ROBOTIC SURGERY… THE FUTURE IS HERE

Dr. Andrew Vorenberg

Disclosures

Intuitive Surgical- case observation site and proctor

Improved

cosmesisFrustrati

onOutcome

s

Cost

Ergonomics

Known entity

PROS CONS

Adopting Robotics

Back in time

Open surgery

Laparoscopy

Along came Laparoscopy

The adoption of laparoscopic colorectal surgery: a national survey of general surgeons

28-item questionnaire to all general surgeon members of the Royal College of Physicians and Surgeons of Canada

Response rate 55% (694/1266) 67% perform colorectal surgery

54% of these perform laparoscopic colorectal surgery Positive predictive factors:

years in practice (p < 0.001) male sex (p = 0.015) practicing in the province of Quebec (p = 0.005) university-hospital affiliation (p = 0.034) minimally invasive surgery fellowship training (p = 0.023) ***Lack of adequate operating time and formal training were

the main reasons cited by surgeons not offering laparoscopic colon resections

Moloo et al. Can J Surg 2009

Robotics vs. Laparoscopy

PROS CONS More cosmetic

incisions Brings back 3D

visualization Articulated

instruments Bring the “open”

feeling back to surgery

Learning curve Longer operative

times Loss of tactile

sensation Initial financial

investment

How did we get here?

TOOLS

EVOLUTION

Surgical tool evolution

Traditional Laparoscopy

PROS CONS More cosmetic

incisions Small graspers

replace hands Better

visualization in “hard to see” places

Learning curve Longer operative

times Loss of tactile

sensation

Electrosurgery

Stapling technology

MACHINES

Notable changes in my approach

Intracorporeal anastomosis

Assure blood supply

No hand-manipulation

Population Complication Rate

ConversionRate

LOS (days)

CRM Positive Margin

Baik SH (2009) 56 5.4% 0.0% 5.7 7.1%Bianchi (2010) 25 16.0% 0.0% 6.5 0.0%Park (2010) 52 19.2% 0.0% 10.4 1.9%Patriti (2009) 29 30.6% 0.0% 11.9 0.0%Pigazzi (2010) 41 22.0% 7.3% 6.5 2.4%Choi GS (2010) 41 29.3% 0.0% 9.9 4.9%Pigazzi (2007) 39 12.8% 2.6% 4.0 0.0%Pigazzi, Luca (2010) 143 24.0% 4.9% 8.3 0.7%Kim SH (2009) 50 18.0% 0.0% 9.2 2.0%Prasad LM (2010) 51 22.0% 3.9% 6.5 0.0%

Robotic 527 20.2% 2.5% 7.9 1.9%

Population Complication Rate

ConversionRate

LOS (days)

CRM Positive Margin

Laparoscopy 242 32.0% 34.0% 10.0 16.0%

Open 132 37.0% N/A 13.0 14.0%

PN

87

43

86

Rev C

06

/12

Where on the curve is da Vinci Surgery for Colorectal Procedure?

Market Penetration

Emergence Adoption Standard of CareTime

Low

High

dVP• #1 treatment option for

prostate cancer1

Colorectal & GS

• New, developing area for robotic surgery• Thought leaders are gravitating to the System• Opportunity to be a first mover in this area

Benign GYN

• Rapid adoption for complex anatomy

• Rapid adoption by GYO’s across the US • Highly attractive to recent fellows

GYN - ONC

PN

87

43

86

Rev C

06

/12

1 http://www.tucc.com/Robotic-Surgery-Most-Common-for-Prostate-Cancer-in-the-US.29.405.html

Pushing the envelope

Is this procedure going to help my patient

Is this procedure going to improve care and outcomes

Would I want this procedure performed on my friends and family?