Swedish expands robotic surgery program

Seattle’s Swedish Medical Center has opened the first operating room in the country specifically configured for robotic surgery.

The Center now has two new state-of-the-art robotic machines that allow surgeons to look into the body and operate in hard-to-reach areas with a dexterity and control far superior to what can be achieved with the human hand.

The $1.6 million devices are revolutionizing how surgery is being done–but at the same time raising questions about the appropriate use of expensive new medical technology.

For Dr. James Porter, medical director of robotic-assisted surgery at Swedish, however, there is no question that for the right operation the cost of robotic surgery is worth it.

Dr. James Porter

Three years ago, Dr. Porter, a urological surgeon, was diagnosed with prostate cancer.

His choices were to undergo either a traditional open prostatectomy, which requires a 6- to 12-inch abdominal incision; a laparoscopic procedure in which the surgeon operates through small incisions using rigid, hand-held tubelike instruments; or to have robotic surgery.

Prostatectomy can be a difficult operation. First, because the prostate is not easy to reach: the gland, which is about the size of an egg, lies at the base of the bladder, at the bottom of the pelvis, in an area that is rich in blood vessels and through which nerves and other structures necessary for erectile function and urinary continence pass.

And, second, the gland is surrounded by other pelvic structures, which means the operation must be performed inside a space about the size of a softball.

So to remove all the cancer while sparing, when possible, the nerves and other adjacent structures is a challenge.

“When you do open surgery, you’re up above the operative field and you’re wearing a headlamp and you trying to look deep into the pelvis,” Porter says, and with laparoscopic surgery, the rigid instruments can be awkward to use and it’s often difficult to see.

As a result, open and laparoscopic operations are difficult and often bloody, says Dr. Porter, with patients losing on average nearly a quart of blood. About 5 percent to 10 percent of patients require a blood transfusion, he said.

And damage to adjacent nerves and other structures also commonly cause urinary incontinence and impotence.

© 2009 Intuitive Surgical, Inc.

“The beauty of robotic surgery is that your eye is inside the pelvis,” says Dr. Porter, “ . . . about an inch from where you’re operating, and you can see blood vessels that you can’t see when you’re doing open surgery. They’re tiny but they look giant to me through the robot so I can control those vessels before they bleed.”

And blood loss is why it takes patients so long to recover from prostatectomies, Dr. Porter said.

© 2009 Intuitive Surgical, Inc.

With robotic surgery, blood loss can be kept to a minimum, Dr. Porter said, and patients can often be up and back to work in one to two weeks–instead of the four to six weeks typically seen with patients who undergo open or laparoscopic surgeries.

Having done hundreds of prostatectomies, there was no question in his mind that he wanted robotic surgery, Dr. Porter says, “Robotic is better.”

And in his case the procedure went well, and Dr. Porter was back at the hospital, working full-time, in a week.

Oversold?

But there are skeptics who argue the benefits of robotic surgery are being oversold, pushed by an aggressive and skillful marketing campaign by the machines’ manufacturers.

In a paper appearing in a recent issue of JAMA, the journal of the American Medical Association, Dr. Jim Hu of Brigham and Women’s Hospital in Boston, Massachusetts and colleagues, presented findings of a study that compared results of open surgery and minimally invasive radical prostatectomy, a term which includes both standard laparoscopic surgery and robotic surgery.

That study found that those undergoing the minimally invasive procedure had, indeed, shorter hospital stays, less blood loss and lower risk of surgical complications.

But the study also found that over the longterm patients undergoing the minimally invasive procedures were twice as likely to be diagnosed with genitourinary complications such as incontinence and impotence than were those who had undergone the open procedure.

Dr. Hu and his colleagues argue that existing evidence does not support the rapid adoption of minimally-invasive procedures over open surgery, “the established gold standard.”

But supporters of robotic surgery raise several objections to the JAMA paper’s findings.

They note that the researchers were working from records from which it is not possible to tell whether the patients underwent the older laparoscopic procedure or the newer robot-assisted operation.

And they note that the data on impotence and incontinence were also based on diagnoses in records and not questionnaires answered directly by patients, a generally more reliable method.

And, finally, they argue the data is relatively old, based on reports of operations performed from 2001 to 2006, a period when surgeons were not as experienced as they are today with robotic surgery.

“Experience is the major determinant of patient outcome,” says Dr. Porter, “and Swedish surgeons have done more than 2,000 robotic procedures.”

Dr. Richard Satava, professor of surgery at the University of Washington, admits he has a bias: he worked on the government program that developed the prototypes that led to the development of the robotic surgery machines currently available.

That project was funded by the Defense Advanced Research Projects Agency (DARPA), an agency of the U.S. Department of Defense that develops advanced technology for the military.

Dr. Satava, who is now a senior science advisor to the Army Medical Research and Material Command and who conducts research on robotic surgery at the University of Washington, says that many of the concerns about poor outcomes with robotic surgery have faded as surgeons have gained more experience.

“In the data that I have seen, once the surgeon has passed the learning curve, with about approximately 50 cases, the result is unequivocal: for the quality of measured outcomes and the overall benefit for the patients there’s absolutely no question” that robotic surgery is better than open surgery, Dr. Satava said.

Dr. Andrew Wright, assistant professor in the Department of Surgery at the University of Washington also who conducts research into robotic surgical devices, however, cautions that robotic surgery isn’t the best choice for all operations.

“It’s a great tool, I actually love using it,” he said, but for some patients “it may not be the appropriate treatment.

For example, for operations like a prostatectomy where it is hard to see the operative field, robotic surgery has advantages, Dr. Wright said, but with many abdominal operations it is relatively easy to reach the areas where you need to operate and you can see well.

For such operations, Dr. Wright said, using robotic devices was more expensive, and, because of the time needed to set up the machine and position the instruments, actually took longer.

“We used it for several years in general surgery, but it didn’t really give us any benefit,” he said.

“It’s like any technology, you have to weight the benefits it gives you against the costs,” Dr. Wright added.

In the new operative suite at Swedish, the robots are integrated with digital media displays on a overhead boom system that keep the operating room floor clear of cables and other obstructions so the surgical team can move freely about the patient.

The Swedish robots will be used primarily to perform urological, gynecological and chest surgery.

© 2009 Intuitive Surgical, Inc.

The robots, called da Vinci Si Surgical Systems, are made by Intuitive Surgical, Inc. in Sunnyvale, California.

The new machines have improved cameras to provide the surgeons with an up-close, high-definition, three-dimensional view of the operative field and a display that can show CT and MRI scans and real-time ultrasound images to help guide the surgeon during surgery.

The operative instruments have a new mechanical “wrist” that allows greater range of motion, giving the instrument the ability to “bend” back on itself to access hard to reach spots.

While the instruments’ movements are totally under the control of the surgeon, the motion of the surgeon’s hands can be “scaled down” so that a large movement by the surgeon’s hand is reduced to a smaller movement of the instrument.

This scaling function gives the surgeon super-human control over the instrument and eliminates any tremor that every human hand has.

“This motion scaling, the enhance vision, and the dexterity of the instruments, all leads to more precision,” Dr. Porter said.

As for cost concerns, while the operation is more expensive, savings are more than made up for by shorter hospital stays and quicker recovery, Dr. Porter says.

“Patients are feeling better, going home sooner and getting back to their lives sooner–and that’s the part we can’t measure,” Dr. Porter says.

PHOTO CREDITS: Photos of the DaVinci device © 2009 Intuitive Surgical, Inc.

To learn more:

• Visit the Swedish Robotic Surgery Programs Web page here.
• Visit the Web site of the manufacturer Intuitive Surgical, Inc.
• To read Dr. Hu’s JAMA paper requires a subscription or payment of a fee, but you can read the abstract for free.

Tags: DaVinci, Prostatectomy, Robotic Surgery, Surgery, Swedish Medical Center

Category: Provider News