1. Robotics: Does Size Matter?
Dima Raskolnikov, M.D.
PGY-1, Department of Urology

2. DISCLOSURES
No financial conflicts

3. OUTLINE Why interested? Pros/cons Recent literature Conclusions
Simulation
Trends
Pros/cons
Recent literature
Conclusions
Not inspired by a specific case, but rather a few opportunities and developments at UW recently

4. OUTLINE Why interested? Pros/cons Recent literature Conclusions
Simulation
Trends
Pros/cons
Recent literature
Conclusions
First of these was a robotic simulator that was housed at UW recently for 1 month, just before SCH rotation

5. BACKGROUND: Simulation at UW
All gen surg, uro, gyn residents explicitly asked to participate
1 month period w/ robot simulator, available 24/7
Dozens of guided activities with wet + dry lab
(unit at SCH as well?)
da Vinci simulator at UW “WISH”
Examples:
Ring Walk
Peg Board

6. BACKGROUND: Simulation at UW
1 month period
43 named surgeons
4,528 minutes of activity
1,464 exercises
Real time feedback
Practical significance?
Successful experience
43 individuals made accounts +
Me: night float. Benefits: constant feedback, could track progress

7. IT WORKS: We Think Lendvay et al. JACS 2013 RCT at UW/SCH
51 residents + faculty GS, uro, gyn
validated training curriculum  achieved performance benchmarks  randomize to VR warm up vs. read a book  robotic surgery tasks
Outcomes: validated measures of performance (task time, tool path length, economy of motion, technical & cognitive errors)
Lendvay et al. JACS 2013

8. Stat. significant improvements: task time, path length.
Cognitive errors, EOM, peg touch all trend towards significance.
Lendvay et al. JACS 2013

9. OUTLINE Why interested? Pros/cons Recent literature Conclusions
Simulation
Trends
Pros/cons
Recent literature
Conclusions
2) Becoming more popular, especially in urology. We’ve done a handful of robotic cases during this rotation, led me to wonder  emerging standard?
Delicate structures, high degree dexterity, small operative workspaces

10. IT’S THE FUTURE 220 studies 2393 procedures 1840 patients
Borne out in studies of cases
Reviewed literature for all case reports robotic surgery in children
11 year period: 220 studies, reporting 2393 procedures in 1840 patients
Cundy et al. J Ped Surg 2013

11. IT’S THE FUTURE Cundy et al. J Ped Surg 2013
Robotic GU cases in particular are becoming more common
Principles likely apply to other fields in pediatric surgery
Cundy et al. J Ped Surg 2013

12. With increased surgeon volume comes increased competition and marketing
some a bit laughable, others with surprisingly specific claims

13. OUTLINE Why interested? Pros/cons Recent literature Conclusions
Simulation
Trends
Pros/cons
Recent literature
Conclusions
Given volume, would expect level 1 evidence depicting pros/cons
Doesn’t exist; instead collection of level 3 and 4 with mostly retrospective reviews + expert opinion

14. EXPERT OPINION Cundy et al. J Ped Surg 2014
Same group as previous study (Cundy).
Surveyed 48 pediatric surgeons w/ first hand experience performing robotic surgery
What do they think?
Cundy et al. J Ped Surg 2014

15. IT’S THE FUTURE Cundy et al. J Ped Surg 2014
Hand held bedside instruments
Flexible snake robots: Natural Orifice Translumenal Endoscopic Surgery (NOTES) = essentially robotic surgery at the end of an endoscope, and SILS = single incision lap surgery
Single site, more conventional
Theoretical
Guidance to subsurface anatomy (e.g., tumor margins)
Least enthusiastic
Cundy et al. J Ped Surg 2014

16. OUTLINE Why interested? Pros/cons Recent literature Conclusions
Simulation
Trends
Pros/cons
Recent literature
Conclusions
Amidst all of this excitement and publicity, what does the most recent data look like?

17. COMPLICATIONS Dangle et al. J Ped Surg 2015
Previous studies of complication rates mostly single center w/ small numbers
Multi-center database study
Dangle et al. J Ped Surg 2015

18. COMPLICATIONS Multi-center retrospective review 2007-2011
858 patients
880 procedures
Clavien Grade IIIa, IIIb complications
Dangle et al. J Ped Surg 2015

19. COMPLICATIONS
Dangle et al. J Ped Surg 2015

20. COMPLICATIONS Multi-center retrospective review 2007-2011
858 patients
880 procedures
Clavien Grade IIIa, IIIb complications
IIIa, IIIb: 41 patients (4.8%)
IVa: 1 patient (0.1%)
Conclusions: technically feasible, safe
Comparable 90 day rates to lap, open surgery
IVa:intra-op vascular injury 2/2 instrument change, 500cc blood loss + emergent conversion to open
Overall rates similar to those published in laparoscopic, open literature
Dangle et al. J Ped Surg 2015

21. COST & OUTCOMES Pepper et al. Obes Surg 2016
Previous study: complication rates are similar
But are the clinical results actually any better? Data fairly disappointing. No level 1 data, but rather retrospective studies w/ narrow indications.
Here: establish safety efficacy, but also investigate costs, operative time, etc.
Pepper et al. Obes Surg 2016

22. COST & OUTCOMES Single-center retrospective review 2013-2014 Outcomes
28 patients w/ sleeve gastrectomy
14 lap, 14 robotic
Outcomes
Length of stay
Operative time
Cost
Complications
Comparative study, though retrospective
Pepper et al. Obes Surg 2016

23. COST & OUTCOMES Single-center retrospective review 2013-2014 Outcomes
28 patients w/ sleeve gastrectomy
14 lap, 14 robotic
Outcomes
Length of stay
Robotic 69.6 vs. lap 75.9 (p=0.0094)
Operative time
Robotic 132 min vs. lap 100 min (p=0.0002)
Cost
Robotic $56k vs. lap $49k (p=0.037)
Complications
No difference
Conclusion:
Safe and effective
Shorter LOS
Expensive
Reality vs. Hype?
Modality with more favorable outcome underlined
Pepper et al. Obes Surg 2016

24. COST & OUTCOMES Murthy et al. Eur Urol 2015 Similar study design
Retrospective comparative study w/ narrow indication (augmentation ileocystoplasty)
Murthy et al. Eur Urol 2015

25. COST & OUTCOMES 2008-2014 Outcomes 17 patients robotic
13 patients open
Outcomes
Operative time
Pain medication use
LOS
Complications
Same as before; more favorable modality underlined
New possibility: more favorable pain control regimen  shorter stays?
Murthy et al. Eur Urol 2015

26. COST & OUTCOMES 2008-2014 Outcomes 17 patients robotic
13 patients open
Outcomes
Operative time
Robotic 623 min vs. open 287 (p<0.01)
Complications
No difference
Pain medication use
No difference, but no epidurals in robotic
LOS
Robotic 6 days vs. open 8 (p=0.01)
Conclusion:
Safe and effective
No epidurals
Same as before; more favorable modality underlined
New possibility: more favorable pain control regimen  shorter stays?
Murthy et al. Eur Urol 2015

27. OUTLINE Why interested? Pros/cons Recent literature Conclusions
Simulation
Trends
Pros/cons
Recent literature
Conclusions

28. CONCLUSIONS Does size matter? Benefits Limitations Depends who you ask
Improves dexterity in small workspaces
Promising initial data, but no well-powered studies
Exciting future directions
Flexible snakes, microbots, image-guidance/augmented reality, remote
Resident training
Limitations
Cost
Operative time
Rapidly expanding technology with limited data
Is there a role for robotics in pediatric surgery?
Unique situation where we have expensive technology, now finding ways to justify

29. THANK YOU Questions/Comments
Begs the question of whether we have truly made a giant leap
Questions/Comments