Robotic surgery less invasive, but slow to catch on

When it comes to surgical incisions, the smaller and less intrusive they are, the better off patients are likely to be.

And surgeons are becoming more and more creative about getting to internal organs via smaller and sometimes unorthodox routes, often using robotic devices to reach remote spots with instruments.

Minimally invasive surgery has been around for several decades and has become standard for procedures like the removal of damaged cartilage from knees or gall bladders through tiny holes.

More recently, there's been a trend of trying to leave no visible incision at all as surgeons in San Diego have reported the U.S. operations to remove a diseased appendix through the mouth and through a patient's vagina.

Aside from the tiny cut to remove the organ itself, only a tiny hole was made through the belly button to insert a camera that allowed the surgeons to see what they were doing.

The vaginal extraction of a kidney with a malignant tumor, carried out at a hospital in Barcelona, Spain, required two one-centimeter holes in the abdomen for a camera and robotic scalpel, according to the Hospital Clinic of Barcelona.

Patients in all the procedures got a quick release from the hospital and reported post-operative pain of 1 or 2 on a scale of 1-10, with 10 representing the worst pain.

Of course, the robotic surgeons are pricey. All the experiments above were part of trials supported by equipment makers. Many of the procedures don't catch on because relatively few hospitals can afford the equipment and insurance companies don't see such a marked advantage in outcomes that they're willing to pay a higher price for the minimally invasive procedures.

Another complaint is that with relatively few places doing the operations, only a small number of surgeons get a chance to train and become proficient with the robots. Indeed, many surgeons say working by remote control robs them of their sense of touch and forces them to rely on sight alone.

That's where the challenge lies for minimally invasive cardiac bypass surgery, one of the more popular but still rare keyhole procedures.

For hundreds of thousands of Americans, the signature of having had surgery to bypass one or more blocked arteries supplying blood to their heart is the scar of an 8-to-10-inch-long cut made down the center of the chest through the sternum (center of the rib cage) to gain access to the organ.

But for a few thousand patients treated at a handful of major medical centers in recent years, the scars of a bypass operation are only a few pencil-sized dots across the rib cage.

"Sixty to 70 percent of the people who get the procedure report they have no pain. We're able to discharge them in one or two days, and they can resume regular activity almost immediately," said Dr. Sudhir Srivastava, a leader in robotic heart surgeries practicing at the University of Chicago Medical Center, one of a few dozen in the country set up to do the procedure.

The operation also differs from conventional bypass operations because the graft arteries are harvested from inside the chest wall rather than from the leg and, if only one or two bypasses are being done, may not require the use of a heart-lung bypass machine.

The Chicago hospital has launched a five-year initiative to make robotic bypass surgery more widely available, both by training more surgeons on the procedures and by demonstrating to insurers that it can save money.

"From the financial point of view, there is no up charge for robotic bypass, so it's not that great for the institution right now, but better for the patient," said Dr. Valluvan Jeevanandam, chief of cardiothoracic surgery for the hospital.

Srivastava said surgeons typically have to do about 20 of the procedures "before they have a complete feel for it, so you need to have a fairly large patient load. The procedure can take longer than conventional surgery at first, but with greater proficiency, it takes about the same time in the operating room."

While Srivastava and others work to improve techniques and bring costs down for robotic surgery, other researchers are trying to give surgeons, who are sitting at robotic consoles 10 to 20 feet from the patient, back their sense of touch by calibrating the force and resistance of different steps in each surgery.

At first, this will be presented to the surgeons visually, but eventually, medical engineers hope to be able to transmit a real-time "feel" of what the robotic instruments are doing directly to the surgeon's fingertips.

www.euro-notes.org

surgery.ucsd.edu

uchospitals.edu