Wanted in Surgery

Over a half century ago, Harlan Ellison’s Wanted in Surgery postulated a future in which human surgeons are reduced to mere assistants to robot surgeons [1]. Ellison described robotic surgery as a purely mechanical operation, devoid of any bedside manner or concern for the patient before or after an efficient, low-risk operation. The bottom line was — as it is today — the economic bottom line.

Hospital management and third-party payors are concerned with minimizing the cost of surgery, postoperative recovery time, the length of hospital stay, and of maximizing operating room turnover. Today, healthcare costs often overshadow all other considerations. Furthermore, costs are typically expressed in terms of outcomes.

An inexpensive procedure that does little to improve patient quality of life (a poor outcome) can be less valuable than an expensive procedure that significantly improves patient longevity and quality of life (good outcomes).

Robotic surgery has enjoyed good press during the past few years because of initial cost savings and short-term outcomes. It’s been widely reported that patients undergoing robotic laparoscopic surgery generally have shorter hospital stays and fewer complications during surgery. However, most outcome studies focus on the surgical procedure and end at the time of discharge. From the patient’s perspective, what happens in the long term — weeks to months after the surgery — is at least as important as surviving the surgery and other short-term outcome measures.

Unfortunately, for surgical robotics manufacturers, a recent study at Brigham & Women’s Hospital in Boston, MA suggests that long-term patient outcomes using surgical robots are inferior to those associated with human surgeons [2]. Although patients undergoing robot surgery typically have shorter procedure times and return to home and work after only a few days, the long-term prognosis is not so glowing. Patients undergoing robotic surgery have more surgical complications — such as strictures (narrowing of anatomical passages). Furthermore, patients that undergo robotic surgery for cancer are more likely to require follow-up or salvage surgery to remove cancerous tissue missed by the robot surgeon. Apparently, the human eye and direct manipulation of tissues are better than robotics at removing every trace of cancer.

What do these problems portend for surgical robotics and robotics in general? Certainly, surgical robotics will be under increased scrutiny until the findings are either refuted or replicated and then adequately addressed. For robotics in general, these findings are a good reminder to consider not only the immediate benefits of robotics, but the long-term consequences, as well.

For example, a rich area of robotic research and development is assistive robotics. Japan is the leader in this field, in part because of its aging population that will soon need assistance in walking, showering, shopping, and other innumerable activities of daily living. Aside from the obvious lack of personal interaction, what can we expect from the long-term caring of elderly humans by robotic servants and assistants? How would you feel if you were fed, bathed, and dressed by robots? I suspect you would long for your ‘free range’ days without the benefit of your robotic keeper.

If I ever find myself in a retirement home under the care of a robotic assistant, I want the final say in my welfare. But most likely, the retirement home management would control my every movement. In effect, I could potentially become a mere extension of the robots, under indirect control by staff coldly controlling my movements with a joystick or keyboard. Such a future doesn’t sound like nirvana to me.

I think it is incumbent on designers and developers of assistive robots to think about how to best empower the user/patient, without placing control of movement in the hands of a business manager or politician.

If you’re involved in the design and/or development of assistive robots, please consider sharing your design with your fellow readers. I look forward to hearing from you.  SV

REFERENCES:

[1] Ellison, H. 1957. Wanted in Surgery. Quinn Publishing Co, NY.
[2] Hu JC, Wang Q, Pashos CL, Lipsitz SR, Keating NL. Journal of Clinical Oncology. 2008 May 10;26(14):2278-84. Abstract available from [url=http://www.pubmed.gov]http://www.pubmed.gov[/url].