The State of Robotic Surgery

kkleiner writes "Robotic surgery is experiencing explosive growth in America's operating rooms, and the unquestioned industry leader in this field is the DaVinci robot, made by Intuitive Surgical. Only 14% of prostate surgeries in the US last year took place not using the DaVinci. Installations have grown from 210 systems seven years ago to 1,395 today. Although typically used for smaller surgeries like prostate removal and hysterectomies, the system was recently used for a kidney transplant, and more complicated procedures are expected in the future. The DaVinci is really just the first wave of robotic surgery as technology continues to push clumsy human hands out of the operating room." The article mentions some of the downsides, or perhaps the growing pains, of DaVinci robotic surgery: "According to a large study of Medicare patients, robotic prostate surgery led to fewer in-hospital complications, but had worse results for impotence and incontinence ..." Another company makes a simulator to train surgeons on the DaVinci. Embedded in the article is a 2009 TED talk on DaVinci by a surgeon.

Comments

Re:Incontinence or Death

[Anonymous Coward]

Having had my Prostate removed the choice is neither with conventional surgery. That tells me this surgery is not as good as non robotic surgery like I had. I don't have problems with leaking or impotence. Given the choice I would go for non robotic surgery.

Cost benefit?

[S1ngularity]

And what effect this sort of technological uptake have on health cost containment?

Really difficult surgery

[MichaelSmith]

It would be interesting if robots like the DaVinci could in future operate on a smaller scale and in trickier parts of the body. Some cancers (for example) are inoperable because of their location in the body. Maybe a robot could cut out most of the tumor in these cases and leave chemotherapy or radiotherapy devices behind the clean up the rest.

Re:Really difficult surgery

[nanoakron]

As a qualified surgeon (albeit junior), I'd like to offer my $0.02 if I may.

To be honest, there aren't many parts of the body that are inaccessible to modern surgery. Closed boxes such as the thorax or skull are a couple, but in these cases the main problem is not physical access but the fact that the cancers themselves are often aggressive and deeply embedded. Brain tumours (particularly GBM) are notorious for sending out stray single-celled metastases before the main tumour even shows itself. Small-cell lung carcinoma is another. Basically, by the time the cancer has revealed itself, it's all but too late to do anything about, and no amount of cutting out the primary will remove distant microscopic spread, even with the best tools for the job.

Fortunately, these 'black book' cancers are the rare ones. Common cancers such as bowel, breast and prostate tend to be slower growing and based in parts of the body that are relatively easy to access.

The main use of robotic surgery is not so much to improve physical access, or to 'remove more', but to reduce surgical trauma, and thereby speed patient recovery and reduce peri-operative complications.

And interestingly, we all know surgery for early or localised tumours is the best chance for 'cure', but did you know that radiotherapy actually cures almost the same proportion of cancers? Together they account for nearly 90% of all cancer cures, but where does all the money go? Chemo - because it's sexy. Well, I guess we're also trying to replicate Erlich's 'magic bullet' theory which applied in the early days of antibiotics but unfortunately it's still a way off.

-Nano.

Re:Really difficult surgery

[quantumghost]

Actaully, being a surgeon who has used the robot, you stand a greater chance of injury.

To set the record staight, the robot is a tool looking for a problem. The robot is no better than a skilled laparoscopic surgeon, and in fact suffers from a "fatal flaw". I'll explain: the most common procedure for the robot is for prostatectomy which involved going deep into the pelvis to remove a walnut sized gland at the base of the penis and below the bladder. To do this using standard laparoscopic instruments is hard beause you would have to stand where the pt's head is to have the proper angle. The robot can operate "upside down" and removes this restriction.

The draw back to the robot is that it does not provide "haptic feedback" or force-feedback....a skilled surgeon relies on his sense of touch as much as his sense of sight. I've removed a pt's colon doing 80% of the surgery not needing to see what I was doing and just going by touch which was more revealing than my sight for those parts of the procedure(hand assisted laparoscopic colectomy). If I can't feel the tumor in the bowel because the robot doesn't provide a sense of touch, guess what - the robot will not provide any advantage.

The true falacy is that the human surgeon is a butcher and that the precision of the robot will be superior. In truth, the surgeon relies on the body's ability to heal to accomplish the miracle of the cure. I cut, but I rely on the body's ability to mend. There are precious few procedures out there that requrie such precise touch...and trust me I've sewn a 1mm vein to a 2mm artery during a bypass operation using my own hand, and with a suture that would break if you sneezed on it (another reason to use a surgical mask!). This case would not be possible with the current generation of robots.

Now, don't get me wrong, there may be some advances in the furture where the robot-assisted surgeon can out perform me, but for at least the next 5-10 years, the robot will be relegate the corner of one of our ORs and used 2-3 times a week for the RALP (robot assisted lapr prostatectomies).

As an aside, the tele-surgery concept may be a valid use in the future, but A) you need 100% up-time on your link B) you still need a semi-qualified individual at the pt's beside to 1) set up the robot, 2) put the ports in so the robot can slip the intruments in to the pt. And in reality, you need someone on stand-by to take over if the case can not be completed and you are stuck at a critical juncition.

Re:Well...

[gmhowell]

They took err jerbs!!!

Re:Incontinence or Death

[gmhowell]

If we had two, I'd never get any typing done.

What was the rate of complications?

[im_thatoneguy]

I wonder what the actual numbers were of complications.

If it reduced deaths from 2 to 1 per 1,000 and only increased the rate of incontinance from 1 per hundred to 2 per hundred then that seems like a good trade off. But two unrelated statistics without the details are difficult to compare.

If you had a procedure that killed 70% of the people and could reduce it to 10% but only increased the chance of side effects by 1% then it's a no-brainer.

It's Cool.

[stuffman64]

I for one welcome our robotic overlords... I mean, helpers!

Last month I got to play with one of the Da Vinci units at a car show (why it was there is anyone's guess). I am amazed at how intuitive it was to use- even though I was just putting tiny rubber bands on small rubbery cone-thingies, the 3D display and 1:1 motion mapping really made it feel like an extension of my body. Even though the unit doesn't use force feedback, it almost seemed like it did (just my brain, I guess). The most amazing part? My 7-year-old niece had absolutely no problem using it, and now she wants to become a doctor.

Cool stuff.

Re:It's Cool.

[radtea]

1:1 motion mapping really made it feel like an extension of my body.

Now if we only had a word to distinguish a system such as you describe from a robot...

Should put one on the ISS (or Antarctica)

[wisebabo]

The best use for this would be to put one on the ISS (or other "nearby" manned spacecraft where speed of light time-lag is not too long).

That way, you'll have an emergency "surgeon" available in case of a medical emergency. Nowhere near as good as a real live doc but better than nothing.

I understand a few years ago, a female scientist had to be evacuated from the Antarctic base in the dead of the ANTARCTIC(!) winter because she had breast cancer. This could have prevented that (and eliminated the risk to the rescue crew. I think they had to keep the plane's engines on so that the skids wouldn't freeze to the ice).

Now what was the name of that "emergency medical program" on Star Trek?

Re:Should put one on the ISS (or Antarctica)

[careysub]

The best use for this would be to put one on the ISS (or other "nearby" manned spacecraft where speed of light time-lag is not too long).

That way, you'll have an emergency "surgeon" available in case of a medical emergency. Nowhere near as good as a real live doc but better than nothing.

OTOH, in low Earth orbit you can bring the patient back to Earth very quickly (an emergency reentry vehicle is always available on the ISS) so the space surgery unit isn't needed. It might be useful on a lunar base, but the 2.5 second time lag would make using it tricky.

For extended space missions (e.g. a trip to Mars) I believe NASA intends to send two astronaut-surgeons (out of crew of 8 or so), so that one can operate on the other if needed.

I understand a few years ago, a female scientist had to be evacuated from the Antarctic base in the dead of the ANTARCTIC(!) winter because she had breast cancer. This could have prevented that (and eliminated the risk to the rescue crew. I think they had to keep the plane's engines on so that the skids wouldn't freeze to the ice).

Yes, she WAS the base doctor and thus could not operate on herself. Sending two surgeons to Antarctica, as in the NASA Mars plan, could have spared this rescue mission (they could have dropped any needed supplies without the hazard of landing). This is possibly a cheaper solution than a million dollar machine (the two surgeons would have other research duties and so are not just additional costs. Keeping the engines running was necessary for the engine's sake. They would not have been able to restart them in the cold.

BTW - the doctor in question, Dr Jerri Nielson Fitzgerald, died from a recurrence of her cancer last year (ten years after the rescue): http://www.abc.net.au/news/stories/2009/06/25/2608384.htm

These devices are not robots.

[jcr]

They're remote manipulation systems, also known as "waldoes". Robots operate under the control of a stored program, not the direction of a human operator.

-jcr

Re:These devices are not robots.

[janek78]

That's a valid point. Also, every technology - and medicine is no different in this - has it's phase of enthusiastic adoption, eventual disappointment when it's found out it's not as good as previously hoped, and then a phase of rational use in indications where it makes sense. I remember the time when surgeons would do 6-hour laparoscopies because it was IN. Later they realized that a 2-hour open surgery is actually better for the patient and laparoscopies were limited to cases where they make sense.

I am a doctor in a university hospital and I recently went out to have beer with a friend of mine from the urology department. He's the chief "robot operator" for our hospital and he hates the machine with a vengence. No only are the operations several times more expensive (and longer), but to get the money they paid for the machine back, the hospital forces him to use the robot even on cases that would be much better done hands-on. Patients with more complications and longer hospital stay are no exceptions. To me this still seems like a technology we are yet to learn to use properly. Use it for remote operations where the surgeon is not physically available, use it in indications where it makes sense, but don't believe in all-saving robotic future of surgery. It's not here yet. The adoption cycle of many older technologies should serve as a warning.

Re:These devices are not robots.

[javilon]

They're remote manipulation systems

What we need is companies like Da Vinci making lots of money and evolving the technology into real robots.

The first phase in the evolution path is likely to be first adding tactile sensors, then chemical sensors, and relying all that information to the doctor, processing it before presentation so the doctor can use all that information in an easy way.

Second phase would be to add more autonomy to the tool, so it makes "decisions" like identifying tissues and for example warning before cutting through nerves or scaling the surgeon movements depending on the area and tissue type it is working at that point, as to make it safer.

Third phase would be to add more autonomy and let some of the tools to be moved by the computer in coordination of the surgeon actions, so for example the computer could take care of draining blood without the surgeon intervention. In order to do that, the computer needs to be able to tell one tissue type from another, and understand the organization of the body area it is working in.

Then some stereotypical parts of the operation could be carried on completely automated.

Finally, eventually the full operation would be carried by the computer.

I would really like computers take over. Even if they are worst than actual surgeons. There are two advantages.

The first one is price. A lot of operations are not carried because of economic reasons. People in that situation would prefer even a "bad" robotic surgeon than nothing.

The second would be consistency. There would be no variability between one robot and the next. Now the outcome of your operation depends so much on what surgeon performs it and if he has a good day.

Re:These devices are not robots.

[radtea]

the hospital forces him to use the robot even on cases that would be much better done hands-on

No one is "forcing" him to do anything. He just doesn't have the guts to do the right thing and say no to his bureaucratic overlords. He is willing to do harm--in his own estimation--to other innocent human beings who have put their deepest trust in him, for the sake of his own comfort and security.

Your friend is a coward, and the most appalling thing is that you apparently see nothing wrong with that.

When people say, "For evil to triumph it is merely necessary for good people to do nothing", this is exactly the kind of behaviour they mean.

Re:These devices are not robots.

[janek78]

While I see you point, I have to disagree. In your extreme logic noone can ever be forced to do anything. Because when it comes to it, you can always refuse (and die).

My friend is a very skilled surgeon - which may be one of the reasons why he feels that hands-on would be better in many cases. And he's not "doing nothing". He's an out-spoken critic and opponent of overuse of the technology and he's actually trying fairly hard to overturn the hospital's decision. Admittedly, not to the point of losig his job.

I applaud your life if you really have the clear consciousness to call people who make compromises cowards.

Re:Nosferatu

[moteyalpha]

I see I have been labeled off topic. I find that amusing, considering my relationship to the person in the video. I plan to have a WebGL interface to the operating system later this year. I suppose I got marked off topic , just for the Nosferatu label. I am sure that when it is done, Google will know. Google seems to know about everything. You seem to have a reasonable knowledge of the field from your posts. It is certainly an area that will yeild many new technologies. The ability to convert a skin cell to an omnipotent stem cell is one. The interesting thing is that contained in the genetic code is the instruction for that transform and once found is just a string of bases. It is very much like writing the code for life.

Just like laparoscopic surgery maybe?

[mednerd]

when laparoscopic surgery came in there were all these studies done that showed one thing or another. for example, a laparoscopic cholecystectomy (removal of the gallbladder) is a very common operation. apparently there are studies done that show 10% of the time you will have damage to the common bile duct (which would be bad). any general surgeon worth his salt these days will tell you that 10% chance is more like 0.5% or better.

my point is, maybe people just need to get better at using these things? it's not like playing a computer game, the surgery is still very complicated.

of course I'm no expert but hey, this is /. isn't it?

The state of robotic surgery

[commodoresloat]

Robotic surgery is actually pretty straightforward. You just pop off a few screws and open the front panel on the robot's torso, and then you can get at the insides pretty easily.

Re:Unanswered question

[radtea]

Okay, so DaVinci is by far the market leader

And we know with a far higher degree of certainty than any of the bogus stats in the article that that means they have mediocre technology but great marketing.

Being "market leader" in a cutting edge (as it were) field is in my experience almost always an indication that the tech is poor to middling but the company is brilliant at marketing. I'm not just talking about Microsoft here, although they are a prominent example of the phenomenon. In the areas I've worked in professionally (which includes image-guided surgery) the best technology has never been close to the market leader.

Personally, I don't want a surgeon using a machine from the market leader on me until the technology is mature, which doesn't happen for decades.

IANAL math

[ibsteve2u]

fewer in-hospital complications
minus
worse results for impotence and incontinence
plus
210 systems seven years ago to 1,395 today
equals
It is a lot harder to sue for impotence and incontinence than it is for in-hospital complications

Sounds likely, but IANAL.

The skill of the person using the tool

[mikefocke]

really matters. No matter if you are using a so called robotic tool or an X-ray generating tool, the Doctor you choose and his or her experience and success rate will determine the outcome far more than the type of treatment you choose.

When you talk to a doctor, ask him how many of the procedures he did last year and what his success rate was. I had the choice of a Doctor who answered "3 and I don't know" and a Doctor who answered "several a day and people with your 'scores" have had a success rate of x and a complications rate of y". Show me the Doctor who measures the success of the way he does a procedure and tries to improve and I'll show you the increased success active learning brings.

Plug ProstRcision into your search engine.

Before having prostate surgery

[Budenny]

Before prostate surgery for you or someone you know, whether robotic or human, check it out very carefully. I did on behalf of someone else, and came to the conclusion that the optimal treatment is intermittent hormone blockage. The technique is, you have total hormonal block for about 9 to 15 months - until PSA falls to zero. Then you go off the blockade.

The rationale is that prostate cancer grows in the presence of testosterone. When testosterone is removed, it dies. It then, in the total absence of testosterone, becomes hormone refractory, that is, it grows in the absence of hormone. You then restore the hormone, and it reverses again.

That at least was my own conclusion, and what I will try if need be. I concluded that local treatments have almost universal side effects of impotence and incontinence, which I think are underreported. And that the dangerous forms of the cancer are probably inoperable locally anyway.

If over some age, don't know quite what, perhaps 80, I concluded there is no point in surgery. We will almost all of us die with prostate cancer. Very few of us will die of it. Over 80, local treatment is probably almost never a good idea.

And do not forget that the biopsy procedure is not risk free, particularly for older men. It can induce total urinary blockage. This then leads to permanent catheterization, which will inevitably result in blockages, followed by hospital visits in the middle of the night, followed by MRSA infections. This happened in a case I knew well. The result was real misery for quite a few years, followed eventually by death from the complications of repeated MRSA infections.

As I said sadly at the time, the tragedy is, he was one of the few men of his age in the country who when biopsied did not test positive. But even if it had, surgery was impossible given his heart health. It wasted the rest of a life, for no good reason.

Re:Incontinence or Death

[OhHellWithIt]

Would you rather be dead or incontinent? I'll take the diapers. Impotent? I'll have to think about it.

For me, the notion of diapers in my fifties was far worse than impotence. As another prostate cancer patient observed, you've got a lot better chance getting a woman into bed if you have bladder control. Luckily, the odds are better for continence than potency, and the former comes back much faster. (But neither one comes back soon enough!)

FWIW, I considered both open and Da Vinci surgery, and I chose the open surgery after lots of reading and discussion, but mainly because I felt like the Da Vinci surgeon was trying to sell me on his method, while the traditional surgeon didn't seem to even be selling surgery; he freely explained reasons that I might want to consider radiation. In one of my meetings with my surgeon, I asked him which he would choose if he were in my situation, and he said "Open, without question!" He said the feel of the tissue was more useful than seeing it. He also said that more Da Vinci patients report dissatisfaction about recovery than open surgery patients, mainly, he believed, because their expectations for Da Vinci were too high. He is learning to use the Da Vinci robot only because more people are demanding it.

The bottom line, though, is that if you are in the situation of needing a prostatectomy, you don't want to look at the statistics of method A vs. method B. You want to look at the statistics of the individual surgeons you are considering and go with the one you are completely confident with. There are no guarantees of full recovery, no matter whom you choose, and when you're recovering, you do not want to be asking "What if?" It's a moot question, anyway: there is only what is.