Automated Medicine: Trends in Robotic Surgery

Automated Medicine

Medical Dealer Magazine | April Cover | Automated Medicine - Trends in Robotic Surgery

Freeman is a nurse coordinator at Rex Hospital in Raleigh, N.C., and she’s talking about her introduction to the da Vinci Robotic Surgical System.

Neither could Freeman believe her eyes when she first saw a medical procedure being performed with the da Vinci System. That a surgeon could be sitting in the corner of a room, removed from the physical operating site, while the machine performed the case on the patient, seemed surreal.

“You could be in another room and do this remotely,” she says.

Freeman, who oversees the robotics program at Rex and also works with sales representatives on new equipment and sales. She says she got her first opportunity to interact with the technology as the coordinator of the gynecological surgeries at the hospital.

“It sort of dropped into my lap,” she says. “I’m glad it dropped into my lap because I think it’s very exciting and interesting.”

More than that, however, Freeman says the device has really put Rex Hospital on the map. Today, the facility is positioned as a “GYN epicenter,” she says, with a gynecological surgeon “who has done so many cases that people come to learn from him,” she says.

“We’re staying busy, I can tell you that,” Freeman says. She adds that the DaVinci device “has put us out there in the market with everybody else,” which includes the university hospitals connected with Duke and the University of North Carolina, which are “right down the road,” Freeman says. On a normal week, she handicaps the robotic surgery caseload at Rex as anywhere from 20 to 25 procedures—and she says “a lot of hospitals around us have more than that.

“Patients are coming to have their surgery here because they’re heard about it,” Freeman says. “They get on the Internet and they read now. The specific case at the console is usually a shorter amount of time than a laparoscopic case. The patients have much less pain postoperatively. They’re out and about much quicker.”

From prostatectomies in mid-2007 to hysterectomies, gastronectomy sleeves, colon resections and some liver resections, Freeman can say with confidence that not only has the use of the da Vinci units at the hospital increased, but so has their sophistication and number.

Medical Dealer Magazine | April Cover | Trends in Robotic Surgery

“We started out with one and after about a year, it was so busy that we got a second robot, which was another S system,” Freeman says. “Then, in the past year-and-ahalf, we graduated to the SI, mainly because it can hook up to an ultrasound, and we ended up buying a second SI.

The three robots split time in two designated surgical suites at the hospital; the two, newer, SI units are fixed in place, and the elder statesman S unit rotates from room to room. Freeman notes that the devices are used pretty much “right around the clock as often as we can.

“The only time we’ve had one go down is if the arm goes down and they can’t use it,” she says. “In the time that I’ve done this, it may have happened twice. But we’ve never had any issue in a case where it goes down in a case. I have a team that they’ll go down and make a call, and it’s something they can pick up immediately. It’s just simple stuff like that.”

Not only are the units durable, Freeman says, but the hospital also pays for a remote service plan with Intuitive, manufacturers of the unit, “where we can call them and they can connect to our system and look at reports and see what the problem is.

“Now that we have this onsite system, we can call them and they can run these reports,” she says. “They have a technician that comes in; maintenance is done remotely.”

Robotic surgery units aren’t just easier on patients and more minimally invasive than traditional procedures—they also help surgeons take it easier. At the beginning of an operation, Freeman says, the surgeon is at the table to make the incisions, dock the robot, and put the trocars in. Then, the specialist retreats to an ergodynamic chair, props his or her arms upon an armrest, and manipulates the robot with a thumb and finger on each hand.

They’re not standing there for hours, they’re not bent over, they’ve got something to rest their arms on,” Freeman says. “They start having carpal tunnel or back issues; it’s an option for them. If they’re a great surgeon, they don’t want to quit; the robot’s not going to make them a great surgeon, and the robot’s not for every case.”

The operating sites are visible in 3D and HD views, which also spares the doctors’ eyes and offers a more in-depth field of vision. The robotic “wrist” can rotate a full 360 degrees as opposed to laparoscopic instruments, which are stiff “so you have to move the whole instrument to make it work and move it in the right position,” Freeman says.

No wonder they’re so popular.

“The doctors that we have here heard about it went to meetings about it, and wanted to get one,” Freeman says—but using such a device to operate is not as simple as merely buying one.

For starters, Freeman says, doctors must be certified in laparoscopy, with the requisite credentials. Then they practice for eight hours in a controlled laboratory environment on a pig or a simulator device. After that, at least the first four cases are proctored by a certified robotic surgeon until both the proctor and surgeon feel comfortable enough with the unit to fly solo. At that point, the surgeon may request credentials before they can schedule a robotics case independently—and even then, he or she still must have a robotics assistant at the bedside.

“We still have some doctors that still help their partner just because they like them that way,” Freeman says. “You really have to have doctors who are willing to invest the time and education to make it work. For us, it’s continuing education all the time, but you’ve got to have the doctors who want to do that.”

Then there’s the cost: the surgeon’s console, patient cart—which is the four-armed, bedside-proximate robot—light source tower, and camera box all together will cost upwards of $1 million. That’s not counting the hours of training and the materials with which to undertake it.

“Buying a preowned system is not a bad idea,” Freeman says, “because you hate to put the money into it and it doesn’t work in your hospital. There was talk of one of our systems being bought by a hospital that can’t afford a new one.”

PUSHING BOUNDARIES

At Swedish Medical Center in Englewood, C.O., general surgeon Eric O. Kortz, M.D., has become the first in the state to apply the da Vinci unit to complex pancreatic and liver surgeries. Kortz, who trained at Mass General and has undertaken immunology research at the National Institutes of Health, sees the applications of robotic surgery in these areas as a natural next step beyond even laparoscopy.

“During my fellowship there was no laparoscopy at all; by the time I came into private practice, it was just starting to make its way [there],” Kortz says; “it was pretty clear I was going to have to know it.

“I pretty rapidly had that experience that most physicians in subspecialties have: 10, 20 years into practice, you‘re not practicing the same medicine you were in medical school,” he says. “If there are technical breakthroughs that occur, you’ve got to find a way to retool.”

Medical Dealer Magazine | April Cover | Trends in Robotic Surgery

After an initial course in laparoscopy and some of the more routine applications of the technology, Kortz says, he started to investigate the potential of laparoscopy for treating surgically diseases like liver and colon cancer, which “have progressively been more laparoscopic” in the past 15 years, he says.

“Ever increasingly, I have added certain portions of those where I think it’s appropriate,” Kortz says.

But laparoscopy is not nearly as fluid and smooth as operating with a surgical robot, nor by traditional means, Kortz says; it’s like “working with sticks, not hands; it’s not like a wrist rotating.

“The accommodation has been that laparoscopy has solved its limitations in terms of closing things with a stapler versus sewing,” he says. But in moving towards “mechanical devices that staple and seal things shut,” doctors encounter other headaches as well, he says.

“When we try to do it for bigger procedures and move to more mechanical devices, yeah, you may be able to stay minimally invasive, but you’re running operations that may take longer for some of the more complex procedures,” Kortz says. “Even though people are able to say they did a major surgery, you look at the time it took them to do that and the time they’re in the room, but you kind of sit back and go, ‘Was that really in the best interest of the patient?’

Still, if nothing else, he believes that the push toward minimally invasive procedures that was begun with the advent of laparoscopy was valuable and necessary in creating a generational shift in approach, even if he believes it may only be an iterative technology when compared with the robotic surgeries.

“If I look at the incisions I was trained to make and the incisions I make today, we are thinking acrossthe-board smaller,” Kortz says. “That’s one of the injuries we make to patients is mechanical; the injuries [to] tissues is a big part of that physiologic stress. The lower the complication rate, the better the patients do.”

But with a surgical robot, Kortz says, not only is the patient benefiting from a minimally invasive technique, but as a surgeon, he is able to close wounds with the sewing motion that helps them knit—which he can’t do without the wristed motion that is foreign to laparoscopic tools—and without introducing staples and such.

“I have certainly felt the upper limit of what I can do with laparoscopy,” he says; “it wasn’t until I started to hit that barrier that I started to say, ‘Could I bring the noninvasive approach to more patients, solve more patients’ problems of anatomy or size by going to the robot?’

“Now that I’ve seen the demonstration of appropriate use in certain circumstances, I think I have a section of my patients who are going to benefit by this,” he says.

And that’s another point Kortz underscores: robotic surgery isn’t for every patient, every procedure. There are some patients whose issues he won’t treat laparoscopically or with the da Vinci device, and he tells them why.

“It’s about results for you,” Kortz says. “To me, yes, it’s important about the physical stress. But if I can do your operation open and get you through your postoperative course without complication, then I can minimize the struggle for you. Most patients usually go, ‘Thank you for that presentation.’”

Like any innovation, Kortz says, laparoscopy or robotic surgery “isn’t the first new technology that I’ve embraced,” but providers need to consider the impact of adding something new to their routine from the perspective of patient benefits. That’s not to say that the interface isn’t intriguingly different; especially the simulation-based trainer. Kortz describes it as becoming the machine.

“It’s a different world,” he says. “You have control of these right hand and left hand, and controlling the camera as well. You’re seeing visually these two instruments respond to your movement. These simulations are a cartoon/virtual-world thing. You have to grab the corner of a box and put it in the box and close the box. Then they have a needle-drive thing, and you practice cutting and cauterizing.

“The differences are if I’m operating in an open case, I have control of my eyes,” Kortz says. “If I go to laparoscopic, I only have control over two things; I’m holding the camera, so I lose control of my eyes unless I’m the one holding the camera. When I go robotically, I regain control of my eyes. I have control of something in my right arm, my left arm, and a third arm. I don’t have active control of it all the time, but I can position it so it’s holding something out of the way.”

Once you get past “the newness of the interface,” Kortz says, “You start to say ‘This is all very familiar to me; I am just operating.’”