Minimally Invasive Surgery Deserts: Is There a Role for Robotic Assisted Surgery?

Abstract

Despite evidence indicating patient and hospital benefits of minimally invasive surgery (MIS) over open surgery, there is still access barriers to MIS. Availability of training and associated learning curve, health literacy, and hospital characteristics (location, size) have been identified as the primary barriers to the adoption of MIS. Robotic assisted surgery could help to overcome some of these barriers and increase access to MIS through easier tele-mentoring and potential for remote access.

The introduction of minimally invasive surgery (MIS) techniques has changed surgical practice, with strengthening evidence supporting clinical benefits, hospital resource utilization improvements, and patient reported benefits of MIS over open surgery for many procedures.¹ MIS reduces length of hospital stay, operative blood loss, and surgical complications, and patients benefit from reduced postoperative pain and recovery time, improving quality of life and allowing them to return to normal activities more quickly.² Despite these well-documented benefits, significant disparities exist in access to MIS.

MINIMALLY INVASIVE SURGERY DESERT

Lack of access to health services that a patient needs or would benefit from substantially is considered a medical desert; access is assessed across five dimensions: availability, accessibility, accommodation, affordability, and acceptability.³ Specialized training is required to perform MIS, which until recent decades was not codified during surgical training; this means that a portion of the existing surgical workforce are not facile with MIS techniques. Furthermore, MIS trained surgeons are not uniformly distributed; this results in issues of availability and accessibility of MIS for patients.⁴ Significant variation in the use of MIS across sociodemographic characteristics also point to issues of accommodation and affordability.⁵ Given the multiple dimensions of access issues for MIS, it is reasonable to posit that MIS deserts exist. Patients that live in these MIS deserts are overindexed to open surgery and miss out on the aforementioned benefits of MIS.

CONTRIBUTING FACTORS

The creation and existence of MIS deserts primarily result from systemic and structural barriers in accessibility and availability, both technological and human. Availability of training and associated learning curve, health literacy, and hospital characteristics (location, size) have been identified as the primary barriers to the adoption of MIS.⁴ When examining factors impacting MIS usage for colectomy, surgeon characteristics (board certification, years of practice, procedure volume) accounted for almost two thirds of the variation in MIS use, followed by sociodemographic characteristics of the patient (28.5%), and hospital characteristics (academic status, rural/urban, volume; 7%).⁶

IMPROVING ACCESS TO MIS

Reducing or eliminating MIS deserts would require a multipronged approach. Given the demonstrated contribution of surgeon training to variation in MIS utilization, addressing this barrier would likely result in the most significant improvement in MIS use. The American Board of Surgeons requires completion of standardized curricula in laparoscopic and endoscopic surgery to gain board certification; thus, surgeons entering the field now are equipped with standardized training in these areas. There is a significant gap in MIS training and safe adoption of MIS procedures among practicing surgeons who completed their core training before these requirements were implemented. This is clearly demonstrated in studies showing surgeon age as being inversely correlated with use of MIS.⁶

While there is no specific approach that has been implemented to facilitate the integration of MIS skills and practicing surgeons, success has been found in various programs adopted by specific societies. To increase MIS for colectomy, the Society of American Gastrointestinal and Endoscopic Surgeons adopted a laparoscopic colectomy Train the Trainer framework from the United Kingdom, which increases the pool of competent instructors.⁷ This framework was successfully adapted to a virtual program during the COVID-19 pandemic, reducing costs and allowing for adoption among surgeons that may live in more remote locations.⁷ While this program could potentially be adopted more broadly to increase MIS use across procedures, a significant barrier remains – there are no specific guidelines to indicate who pays for practicing surgeons to acquire new skills. If a surgeon does not wish to invest the time or money to develop these skills, and hospitals are unable or unwilling to cover these costs and the costs of training support staff for MIS in the operating room, it is likely that the surgeon will continue to do open surgeries, even in the face of strong evidence indicating improved outcomes associated with MIS.

Surgeons may also be hesitant to take on additional training due to the challenges associated with laparoscopic surgery. For some procedures, laparoscopic approaches are more difficult than open approaches due to ergonomic challenges. Additionally, the learning curve to mastering laparoscopic surgery is quite steep⁸; this can be particularly challenging for surgeons that live in regions with low clinical volume for procedures that show the greatest benefit in using a minimally invasive technique.

Patient characteristics accounted for more than a quarter of the variation in MIS use for colectomy.⁶ This includes factors such as patient age, type of health insurance, location, comorbidities, and race/ethnicity. Patients that would likely benefit the most from the advantages of MIS, such as older patients and those with more comorbidities, are often denied MIS⁵; Research has clearly shown that MIS procedures are safe for older patients and individuals with comorbidities⁹; this evidence should be considered when determining the best surgery modality for a specific patient.

CAN ROBOTIC ASSISTED SURGERY REDUCE MIS DESERTS?

Robotic assisted surgery (RAS) is increasingly being used to conduct MIS across a broad range of procedures. Some advantages of RAS may provide opportunities to begin reducing the size and number of MIS deserts.

The learning curve for mastering procedures using RAS is shorter than for mastering laparoscopic procedure.⁸ This is critical, as it allows surgeons in lower-volume settings to become proficient more quickly; this could be of particular benefit to patients living in rural settings. The infrastructure around RAS training also facilitates on-demand telepresence and easier tele-mentoring, providing surgeons in areas without on-site MIS training to improve and maintain their skills.

Remote-access capabilities for RAS can also provide the opportunity for a highly-skilled surgeon to take over a case if a surgeon is struggling with complex anatomy or complex techniques. This could be implemented through a hub-and-spoke model, in which highly trained RAS surgeons at anchor hospital (likely in a more urban area) would provide support to surgeons in surrounding hospitals (potentially in more rural areas) that may have less experience with complex cases.¹⁰ This would allow for more complex cases to be done in lower volume hospitals, and would provide more training opportunities for surgeons practicing in these settings. Having access to more advanced surgeons to provide support or take over on more complex cases may also reduce patient selection challenges seen with MIS, as surgeons may be more likely to take on complex cases knowing they have support if needed. Additionally, this would allow patients to remain in their own communities, surrounded by their support systems.

Fully taking advantage of the opportunities RAS provides in reducing MIS deserts would require the implementation of several processes. First, surgeons would need to be able to have hospital privileges in multiple hospitals; this would facilitate the hub-and-spoke model. This model would also require existing surgeon networks to be leveraged. Second, there are still some technology hurdles (e.g., internet bandwidth and speed) in rural regions that may hinder the use of tele-mentoring or for a more experienced surgeon to take over remotely in complex cases. Upfront capital investment was previously a significant barrier to the placement of surgical robots; new leasing models and per-use agreements have made the acquisition of a robotic system less daunting for hospital administrators.

Although telemedicine reimbursement models have been implemented in the preoperative and post operative space within surgical practices, telemedicine reimbursement models for the intra-operative portion of care are currently lacking in the US. Payment models would need to enable renumeration for both the surgeon and facility providing the back up support. Surgeon scheduling software would be needed to ensure that adequate remote surgeons are available for unplanned consultations, to minimize disruptions to the remote surgeon’s pre-existing schedule. Lastly, patients would need informed consent about the possibility of remote consultation as well as remote telesurgery.

Thus, with a reduced learning curve and the opportunity to train remotely and collaborate with more experienced surgeons, the investment in RAS has the potential to close the implementation gap for MIS, reducing MIS deserts and providing more patients with optimal care. Further research is needed to assess the success of pilot tele-mentoring programs for RAS and the impact that this could have on reducing access issues for MIS.