Thursday, May 09, 2013

And now presenting . . . robotic lap choles!

As a non-medical person, I was so excited when I could say "laparoscopic cholecystectomy" without pausing or tripping over all the syllables.  In English, this is a surgery to remove a gall bladder using laparoscopic instruments through holes in the abdomen instead of cutting it open.  Lap choles, for short, are among the most routine and safest surgical procedures.  The folks at USC note:

Laparoscopic cholecystectomy is a very safe operation. The overall complication rate is less than 2%. The complication rate for laparoscopic gallbladder surgery is similar to the complication rate for traditional open gallbladder surgery when performed by a properly trained surgeon. Many thousands of laparoscopic cholecystectomy have been performed in the USA and this operation has an excellent safety record.

An article on Medscape notes:

Laparoscopic cholecystectomy has rapidly become the procedure of choice for routine gallbladder removal and has become the most common major abdominal procedure performed in Western countries. LC decreases postoperative pain, decreases need for postoperative analgesia, shortens hospital stay from 1 week to less than 24 hours, and returns the patient to full activity within 1 week compared to 1 month after open cholecystectomy (OC).

In 1990, 10% of cholecystectomies were being performed laparoscopically. By 1995, 10 years after the introduction of LC, close to 80% of cholecystectomies were being performed laparoscopically. 

In 2008, 750,000 patients underwent cholecystectomy in the United States; in 90% of these patients, the operation was done laparoscopically.

So, what do you do if you are a robotic surgery device company that has saturated the marketplace for robot-assisted prostate surgery and if the president of the American College of Obstetricians and Gynecologists has said:

Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.

At a time when there is a demand for more fiscal responsibility and transparency in health care, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes. 

Answer:  You try to create a demand for robot lap choles. You drool as you read the last line of the quote above:

In 2008, 750,000 patients underwent cholecystectomy in the United States; in 90% of these patients, the operation was done laparoscopically.

This is huge compared even to the 90,000 radical prostatectomies that are undertaken each year, where you have grabbed 70,000 of the total.

Just imagine if we could get doctors and hospitals to buy our robot to do a portion of those.  

Let's even make a video and have a doctor and a patient make unsupported assertions about the relative benefits compared to the excellent safety record of traditional lap choles.  The narrator says, "Having gall bladder surgery is a lot easier."  "It's a lot better," says the patient.

A few months later, the surgeon, Dr. Babak Eghbalieh, announces: "As of February 1st, 2013, the Robotic Surgery Program at CRMC [Community Regional Medical Center in central California] will be the fourth busiest Single Site Robotic Gallbladder surgery in the west coast of US!!"

Where do these videos come from?  No production credits are provided, but if you watch the next one, you'll see (starting at 59 seconds), an lengthy insertion of visual material from the company that produces the robot.

The patient notes, "Everybody was so friendly."


Mark Graban said...


Did you see the story about sales incentives for robotic surgery sales people based on the volume of procedures??

I haven't watched the CNBC video yet.

Jesse said...

Simple solution. Unless there is proven benefit, pay the same for robotic assisted as is paid for without the robot. If there is a marginal additional benefit (shorter recovery less pain???) pay more in proportion to the benefit, not in proportion to the cost.

Still may take hold as the marketing hype makes people vote with their feet, BUT hospitals will think twice before doing it, tying up OR time, and likely losing money on each case.

Paul Levy said...


They are paid the same.

David Joyce MD said...

Would it shock anyone to believe that a hospital would spend a large chunk of their capital budget without having a sophisticated business plan that is based on a discounted cash flow over the useful life of the equipment that produces an ROI stated in terms of Net Present Value. I wouldn't, but hospitals just buy sexy stuff first with only cursory projections on volume and then force their staff to use it when it looks like they are taking a bath on the investment. Any other industry, they would go out of business.

Unknown said...

While I agree with the idea that perhaps hype is winning over numbers. I do remember the hype over personal computers and the internet when some lap tops cost $8000. Perhaps if the machine can support flow then it may get less expensive over time to use the robot. In the case of prostate surgery perhaps the case is not that far away given the evidence of significant variation of outcomes based on surgical team experience. For gall bladders, I am not sure that you could run the factory hard enough to prove the case.

Anonymous said...

Dr. Joyce:

I've worked in various areas of hospital finance most of my life, and I've found it's practically an iron clad rule that senior leadership only calls for a careful ROI analysis on purchases/programs they absolutely Do Not Want.

Thomas Pane said...

The question is how much better is a robot lap chole over a 'straight-stick' lap chole? The standard 4 incision surgery is very safe and the recovery is quick compared to the open.

Its hard to show benefit in real studies because robot v standard treatment arms are not an easy sell, and the marginal improvement over the standard treatment is likely to be small.