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Patient complications not the fault of robot, says WDH surgeon

Wednesday, May 12, 2010

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Krauss/Democrat photo Dr. Anne Kalter, who chairs the robotic review committee at Wentworth-Douglass Hospital, explains the use of EndoWrist instruments used by the da Vinci surgical robot.

DOVER — Dr. Anne Kalter, a surgeon who heads Wentworth-Douglass Hospital's robotic surgical committee, says she's confident the few complications experienced with the da Vinci machine were not the result of inadequate training, human error or technical difficulty.

“Most of the post-op complications are considered inherent risks with any surgery,” she said in an interview Tuesday. “We don't specifically attribute our complications to the use of the robot. We attribute it to the use of laparoscopic surgery in general, or the difficulty of the surgery. We do not blame it on the robot per se, and the complications that happened were pretty much within our normal complication rate.”

Laparoscopic surgery is considered minimally invasive and entails surgeons using instruments that allow them to operate in areas that used to be accessible only by open surgery.

The da Vinci robot is the latest evolution in laparoscopic surgery. The robot doesn't have a mind of its own, said Kalter, an OB/GYN surgeon, though it equips surgeons with EndoWrist instruments that give them greater dexterity and precision.

"You can get to tricky, small places,” she said.

WDH says it cannot provide a figure of its complication rates because it's protected peer-review information, though Kalter stressed the rate experienced during robotic surgery is lower than the 4.8 percent cited in a 2009 Northwestern University study that spanned 2003 and 2008 and focused on 835 patients who underwent robotic surgery.

WDH encouraged Foster's to speak with Kalter in the wake of a recent Wall Street Journal story that reported on complications in three robotic surgeries and concerns the hospital has used the da Vinci, which has been marketed as a way for hospitals to gain market share, in some 300 surgeries since 2006 despite inadequate training.

The Journal also reported on the death of a patient who underwent robotic surgery for a stomach condition until the surgeon opted for open surgery. The man's esophagus was perforated, but it's unclear when the esophagus was injured, the Journal reported.

The hospital has said it has not had any deaths as a result of robotic surgery.
About 130 of the 853 hospitals with a da Vinci have fewer than 200 beds, including the 178-bed WDH, the Journal reported.

The bulk of WDH's robotic surgeries are hysterectomies, Kalter said, adding the robotic surgery reduces complications, patients' turnaround times, blood loss and pain.

Asked if WDH is confident none of the complications were tied to surgeons' inexperience with the robot, Kalter, who has performed about 100 robotic surgeries, said:

“I think the complications were due to difficult anatomy. The cases had something difficult inherent in the case itself. In other words, the same type of complication might have happened if there were an open incision. It was sort of inherent in what we encountered during the surgery. It wasn't like somebody hit the wrong button.”
Kalter said WDH has not changed its protocol around training or use of the da Vinci because it was not deemed to be appropriate.

She also said the hospital does not turn a profit on robotic surgeries and da Vinci surgeries are reimbursed at the same rate by insurance companies as other laparoscopic surgery. WDH spokeswoman Noreen Biehl said the hospital's overall revenues support the machine, which is leased.

Kalter recapped the training that takes place for robotic surgeons.

Surgeons “are allowed to be unsupervised but the rules at the hospital are that you have an experienced surgeon with you for your first 10 surgeries,” she said. Surgeons are joined by a proctor for the first four surgeries and an experienced robotic surgeon is present for the next six, she said.

“There is no national standard requirement for this,” she said. “It probably will be coming in the next couple years. The technology is so new that every hospital has been finding out on its own what path is comfortable for them to take.”