Thursday, September 22, 2016

How long is too long for robotic surgery?

A surgical chairman writes [some details were changed to obscure the surgeon’s identity]:

We currently have surgeons who are trying to establish themselves as experts in performing a certain robotic operation. As an open case, it rarely takes more than about 4-5 hours.

With the robot, it is generally taking around 6 hours as reported in the literature, and morbidity and mortality in expert hands appears to be pretty good.

What is happening in the real world is that surgeons are taking 12 or more hours to perform these operations robotically. I am aware of one death after a 14 hour procedure in another hospital. One case in my own institution took 16 hours, and luckily the patient did well. Of course this sort of data never gets reported publicly. 

I am trying to develop a policy on prolonged robotic/laparoscopic surgery. My surgeons say it needs to be evidence-based and are worried it may disenfranchise some of them. One does not want to ruffle feathers, but in my mind, 16 hours represents nothing but surgeon ego taking precedence over patient safety.

Creating an evidence based document is almost impossible as there is only circumstantial and anecdotal evidence. By circumstantial, I mean the knowledge such as the effects of CO2 in prolonged laparoscopy although it has never been scientifically correlated with patient mortality. 

You may have heard of the death of a patient in India where during a live laparoscopy demonstration, the visiting Japanese surgeon did not yield to recommendations from the audience that he convert to open surgery. When should a line in the sand be drawn for prolonged robotic/laparoscopic surgery and conversion to open surgery be undertaken? 

I had heard about the case that occurred in India. It was a laparoscopic liver resection. I blogged about it on Physician’s Weekly.

I was a chairman of surgery at a community hospital in 1990 when laparoscopic cholecystectomy began in the US. We had the same problems you describe. People were taking hours and hours to do cases. Some felt that there was a stigma attached to the conversion of a case to open, and opening was associated with the word "failure."

Fortunately I had a good group of surgeons working with me. We decided that conversion to open was no longer a case that needed to be discussed at M&M. Instead, the surgeon was to be commended for recognizing that the case was not going to be safely done within a reasonable length of time via the laparoscope. We started out by saying if it was clear that no progress was being made by 2 hours into the case, it should be converted to open.

After a year or so, we all came to the conclusion that 1 hour of no progress was enough, and we converted cases at that time. After 20+ years of doing lap choles, I still used 1 hour as my cutoff although I have aborted laparoscopic cases within 5 minutes on occasion. As the song goes, “You've got to know when to hold 'em, know when to fold 'em.”

I think the biggest problem is that each surgeon must be intellectually honest and admit that the case is going nowhere. This can be overcome if everyone gets on board and doesn't refer to a case that is converted as a failure.

There is no evidence. You and your staff need to decide what the threshold for converting is in your situation. Perhaps 6 hours is the magic number.

My readers may have some suggestions too.


Anonymous said...

I am a Chairman of Surgery and a fan of robotic surgery, and full disclosure, a proctor for the daVinci company. The writer is bringing up a very important issue, one that is present in many places that are learning to use the robot, or in a surgeon’s learning to use it, or learning a new procedure.
I agree with all your comments, Scalpel. Converting to open is good, safe judgement, and never a failure. Of course the critics will never see it that way, and instead of dismissing them, we should use them as our external conscience.
I had the same problem with a “meticulous” surgeon, and needed to deal with it. We tried to look into the literature, and there is little evidence on the proper length of robotic assisted surgeries, but there are numbers out there to use as reference points. The problem with the published numbers is those are after the surgeon is out of his learning curve, and that will not help the neophyte who is taking way too long. We agreed more on a 50% percent-of-overtime than a hard number. So if a case was booked for 4 hrs, and they were still going at it for 6 (50% overtime) , the case had to be converted. Sometimes the conversion was to open, sometimes to laparoscopic (the technique of using the robot controls can take longer, even if the surgical part is faster). My hospital had this as a historic practice from the early days of laparoscopic surgery. Of course, if the surgeon wants to convert earlier, he should. The only times these cases get to M&M is if something goes wrong, or the surgeon refuses to stop a the appropriate time.
BTW - If you think this is frustrating, try it with residents!

Skeptical Scalpel said...

Thanks for your comments and for describing how you deal with this in your hospital. I appreciate your support for my thoughts on the matter.

I blogged about the effect of robot surgery on resident education 4 years ago [}. I guess they are getting training somehow.

Anonymous said...

Anonymous said...

Anonymous said...

I am an MS4 going into urology - a field that favors robotic/lap cases. As a student I have wondered about the added risk of longer surgeries for the sake of being "minimally invasive". Especially when a big incision has to be made to get the organ itself out, whether bladder, kidney or prostate - these are typically cancer surgeries - no carving up the organ within the body. And then often people will open to do the ileal diversion or the neobladder, in the case of cystectomy. What is the benefit, then, of prolonging the earlier part of the surgery? Part of this may be greed as a student. I would love to be able to do more open cases as a resident. So much more learning there. And it seems the cases that convert to open are typically for emergent reasons - at which point the residents get little direct involvement. In urology I think it is certainly a loss for eduction. Which doesn't answer the bigger question about patient safety. But I do think it is also a patient safety issue - on a grander scale - to have a generation of urologists who have no real exposure to open surgeries when they start practicing themselves. ... So anyway - lots of aspects to this. But a study looking specifically at added risks of OR time would be great. On a related note, there is a recent article in Lancet looking at robotic vs. open prostatectomy. I read it a while back - don't recall if there was a difference in surgeon experience.

Skeptical Scalpel said...

We have similar problems in general surgery. I have blogged about the possibility of future surgeons being unable to do open cases.

There is no incentive for anyone to study the risks of longer surgery and anesthesia. Who would fund it?

The paper you cited shows no difference in long term outcomes but the open patients had more postop complications and adverse events. I don't think that paper settles the issue.

Henry Woo said...

In Australia, where I practice, we have similar challenges to what is observed in the US. There is probably nothing to be surprised about. It has had me thinking about how we should approach this type of problem where in many institutions, there is simply no governance over excessive laparoscopic procedural times.
We are all familiary with the procedural requirement to perform a 'time out' or 'final verification' - the team must stop and focus on this process prior to each surgical procedure (whether this is a worthwhile procedure or not is besides the point). In a similar way, we should perhaps be performing period Case Reviews during prolonged laparoscopic procedures. After perhaps 4 hours (we can argue about times but this isn't relevant to the point I am making) into a robotic cystectomy, the team should stop and together review where they are currently up to in procedural steps, to candidly discuss as to whether they are struggling or not, whether there are any medical or anaesthetic issues to that point in time, how much longer the surgery is anticipated to take and the big question of whether or not conversion to open surgery should be considered. These periodic Case Review stoppages should be recorded and tabled at relevant commitee meetings. Surgeons can behave very differently when they think that nobody is taking notice of what they are doing. When they are cognisant of governance processes surrounding their OR activities, I am sure that this would provide an opportunity to reflect.

Skeptical Scalpel said...

Henry, thanks for the comments. The idea of a mid-case time out is a good one. That's really what we are talking about here. Again though, the surgeon would have to be honest and also be able to accept the point of view of his assistant, the tech, the curcuma ting nurse, and anesthesia.

Anonymous said...

Good luck on getting a surgeon to do that. It has been the personal experience here that doesn't happen. I know Skep and Artiger, you might be different, but the vast majority are not like that.

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