Why robotic adrenal surgery is not recommended
Robotic adrenal surgery is not recommended.
No significant or high-volume adrenal surgeon uses a robot. If your surgeon recommends a robotic adrenalectomy, seek out a better alternative. Typically, surgeons recommend robotic adrenal surgery due to inexperience, or they usually use the robot for prostate surgery which is a completely different type of surgery. If your surgeon recommends robotic surgery, we are here to explain why you should seek another option. This blog explains why robotic adrenalectomy should be avoided.
Figure 1: Robotic adrenalectomy and robotic adrenal surgery should be avoided. If your surgeon recommends it, he/she is likely to perform less than 4 adrenal operations in a year, Dr. Carling and the Carling Adrenal Center performs up to 6-8 adrenal operations in a single day.
When considering adrenal surgery, there are two fundamental approaches, open or minimally invasive (laparoscopic or robotic). The open approach is typically reserved for large tumors (>8-10 cm) or cancerous tumors that may be invading surrounding structures. Under the minimally invasive umbrella, there are the laparoscopic and robotic approaches that go through the belly (trans-abdominal), or the scopes that go through the back (Mini-Back Scope Adrenalectomy, or MBSA). The Mini-Back Scope Adrenalectomy is by far the best option in >97% of patients and should always be the option you seek out first.
We’ve discussed elsewhere at length the MBSA and its several advantages over the other minimally invasive trans-abdominal options. Robotic adrenal surgery is a technique adapted from surgeons that have used the robot elsewhere, namely in pelvic surgery: prostate, rectum, and uterus. The idea behind the robot is to give the surgeon the fine motor skills in tight spaces not typically afforded by the standard laparoscopic instruments. While the robot is excellent for these deep pelvic operations, and in particular remote access to the thyroid gland, avoiding a visible neck scar, the robot is not a great option for adrenal surgery.
Figure 2: Robotic adrenalectomy and robotic adrenal surgery should be avoided. It is, however, a great tool for scarless thyroid surgery as Dr. Suh (Dr. Carling’s partner and good friend) performs it. More on Dr. Suh and robotic thyroid surgery.
Robotic adrenal surgery takes too long and is too expensive
Robotic adrenal surgery is not recommended. Only very inexperienced adrenal surgeons use the robot as a crutch because they do not know how to perform an adrenal operation properly in 15-20 minutes as Dr. Carling and the Carling Adrenal Center. The Carling Adrenal Center has developed the proper technique to perform adrenal surgery the best way. Robotic adrenal surgery takes significant time to “dock” (set-up) the robot to use. Meanwhile, the patient is asleep, under general anesthesia. In the time it can take to set-up the robot and change its instruments, the mini-back scope adrenalectomy can be finished! We frequently see patients having had robotic adrenal surgery taking 4-6 hours, and sometimes 8 hours and many of the patients develop serious complications. The longer the anesthesia time, the greater is the risk of complications such as blood clots, heart attacks, stroke, etc. In many things, and surgery is no exception, time is money. The most expensive piece of real estate in the hospital is the operating room. The longer time it takes for the surgeon to complete the surgery, the more overall cost of the operation. Further, longer operative times have proven to equate to higher complication rates (risk of infection, increased blood loss, and anesthesia-related complications). The longer anesthesia times associated with robotic adrenal surgery correlate with increased risk of post-operative nausea, disorientation, sleepiness, imbalance, memory loss, and other related complications from anesthesia.
Robotic adrenal surgery is too painful, and the scars are too big
Robotic adrenal surgery causes bigger scars. The ports are bigger than the ones used with the Mini Back Scope Adrenalectomy (MBSA). Larger incisions (as encountered with robotic adrenal surgery) cause more postoperative pain, longer hospital stays, and longer time until return to normal activities and work. The reason robotic adrenal surgery is so painful is that the incisions are through the abdomen, splitting the muscles of the belly. This will lead to significant post-operative pain. Oftentimes, to make the pain bearable, narcotic pain medications are required. Narcotics can not only cause dependency and addiction (we all know about the opioid epidemic in our country), but can also slow down bowel function, leading to higher rates of constipation. Not surprisingly, constipation after an operation leads to even more pain.
Increased pain = longer hospital stay = slower recovery, after robotic adrenal surgery, when compared to the MBSA. More extensive surgery (longer anesthetic times, greater dissection to reach the adrenal glands sitting in the back of the abdomen), results in typically at least three times as long hospital stays when compared to the overnight stay after MBSA. In addition, it takes longer to return to normal activities such as walking, running, biking, tennis, golf, skiing, and other enjoyed physical activities.
Figure 3: Robotic adrenalectomy and robotic adrenal surgery cause more pain, longer anesthesia time, longer hospital stay, higher risk of complications and cause scarring in the abdomen, with risk of hernia formation. Do not have your surgeon recommend a robotic adrenalectomy
Robotic adrenal surgery can cause scarring inside the belly and hernias, both of which can lead to bowel obstruction
Since robotic adrenal surgery, like laparoscopic adrenal surgery, is performed through the belly (trans-abdominal), the scars are not only greater through the skin and abdominal muscles, but also increased within the abdominal cavity. Belly scarring occurs from entering the abdomen surgically. The scarring is greater when a greater number of organs are manipulated. With the robotic instruments and scope (camera) going through the front of the abdomen (and with the adrenal glands sitting in the back, on top of the kidneys), the bowel, spleen, liver, and pancreas must be manipulated (increasing the potential for injury) just to visualize the adrenal glands.
Robotic adrenal surgery through the belly has the surgeon dissecting the small bowel (duodenum), the right colon, the liver, the vena cava, and the right kidney, just to get safe access to the right adrenal gland. On the left, the spleen, stomach, pancreas, left kidney, and left and transverse colons must be dissected. More dissection = more surgery, inevitably leading to more problems, blood loss, and complications. This is a very important concept to understand.
Since intra-abdominal adhesions (scars) form from undergoing belly surgery if you have had prior
- cholecystectomy (gallbladder removal)
- bariatric surgery (gastric band, sleeve gastrectomy, gastric bypass)
- liver, stomach, or pancreas surgery
- bowel surgery (colectomy, appendectomy, etc.)
- gynecological operations (C-section, hysterectomy, ovarian cyst excision, etc.)
the robotic adrenal surgery will force the surgeon to face this belly scarring before addressing the adrenal gland tumor. Cutting through these scars from the previous operation is risky to finally allow manipulation of the organs needed to reach the ‘back-located’ adrenal glands. In fact, robotic adrenal surgery through the belly will cause future intra-abdominal adhesions (scarring). The old surgical adage holds true, “surgery causes scarring, and scarring can cause more surgery.”
The number one reason for bowel obstruction, a devastating post-belly surgery complication, is adhesions (scarring from previous surgery). Bowel obstruction can cause vomiting, dehydration, emergency room visits, X-rays and CT scans, decompression tubes, hospitalizations, and need for additional surgery to break-up the scar tissue.
Robotic adrenal surgery is particularly not recommended if you have had previous abdominal surgery. Why would you want your surgeon to put you at increased risk while having to deal with any scarring, if the Mini-Back Scope Adrenalectomy is an option?
Another potential complication of intra-abdominal surgery is developing a hernia. A hernia is a defect (hole) in the abdominal wall. After any operation going through the belly, there can be a hernia if the abdominal wall does not heal properly after being violated. A hernia is another common cause of bowel obstruction, since the small bowel can become trapped within the abdominal wall defect, leading to a kink in the bowel. Similar to when a garden hose gets a kink, the water (bowel contents) cannot flow freely, leading to a back-up upstream from the kink, or obstruction.
Having a more modern operation (MBSA), going through the back, does not lead to any of these complications since the operation is designed in such a way where the bowels are not even touched or manipulated. The whole operation is performed behind the abdominal cavity in what is called the retroperitoneum.
With all that we discuss, let's summarize...
Reasons why robotic adrenal surgery is not recommended:
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Longer operative times (increased complications: risk of infection, blood loss, anesthesia-related)
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Increased cost
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Increased pain (longer recovery and delayed return to activities and work)
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Bigger incisions (increased risk for hernias, bowel obstruction)
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Intra-abdominal (belly) adhesions (scarring), leading to bowel obstruction
If your surgeon is discussing robotic adrenal surgery, when you know MBSA can offer you a quicker surgery, with quicker recovery times, less complications and no belly scarring, consult with a surgeon with the world’s best experience in adrenal surgery. To be clear, we believe using the robot for adrenal surgery is a gimmick and surgeons and hospitals use it for marketing. Dr. Carling has performed robotic adrenal surgery and found it time-consuming, and completely useless, and he has more experience with adrenal surgery than anyone in the USA. Further, we know all the world's top adrenal surgeons, and all of them abandoned robotic adrenal surgery over a decade ago.
Robotic adrenal surgery is typically offered by inexperienced adrenal surgeons, not capable of providing MBSA. Again, the best adrenal operation is the Mini-Back Scope Adrenalectomy (MBSA). The access is through the back, allowing the adrenal gland to be encountered and dissected within minutes, not hours. The entire MBSA typically takes 15-25 minutes.
Figure 4: Many hospitals use the robot for marketing purposes. It is true that the robot is helpful in some gynecological, prostate and scarless thyroid operations, the robot should not be used for adrenal surgery and adrenalectomy.
Additional Resources:
- Learn more about the Carling Adrenal Center
- Learn more about Dr. Tobias Carling
- Learn more about our sister surgeons at the Norman Parathyroid Center, Clayman Thyroid Center and Scarless Thyroid Surgery Center
- Learn more about the Hospital for Endocrine Surgery