Would You Consent to a Robot Surgeon?

When we are about to have any kind of surgery, we are asked for our informed consent.  We are informed of the risks and possible complications of the intervention. There is now another factor for which we may be asked to give our consent: "Do you agree to the surgery being performed by a robot?"

While that may seem to be a sci-fi option, the fact is that robots are doing some of the surgery in hospitals. Given that this is what’s happening,  we may have to consider whether this is the kind of surgeon we want. It is true that there is a human surgeon watches the monitor and guides the robot’s "hands."  But this does not remove the reality that the entity that does the cutting, removing, moving, and stitching is a robot.  Is this a bad thing?

According to the hoopla, "the da Vinci® Surgical System combines computer and robotic technologies to create a new category of surgical treatment, robotic-assisted laparoscopic, thoracoscopic or endoscopic surgery. By providing surgeons with enhanced capabilities, the da Vinci Surgical System makes it possible to treat a broader range of conditions using a minimally invasive approach. This means that with da Vinci, you can have major surgery with only a few tiny incisions. In addition, your surgeon can operate with better visualization, precision, dexterity, and control than possible using traditional surgical approaches.”

That sounds like a good advertisement and that's what it is. It also seems plausible.  Human hands are large and can even shake during surgery.  A robot can make tiny incisions and its "hands" should be perfectly steady. These are certainly benefits. Also, as Peter Angelos, MD, tells us, "There is an overwhelming assumption by the public that whatever is new must be better. This idea is captured in the ubiquitous use in advertising of the term 'new and improved'… and 'cutting-edge.'"

I don't know how comfortable I would be with robotic surgery or whether I would give my consent. When you think about it, do you think putting robotic arms between you and your surgeon is for the better?  Some of you may think so, and I'd welcome your opinions. I know some folks who would prefer to have a top surgeon working on them and would never agree to the surgeon guiding a robot.

Yet we can assume that a lot of people have consented to this kind of surgery. (One difficulty with informed consent with such complicated surgeries is the degree to which an average patient can be fully informed.) There were approximately 400,000 robotic surgeries last year. While we can assume that most of these went well, there were a number of decidedly freakish and even fatal accidents. Reports filed in the past year include five deaths. In one case, a woman who died during a hysterectomy when the surgeon-controlled robot accidentally nicked a blood vessel. Would that have happened with a flesh-and-blood surgeon? It might have, but one would have hoped the surgeon would have noticed and stopped the bleeding.

In a more recent case, a robotic arm that wouldn't let go of tissue grasped during colorectal surgery. "We had to do a total system shutdown to get the grasper to open its jaws," said the report filed by the hospital. In this case the patient was not injured. The reports don’t tell us if the patient was injured when the robot hit her in the face during a hysterectomy, though I certainly hope not. The physician had to switch surgical methods, and this itself takes time and can lead to further complications (e.g., loss of blood or the need for more anaesthesia).   

Several folks whom I have questioned would absolutely refuse robotic surgery. I can see the advantages when it works well: smaller incisions and a quicker healing time. Yet there are serious disadvantages, especially if we want to give knowledgeable informed consent. For one thing, there's not a lot of information out there about risks. "Because robotic surgery is so young and has little supporting data, the standard of disclosure of the risks and benefits that hospitals must provide each patient is fluid and evolving. Some have argued that in situations where a procedure is novel or a practitioner is unfamiliar with it, the duty to disclose all relevant information exists." 

Yet to provide all relevant material to a patient would likely be to swamp the patient with the odds of a variety of counter indications and problems arising. What patients are sometimes reported to do in such circumstances is to let the surgeon choose what is best for them — but that hardly seems like informed consent.

It is important also to note that with any new surgical procedure, it is relevant to know the track record of the human surgeon involved. How often has the surgeon used the procedure? That’s why it’s important to know a surgeon’s history before any kind of surgery. The surgeon’s history is relevant to the risks a patient will be taking, whether there is a robot involved or not. But when we turn to robotic surgery, there is also the added  learning curve for a physician using a new technology. "Medical professionals have said it could take at least 200 and up to 700 robotic-assisted surgeries for a surgeon to become highly proficient."

Taking all of this into account, I know I would be very cautious before giving my consent for robotic surgery. I’d want to know both the surgeon's record and the robot's record and how good the hospital staff was at setting up the robot. My initial inclination would be not to agree, but I'm sure I could be persuaded. Would you agree to having a robot performing your surgery?