A Guiding Hand
Robots are showing up in ever more surgical suites. But they're better suited for some operations than others
When John Lynch was diagnosed with prostate cancer earlier this year, he was determined to fight it. The 47-year-old former New York City police officer had dodged bullets all his professional life, and now that he'd retired he wasn't about to be struck down by cancer. Biopsies indicated that the disease was in its earliest stage, so his chances of beating it were good. But survival wasn't his only concern. Impotence and incontinence are common following surgery to remove the prostate, a gland about the size of a walnut located just below the bladder. Lynch wanted to avoid those two unpleasant side effects at all costs.
Lynch spent days researching treatment options on his computer and talking with doctors. He considered everything from cryosurgery--freezing prostate tumors to kill the cancer cells--to implanted radioactive seeds to traditional surgery. But the treatment that offered the most promise for getting rid of the cancer while preserving his other bodily functions seemed like something straight out of a science-fiction movie: robotic surgery.
Though they conjure up images of the leggy androids of I, Robot or the gilded physique of C-3PO of Star Wars, surgical robots look nothing like humans. The 1,400-pound metal-armed machines resemble dental office equipment more than anything else. And unlike the independent-minded machines in the movies, these robots don't think for themselves and can't perform any tasks on their own. A surgeon controls their every move. But they do enhance a surgeon's performance. And they're being used for an increasingly wide array of surgical procedures, from performing hysterectomies and removing uterine fibroids to repairing heart valves and doing gastric bypass surgery. Although the Food and Drug Administration approved the technique just five years ago, by 2009 half of the estimated 60,000 prostate gland removals done annually in the United States will be done using a robot, according to Sg2,a Chicago-based company that evaluates new technologies for hospitals.
Hands off. Robotic surgery was originally conceived as a way to treat soldiers wounded in battle. The idea was that the patients could be loaded into a mobile surgical unit equipped with a robot, and a surgeon far from the front lines could patch them up. Research into "telesurgery" continues, and doctors have successfully performed long-distance surgeries a few dozen times. But today the focus is on adapting robotic technology for use in everyday surgical situations.
In robotic surgery, the robot is positioned next to the patient, while the surgeon sits several feet away at a special console, controlling the robot's arms, which hold surgical instruments and cameras. Instead of a long incision in, say, the abdomen, a number of small incisions, or "ports," are made through which the instruments are inserted. Sitting at the console, the surgeon looks at the computer screen through binocular-like lenses, which provide a magnified, three-dimensional view from inside the patient. Using hand and foot controls, the surgeon manipulates the instruments as if they were in his or her hands, cutting away tissue, cauterizing blood vessels, and suturing using needles held by pincerlike "needle drivers." The robot's wrist can turn nearly 360 degrees, allowing great flexibility. The robot also eliminates any tremor in a surgeon's hands, and for delicate work, "motion scaling" software reduces a surgeon's actual hand movements to much smaller, finer instrument movements.
For patients, robotic surgery promises many of the same benefits as other minimally invasive surgical techniques: shorter hospital stays, quicker recovery times, and reduced blood loss. But for certain procedures, robotically assisted surgery is proving to be even better for patients than laparascopic surgery, which can be hampered by its long, inflexible chopsticklike instruments. With the robot's agility and precision, a surgeon can perform reconstructions that involve complicated suturing, like attaching the urethra to the bladder after the prostate gland has been removed. And it allows them to access small or hard-to-reach areas without damaging delicate networks of nerves or blood vessels.
John Lynch spent just one night in the hospital following his robotic prostatectomy at New York-Presbyterian Hospital/Weill Cornell Medical Center in June. Although he felt some discomfort afterward, by the second day he was taking nothing stronger than ibuprofen to manage the pain. His catheter was removed a little more than a week after surgery, and he had no difficulty with either incontinence or impotence. A month after his procedure, he still felt an occasional twinge from the surgery, but the six small scars on his abdomen, each less than an inch long, were his only reminder. "I wasn't thinking it would take me a year to recover, but this is even better than I expected," says Lynch.
A study published in the British Journal of Urology in 2003 found that robotic surgery to remove the prostate was superior to both laparoscopic and traditional open surgery in every clinical measure, from time spent in the hospital to complication rates to cancer removal. As promising as robotic surgery is, however, even many of its supporters caution that, except for prostatectomies, the jury is still out on whether a robot offers a clear clinical advantage over other surgical methods for many procedures. "It's been demonstrated as a safe and effective device for general surgery, but it may not improve patient outcomes in every case," says W. Scott Melvin, chief of the division of general and gastrointestinal surgery and director of the Center for Minimally Invasive Surgery at Ohio State University-Columbus, one of several training centers that surgeons visit to learn how to use the da Vinci Surgical System, manufactured by Sunnyvale, Calif.-based Intuitive Surgical. It is the only robot approved for use in the United States.
So why are hospitals large and small, more than 300 across the United States, investing up to $1.5 million for a surgical robot whose clinical superiority has yet to be conclusively demonstrated? Attracting top talent is one reason, especially in urology, where graduating students have often trained on robots and are eager to use them. Surgeons also say they like robots because they make some operations much easier, and they believe that results in better patient outcomes, even if they don't yet have much hard data to prove it.
But perhaps just as important, having a robot sends a signal that a hospital is cutting edge, and that can be good for business. "Being able to provide the robotic as well as nonrobotic technology demonstrates a commitment to having the most advanced techniques available," says J.P. Gallagher, senior vice president for Evanston Northwestern Healthcare in Evanston, Ill., which recently purchased a da Vinci system. Some are more blunt. "It's a marketing tool," says Hanmin Lee, associate professor of surgery, pediatrics, OB-GYN and reproductive science at the University of California-San Francisco. "For most uses, I'm not sure the robot adds a lot except to say, 'Look, I'm using a robot.'"
Research shows that the first hospital in a geographic market to get a robot generally sees a handsome payoff. "There's a huge halo effect for the first hospital," says Giri Venkatraman, who oversees surgical services research for Sg2. "They get a huge increase in volume, both in patients in general and in patients who want the prostate procedure." Competitive pressure sometimes spurs other hospitals in the area to invest in a robot as well, says Venkatraman.
Why should patients care about a hospital's business strategy? With any new surgical technology or procedure, there's a learning curve. The more experienced the surgeon, the better the outcome is likely to be. Each hospital sets its own credentialing requirements for surgeons to perform robotic surgery. But many surgeons agree that to become comfortable and efficient at performing a robotic procedure often takes 30 or more operations. To become skilled enough to save nerves may take much longer. "The finesse part takes at least a couple hundred cases," says Ash Tewari, director of robotic prostatectomy for New York-Presbyterian/Weill Cornell, who operated on John Lynch and has performed some 1,400 robotic prostatectomies.
Do your homework. There are other questions to ask when considering robotic surgery. In addition to how many times a surgeon has performed a particular procedure, find out how many times the procedure itself has been performed at the hospital, says Jihad Kaouk, codirector of robotic urological surgery at the Cleveland Clinic. "I wouldn't go to a surgeon who just started doing robotics for a new procedure," he says. "There are just too many variables." It's always a good idea to talk to previous patients as well.
Although many procedures can safely be performed robotically, most surgeons agree that certain operations don't warrant such cutting-edge intervention. Repairing hernias and removing gallbladders, appendixes, or ovaries with benign conditions generally fall into this category of straightforward laparascopic operations for which the robot is overqualified. And although a few procedures can be performed in older children, at this time the da Vinci's instruments generally aren't small enough to be used in children under 5 or in fetal surgery, says Michael Klein, surgeon in chief at the Children's Hospital of Michigan in Detroit.
Shorter recovery. Some patients choose robotic surgery because they believe it offers the quickest way to get back on their feet. When Kris Zellmann was considering gastric bypass surgery, the time factor was critical. The 32-year-old bookkeeper couldn't afford the eight- to 10-week recovery period of a standard operation. She decided to have the procedure done robotically at the Hackensack University Medical Center and was back to work in nearly half that time.
Insurance is another factor. Although Zellmann's health insurer approved her robotic surgery without questioning it, coverage isn't always assured. Lynch says his insurer denied coverage for his prostatectomy because the procedure is considered experimental. He is appealing the decision. A study published in 2004 in the Journal of Urology found that open prostatectomies were about $1,700 less expensive than robotic ones, and nearly $500 less expensive than laparascopic ones. Even though patients' hospital stays are about two days shorter with robotic surgery than open procedures, the equipment itself is so expensive that it offsets the savings. Some hospitals absorb the added expense, but before signing on for robotic surgery, make sure you understand what your insurer will cover.
Medical trend watchers and practitioners expect that as the machines become more sophisticated, their use will become accepted as the standard of care for many procedures rather than an oddball exception that insurers aren't sure how to handle. One of the key enhancements researchers are exploring is giving the machines a sense of touch. Surgeons rely on how tissue feels to guide them as they cut and sew, but the current robots don't give any tactile feedback. Researchers are working on a sensor that would measure pressure at the tip of an instrument and relay that information to surgeons' own fingertips. Another exciting possibility involves superimposing ultrasound or CT scans onto what the camera inside the patient sees, so that nerves, blood vessels, and organs can easily be avoided or even programmed into the software as no-fly zones for the robot's instruments.
Some researchers are heading in the opposite direction, developing simpler, stripped-down robots with disposable instruments that could be used easily and cheaply for certain procedures. "You wouldn't take an Indy car to the grocery store," says William Peine, a faculty member of the Regenstrief Center for Health Care Engineering at Purdue University. "I'd like to make a surgical robot that's the equivalent of a Toyota."
In the end, however, a robot is just a tool, and what matters most is not the surgical method used but the surgeon who's using it. Without a sure hand to guide it, after all, a robot is just a flashy piece of high-tech hardware.
This story appears in the July 31, 2006 print edition of U.S. News & World Report.