Robotics in SurgeryRobotics in Surgery

Marc S. Milsten, M.D., F.A.C.S.Marc S. Milsten, M.D., F.A.C.S.Urologic Specialists of Urologic Specialists of

OklahomaOklahomaNovember 17, 2007November 17, 2007

Definition of a RobotDefinition of a Robot

Machine that resembles a human Machine that resembles a human and does mechanical, routine tasks and does mechanical, routine tasks on commandon command

Any mechanical device that operates Any mechanical device that operates automatically with human-like skillautomatically with human-like skill

““A robot is not a machine….it is an A robot is not a machine….it is an information system with arms”information system with arms”

Robots: Better Than Robots: Better Than Humans?Humans?

Robots: Better Than Robots: Better Than Humans?Humans?

Types of RobotsTypes of Robots

Passive Passive Retractor systemRetractor systemPosition the tool and then hold Position the tool and then hold

ActiveActiveRobot would actively move the tool Robot would actively move the tool

upon the surgeons commandupon the surgeons command

Surgical Robots in 2007Surgical Robots in 2007

AESOP (Automated Endoscopic AESOP (Automated Endoscopic System for Optimal Positioning)System for Optimal Positioning)- Voice activated mechanical arm- Voice activated mechanical arm- Steadier than human, never tires- Steadier than human, never tires

daVincidaVinci- FDA approval in 2002- FDA approval in 2002- Laparoscopic instrumentation - Laparoscopic instrumentation controlled by the surgeon positioned controlled by the surgeon positioned remotely at a consoleremotely at a console

Development of daVinciDevelopment of daVinci

Defense Advanced Research Projects Defense Advanced Research Projects Agency (DARPA) for military research Agency (DARPA) for military research of remote battlefield surgeryof remote battlefield surgery

Cholecystectomy performed remotely Cholecystectomy performed remotely via telesurgery from 300 miles awayvia telesurgery from 300 miles away

Intuitive Surgical created in 1999 after Intuitive Surgical created in 1999 after acquiring patent rights from militaryacquiring patent rights from military

First robotic prostatectomy performed First robotic prostatectomy performed in 2001in 2001

““Operation Lindberg”:Operation Lindberg”:Remote Transatlantic Remote Transatlantic

TelesurgeryTelesurgery

Remote Surgery

Advantages of Laparoscopic Advantages of Laparoscopic SurgerySurgery

Shorter hospital stayShorter hospital stayLess painLess painLess risk of infectionLess risk of infectionLess blood loss and transfusionsLess blood loss and transfusionsLess scarringLess scarringFaster recovery Faster recovery Quicker return to normal activities Quicker return to normal activities

Challenges of Laparoscopic Challenges of Laparoscopic ProstatectomyProstatectomy

Prostate located in fixed confines of Prostate located in fixed confines of pelvispelvis

Laparoscopic instruments limited in Laparoscopic instruments limited in articulated movementsarticulated movements

Approximation of bladder-urethral Approximation of bladder-urethral anastomosis difficult to sutureanastomosis difficult to suture

French experience: >300 cases French experience: >300 cases reported, learning curve >100reported, learning curve >100

Oklahoma experience: 1 case, 19 Oklahoma experience: 1 case, 19 hours, patient diedhours, patient died

Advantages of daVinci RobotAdvantages of daVinci Robot

Magnified (12x), stereoscopic 3-D Magnified (12x), stereoscopic 3-D visionvision

Robotic wrist with 6 degrees of Robotic wrist with 6 degrees of freedomfreedom

Movements are scaled, filtered, Movements are scaled, filtered, translatedtranslated

daVinci Robotic SystemdaVinci Robotic System

Disadvantages of daVinci Disadvantages of daVinci RobotRobot

ExpensiveExpensive- $1.4 million cost for machine- $1.4 million cost for machine- $120,000 annual maintenance - $120,000 annual maintenance contractcontract- Disposable instruments $2000/case- Disposable instruments $2000/case- Hospital reimbursement same DRG- Hospital reimbursement same DRG

Steep surgical learning curveSteep surgical learning curve Increased staff training/competanceIncreased staff training/competance Increased OR set-up/turnover timeIncreased OR set-up/turnover time

Robotic DisbelieversRobotic Disbelievers

““No long term data”No long term data”- Margin positive rates equivalent- Margin positive rates equivalent- No difference in risk for - No difference in risk for incontinence and incontinence and erectile erectile dysfunctiondysfunction

““Loss of tactile feedback”Loss of tactile feedback”- Improved vision- Improved vision- Haptic feedback: visual resistance- Haptic feedback: visual resistance

ENABLER: same operation, new toolENABLER: same operation, new tool

daVinci Robotic daVinci Robotic ProstatectomyProstatectomy

OpenOpen RoboticRobotic

OR timeOR time 3 hrs3 hrs 2-4 hrs2-4 hrs

Hospital stayHospital stay 3 days3 days 24 hrs24 hrs

Foley catheterFoley catheter 14 days14 days 7 days7 days

Blood lossBlood loss 600 ml600 ml <100ml<100ml

RecoveryRecovery 4-6 wks4-6 wks 2-3 wks2-3 wks

Margin PositivityMargin Positivity

SeriesSeries % Positive margins% Positive margins Soloway Soloway (Open)(Open) 28 %28 % LeporLepor (Open)(Open) 26 %26 % GuillonneauGuillonneau (Laparoscopic)(Laparoscopic) 13.7 %13.7 % AbbouAbbou (Laparoscopic)(Laparoscopic) 20%20% RassweilerRassweiler (Laparoscopic)(Laparoscopic) 24 %24 % TurkTurk (Laparoscopic)(Laparoscopic) 26 %26 % BollensBollens (Laparoscopic)(Laparoscopic) 22 %22 % SulserSulser (Laparoscopic)(Laparoscopic) 18%18% MenonMenon (Robotic)(Robotic) 26%, 17%, 6%26%, 17%, 6% AhleringAhlering (Robotic)(Robotic) 17%17% LeeLee (Robotic)(Robotic) 21%21%

Continence DataContinence Data

SurgeonSurgeon 3 mo 6 mo 3 mo 6 mo12 mo12 mo WalshWalsh (Open)(Open) 54 % 80% 93%54 % 80% 93%

AbbouAbbou (Laparoscopic) (Laparoscopic) 58%58% 69% 78%69% 78%

GuillonneauGuillonneau (Laparoscopic) (Laparoscopic) N/AN/A N/AN/A 85 % 85 %

RassweilerRassweiler (Laparoscopic) (Laparoscopic) 54%54% 74%74% 97% 97%

MenonMenon (Robotic)(Robotic) N/AN/A 96%96% N/A N/A

AhleringAhlering (Robotic)(Robotic) 76%76% 91%91% 94% 94%

LeeLee (Robotic)(Robotic) 60%60% 82%82% N/A N/A

Potency DataPotency Data

AuthorAuthor Capable of IntercourseCapable of Intercourse Walsh (age 60 to 67) (Open)Walsh (age 60 to 67) (Open) 75%75% Catalona (60’s/70’s) (Open)Catalona (60’s/70’s) (Open) 60% / 47%60% / 47% GuillonneauGuillonneau (Laparoscopic) (Laparoscopic) 66% overall66% overall AbbouAbbou (Laparoscopic) (Laparoscopic) 54%54% TurkTurk (Laparoscopic) (Laparoscopic) 59%59% MenonMenon (Robotic) (Robotic) 64%64% AhleringAhlering (Robotic) (Robotic) 65%65% Lee (Robotic)Lee (Robotic) Too Too

earlyearly

Tulsa daVinci ExperienceTulsa daVinci Experience

Machine located at St. JohnMachine located at St. John>130 prostatectomies performed to date>130 prostatectomies performed to dateAverage operative time 2-3 hoursAverage operative time 2-3 hours>95% patients discharged in <24 hours>95% patients discharged in <24 hoursNo conversions to open surgeryNo conversions to open surgeryComplications: 2 post-op bleed, 1 port Complications: 2 post-op bleed, 1 port

site hernia, 1 anastomotic stricturesite hernia, 1 anastomotic stricture

daVinci Clinical ApplicationsdaVinci Clinical Applications

Urology: radical prostatectomy, Urology: radical prostatectomy, dismembered pyeloplasty, radical dismembered pyeloplasty, radical cystectomy, cyst decorticationcystectomy, cyst decortication

Cardiac: mitral and aortic valve Cardiac: mitral and aortic valve replacement, aorto-iliac bypass, off-replacement, aorto-iliac bypass, off-pump synchronized bypasspump synchronized bypass

GYN: hysterectomy, prolapse repair, GYN: hysterectomy, prolapse repair, tubal reversals, fistula repair, tubal reversals, fistula repair, myomectomymyomectomy

General: gastric bypass, NissenGeneral: gastric bypass, Nissen

daVinci Clinical LimitationsdaVinci Clinical Limitations

No advantage over standard No advantage over standard laparscopic approach for laparscopic approach for cholecystectomy, spleenectomy, cholecystectomy, spleenectomy, colectomycolectomy

Increased operative time observedIncreased operative time observedPrecise dissection not necessaryPrecise dissection not necessaryOpen space: limitations with broad Open space: limitations with broad

sweeping motionssweeping motions

daVinci vs. LaparoscopydaVinci vs. Laparoscopy

Laparoscopic surgical fellow at StanfordLaparoscopic surgical fellow at StanfordFirst 50 Roux-en-Y procedures randomized First 50 Roux-en-Y procedures randomized

laparoscopic or robotic with DaVincilaparoscopic or robotic with DaVinciBoth surgery with hand-sewn anastomosisBoth surgery with hand-sewn anastomosisOR time: 149 min (lap) vs 131 min (robot)OR time: 149 min (lap) vs 131 min (robot)No difference for complications, LOS, EBLNo difference for complications, LOS, EBLConclusion: Robot is an ENABLERConclusion: Robot is an ENABLER

Off-pump CABGOff-pump CABG

30 patients, 2.6 grafts/patient30 patients, 2.6 grafts/patient Majority: IMA to LADMajority: IMA to LAD 15/30 discharged <24 hours15/30 discharged <24 hours Complications:Complications:

- 2 return to OR for bleeding- 2 return to OR for bleeding

- 1 converted to open- 1 converted to open

- 2 readmits: pleural effusion, wound - 2 readmits: pleural effusion, wound infectioninfection

No mortalityNo mortality

Advanced EndoscopyAdvanced Endoscopy

Natural Orifice Surgery

Courtesy of N Reddy, Hyperbad India 20005

Courtesy of N Reddy, Hyperbad India 20005

Peroral Transgastric Endoscopic SurgeryPeroral Transgastric Endoscopic SurgeryNatural Orifice Transluminal Endoscopic Surgery Natural Orifice Transluminal Endoscopic Surgery

(NOTES)(NOTES)

Trans-gastric AppendectomyTrans-gastric Appendectomy

Climbing the Learning CurveClimbing the Learning Curve

Standard surgery: “see one, do one, teach Standard surgery: “see one, do one, teach one”one”

Robotic surgery: “see one, do one, kill one”Robotic surgery: “see one, do one, kill one” Requires entirely new skill set beyond Requires entirely new skill set beyond

traditional surgical and laparoscopic trainingtraditional surgical and laparoscopic training Training opportunities limited Training opportunities limited Animal labs helpfulAnimal labs helpful Cases require outside proctor to determine Cases require outside proctor to determine

competencycompetency Credentialing challenges??Credentialing challenges??

Surgical SimulationSurgical Simulation

Surgical SimulationSurgical SimulationRed Dragon/Blue DragonRed Dragon/Blue Dragon

Hand Motion AssessmentHand Motion Assessment

Robotic RoundingRobotic Rounding

Robotic Scrub NurseRobotic Scrub Nurse“Penelope”“Penelope”

Robotic Scrub NurseRobotic Scrub Nurse

Operating Room of the FutureOperating Room of the Future

Moral DilemmaMoral Dilemma

Technology is neutral - it is neither good or evil

It is up to us to breathe the moral and ethical life into these technologies

And then apply them with empathy and compassion for each and every patient

ConclusionsConclusions

The rate of discovery of new technology The rate of discovery of new technology is outpacing the ability of business, is outpacing the ability of business, society, and healthcare to integrate and society, and healthcare to integrate and applyapply

Robotic surgery is but one example of Robotic surgery is but one example of such technology that MAY reduce such technology that MAY reduce operative morbidity, hospital stay, and operative morbidity, hospital stay, and recovery, while POTENTIALLY improving recovery, while POTENTIALLY improving clinical outcomes, but at what point do clinical outcomes, but at what point do the BENEFITS justify the increased the BENEFITS justify the increased EXPENSE?EXPENSE?