The Impact of Technology on Surgery: The Future Is Unwritten

Mario Morino, MD


Annals of Surgery. 2018;268(5):709-711. 

In This Article

Industry–physician Relationship

The analysis of the penetration and diffusion of the 4 techniques and technologies discussed above shows that the role of the industry is at present the main driving force that determines the adoption of innovations in surgery. Only once in a while, a disruptive innovation changes the history of surgery and in that case the change is driven by physicians and patients. This was the case of laparoscopic surgery after the advent of CCD cameras or of organ transplantation after the development of effective immunosuppressive drugs. Otherwise, in the vast majority of cases, a technological innovation modifies only partially a given surgical procedure needing hundreds or thousands of patients to prove its efficacy Nevertheless, it is of the utmost importance to submit a new technology to a carefully structured validation process before introducing it into the routine clinical practice.

One of the main challenges for the surgical community in the coming years will be to improve EBM evaluation of any given new technology before its widespread clinical application.

In this scenario the relationship among industry, physicians, and professional medical associations plays a crucial role.[11] In a recent article, Patel et al[12] assessed the conflict of interest (COI) in robotic surgical studies, validating author's declarations with the open payments database reported to the Centers for Medicare and Medicaid Services. The results were unexpected and worrying: only 21% of studies with a COI declared it in a COI statement, and only 18% of the authors who received payments declared it. Moreover, studies that had undeclared payments from Intuitive Surgical Inc were more likely to recommend robotic surgery compared with those that declared funding (odds ratio 4.29, 95% confidence interval 2.55–7.21).

Similar data have been published in the fields of spine surgery,[13] gynecology,[14] and more recently ventral hernias.[15]

In 2015, Surgical Endoscopy published the results of an analysis conducted by SAGES on safety and effectiveness of Da Vinci. The conclusions stated that "Gastrointestinal surgery with the Da Vinci Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for selected gastrointestinal procedures."[9] The same journal published a few months later, "A response to the SAGES assessment of the Da Vinci Surgical System" by Myriam Curet, Chief Medical Officer of Intuitive Surgical (Sunny Vale, CA) stating that robotic surgery should not be compared with laparoscopic but with open surgery, and that the SAGES assessment "used a questionable methodology: relying on RCTs data is no longer necessary."[16] Accepting such a statement can be very dangerous for the surgical community. It is worthless to remind that in 1996 an editorial on the Lancet by Horton compared surgical research to "comic opera" reporting that only 7% of all surgical articles published in 1995 on the 4 main surgical journals reported results of RCTs whereas 46% described case series with low grade of evidence.[17] Despite the indignation that this remark caused, "the proportion of RCTs in surgery remains low and poor quality research continues without benefit to surgeons or patients."[18]