BB&T Contributing Writer

CHICAGO — At the American College of Surgeons (Chicago) 96th Clinical Congress held here in October, virtually all manufacturers of laparoscopic instruments were exhibiting their contribution to the new fashionable single port surgery collection. In addition, there were excited panel discussions on cost effective use of the robot (the generic term for Intuitive Surgical's (Sunnyvale, California) da Vinci robot). The theme appeared to be how do we supply advanced surgical technologies in an environment driven by cost-effectiveness?

Single port surgery strives for cost-effectiveness

There is no other industry where advanced technologies do not command a premium price. One expects to pay a premium for the latest in plasma screens, computers, smart phones, etc., yet the healthcare consumer feels entitled to all the advancements without paying the premium. Single port surgery is a prime example. Now that patients know they can have a virtually scarless procedure, they are demanding it; yet insurers pay only the same as they would pay for a standard laparoscopic procedure. Given that studies to date can only predict that the outcomes are identical, who determines which patients receive standard laparoscopy and which get single port? Despite the increase in costly OR hours and the incremental cost of the new instrumentation required to perform single port surgery, the hospital can only charge the same as for a standard procedure; leaving hospitals with much smaller margins. In an effort to get their newer advanced products into the hospital, manufacturers and surgeons are trying to find ways to perform the latest in surgical advances without breaking the bank. Almost every company that plays in the laparoscopic arena has developed products to serve the single port space. Unfortunately, this rapid technology advancement developed in parallel time with an economic recession and healthcare reform. Yet, interest in single port surgery is bounding. Patients are demanding it, surgeons are learning it, and industry is supplying enabling devices to perform it.

Just as these new products are being unveiled, hospitals are putting the pressure on surgeons to keep the costs down. A presentation that demonstrated, to a degree, the variability of price for these new single port devices was given by Lawrence Yee, MD, Associate Clinical Professor of Surgery, University of California San Francisco, (San Francisco). He discussed and compared the most popular single port access devices being used. Access devices are an advanced technology port that allows the surgeon to enter the abdomen and also place several instruments through it. In addition to the single port access device, they may also use articulated or angled new instruments for single port surgery (See Table 1). Although the table below only compares one component of new instrumentation for single port surgery–the access device–the message is the same for the cascade of new products required: an increase in cost and large cost variability among the new instruments.

While each of these devices “can get the job done,“ they also each provide a distinct advantage, along with a strategy for cost effectiveness. While TransEnterix (Durham, North Carolina) appears to be the most expensive, their single piece disposable platform for introducing articulating instruments through a single port also incorporates working channels, thereby eliminating the need for additional trocars. And according to the company representatives exhibiting the product, it allows for an easy transition and shorter learning curve that can enable most surgeons to bring this new technology into their hospital. Surgiquest (Orange, Connecticut), due to its proprietary AirSeal technology, allows for standard instrumentation to be used, saves costly OR time because the surgeon does not need to remove instruments for de-fogging or cleaning; thus shortening the OR time to perform the procedure. Other companies are entering the single port arena by making their devices less expensive indirectly. Karl Storz Endoscopy-America (El Segundo, California) has the only reposable single port access device and Apple Medical Corporation (Marlborough, Massachusetts), though not exhibiting at this show, has trocars that can be re-used with just the silicone top being disposable. Although this only tells the tale of access devices, pretty much all other specialty instruments for single port surgery are going through the same scenario: can we make them less expensive by manufacturing design, or by indirect improvements that will effect the overall cost? Then there is Paul Curcillo, MD, vice chairman department of surgery, University of Pennsylvania (Philadelphia) who uses “God's own single port“ — the umbilicus, coined the SPA (single port access) procedure. He fashions access to the abdomen through careful dissection of the umbilicus using standard surgical tools and placement of trocars through the opening he created, not using any purchased access device at all.

Robots are still controversial

Even though a robot can be found in every state now, it remains somewhat controversial, with discussions often centering on the cost vs benefit. In the panel discussion “Robotic Surgery: Established and Emerging Applications Across Disciplines,“ the advantages and disadvantages of using the robot for various surgeries were discussed.

According to Ronney Abaza, MD, assistant professor of irology, Ohio State University Medical Center (Columbus, Ohio), “The foundation for robotic surgery was built on prostatectomies, where over 80% are performed minimally invasive or with the robot.“ While the New York Times cited a Journal of the American Medical Association article finding that incontinence and impotence are no better when using the robot, surgeons here claim that it depends on the surgeon's experience with the robot. What everyone does agree on is that there is less blood loss, less pain, and the patient returns to work sooner when the robot is used. But does that justify a million dollar-plus purchase price coupled with a 1% annual maintenance fee? According to presentations at this discussion, in some cases, yes. Across the specialties presented at this panel discussion — cardiovascular, urology, gynecology, general surgery, and head and neck surgery, there was agreement that in routine procedures the robot was “non-inferior“ and for select procedures it enabled the procedure to be performed at all. For instance, in renal surgery, the robot showed non-inferiority for pyeloplasty but for partial nephrectomy — the fastest growing procedure in urology — the robot actually makes it possible. However, partial nephrectomy is performed rarely and the ability to do so using the robot only benefits the extreme cases representing about 10% of complex renal tumors. In gynecology, the story seemed similar: for routine hysterectomies it is difficult to justify other than for hospital marketing purposes. However, for radical hysterectomies due to cancer, there does seem to be advantages (see Table 2). Paul Magtibay, MD, Mayo Clinic (Phoenix) presented a comparison of the different techniques used for endometrial cancer procedures, the most common gynecologic malignancy, with about 40,000 annually in the U.S. Survival of all three groups was identical.

He also noted anecdotally that there are fewer conversions to an open procedure when using the robot than when performing a procedure laparoscopically. He feels that may be the case across all specialties as well. Another speculation of his is that regardless of procedure, it is very difficult to perform a laparoscopic procedure in obese patients, a fact that was also noted by Dr. Abaza, who reported on urology in the previous presentation. Most strikingly, Magtibay said, “Surgeon fatigue after a long procedure is virtually absent when using the robot.“ Garth Ballantyne, MD, of Lawrence and Memorial Hospital (New London, Connecticut) echoed those feelings when he spoke about general surgery procedures using the robot. “The fact that the robot is ergonomically comfortable prolongs the lifetime career of a surgeon,“ he professed. Even though it is very difficult to demonstrate a clinical advantage for the patient when using the robot, “There is no question that it is easier on the surgeon,“ claimed Ballantyne. According to him, there is decreased stress, fewer orthopedic injuries, increased precision, and a shorter learning curve for the surgeon; along with fewer conversions to an open procedure when using the robot. The jury is still out regarding the measurable cost effectiveness of the robot since so many of the advantages of using it are not able to be measured in terms of dollars.