Times article, for example, physicians discussed feeling pressure from their patients to use robotic surgery (Kolata G. Results unproven, robotic surgery wins converts. February 14, 2011. The New York Times online.). Otolaryngologists are paying attention.

“Robot is a hot word,” said Eric Genden, MD, chair of otolaryngology-head and neck surgery at Mount Sinai School of Medicine in New York City. “People like to put it in their brochures, and patients like to feel like they’re getting the most cutting-edge, the most technologically advanced, treatment.”

In otolaryngology, the da Vinci Surgical System, the only surgical robot approved by the U.S. Food and Drug Administration (FDA), is currently used to excise cancers of the oropharynx transorally, to perform transaxillary thyroidectomies and to treat sleep apnea. But are these approaches scientifically sound? Is the robotic approach truly better than traditional treatment? In some cases, at least, the answer seems to be yes.

On paper, robotic surgery offers several advantages over traditional surgery. The robot provides 3-D visualization of the surgical field, mitigation of surgeon tremor, advanced magnification and increased range of motion (Open Access Surgery. 2010;3:99-107).

“When you’re working through a laryngoscope, the instrumentation is limited by the physical configuration of the distance from your hand to the tips of the instrument. With the robot, it’s as if your whole arm is in the wound,” Dr. Eibling said.

Robotic surgery comes with a significant cost, however. The robot itself costs close to $1.5 million dollars; maintenance costs run about $140,000 to $340,000 per year and each case requires about $500 worth of disposable equipment (Open Access Surgery. 2010;3:99-107). Thoughtful otolaryngologists and head and neck surgeons are still comparing the outcomes of robotic surgery and traditional treatments; an examination of the cost-benefit ratio of different procedures is also underway.

Transoral Robotic Surgery

Perhaps the most widely accepted use of robotic surgery in otolaryngology is transoral robotic surgery (TORS). Developed in 2005 by Bert O’Malley, MD, and Gregory Weinstein, MD, FACS, professors of otolaryngology at the University of Pennsylvania in Philadelphia, TORS was approved by the FDA in 2009 for the removal of T1 and T2 cancers of the oropharynx. Only about 200 surgeons in the U.S. are currently qualified to perform TORS, said Dr. Weinstein, who is also the first president of the Society of Robotic Surgery (SRS). He believes that the number of qualified surgeons will increase.