SEATTLE — Dr. John Lenihan sits at a computer console about 20 feet from his hysterectomy patient lying on the operating table.
As if playing a video game, Lenihan manipulates foot pedals and joysticks as he watches the action on a screen, remotely controlling tiny instruments on robotic arms inserted into her abdomen through small incisions.
A camera on one of the robot’s arms gives Lenihan, an experienced robotic surgeon at Tacoma General Hospital in Tacoma, Wash., a greatly magnified 3-D view. The swiveling instruments allow him to make more complex, precise moves, he says, than he could accomplish with conventional instruments.
Lenihan and many other surgeons say the surgical robot, the da Vinci, gives them powerful new abilities in the operating room, shortens recovery time for their patients, and decreases their risk of complications.
Despite its stunning price - up to $2.6 million - the robot has been enthusiastically adopted by hospitals large and small. In the competition for patients, they say they can’t afford not to use this latest technology.
This headlong proliferation, with uneven safeguards and significant costs that may ultimately push insurance costs higher, has raised alarms even among surgeons.
Today, 12 years after the federal Food and Drug Administration first approved the da Vinci, there is still no industry standard for training and credentialing of doctors to use the robot, beyond a basic course by the manufacturer.
Critics - and lawsuits - claim some hospitals allow surgeons without sufficient experience to use the robots. And some surgeons and hospital officials say it’s being overused, employed for procedures where it offers no advantage.
Splashy ads by hospitals claiming better outcomes and shorter stays appeal directly to patients, despite conflicting studies on outcomes and complications, depending on the procedure.
But there is no question it adds thousands of dollars to the costs of each surgery - up to $4,800 for a prostate surgery, for example - in an era when businesses and governments are struggling to pay rising health-care costs.
“Out of all the instruments and surgical tools that hospitals have adopted, this is one of the most expensive items in American operating rooms today,” said Dr. Marty Makary, a general surgeon and director of surgical quality at Johns Hopkins Hospital in Baltimore.
“It’s a symbol of what’s wrong with American health care: the widespread adoption of expensive new technology with little evidence to support its use, all within the context of a poorly informed, even misinformed, public.”
Is the da Vinci worth its cost? Surgeons and others debated that point recently during an inquiry by Washington state’s Health Technology Assessment committee, which decides what treatments the state should cover for state employees, injured workers and people on Medicaid.
In testimony and comments, many surgeons said the robot has reduced complications such as bleeding, shortened expensive hospital stays, and allowed a less invasive approach for many procedures.
“I think open surgery is going by the wayside,” said Dr. Jim Porter, a urologic surgeon at Swedish Medical Center in Seattle who has done more than 1,300 robotassisted prostate surgeries since August 2005, and had one himself in 2006. “It’s great technology, and it’s made a huge difference for my patients.”
But others, including Dr. Michael Florence, a Seattle general surgeon, questionedthe robot’s rapid rise. “Robotic assisted surgery is clearly part of the ‘medical arms race,’ as hospitals struggle to keep market share.”
Critics say that in the wrong hands, on the wrong patients or for the wrong procedures, the robot poses unique risks to patients, including burns and lacerations detailed in lawsuits and in reports to a federal “adverse event” database. Because surgeries may take more time, patients may be anesthetized longer.
But hospital ads for robotic surgery don’t mention risks, said Makary, the Johns Hopkins surgeon, who studied hospital websites for a paper published last year. While patients wrongly believe hospital websites and ads are vetted by doctors, he says most are “misleading to outright dishonest.”
There are good arguments for the robot, too.
“You can do things with the robot that you can’t do with a laparoscope, or only the world’s best surgeon can do,” said Dr. Richard Satava, a robotics pioneer at the University of Washington. “It’s kind of a democratizing tool, if you will.”
Porter, who helps train other surgeons on the robot for Intuitive, says his robotic prostate-surgery patients have shorter hospital stays,less blood loss and more complete cancer removal.
Dr. Paul Kozlowski, director of minimally invasive surgery for Virginia Mason Medical Center’s urology department in Seattle, says the surgeon’s experience is key: “The bottom line is, it’s who does your surgery, not how they do it.”
Even supporters have concerns about training.
Intuitive runs an intensive three-to-four-day course at its Sunnyvale, Calif., home, including cadaver work, and dispatches mentors to monitor trainees for several cases before certification.
Then, it’s up to the hospitals to set rules.
Business, Pages 19 on 07/23/2012