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Published: Monday, 9/16/2002

Remote-control surgery

BY LUKE SHOCKMAN
BLADE STAFF WRITER

Melba Young's blockage in the main artery supplying blood to her legs came at a good time.

A few years ago, doctors would have sliced her open from her sternum to her waist to bypass the clogged artery. She'd be laid up for at least a week. Recovery would be slow and painful.

Today her surgeon at St. Vincent Mercy Medical Center in Toledo looks at her insides with the aid of a remotely controlled camera, which will display her internal blockage on a computer screen. Instead of a large cut, tiny instruments will be inserted through small incisions to perform the bypass. Recovery will be quicker and less painful.

So painless, in fact, she later said she was a little suspicious when she woke up.

“After the surgery I woke up and argued with them that I hadn't had it yet,” she chuckled.

Ms. Young's experience could become more common over the next decade as surgeons begin to exploit technology allowing them to operate on patients using tiny remotely controlled instruments. Surgeons have been using similar laparoscopic instruments for years for knee replacement surgery and other procedures. The technique is referred to as “minimally invasive surgery.”

What's new is that some surgeons are beginning to use machines - sometimes referred to as robotic surgery - to control those tiny instruments. These machines range from basic voice-controlled arms that hold instruments to complex cutting and sewing arms controlled, through a computer console, by a surgeon.

Dr. W. Randolph Chitwood, Jr., a cardiac surgeon at East Carolina University in Greenwood, N.C., said the technology is called “robotic,” but humans are still in charge of all the movements.

“This is really telemanipulation.” he said. “It's like having a long pair of scissors with a million-dollar middle [the computer].”

Using this technology, surgeons are trying complex surgeries once thought off-limits. For example, trying to do a bypass of a major artery like that in Ms. Young's leg would have been unheard of 10 years ago.

These new surgical techniques could theoretically reduce patients' recovery time and cut down on complications such as infections. Surgeons have long known that a large gaping incision is both a risk for infection and a cause of inflammation, which causes soreness and slows down recovery time.

“If you were to have heart surgery and do it [by cutting open the chest] you'd be back to work in four to six weeks,” said Dr. Robert Michler, chief of cardiothoracic surgery at Ohio State University Medical Center and a user of robotic surgery technology. “I've had patients who came in, we did it minimally invasively, and they left the hospital the next day and were back to work by the end of the week.”

Dr. Juan Arenas, a transplant surgeon at the University of Michigan Medical Center, said surgeons there got a robot surgery system recently and are enthusiastic about the new technology.

“It's hard to get the robot sometimes because everyone wants to use it,” he said. “We're just seeing the beginning of this technology. It will revolutionize many of the procedures we do.”

The field of “robotic surgery” is in its infancy, but Ms. Young's surgeon, Dr. Bernardo Martinez, thinks the day is coming when the technology will become standard for many types of surgery.

“It's like knee surgery today. Who does open-knee surgery now? This is where everybody is going,” he said.

Well, maybe.

Some surgeons are still skeptical of the technology and feel the robotic surgery field needs much more study before widespread use.

“Its introduction into clinical medicine has been premature, and it's still a long ways off before patients will actually benefit from it,” said Dr. Michael Mack, a cardiac surgeon and chairman of the Cardiopulmonary Research Science and Technology Institute in Dallas.

Dr. Mack, who took part in the initial clinical trials of some of the robotic technology, said robotic surgery has potential, but there's still no proven benefit to patients. While the Food and Drug Administration has approved the technology for some surgeries, the government did not say the technology was better than conventional technology.

“I just think [the technology] isn't getting there as fast as everybody wants it to,” he said. “I don't think every hospital on every street corner needs one of these.”

Dr. Mack said the public is fascinated with robotics, but needs to realize that this technology is being pushed by companies hoping to sell it. When he and his colleagues did a trial, “we practically had to talk patients out of it they were so enthused about it,” he said.

There are two main competing technologies for robotic surgery: The da Vinci system, which is in use at Ohio State University Medical Center and University of Michigan Medical Center; and the Zeus system, which is in use at Cleveland Clinic and the Children's Hospital of Michigan in Detroit. Each system costs about $1 million, not including annual maintenance contract expenses. There are about 50 Zeus systems and 100 da Vinci systems in use nationwide.

St. Vincent has some of the Zeus technology, but not the full complement. There are three basic components to Zeus:

  • A robotic arm called Aesop. This holds a camera or other instrument steady.

  • A computer called Hermes. This can process images and control the Aesop arm through the use of voice commands from a surgeon.

  • A console called Zeus. Think of a computer video game in which a player, in this case a surgeon, sits at the console and controls surgical instruments by turning knobs and joysticks on the console.

    Dr. Martinez has been using Aesop and Hermes since 1998 and has done about 200 operations. He's trying to convince St. Vincent's to purchase Zeus as well because he thinks if medical centers don't embrace the new technology, they'll be left behind.

    “We have to either run with the big boys or not run at all,” he says.

    A native of Argentina, Dr. Martinez talks in a rapid, Spanish-tinged dialect as he explains his surgical techniques. He greets a Blade reporter and photographer outside a St. Vincent's operating room where Ms. Young waits for him to begin.

    Her operation starts out on the operating room as Dr. Martinez punches several small access holes through her skin and tissue. He inserts various medical instruments, as well as a slender camera.

    Dr. Martinez peers at an overhead computer monitor that displays internal images of Ms. Young's insides; images that are coming from the tiny camera. With his hands controlling laproscopic instruments, he slowly pokes and snips tissue, searching for the blockage. Every few minutes he gives a command, such as, “Hermes. Up. Stop.” And the camera moves up a few centimeters and stops. For the next seven hours he'll carefully manipulate miniature cutting instruments to bypass the blockage, all the while guided by the Hermes-controlled camera.

    “It went great,” Ms. Young said of the surgery. “I only had pain medication one night.”

    Three years ago the blockage in her artery made walking painful and next to impossible, she said. While it's still early, the 74-year-old Delta woman said she can already move around better than she has in years.

    Dr. Richard Satava, a surgeon at the University of Washington in Seattle, said stories like Ms. Young's of reduced pain and quicker recovery time are nice, but he thinks the benefit of robotic surgery to hospitals, doctors, and nurses is even greater.

    Using a robot system should dramatically cut down on the number of operating personnel needed, he said, which is good because of the growing doctor and nurse shortage.

    “The idea is we're going to get everyone out of the operating room and replace them all with robots, and just have the surgeon,” he said.

    Dr. Satava, a big supporter of robotic technology, acknowledged he's biased because he helped develop the technology.

    Robot technology started when the military began exploring its use on the battlefield. Dr. Satava was at the top-secret Defense Advanced Research Projects Agency (DARPA) in the early 1990s assisting the military in studying robotics. The idea was surgeons could be stationed miles from the front line, and then beam commands to robotic surgical machines at field hospitals on the front lines. In fact, experiments in the last several years have shown this feat is possible even across thousands of miles, although researchers caution it's still experimental.



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