When some people hear the term ‘robotics’ in relation to surgery, they might conjure up visions of autonomous machines doing the work doctors used to do.
That’s an inaccurate picture, to say the least, said Dr. David Earle, a surgeon at Baystate Medical Center. He believes in the future of robotics in his field, not because computers will do the work of doctors, but because they will enhance the ability of surgeons to perform their work more quickly, more precisely, and with less fatigue.
“Robotic surgery is specifically de-signed to enhance human performance, but not to replace human performance,” Earle said. “It’s like a calculator, or a computer searching for a particular word in a 20-page document — it can do the work faster than a human could, but it only does what the human tells it to.”
Baystate surgeons have already made a leap into robotically assisted surgery through its Automated Endoscopic System for Optimal Positioning (AESOP), a robot arm that responds to voice commands to move an endoscope — a small camera inserted into a patient — which delivers pictures to video screens.
That $60,000 system, which effectively serves as another pair of hands and allows for extremely precise movements within a patient, has been used at Baystate for procedures ranging from gall bladder surgery to hernia operations.
But Earle says that’s just the tip of the iceberg, and Baystate is already considering purchasing a more advanced — and much more costly — system to take robotics in the operating room to the proverbial next level. As he told The Healthcare News, robotics is pushing human surgical skill to unprecedented heights.
The Next Big Thing
The specific technology under consideration at Baystate is called da Vinci and is made by California-based Intuitive Surgical. The machinery is positioned over the patient, and the surgeon controls three mechanical arms from a nearby console.
Once the instruments are positioned inside the patient, a surgeon’s assistant remains at the table for instrument exchanges. While manipulating the robotic arms, the surgeon uses a binocular vision feature that provides a three-dimensional view.
“This obviously allows for a lot of precise movements with a lot less fatigue for the surgeon,” Earle said, adding that such a system would be used for numerous procedures, including cardiac surgery.
To demonstrate the precision he spoke of, Earle compared surgery to using a pencil. For example, if a human being can make two dots with a pencil a minimum of 200 micrometers apart, a robot could place the dots within 10 microns of each other. The surgical precision gained through technology such as da Vinci can make surgery more precise to an equally significant degree.
Intuitive Surgical claims that more than 115 da Vinci systems are in use in hospitals and other surgical facilities throughout the United States, Europe, and Japan. The only surgical robotic system currently cleared by the U.S. Food and Drug Administration, da Vinci has been approved for use in numerous procedures, including general laparoscopic surgery, thoracoscopic (chest) surgery, and laparoscopic radical prostatectomies. It is also involved in three cardiac clinical trials for mitral valve repair, atrial septal defect repair, and totally endoscopic coronary artery bypass graft surgery.
Currently, the system costs $1 million, plus about $200 per surgery in disposable instruments. “They’re like metal instruments, but there’s a chip in them that knows how many times they’ve been used, and you can’t use them more than 20 times,” Earle said. “It’s pretty wild.”
Clearly, cost is a factor for Baystate and other hospitals considering robotics, but Intuitive Surgical notes several benefits of the system in its marketing, including reduced trauma, less anesthesia, less risk of infection, less post-operative pain, often less blood loss and need for transfusions, less scarring, shorter hospital stays, and quicker recovery.
From the hospital’s perspective, Earle said, the technology will broaden the range of surgeons able to perform minimally invasive operations and make difficult minimally invasive procedures easier and faster. And by manipulating the arms in tiny spaces while viewing a dramatically enlarged picture of the treatment area, surgeons can get much closer to the action without fearing hand tremors in tight spaces.
Dean Knoll, a urologist at Centennial Medical Center in Tennessee, which recently purchased the da Vinci system, told The Tennessean that, no matter how experienced he or she is, every surgeon has an innate tremor. But through robotics, doctors are able to eliminate that problem while using radically smaller incisions than in conventional surgery.
“Instead of an incision from across his abdomen to take a prostate out, there’ll be three little puncture sites,” Knoll said. “Guys will go home and not have six weeks of healing up where they can’t do anything. It just allows us to operate on these patients in a less-invasive way.”
Indeed, the manufacturer boasts, da Vinci allows surgeries to be performed more quickly and easily, reducing the invasiveness for patients while retaining the feel of open surgery for the doctor. In addition, many surgeries that normally cannot be performed in a minimally invasive way can be performed through 1-centimeter ports using robotics.
If there is a common misconception about robotics in surgery, Earle said, it is the idea that doctors are doing less work by allowing robots to perform the critical tasks. In conventional terms, he ex-plained, ‘robot’ does often refer to an autonomous machine, but devices such as da Vinci and Baystate’s current AESOP system simply use robotic technology as a tool in the hands of the surgeon.
“It doesn’t function autonomously,” he stressed. “This is more of a master-slave relationship. It mimics the surgeon’s actions, so it’s not a true robot. It’s completely controlled by the surgeon.”
Still, da Vinci would be a significant step up from AESOP, which uses less-advanced technology to maneuver the endoscope — a key component of much minimally invasive surgery — inside the patient.
Even that system is a great benefit to surgeons, particularly in a protracted operation in which fatigue becomes a factor: controlled by voice commands, it’s one less thing the doctor must manipulate manually. As a result of the robotic aid, the surgeon gets an image that is perfectly still — and the ability to return the camera to specific, designated spots, something a human can’t do as easily.
“We’re still using that, but our vision is to go beyond it,” Earle said. “We would like to purchase a more integrated robotics system, but the capital budget process turns a little slowly.”
That’s not surprising, considering the financial stress on hospitals and the fact that $1 million purchases are not everyday occurrences. “Yes, it will make things easier,” he said, “but the question is, who’s going to pay for it?”
Earle does predict an encouraging development, however: the inevitable price drop of any new technology after its acceptance into the marketplace. “Like any computer-enhanced device of any time, as the technology advances, the price goes down, and it will become more affordable in the future.”
That’s certain to be the case as long as multiple companies compete to introduce the next wave of innovations. Currently, the commercial field of surgical robotics has three leaders: Intuitive Surgical; California-based Computer Motion, which makes the AESOP; and the Boston-based firm Brock Rogers Surgical, an up-and-comer which, to date, boasts no FDA-approved devices, Earle said.
Into the Future
Baystate Health System is clearly focused on the potential of robotics in surgery in the 21st century. It recently opened a new research facility and included a space within it to accommodate a robotic system for the purpose of training for laparoscopic surgery. After funds become available for such a system, Earle said, he sees widespread use of computer-simulation technology for staff training, resident education, and skills-performance testing.
“It’s just another way to train our surgeons,” said Carolanne Lovewell, manager of the facility on Main Street in Springfield. “I work with surgeons, and I feel that there’s great interest in laparoscopic surgery because it’s minimally invasive and people are always interested in anything that can improve surgical procedures.”
To Earle, the benefits of robotics are many and obvious. “It allows you to cross barriers of human performance,” he said. And patients who are going through the emotional ordeal of surgery want to know that they’re in good hands.
Robotic technology, in the end, does not replace those hands. It only makes them more precise.