Surgery's past, present and robotic future

[Rabbit Hole]

I was looking around on one of my favoritest websites (TED) and came across this video:

Catherine Mohr: Surgery's past, present and robotic future

I thought it was fascinating and I'd like to hear your thoughts on it (19 minutes long). Are any of you involved in robotic surgery and do you think there is a threshold between the advancement of surgical technology and actual benefit for the patient? Sure, maybe one day surgeons can develop a technique to extract the gallbladder through the nose, but is that really necessary?

The reason I ask is because many traditional "open" procedures are now done using "scopes" (I hope that's the right term). Do you think your ability/confidence in doing open procedures will decrease as a result of becoming too reliant on advanced non-invasive surgical techniques?

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[JackADeli]

DrMohr is a dynamic speaker. I hear she does well on the lecture circuit. Her invention device is nice concept but doesn't really have a market. I haven't heard that she does much as far as a superstar surgeon.

All that said, I think the robotics have a big future. Its use and case volume continues to steadily climb in numerous fields including Uro/Gyn/ENT/Cardiac/Thoracic. We have discussed this a little before:

http://forums.studentdoctor.net/showthread.php?t=707285

There is much to say about the 10x, high definition, magnified 3D imaging and high dexterity instruments. Add to that more and more studies showing laparoscopy good at the expense of surgeons enduring repetitive stress and ergonomics injury.

...Do you think your ability/confidence in doing open procedures will decrease as a result of becoming too reliant on advanced non-invasive surgical techniques?

The American College of Surgeons seems to believe so.... I have been at numerous meetings in which the echoeing cry is about future "open surgery" fellowships to get general surgeons specialized in classical open procedures! laparoscopy MIS fellowships, IMHO, serve one of two purposes:
1. remediation for a mediocre general surgery residency
or
2. certificate (marketing) that you spent a year doing what you already were trained to do for five years... just to give you a competitive edge and/or maybe get you out of straight general surgery/trauma call rotation.

 

[Rabbit Hole]

That's interesting.. so pretty much the "technique" of surgery you get to do in residency is directly related to how much $$$ the hospital has.

1. Traditional "open" surgery
2. Laparoscopic surgery
3. Laparoscopic surgery w/ minimal scars or through natural orifice
4. Robotic surgery (da Vinci)

If I had to compare these groups, I would say that 2 is better than 1. 2 & 3 are about equal. 4... good for astronaut patient stuck in outer space needing immediate surgery.

"Open surgery" fellowships?
That would be considered remediation instead of specialization for sure.

 

[SocialistMD]

That's interesting.. so pretty much the "technique" of surgery you get to do in residency is directly related to how much $$$ the hospital has.

"Open surgery" fellowships?
That would be considered remediation instead of specialization for sure.

The limiting factor is not the $$$ for technology, but rather the skill of the surgeon. Even poor county hospitals have the abilty to perform basic laparoscopic procedures (choles, appys), which means they could perform advanced ones, too, if the surgeons there were trained to do so (or if the payor were willing to pay for it; a factor not in the hospital's control).

There are residents at my hospital who have never performed an open appendectomy or an open cholecystectomy. I doubt this phenomenon is limited to my institution. If you ever get into trouble, it is good to know the "old school" way to do a procedure, so I completely understand an "open surgery" fellowship in those cases, though logistically I think it might be difficult, as one isn't going to withhold standard of care (i.e. lap chole) for training.

 

[opr8n]

laparoscopy MIS fellowships, IMHO, serve one of two purposes:
1. remediation for a mediocre general surgery residency
or
2. certificate (marketing) that you spent a year doing what you already were trained to do for five years... just to give you a competitive edge and/or maybe get you out of straight general surgery/trauma call rotation.[/QUOTE]


do you really think that most gen surg residents throughout the country come out of residency with enough experience to do nissens, toupets, hellers, spleens, distal panc, kindey, adrenal, bariatrics to be able to do it well without specialized training??

I dont

 

[JackADeli]

..."Open surgery" fellowships?
That would be considered remediation instead of specialization for sure.

...There are residents ...never performed an open appendectomy or an open cholecystectomy. ...understand an "open surgery" fellowship in those cases...

I don't foresee anyone actually doing a "open fellowship".... It is the fact of changes in care that has board members of ACS waking up in a swet at night. Very few if any residents have done/will do a gastric ulcer resection in current times. Less then 2 decades ago, residents were doing numerous gastric resections of a multitude of variations. Most residents have very limited exposure to open cholecystectomies... beyond part of a whipple. Again, a major change from a few years back.

...do you really think that most gen surg residents throughout the country come out of residency with enough experience to do nissens, toupets, hellers, spleens, distal panc, kindey, adrenal, bariatrics to be able to do it well without specialized training??...

I guess it depends on the perspective. Let me put it another way.

Do you think it acceptable for a resident to graduate from a program with innadequate experience to do lap x, y, z while at the same time their program runs a "unaccredited"/non-ACGME Lap MIS "super fellowship"??? I assure you the ACGME/RRC does NOT see that as acceptable.

 

[SocialistMD]

Do you think it acceptable for a resident to graduate from a program with innadequate experience to do lap x, y, z while at the same time their program runs a "unaccredited"/non-ACGME Lap MIS "super fellowship"??? I assure you the ACGME/RRC does NOT see that as acceptable.

Interesting point with which I agree in terms of MIS and other non-ACGME fellowships, but are you willing to extend it to the accredited ACGME fellowships (like vascular or cardiothoracic)?

 

[opr8n]

Do you think it acceptable for a resident to graduate from a program with innadequate experience to do lap x, y, z while at the same time their program runs a "unaccredited"/non-ACGME Lap MIS "super fellowship"??? I assure you the ACGME/RRC does NOT see that as acceptable.

this is an interesting point, AND it was the focus of a 1h session at SAGES this past week, with different profs taking different sides

My personal opinion is that an MIS fellowship designed to train the MIS fellow connot co-exist with a surgical residency wihtout taking all those cases, and the fellow should have the right to take cases (not always the case)
Even at programs that dont have an MIS fellow, i dont necessarily think there are enough cases of certain advanced MIS cases to train all the grad residents well enough for them to come out feeling competant to do those cases.

Lets be realistic, when you graduate from a gen surg residency, you should be able to do dig lap, chole, appy, ventral/inguinal hernia lap and beyond that its a crap shoot.

 

[JackADeli]

Interesting point with which I agree in terms of MIS and other non-ACGME fellowships, but are you willing to extend it to the accredited ACGME fellowships (like vascular or cardiothoracic)?

No. The ACGME (often actually residencies and NOT "fellowships") such as CT & Vascular have an additional knowledge fund and board exam over and above GSurgery. When in CT/Vasc residencies, you are studying additional knowledge base over and above GSurgery for an additional board. GSurgery vasc/CT experience/exposure is meant as more of a survey and the basics. I haven't looked at the numbers.... but last I checked, national average number of anatomic pulmonary resections "done" during general surgery is six. The number required by thoracic board is something like 50-100 (in addition to the other cases). If one wants to be competent to practice in CT/Vasc after completing GSurgery.... well then we need to revamp the GSurgery training requirements, add more cases and increase the science knowledge base.

When one is in lap MIS fellowship, you are studying for GSurgery boards. The "program" is pretty much experiencial/operative.... you should already have learned the management. These non-ACGME accredited programs are NOT comprehensive like other additional residencies.

...My personal opinion is that an MIS fellowship designed to train the MIS fellow connot co-exist with a surgical residency wihtout taking all those cases, and the fellow should have the right to take cases
Even at programs that dont have an MIS fellow, i dont necessarily think there are enough cases of certain advanced MIS cases to train all the grad residents well enough for them to come out feeling competant to do those cases...

Both of the points highlighted above support my position. First, NO. A non-accredited "fellow" should not be adversly impact the basic residency training of the accredited program. They should NOT have "right to take cases". If a program lacks sufficient numbers to provide competence for its own primary residents, it shouldn't be running additional/advance training. You can not justify such a scenario. In all honesty, such scenarios exist and do so at the detriment of primary residents and benefit of attendings.... the "super fellow" has no 80hr/wk limits, no call limits, can often bill as an attending, often adds to the trauma/Gsurgery attending call rotation, and is paid under $60K for the year. We can argue about merits all day long but it is on its face crap. It is worse if it is crap that skid-marks the GSurgery residency experience.... especially when you now have the GSurgery residents servicing the "superFellows" patients!

Yes, there are programs with innadequate volume of Lap MIS cases and do not (thankfully)have advanced "fellows".... Such programs have a difficult challenge. They have an obligation, if they want to ethically and sincerely count themselves amongst modern QUALITY programs, to higher skilled MIS attendings and invest in their program/service line. You definately have high end programs and low end programs. But, all programs should be training residents for competence in modern GSurgery practice.... this includes Nissens/etc....

 

[SocialistMD]

My personal opinion is that an MIS fellowship designed to train the MIS fellow connot co-exist with a surgical residency wihtout taking all those cases, and the fellow should have the right to take cases (not always the case)

Coming from a program with an MIS fellow and the volume to support both a fellow and two chiefs on the MIS service (and considering adding a second fellow), I have to disagree. Those cases are general surgery cases, and the residency should have first priority with cases to ensure the fellowship does not encroach on the resident experience. Furthermore, the institutional RRC/ACGME has to approve all non-ACGME accredited fellowships (at least ours does), and a primary concern is how the fellow will impact the residency. If there is any real negative impact, the fellowship isn't approved (this counts for non-surgical fellowships as well).

 

[Rabbit Hole]

There are residents at my hospital who have never performed an open appendectomy or an open cholecystectomy. I doubt this phenomenon is limited to my institution. If you ever get into trouble, it is good to know the "old school" way to do a procedure, so I completely understand an "open surgery" fellowship in those cases, though logistically I think it might be difficult, as one isn't going to withhold standard of care (i.e. lap chole) for training.

I don't foresee anyone actually doing a "open fellowship".... It is the fact of changes in care that has board members of ACS waking up in a swet at night. Very few if any residents have done/will do a gastric ulcer resection in current times. Less then 2 decades ago, residents were doing numerous gastric resections of a multitude of variations. Most residents have very limited exposure to open cholecystectomies... beyond part of a whipple. Again, a major change from a few years back.I guess it depends on the perspective. Let me put it another way.

Do you think it acceptable for a resident to graduate from a program with innadequate experience to do lap x, y, z while at the same time their program runs a "unaccredited"/non-ACGME Lap MIS "super fellowship"??? I assure you the ACGME/RRC does NOT see that as acceptable.

The reliance upon non-invasive surgical techniques at the expense of not having enough training in "open" technique is something that has come across my mind a few times. I have been in hospitals (across the pond) run by the government (= not enough $$$) - most of their residents are masters of the "open" technique with only a handful trained in laparoscopic techniques (training which is usually done in specialized private hospitals elsewhere or in other EU countries, then those residents training others at their home hospital). Then I see the surgical clinics in the US - very heavy in non-invasive. I'm not making generalizations, just talking about my own limited exposure to the land of surgery thus far.

The funny thing is, those fellas in other countries wish they could get more training in the modern techniques but logistically they can't. While here in the US - some residents are super trained in laparoscopic procedures but get nervous about their skill to do open abdomen procedures. It's an interesting observation. In my opinion, If I decide to go into surgery, I would like to have the opportunity to do enough open complicated cases because I think that is important for a solid foundation. I want the confidence to know that if **** goes down - I can get in there and handle it. Old school? I don't know, but I'm okay with it.

(Or this could possibly be related to my anxiety about finding myself in some strange apocalyptic situation where I should know enough to make intelligent decisions and keep my body bag count to an absolute minimum - as expressed in my previous posts about trauma surgery.)