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Ann Thorac Surg 2006;82:693-694
© 2006 The Society of Thoracic Surgeons
Medical City Dallas Hospital, 7777 Forest Lane, Suite A323, Dallas, TX 75230
(Email: mjmack{at}earthlink.net).
We are now approaching a decade since the introduction of robotics into clinical cardiac surgery. With this well performed study of learning curves in the application of robotics for atrial septal defect closure by the respected group from Innsbruck [1], perhaps it is time to step back and examine the contribution of robotics to cardiac surgery and the expectations for the foreseeable future. Clinical experience has now been gained with robotics in general surgery, urology, thoracic surgery, and cardiac surgery, including mitral valve repair, internal mammary artery harvest, coronary anastomoses, patent ductus arteriosus ligation, and atrial septal defect closure. Has a decade of experience made an impact in the performance of these procedures and resulted in patient benefit, or is it likely to in the future?
The theoretical contribution of robotics to surgical procedures includes remote telemanipulation and precision and dexterity enhancement. It has always escaped me as to how having a surgeon at a remote distance has or will be likely to benefit a patient. In the original concept, remote telemanipulation (ie, the ability to perform an operation at a distant geographic site or a space station) made sense on some level. Yet the prospects for these applications are as remote today as when they were originally conceived. In the current paradigm of patient care, the contribution of the remarkable technological tools of robotics is still not clear. The second potential benefit of robotics (ie, precision enhancement) has also proved elusive as a contributing value. The area in which could most benefit from scaled motion (ie, totally endoscopic coronary artery bypass) has not been able to gain traction. With the exception of isolated success in complex mitral valve repair by Chitwood [2] and a few others, no significant impact on the management of this disease has occurred.
This report by a very experienced center of robotic surgery performing a rigorous scientific study raises the same ultimate questions with atrial septal defect closure. With prolonged cardiopulmonary bypass and cross-clamp times for performing a direct suture repair only, even after surmounting a significant learning curve by acknowledged experts on one hand and the success of even less invasive percutaneous approaches on the other, one must ask where we are going with this.
Robotics is clearly a disruptive technology that represents a significant shift from what preceded it. The value of original disruptive technology is ultimately enhanced by the sustaining technology and the ability to surmount application learning curves that follow (eg, mobile telecommunications and digital photography). Now nearly a decade after the introduction of robotics into clinical cardiac surgery, what is the sustaining technology or techniques that are going to translate to direct patient benefit? All technology introduced into clinical medicine reaches a definition of clinical usefulness, which can change with time based on sustaining technology. Although the group at Innsbruck and others who are embracing and furthering robotics in surgery are to be admired and commended for their efforts and achievements, it is now time to ask what has really been accomplished and what are the reasonable expectations to achieve clear and unequivocal patient benefit in the foreseeable future? There are three barriers to the adoption of any new technology: (1) demonstration of value, (2) user friendliness, and (3) teachability. I submit that after 10 years none of these barriers have been surmounted. I encourage this group and others who embrace this technology to convince the rest of us by well executed studies such as this one that robotics is truly the future. Although on an emotional level I have a strong bias toward wanting robotics in surgery to succeed, on a rational level I am somewhat skeptical that significant progress has been truly made.
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