[March 16, 2013]

Minimally Invasive Surgeons Group Responds to ACOG President's View on Robotic Surgery

A leading group of surgeons, including members of ACOG from across the United States today strongly protested the comments made by Dr. James T. Breeden, the President of the American College of Obstetricians and Gynecologists about the use of robotic surgery.

"Today, we have sent Dr. Breeden a letter strongly protesting his remarks. We see a failure in ACOG's ability to embrace the education of Minimally Invasive Surgery. Even at their peak, the combination of vaginal and laparoscopic approaches barely represented one-third of all benign hysterectomies performed, again despite their availability for decades. Robotic Surgery is an enabling technology that has transformed our ability to operate in a more efficient, controlled surgical field and master complex anatomical environments. It has allowed us to extend a level of quality surgical care to our patients that is exceptionally more diverse and complete than was ever possible with traditional methods of surgery."

Full text of the letter to Dr. Breeden below.

Dear Dr. Breeden and the American College of Obstetrics and Gynecology,

We appreciate that you recognize the benefits of Robotic Surgery, and have taken this opportunity to address the ACOG membership. However, we are dismayed by the overemphasis on the perceived negative aspects of Robotic Surgery, and are surprised at the lack of evidence upon which may of these conclusions have been made.

We agree that Robotic Surgery is not the only minimally invasive solution for the treatment of gynecologic problems. We fully endorse a minimally invasive approach for every patient, including vaginal and standard laparoscopic approaches. Unfortunately, history shows that the vast majority of GYNs in this country cannot offer a minimally invasive approach to even half their patients, much less all. The facts are unassailable: despite widespread availability of both vaginal surgery and traditional laparoscopic surgery for decades, neither materially impacted the laparotomy rate. Robotic Surgery, in a fraction of that time, has enabled minimally invasive surgery for nearly every one of our patients, and >100,000 more women were offered a minimally invasive hysterectomy in 2012 as compared to 2005 as a direct result of the robotic platform. The cumulative experience of the authors exceeds 12,000 robotic surgery cases and each of us can count the number of conversions on one hand; none of us can say that about any other surgical modality. The relevant comparator is thus laparotomy, not vaginal or laparoscopy.

Additionally, your comments address cost concerns that have not fully been studied. In fact, all studies published thus far have compared learning curve robotic cases to steady-state laparoscopic cases, which substantially skew the results. Most importantly, these studies do not address the reproducibility of Robotic Surgery which is lacking in standard laparoscopic and vaginal approaches. Patient care is and always should be the number one goal of any physician; in a political and economic climate such as ours, focusing on this goal is even more imperative. Receiving a minimally invasive surgery is without question advantageous to the patient in whom this approach is prudent. Hopefully, we can all agree on that. The question then becomes: is she being offered a minimally invasive approach The data clearly idicates that prior to Robotic Surgery that was not the case for the majority of women. This carries a substantial cost benefit to the patient and to society which has not been acknowledged.

As we enter a new era of health care in the United States, technology becomes much more important as a means to achieve cost savings and superior outcomes. We would ask you to look to the aviation industry to see the benefits of technologic advances leading to increased safety and efficiency. With respect to surgery, we believe any lay person could see the benefits of the improved visualization of 3-D technology, the dexterity provided by wristed instrumentation, and the precision enabled by a computer-assisted interface. As a society, both the direct costs to the patient and employer are as important as the indirect costs of decreased productivity and lost wages. This becomes even more important in an economy with little resources to spare, and multiple publications have demonstrated that Robotic Surgery enables patients to return to their work and their lives faster than with laparotomy.

We disagree that adoption of Robotic Surgery has been achieved through deceptive marketing. To say so demeans the role that we as physicians play in helping our patients choose an appropriate procedure. In fact, we agree that speaking directly to women allows them to make educated decisions regarding their health care. Unfortunately, our specialty has failed women in what it represents: women have no idea if their Obstetrician/Gynecologist offers the same care as any other Board Certified Obstetrician/Gynecologist. There is little uniformity to the training and services offered and many women are denied the ability to make informed decisions about surgical and nonsurgical options.

We see a failure in ACOG's ability to embrace the education of Minimally Invasive Surgery. Even at their peak, the combination of vaginal and laparoscopic approaches barely represented one-third of all benign hysterectomies performed, again despite their availability for decades. Robotic Surgery is an enabling technology that has transformed our ability to operate in a more efficient, controlled surgical field and master complex anatomical environments. It has allowed us to extend a level of quality surgical care to our patients that is exceptionally more diverse and complete than was ever possible with traditional methods of surgery. In the light of the recent flurry of negative news based on the early experience with robotic surgery, we robotic surgeons are now compelled to collaborate and produce outcomes research to document the benefits we are seeing clinically and to comprehensively evaluate the "cost" of this technology. We implore you to reflect upon your statement and reconsider an opinion based on incomplete data. It would be incongruent to the ACOG's mission statement to deny technological advances to women in this current state of health care paradigm shifts, and is in direct conflict with ACOG's goal to "continuously improve health care for women."

Respectfully Yours,

Bruce J. Bernie, MD
Director of Robotic Surgery
Good Samaritan Hospital
Dayton, OH

John Crane, MD
Director of Robotic Services
Banner McKee Medical
Loveland, CO

Gregory Eads, MD, FACOG
Director of Robotic Surgery
Memorial Hermann Hospital
The Woodlands, TX

Eric John English, MD FACOG
Partner, OB/GYN West
St. Paul, MN

Richard Farnam, MD
Chief of Staff Las Palmas Medical Center
Director of Minimally Invasive Surgery
Clinical Associate Professor Texas Tech University
El Paso, TX

Michael Fields, MD
Director of Robotic and Minimally Invasive Surgery
Tennova Healthcare
Knoxville, TN

Gerald A. Feuer, MD
Atlanta Gynecologic Oncology
Atlanta, GA

Greg Fossum, MD
Director of Reproductive Endocrinology
Thomas Jefferson University Hospital
Philadelphia, PA

Devin Garza, MD
Director of Minimally Invasive Surgery
Renaissance Women's Group
Austin, TX

Bang Giep, MD
Medical Director for Spartanburg Regional Institute for Robotic Surgery
Spartanburg, SC

Hoang N Giep, MD
Spartanburg & Pelham ObGyn
Spartanburg, SC

Thomas P. Heffernan, MD, FACOG
North Texas Gynecologic Oncology
Dallas, TX

Dwight D. Im, MD, FACOG
Director, The Gynecologic Oncology Center at Mercy
Baltimore, MD

Jack Inge, MD
Rex Healthcare
Raleigh, NC

Meenakshi Jain, MD, FACOG
St. Petersburg General Hospital
St. Petersburg, FL

Mel Kurtulus, MD, FACOG
Medical Director
San Diego Women's Health
La Jolla, CA (News - Alert)

Norman L. Lamberty, MD
Physician Associates Orlando Health
Orlando, FL

John Lenihan Jr., MD, FACOG
Medical Director of Robotics and Minimally Invasive Surgery
MultiCare Health Systems
Tacoma, WA

Peter C. Lim, M.D.
Medical Director
Center of Hope @ Renown Robotic and Minimally Invasive Surgical Institute
Reno, NV

Michelle Luthringshausen, MD
Director of Robotics
Northwest Community Hospital
Arlington Heights, IL

Timothy Machon, MD
Hartford Hospital
Hartford, CT

Ross F. Marchetta, MD
President
Obstetrics & Gynecology of The Reserve
Director, Minimally Invasive Surgery and Robotics
Akron, OH

Pamela Paley, MD
Pacific Gynecology Specialists
Division of Gynecologic Oncology
Associate Clinical Professor
University of Washington
Seattle, WA

Thomas N Payne, MD
Medical Director
Texas Institute for Robotic Surgery
Austin, TX

Michael Pitter, MD
Chief of Minimally Invasive and Gynecological Robotic Surgery
Newark Beth Israel Medical Center
Newark, NJ

Jerry Rozeboom MD, FACOG
President, Ob/Gyn Associates, Head of Gyn Minimally Invasive Surgery, St. Lukes Hospital
Cedar Rapids, IA

Danny Shaban, MD
Director, Minimally Invasive Robotic Surgery
Bonsecor, VA

Jessica Vaught, MD
Director of Minimally Invasive Surgery, Winnie Palmer Hospital for Women & Babies
Orlando, Florida

Dan S. Veljovich, MD
Associate Clinical Professor
University of Washington
Gynecologic Oncologist, Pacific Gynecology Specialists
Seattle, WA

Marc L. Winter, MD
Director of Minimally Invasive Surgery
Saddleback Memorial Medical Center
Laguna Hills, CA

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