Sunday, September 5, 2004

In the arms of a robot

Remote-controlled devices
get increased surgical uses

By Tim Bonfield
Enquirer staff writer

Cardiothorasic Surgeon Dr. Bill Schneeberger demonstrates a robotic surgery apparatus at University Hospital.
(Michael E. Keating/The Enquirer)
When Jack Davis got his bypass operation in July, he expected to wind up with a long scar down his chest, as several of his friends had.

Instead, the 74-year-old Colerain Township man joined a small but rapidly growing fraternity of people who have received robotic surgery in Greater Cincinnati.

Rather than cracking open his chest, a surgeon at Good Samaritan Hospital guided tiny robotic "hands" mounted on slender metal probes that were poked between his ribs to perform the operation. The big chest scar was replaced by three quarter-sized "poke hole" scars that took far less time to heal.

Instead of waiting several weeks for his breastbone to mend, Davis was walking around and doing chores at home less than a month after surgery.

He recently started doing cardiac rehabilitation and this month he hopes to resume playing drums for a 13-piece big band called the Seven Sharp Orchestra. "There really was hardly any wound at all. Both my brothers-in-law had full open-heart surgery for quadruple bypasses. They looked at me and said, 'Oh my gosh, what a difference,' " Davis said.

Since the region's first da Vinci robotic system was installed in March, more than 110 people have had robot-assisted operations at two area hospitals. They join thousands who have been treated by more than 240 da Vincisystems worldwide, including 179 in the United States, according to the California-based manufacturer Intuitive Surgical.


Good Samaritan: 82 cases

20 cardiac bypass surgeries
28 mitral valve repairs
1 angina laser surgery
22 other chest operations
9 prostate removals
1 kidney removal
1 other urology case

University Hospital: 31 cases

10 cardiac cases
7 prostate removals
1 kidney removal
3 stomach surgeries
7 esophageal surgeries
2 gall bladder removals
1 adrenal gland removal


So far, 242 da Vinci robotic surgery systems made by Intuitive Surgical have been installed worldwide, including 179 in the United States.

Surgeons are using the robots, which cost about $1.2 million each, for a growing list of operations, including cardiac bypasses, heart valve repairs, prostate removals, gastric bypass, lung surgery, even kidney removals for organ transplant procedures.

Doctors also are studying ways to adapt the devices for neurosurgery, to develop surgery simulator systems to train other doctors, even to perform remote-control operations from half a continent away.

"Each time the FDA approves a new use, robotic surgery becomes more popular. We're almost to the point of buying a second system," said Dr. J. Michael Smith, a cardiothoracic surgeon and TriHealth's director of robotic surgery.

Local robots

Greater Cincinnati hospitals were slow to buy into robotic surgery. Devices already had been installed in more than 100 cities before Good Samaritan Hospital installed the first one in town - and that device was donated.

Within months, the University of Cincinnati and University Hospital installed two robotic systems, one for clinical use and one for research - one of which also was a gift.

Cincinnati Children's Hospital Medical Center has purchased a Zeus robotic system but hasn't used it because the manufacturer has stopped making the robot and hospital officials are not confident they will be supplied replacement parts.

TriHealth, which runs Good Samaritan Hospital, has aggressively marketed robotic surgery as a symbol of its high-tech care. For example, fans attending Cincinnati Reds games this season have frequently seen an advertisement that says: "108 stitches in a baseball. Just 12 for open-heart patients. Robotic Surgery. Good Samaritan Hospital."


The da Vinci robot was approved for use in the United States in 2000. It is the only robotic surgery system being sold in the U.S. today, after a merger with Computer Motion Inc., the company that previously made the competing Zeus robotic surgery system. Other, potentially competing systems are in various stages of development.

The da Vinci robot features a set of arms that are placed above the operating table and can extend probes into the patient's chest or abdomen. The probes carry pincers, cutters and other tools that are controlled by a surgeon sitting several feet away.

The small incisions allow for less blood loss and quicker recovery, supporters say. The ability to precisely control the robot hands and hold them in position without tremor or fatigue also helps reduce potential complications.

For example, not cutting the breastbone to conduct cardiac surgery eliminates rare but serious bone infections that can occur during the healing process. In prostate surgery, robotic tools that tremble less than even the steadiest surgeon's hand can avoid nerve damage.

Limitations and concerns

Some local hospitals are considering buying more robotic systems, but say they are taking a cautious approach.

TriHealth is considering a second robot, to be located at either Good Samaritan or Bethesda North Hospital. A scheduling bottleneck has already emerged because two urologists trained to use the robot are limited to using it primarily on one day a week.

The Mercy Foundation is considering launching a fund-raising campaign in 2005 to buy a robot system for Mercy Fairfield Hospital, officials said.

At University Hospital, where more than 15 doctors have been trained to use the robot, demand for access will soon overwhelm the capacity of the device.

But the Health Alliance of Greater Cincinnati, which runs University Hospital, has not decided whether it will buy another robot, officials said. Funding was delayed earlier this year for a robot proposed for Christ Hospital and the Alliance has no immediate plans to add robots at Jewish, Fort Hamilton or the two St. Luke hospitals in Northern Kentucky.

St. Elizabeth Medical Center - the biggest Northern Kentucky hospital system - also has no plans to buy a robot soon.

Robotic surgery "is not something we are looking to do in the immediate future," said Karla Webb, spokeswoman for St. Elizabeth.

The types of surgeries that can be done with the robot remain limited, Webb said.

Beyond the $1.2 million price tag, the da Vinci robot costs as much as $100,000 a year to maintain. That's expensive, but no more expensive than many MRI and CT scanners.

Costs questioned

Still, the biggest concerns about robotic systems have been proving they are worth the expense and figuring out ways to be reimbursed for using them.

Detractors say robots pose risks of their own. In many cases, operations take longer, which means patients spend more time under anesthesia. In some cardiac cases, patients also spend more time on a heart-lung machine. Both situations increase the risk of death or serious complications.

Meanwhile, hospital administrators say government programs and private insurers generally do not reward hospitals for investing in robotic devices. In most cases, insurers pay the same for a surgical procedure whether or not a robot is used.

At the University of Cincinnati, the interest in robotic surgery has focused more on research than immediate clinical care. Officials say robotic surgery is a big part of UC's new Center for Surgical Innovation, where experts have been working since September 2003 to design the operating room of the future.


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