ARTICLE SUMMARY:
While complications are extremely rare from robotic surgery failures, they have the potential to be catastrophic. Guidelines for reducing them, excerpted from our recent feature, “Safety in Spine Surgery.”
Since 2017 big robotic platforms have become available, resulting in more than 127,000 robotic-assisted spine surgeries worldwide since 2016, according to data from Medtronic and Globus (the market leaders in robotics), said Brandon Carlson, MD, a spine surgeon and assistant professor of orthopedics at the Marc A. Asher, MD, Comprehensive Spine Center at the University of Kansas Medical Center, who studied learning curves for robotic surgery.
Current robotic platforms are rudimentary, with capacity to place screws and with single trackers relative to segmental motion of the spine, with learning curves ranging from three to 30 cases, and 15 to 62 screw placements, based on studies of metrics associated with operating time or, to a lesser extent, screw placement accuracy. But Carlson looked closely at the 1% of his cases in which screws were malpositioned—a total of six procedures in which screws were pulled out or misplaced for unclear reasons. Most of missteps occurred before the 10th case, but the 75th case also involved a misplaced screw in a patient with a fractured pedicle. He determined that the learning curve was not entirely dependent on the number of cases.
To better understand reasons for robotic failures, Carlson filmed his operating room, much like athletes videotape their moves to improve performance. While he had dozens of preventive strategies in place, he recognized three key areas that needed to be addressed, including better preoperative planning, reduced motion, and appropriate response to failure identification.
Preoperative planning involving room setup, instruments, or screw trajectories requires identification of high-risk scenarios before the start of a procedure, Carlson noted.
Motion reduction is also crucial to improving the learning curve and accuracy of the surgery. The operating room has lots of sources of motion, and the more things move during the procedure execution, the higher the risk of failure. “Every time I missed one of the screws, I appreciated how nuanced spine motion could be,” Carlson said.
Last, failure scenario identification, that is, identification of failures and appropriate responses to them, distinguishes good from great surgeons—those who know when to reset so they can correct for mistakes and get through procedures without catastrophic consequences, he added.
In summary, Carlson stressed that the learning curve is much, much longer than surgeons generally appreciate, and skills are built at some level not by the number of cases performed but by building that media library and observing problematic scenarios.