ChesterCountyMedicine Spring 2018 - 14

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Robotic-Assisted General Surgery
continued from page 13
performed laparoscopically. They concluded, unequivocally:
"With the robotic approach we perform (sic) a CME and
although we did not specifically evaluate, we feel we are able to
obtain better nodal clearance with the robotic as compared to the
laparoscopic approach."
This difference between robotic-assisted and laparoscopic surgery
is real, even though intangible, and difficult to quantify.
In time, I believe other aspects of general surgery operations-more
durable hernia repairs, fewer intra-operative complications, less postop pain, and better surgical results-will turn the intangibles into
concrete results.
In 2013, the same year of Dr. Breeden's ACOG position
statement, Drs. Griffen and Sugar wrote an editorial in the Bulletin
of the American College of Surgeons titled "The future of robotics:
A dilemma for general surgeons." One of the concluding paragraphs
stated:
"In this era of health care reform and limited funding,
robotics in surgery is correctly under intense scrutiny. Thus
far, the cost/quality equation for value often has been at odds
with additional investment of the health care dollar in robotic
technology. The apparent waste incurred pursuing a flight to the
moon led to a giant step forward in technology that proved to be
of tremendous value in other areas. Is this a paradigm for robotic
surgery, thus justifying the cost, expecting benefits with experience
over time? Surgeons must contribute meaningfully to the debate,
helping to guide industry, government, and payors in a path that
best serves the safe, efficient, value-based care of their patients."

A personal and professional perspective
My initial interest in robotic-assisted surgery was purely to
assist my urology and gynecology colleagues when they were
performing operations. On occasion, the urologist or gynecologist
would call me into their room to look at the patient's anatomy
or discuss if a section of the GI tract would need to be removed.
As I began my training, and observed surgeons utilizing robotic
surgery for their patients, I realized that the technology had
valuable improvements on standard techniques and applications
for my own patients. During one observation session I looked
through the surgeon's console during a sigmoid colon resection
and saw the left ureter more clearly than I had in any previous
laparoscopic case. As I began to do more robotic-assisted operations
at Chester County Hospital, I knew there were challenging cases
I would have had to convert to an open procedure, if I were
performing it laparoscopically, but because of the superiority of
the instrumentation, 3-D imaging, and the technology, I could
complete the case with a minimally invasive approach.
Revisiting the reason for my original rationale for training in
robotic-assisted surgery, a gynecologist asked me to evaluate her
patient who had dense adhesions and had sustained a serosal tear of
the large bowel. I sat down at the console, repaired the superficial
tear, and never physically touched the patient. Ten years ago, had
someone told me I would operate on a patient and never "scrub
14 CHESTER COUNT Y Medicine | SPRING 2018

my hands" I would have told them that was impossible. Patients
frequently ask me if the "robot" is going to do the surgery and I
explain that there is not a button I can push that says "Remove
gallbladder" or "Take out sigmoid colon." I explain to my
patients that I'm still manipulating the robotic arms and making
intraoperative decisions about what to do next in the operation. At
Chester County Hospital we have an OR table that can move with
the patient, I can work in any quadrant of the abdomen, and I have
vessel-sealing instruments and staplers for any potential operation.
Robotic-assisted surgery is here to stay. If you have a backup
camera in your current car, you would think it was unsafe if there
wasn't one in your next vehicle. You cannot comprehend life
without your smart phone. How much is necessity versus luxury
can vary from person to person, but the benefits provided by
robotic-assisted surgery would make it extremely difficult for me
to return to the surgical techniques of the last millennium. In
this age of self-driving cars, drones that can follow you down a ski
slope, and smart phones that can translate foreign words in real
time, robotic-assisted surgery will become more sophisticated, safe,
efficient, and yes, affordable. The robotic-assisted surgery button
for "cholecystectomy" or "colectomy" or "hernia repair" may arrive
some day: As far as you know, I may have been dictating this article
on my smart phone, in my self-driving, hydrogen-powered car.
References
Laparoscopic cholecystectomy: Threat or opportunity? Tomkins RK,
Arch Surg, Vol 125, Oct 1990.
Personal communication with Dr. Maury Hoberman, Feb 2018.
Robotic Surgery A Current Perspective. Castellanos AE, et al., Ann
Surg, Vol 239, Jan 2004.
Statement on Robotic Surgery, ACOG Newletter, Breeden JT, Mar
2013.
Robotic right colectomy with intracorporeal anastomosis for malignancy.
Kelley SR, Duchalais E, Larson DW, J Robotic Surg, Oct 2017.
The future of robotics: A dilemma for general surgeons. Griffen FD,
Sugar JG, Bulletin of the American College of Surgeons, Jul 2013.
Dr. Steven Fukuchi is a graduate of Northwestern
University Medical School and completed his general
surgery residency and GI surgery research fellowship at
Temple University Hospital. He is in private practice with
Surgical Specialists, P.C. and has been on staff at The
Chester County Hospital since 2005. He has served as
Chair of the Department of Surgery, is the former Chiefof-Staff for The Chester County Hospital, and one of the
physician-members of the CCH-Penn Medicine Hospital
System Board. Chester County Hospital's robotic surgery
program started in 2011. They have completed over
3,000 robotic-assisted procedures and Dr. Fukuchi and
his partners have completed over 1,200 general surgery
operations since 2013.

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