Are automatic laparoscopic suturing devices worth the expense? The question is easy, but depending on whom you ask, the answers are considerably more complex and sometimes paradoxical - as is often the case when considering costs in relation to the benefits devices provide.

'They are efficient and technically very good, as far as the function of the devices goes, and they are certainly technically easier,' says Sabi S. Kumar, MD, of the NorthCrest Medical Center in Springfield, Tenn., and a member of the clinical faculty at Vanderbilt University in Nashville, Tenn. 'But the cost is definitely a problem.'

For Dr. Kumar, who is already equipped with the confidence years of experience brings, the tradeoff doesn't warrant the expense.

'I have looked at all of them and I do manual tying,' he says. 'I don't use them.'

But others say expense can be a motivating factor rather than a deterrent. James Presthus, MD, of Minnesota Gynecology and Surgery in Edina, Minn., says that, while he is equally confident in his ability to do things the old-fashioned way, the devices are potential cost-cutters.

'When I started doing laparoscopic procedures, I learned conventional instrumentation,' he says. But today, if he can get a stitch done faster with a device than with his hands, he'll go with the device.

How do you know whether to stick with manual methods or to stock automatic laparoscopic suturing devices at your facility? Here's what you need to know to help you discuss the issue with your surgeons and decide.

Navigating the curves
For laparoscopic surgeons, the challenge of performing intricate operations in a three-dimensional world based solely on the images they see on a two-dimensional screen has always been daunting. As Dr. Kumar says, it's technically demanding because 'you're working in a monoplane field of vision without feedback or depth perception.'

Dr. Presthus compares it to 'playing video games. You have to dissociate your hands from what you see on the video screen.'

Nonetheless, it's viewed as an important skill for surgeons to master and, having done so, some surgeons feel no need to use devices that are designed to make suturing less skill-reliant.

David L. Crawford, MD, an associate professor of clinical surgery at the University of Illinois in Peoria who also runs a private practice, sees the devices as very useful, but insists that his students learn to function without them.

'I tease the residents,' he says. 'I tell them they don't get to use any crutches when they're working with me. There's a very steep learning curve with conventional suturing, and it can be back-breaking for residents.'

Back-breaking, but important, says Dr. Crawford.

'What if sometime in some situation the gadget isn't available?' he asks. 'It's good to have that skill set as a backup.'

Bridging the gap
Surgeons who are used to conventional suturing are concerned about the learning process, too, but their concern is about learning the new technology.

'There's going to be a learning curve [with new devices], and you like to learn in situations when it's not critical,' says Robert Grant, MD, of New York Presbyterian Hospital/Columbia University Medical Center. 'That means sitting down and spending time with a representative.'

And despite the efforts of professors like Dr. Crawford to ensure residents are adequately trained in manual suturing, it's 'the newer generations of surgeons [who] are very quick to embrace new technologies,' says Dr. Grant. With more experienced physicians, he says, 'it depends on the ease and the familiarity of the surgeons who want to use them. If they find it really helps speed things along, they're going to want them as part of their practice.'

Convincing the skeptics
Jude Sauer, MD, has heard all the arguments and takes them in stride.

'I never try to persuade people who are not comfortable with a device,' says Dr. Sauer, a longtime innovator in the field and a principal in LSI Solutions, which manufactures Sew-Right.

'More often than not, people who suture well are innately gifted or people who have gone through extensive training programs. But the reality is that there are certain things technology lets you do better,' Dr. Sauer says.

And concern about the learning curve is unfounded, he says: 'We can have a person doing a great job in his first case. The learning curve is very, very short.'

So who can profit most from the existence of suturing devices? Herein lies yet another paradox.

'If someone does suturing very rarely, they're probably not going to care about the cost,' says Dr. Crawford. 'If you can take time off the operation, cut it down from 10 minutes to one minute, it's going to pay for itself. That's good for people who haven't mastered the skill to begin with.'

But, says Dr. Sauer, the devices are most valuable to people at the opposite end of the spectrum.

'Our best customers are people who do the most surgery, because they like to go really fast and do an excellent job,' he says. 'We look for people who want to do six operations a day and be just as good on the last one they do that night as they were on the first one they did that day.

'If you're doing one hysterectomy every two months, you don't need it. But if you want to be a high-volume, very successful surgeon, having other technology available makes sense,' he adds.

Talk to the hands
There may be another important consideration in the discussion. Laparoscopic surgeons who spend large amounts of time doing manual suturing may be in for trouble down the road.

'I study OR ergonomics,' says Dr. Sauer. 'We already know that with interventional cardiologists, approximately 50 percent have their backs ruined because they wear lead aprons while performing surgery. There's an epidemic of spinal injuries out there.

'Now, there's already a cadre of physicians who have been hurt by using [conventional suturing] equipment,' continues Dr. Sauer. 'So whether your hands hurt really matters to us, too. Some of our best customers are people who are doing three to five hysterectomies a day, and want to make sure their hands aren't numb at the end of the day.'

Here again, while surgeons appreciate that effort, they aren't convinced it will make much of a difference.

'I'm delighted to hear that manufacturers are trying to make devices more comfortable for surgeons,' says Dr. Grant. 'But unless there's a real dollar value associated with that, it won't be a factor for administrators.'

One case at a time
Ultimately, the case itself will probably determine usage, says Dr. Presthus.

'I will assess at the time of surgery,' he says. 'It depends on how much you have to do and what the access is. Time is money in the operating room. If you're struggling using more conventional means, you're much better off [using a suturing device], and you'll get more consistent results.

'But if it's a simple stitch across the cervix, I'll do it with conventional material rather than get a device out that costs a lot more,' he says.