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Will The da Vinci Robot Go The Way Of Laparoscopic Surgery?

Mon, 05/13/2013 - 9:37am
Richard Patterson, M.D.

The real problem is not whether machines think, but whether men do.
- B. F. Skinner

When I was a relatively junior member of the surgical faculty, an even more junior member came to my office and announced that a general surgeon and gynecologist in Georgia had performed gallbladder surgery with a laparoscope.

“Stupid stunt,” I snorted, or something equally derisive and all-knowing.

Some weeks or months later he returned to the topic, telling me it was just the beginning, and we should get in. I admired him, and I was also feeling a little guilty for squelching his enthusiasm. I agreed to visit another medical center with him and have a look.

That experience convinced me the approach was legitimate, and we returned to organize a series of operations in our animal lab to learn the procedure. We struggled initially, but eventually we became proficient enough to satisfy our credentials committee and begin offering the minimally invasive technique to patients.

Fast forward. Laparoscopy revolutionized abdominal surgery on a scale commensurate with that of general anesthesia. Whiz-bang engineers and well-financed manufacturers produced ever more sophisticated instrumentation, extending the benefits of smaller incisions and quicker recoveries to myriad procedures which had theretofore required large incisions and significant tissue trauma.

Those undeniable patient benefits were not the reason, however, that laparoscopy displaced conventional (“open”) gallbladder surgery so rapidly. The reason was … um … market pressure.

Though they got up to speed rather quickly, the makers of laparoscopes and laparoscopic instruments weren’t at first very mobilized and could barely meet the crescendo demand for what were still fairly primitive products. The drivers of the explosive proliferation were the manufacturers of surgical lasers.

In what must rank as one of the great marketing coups in healthcare history, they somehow succeeded in getting the procedure branded as “laser” (rather than “laparoscopic”) gallbladder surgery. They then advertised heavily — to the medical community, of course — but more importantly and effectively to the lay public. One of their executives, in a moment of hubris and indiscretion, told me they knew physicians to be too slow in adopting and applying new technology and products. The strategy was to go over the profession’s head and enflame public interest. They also offered dirt-cheap weekend seminars for surgeons to learn the technique, at which the indispensability of the laser was a point of emphasis.

The strategy worked. Patients began calling surgeons and hospitals to ask if they offered “laser” surgery. Primary care doctors and gastroenterologists started steering patients to “laser” surgeons, even if they were out of town. Those referring doctors also reportedly lowered the threshold for surgical referral, resulting in an increase in the number of what was already one of the most common surgical procedures in America.

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