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

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: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.

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.

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.

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.