Evidence‐Based Surgery: Barriers, Solutions, and the Role of Evidence Synthesis

Garas, George; Ibrahim, Amel; Ashrafian, Hutan; Ahmed, Kamran; Patel, Vishal; Okabayashi, Koji; Skapinakis, Petros; Darzi, Ara; Athanasiou, Thanos

doi:10.1007/s00268-012-1597-x

Cited by 55 publications

(60 citation statements)

References 51 publications

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“…Following the wide uptake of robotic surgery among the various surgical specialties and the concurrently increasing experience with endoscopic parathyroidectomy and robotic thyroidectomy, robotic parathyroidectomy was the next advance [18, 19]. This innovative technique representing the “fourth generation” in the evolution of parathyroid surgery was first described by Tolley et al [5] in 2011 and involved a “scarless-in-the-neck” approach through an anterior chest (infraclavicular) incision and 3 trocars in the ipsilateral axillary line.…”

Section: Robotic Parathyroidectomymentioning

confidence: 99%

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations

Arora

Garas

Tolley

2018

ORL

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Robotic parathyroidectomy represents a novel surgical approach in the treatment of primary hyperparathyroidism when the parathyroid adenoma has been pre-operatively localised. It represents the “fourth generation” in the evolution of parathyroid surgery following a process of surgical evolution from cervicotomy and 4-gland exploration to a variety of minimally invasive, open and endoscopic, targeted approaches. The existing evidence (levels 2–3) supports it as a feasible and safe technique with equivalent results to targeted open parathyroidectomy for primary hyperparathyroidism in carefully selected patients. However, it takes longer to perform and is more costly than conventional parathyroidectomy. It offers superior cosmesis by completely avoiding a neck scar making it a valid option for those patients who for biological and/or cultural reasons may wish to avoid a neck scar. Robotic parathyroidectomy is not for every patient, surgeon, or hospital. Its application should be confined to high-volume centres and experienced surgeons. Intensive training and proctorship are required for its safe implementation combined with careful patient selection. This particularly relates to the patient’s body habitus (BMI < 30 kg/m²) and concordance among the different imaging modalities used pre-operatively. With robotic market competition driving down costs, its role may change. For now, robotic parathyroidectomy occupies a niche role and can only be justified in a select subset of patients.

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Section: Robotic Parathyroidectomymentioning

confidence: 99%

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations

Arora

Garas

Tolley

2018

ORL

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“…The cost of purchasing the da Vinci® surgical robot is GBP 1.5 million. Added to this are maintenance averaging GBP 120,000 per annum and surgical consumables at approximately GBP 1,300 per case [14]. Higher costs are achieved by the monopoly status of Intuitive Surgical Inc. in the surgical robotics market.…”

Section: Cost-effectiveness and Valuementioning

confidence: 99%

“…In today’s practice, evidence-based surgery is paramount and as such, no discussion would be complete without presenting this [14]. …”

Section: The Evidence Basementioning

confidence: 99%

Robotic Thyroid Surgery: Current Perspectives and Future Considerations

Aïdan

Arora

Lőrincz

et al. 2018

ORL

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Robotic transaxillary thyroidectomy, pioneered in South Korea, is firmly established throughout the Far East but remains controversial in Western practice. This relates to important population differences (anthropometry and culture) compounded by the smaller mean size of thyroid nodules operated on in South Korea due to a national thyroid cancer screening programme. There is now level 2 evidence (including from Western World centres) to support the safety, feasibility, and equivalence of the robotic approach to its open counterpart in terms of recurrent laryngeal nerve injury, hypoparathyroidism, haemorrhage, and oncological outcomes for differentiated thyroid cancer. Moreover, robotic thyroidectomy has been shown to be superior to open surgery for certain patient-reported outcome measures, namely scar cosmesis and pain. Downsides include its high cost, longer operative time, and risk of complications not encountered in open thyroidectomy (brachial plexus neurapraxia). Careful patient selection is paramount as this procedure is not for every patient, surgeon, or hospital. It should only be undertaken by high-volume surgeons operating as part of a multidisciplinary robotic team in specialised centres. Novel robotic approaches utilising the retroauricular and transoral routes for thyroidectomy have recently been described but further studies are required to establish their respective role in modern thyroid surgery.

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“…However, the recent introduction of pure endoscopic techniques and well-established efficacy of medical therapy should lead to a theoretical five arms of study (medical vs endoscopic vs open surgery vs laparoscopy vs robotics), although such studies are very hard to design and to conduct. 8 All the esophageal procedures for benign disease were codified with a robotic approach, including those for achalasia, reflux disease, and diverticula. 21 A very large retrospective study by Shaligram The authors concluded that the perioperative outcomes were superior in the LM and RM groups when compared with OM.…”

Section: Esophagusmentioning

confidence: 99%

“…8 Nevertheless, the progressive popularity of RS among urologists, gynecologists, and patients, mixed with some industrial pressure, has led to the worldwide diffusion of the robot in many hospitals. 9,10 Interestingly, the pioneers 11,12 of general and gastrointestinal RS reported many benefits and few complications of this technique in terms of intraoperative morbidity, return to normal activities and, mainly, feasibility of some of the most complex procedures that were previously precluded by pure laparoscopy without the robotic interface.…”

Section: Introductionmentioning

confidence: 99%

Gastrointestinal robotic surgery: challenges and developments

Becchini¹,

Annecchiarico²,

Marino³

et al. 2015

RSRR

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Abstract:The rapid diffusion of new technologies in surgery, together with high expectations of both patients and the mass media, has led to many gastrointestinal procedures being approached using robots. Robotic technology seems to resolve many of the drawbacks of laparoscopic advanced procedures, such as anastomotic reconstructions, accurate lymphadenectomy, and vascular sutures. In addition, a deeper tridimensional steady vision with excellent high definition, the EndoWrist technology offering seven degrees of freedom, tremor filtration, scaled motion, optimal working ergonomics, and avoidance of the 'fulcrum effect', are the main strengths of the da Vinci ® system. The use of near-infrared technology and the possibility of tutoring through a double-console will most likely add many more advantages of this technology over laparoscopy alone. However, none of the gastrointestinal robotic interventions has reached a level of evidence-based efficacy that enables it to be routinely applied. The main limitations of robotic gastrointestinal procedures are represented by the learning curve, the higher costs of robotic surgery compared to traditional and laparoscopic surgery, and the longer operation times, including setup and organizational troubles. Moreover, while the limits of robotics for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies, and long-term follow-up is still lacking. On the other hand, a word of caution should be presented on the adoption of robotics in too many surgical units without the correct and formal technical background and third-party control to guarantee the best outcomes for patients at minimum risk. Therefore, the robotic treatment of gastrointestinal diseases requires a thorough analysis of the published evidence, in order to determine the correct indications and patient selection. This review aims to examine the evidence for the use of robotic surgery in both malignancies and benign disease arising from the gastrointestinal area. Future developments in robotics and ongoing areas of research are also analyzed.

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Evidence‐Based Surgery: Barriers, Solutions, and the Role of Evidence Synthesis

Cited by 55 publications

References 51 publications

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations

Robotic Thyroid Surgery: Current Perspectives and Future Considerations

Gastrointestinal robotic surgery: challenges and developments

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