It”™s all about the incision.
“I”™ve been practicing urology for about 20 years, and the clear goal in surgery over the last decade has been to minimize the amount of discomfort patients have, get patients back to their regular lifestyle as soon as possible and to minimize the amount of time the patient spends in the hospital,” said Dr. Warren Bromberg, chief of urology and medical director of the prostate cancer program at Northern Westchester Hospital in Mount Kisco. “In order to do that, you have to make smaller incisions.”
Initially, surgeons went from making incisions to laparoscopy, a process in which surgeons could make minimal incisions using very fine instruments.
“The problem with laparoscopy is the instruments are relatively primitive, so you”™re asking the surgeon to do complex work using primitive instruments,” Bromberg said. “In a way it was a step back from the open surgery. It was an advantage to the patient, but it was a disadvantage for the surgeon.”
Robotics, specifically the da Vinci Surgical System made by Sunnyvale, Calif.-based Intuitive Surgical Inc., takes the computer and interposes it between the surgeon and the patient using a laparoscopic-style approach, Bromberg said.
According to Intuitive Surgical, the company has expanded its installed base to more than 900 academic and community hospital sites while sustaining growth in excess of 25 percent annually since the first da Vinci was introduced in 1999. Intuitive Surgical reported third quarter 2009 revenue of $280 million, compared with $236 million for the third quarter of 2008.
“The da Vinci uses small instruments that go through small ports, which go through the skin,” Bromberg said. “The computer allows much more technical advances in the actual mechanism behind the surgery.”
To perform surgery using the da Vinci, Bromberg sits at a console a few feet away from the operating table, looks at a television monitor through a binocular device and operates handheld instruments attached via computer to the robotic system, which is attached to the instruments that go into the patient. The da Vinci hovers over the patient and makes the cuts as instructed.
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“Ergonomically, it is much more comfortable to be sitting,” Bromberg said. “The wrist joint of the instrument on the robot side is very complex and it actually mimics the movements that my fingers, hands wrists and elbows would do, where as the laparoscopic instruments are very rigid and stiff and have very minimal movement.”
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In addition to improved dexterity and ergonomics, the da Vinci computerized system offers the surgeon better optics: a three-dimensional image of the patient.
“It”™s a huge advantage to have the robotic system as opposed to the laparoscopic system,” Bromberg said. “I became interested in the robotics as soon as I heard about it about five years ago. Most robotic surgery is very, very recent.
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Everybody”™s talking about it, and the number of surgeries being done is growing, but in fact it really is a very recent phenomenon. The first robotic surgery was probably done in 2002 or 2003, so this is a very recent concept.”
The da Vinci is particularly helpful in reconstructive surgery, “which much of our urology surgery is.”
“We”™re not only removing things like tumors, but then we have to reconstruct the urinary tract and put it back together, so there”™s a lot of suturing and that”™s very difficult to do laprascopically,” Bromberg said. “The robotic system makes it much more user-friendly and easier to adapt, so it naturally caught on very quickly.”
Length of surgery using the da Vinci is similar to the amount of time it takes for traditional open surgery, Bromberg said.
“You don”™t have a big incision to close or open but you still have to set the robot up and remove, or undock the robot, afterwards,” Bromberg said.
Initially, the use for surgical robots was intended for cardiac surgery, Bromberg said, to pass very fine instruments through the ribs to access the heart without opening the chest.
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Then the urologists embraced it because “we found it was very useful for prostate cancer surgery.”?“It has grown to the point where at least 60 percent of prostate cancer surgery is now being done with the robot,” Bromberg said. “We use it for kidney surgery. We have used it to remove portions of the urinary tract. The gynecologists are using it for hysterectomies. There are general surgeons who are using it for gastric bypass surgery, colon surgery and adrenal surgery. It has lots of uses, and it actually has FDA approval ear, nose and throat surgery.”
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The da Vinci is not the typical robot in the sense that it is not automated, or programmable without human interaction.Â
“One of the fears that patients have is anyone who remembers the movie ”˜2001: A Space Odyssey”™ and the computer system Hal,” Bromberg said. “The big fear was in that setting the computer essentially took over the spaceship, and so the concept that computers would be so smart that they could take over and do everything is a fear.”
Bromberg likens the relationship between surgeon and da Vinci as a master/slave relationship.
“It is completely immobile unless we operate it,” Bromberg said. “It completely mimics what our hands do in real time. There”™s nothing automated about it. We control every single movement or operation of the system.”
Bromberg said the da Vinci system, which costs up to $2 million and another $200,000 annually in maintenance expenses, is still too expensive for every hospital to have one.
He expects prices to decrease and access to increase.
As time goes on, the da Vinci system will probably become smaller, “and what we”™ll probably find is at some point there will be natural orifice surgery, where you”™re using any natural body opening to do the surgery,” Bromberg said.
Robotic surgical systems are the new lasers.
“Lasers at first impressed people tremendously,” Bromberg said. “I remember a few years ago where everybody would ask if I could do their surgery with a laser. Now, people actually ask, ”˜Can you do it with a robot?”™ There”™s been a lot of interest and fascination with it. I think when they actually see it they”™re very impressed. What”™s interesting to me is that people are not more afraid of the system. When you tell people they”™re having a major operation and will be going home within 24 hours, I think they”™re very quickly willing to look past the technological fear for the benefit.”
You could, with the right communication system, perform surgery on a patient from the other side of the world, and it has been done, Bromberg said.
“The concept of telemedicine is certainly applicable to the computer,” Bromberg said. “If you don”™t have surgeons that are fully trained in countries where they don”™t have as many surgeons, you can have a surgeon from the United States performing surgeries remotely.”
Bromberg uses the da Vinci now for 100 percent of prostate, kidney and adrenal surgery.
The robot works five days a week.
