Policy guidelines suggested for robot-assisted prostatectomy

摘要

One of the innate qualities of all doctors is the desire to do what is best for the ailing patient. This quality then becomes an objective sought by all clinical physicians to improve medical standards as they try to find better ways of delivering healthcare to their patients. Although incorporation of minimally invasive laparoscopic, robotic, and endo-operative techniques into mainstream care has proved disruptive, our patients are demanding effective yet minimally invasive approaches to their healthcare needs. Accompanying these advances and advantages are the challenges and ethics of applying surgical technology to our respective patients. Currently, in the United States, every individual hospital is required to develop criteria and policies for granting clinical privileges to surgeons operating in their hospital. This task is usually assigned either to the medical director or the chief of each particular surgical service, who verifies whether the respective surgeon is “credentialed” for that procedure. The hospital, compromised by the medical staff office, is, in turn, required by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) to verify the credentials and training of their practitioners to delineate clinical privileges. One areas in which this process came into existence was credentialing aged surgeons. It is well known that fine motor skills wane as one ages. It was, therefore, recommended that “as age advances, a physician should, from time to time scrutinize impartially, the state of his faculties; that he may determine, bona fide, the precise degree in which he is qualified to execute the active and multifarious offices of his profession” [1]. Clearly, the above-mentioned process that materialized, which is generally standard across the nation, was not designed to address the introduction of new revolutionary surgical techniques and machinery. What remains is the question—how do we credential surgeons with new surgical technology, in particular robot assisted surgery? Robot-assisted surgery is the application of advanced computerized technology in the planning, performance, and follow-up of invasive surgical procedures. The Food and Drug Administration (FDA) approved the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) April 2004 for use in several surgical disciplines, including cardiac, urologic, and gynecologic surgery. The da Vinci telerobotic surgical system consists of a three dimensional laparoscopic vision system and two or three robotic arms that can perform high-precision articulating movements with a variety of instruments. Both the vision system and the robotic arms are controlled by the surgeon in a “master/slave” relationship via a remote surgeon’s console that houses the vision system and the telemanipulators for the robotic arms. The technology enables for more precise and anatomical dissection with outcomes equal to or better than conventional techniques in both academic and private practice-based settings [2–6], for both laparoscopic and non-laparoscopic trained surgeons [7, 8]. Robot-assisted surgery is not a mere extension of one’s innate ability to perform open or laparoscopic surgery. The appropriate and safe use of this technology requires specialized training and experience. Although the FDA reviews the results of laboratory, animal, and human clinical testing, it does not develop or test products. The FDA does not, moreover, regulate who buys or uses the product, or whether a physician is qualified to use the equipment. The ability to perform a surgical procedure is regulated by hospital-based credentialing policy. Credentialing is the systematic approach to the collection, review, and verification of a practitioner’s professional qualification. Robot-assisted surgery may not be learned safely during a weekend course. Dedication, commitment, and unique cognitive and technical skills are required to transfer skills from an open or lap