What's Wrong with the da Vinci Robot?

Leonardo da Vinci was a study in contradictions: He was an artist and a scientist who often didn't finish what he started. He despised war but invented deadly weapons.  As the painter of the Mona Lisa, he was highly praised, but only completed a few other artistic works.  He studied elements of flying, but never published his ideas.

Da Vinci's inconsistencies made me think of the da Vinci Robot, his namesake device that some see as revolutionizing healthcare and others see as revolting: Indeed, it is a study in conflict itself.

Surgeons control the da Vinci from a console designed for minimally invasive techniques.

The robot was once again in the news recently in the wake of a report from the ECRI Institute that identified the da Vinci robot, as well as some other technologies, that fail to improve care—or were weak—based on data the institute collected. The ECRI Institute, based in Plymouth Meeting, PA, researches cost-effectiveness in patient care.

ECRI acknowledges that, as more physician residents are trained in the da Vinci robot, there is growing pressure among hospitals to acquire it, which costs between $1 million to $3 million apiece. What's more, applications for robot-assisted surgery have "outpaced supporting clinical evidence for improved patient outcomes, cost-effectiveness and commensurate reimbursement," ECRI states.

Some physicians acknowledged to me that in certain surgical areas, such as in cardiothoracic surgery, the da Vinci at this point doesn't lend itself to more efficiency, and is no better or worse than other treatment options. One physician told me it's "going to be the future." That's a bit of a bit flimsy reason to use it now.

Still, in its report, ECRI didn't capture the full possibilities of the da Vinci. Physicians in the field of head and neck cancers, for instance, say they are thrilled by the prospects that the da Vinci represents, offering better patient care options than they have seen in decades.

Neck and throat cancer is devastating because of its impact on speech, swallowing, and facial structures.

Currently, about 80% of all head and neck cancers are caused by tobacco and alcohol use. More than 50,000 Americans are diagnosed with cancers of the head and throat each year, including the tonsils, tongue base and voice box.

Looking ahead, healthcare industry experts expect to see increasing instances of oral cancer tumors related to sexually transmitted diseases. In 2009, the Food and Drug Administration opened the door for use of the da Vinci surgical system for transoral otolaryngologic surgical procedures to treat tumors in adults.

Robert DeFatta, MD, PhD, ENT, a surgeon at the Head and Neck Center at Sacred Heart Hospital in Eau Claire, WI, praises the da Vinci robot as the vehicle for entering a "new era" of treatment that, among other things, reduces the amount of chemotherapy needed in treatment. In addition, it has mitigated the need for feeding tubes, and enabled patients to return to normal speech and swallowing soon after surgery, tells HealthLeaders Media.

With the robot and the so-called Transoral Robotic Surgery (TORS), DeFatta says he can reach into areas of the throat that were virtually inaccessible before, while maneuvering the da Vinci device and treating patients in that delicate area with precision, control, and ease. Benefits to the patient include shorter hospital stays, easier recovery, less tissue damage, and lower risk of infection.

In the past, cancers of the throat were treated with   a combination of radiation and chemotherapy, which frequently resulted in the patient needing a feeding tube for the rest of his or her life, DeFatta says.

The conventional open surgery for tumors involving the throat typically required a large incision that produced significant cosmetic deformity, as well as the possibility of speech and swallowing problems.

"There's no way you can visualize it as well as you can with the da Vinci," DeFatta says, referring to the doctor's view of the surgery procedure. "It's a three-dimensional view of what you have." These patients cannot swallow, they cannot go out to eat with their families. When you turn to the da Vinci, you can take out the tumor with lower amounts of radiation, a lower dose of chemo, and for thousands of people, that's a huge difference."

"I can only speak for what I do," DeFatta says. For surgeons in his field, "by not using it they are missing the boat," he adds.

DeFatta isn't the only throat and neck cancer surgeon who is enthusiastic about the possibilities of the da Vinci.

"It is the paradigm shift in our treatment, with minimally invasive robotic surgery that leaves patients with improved ability to swallow and speak and function," Tod C. Huntley, MD, FACS, co-director of head and neck cancer services at St. Vincent's Health System in Indianapolis told me for an article in the January issue of  HealthLeaders Magazine.

Patients are now discharged in less than five days as opposed to multiple weeks of inpatient recovery from the traditional surgery, Huntley says.

In his field, DeFatta says it appears the da Vinci robot will be increasingly put to use in surgeries for obstructive sleep apnea when it is caused by the collapse of the upper airway due to a large tongue base. He says patients that have the TORs procedure typically go home in two to three days, compared to 10 days with conventional surgery.

In ECRI's opinion, the da Vinci is part of potential "costly robot wars" in healthcare. The organization's report says that although proponents tout the da Vinci's improved visualization capabilities, as well as its precision and dexterity, "real unanswered questions are how much value they add, and, more importantly, how and when they definitely improve patient care and long-term outcomes."

While ECRI cites cardiology and other procedures used with the da Vinci, it also mentions head and neck cancer surgery, where doctors say it appears to be opening doors to improve patient care.

But the robots are used in many procedures, and there are still unanswered questions about them, not unlike the incomplete scientific and artistic picture left by da Vinci the man. Despite ECRI's viewpoint, the enthusiasm expressed by certain surgeons using the device show that the full story of the medical robot is still incomplete. Much more needs to be studied, and written.