07 February 2006

Robot Surgeons: For Prostate Cancer and Gastric Bypass?

Robotic surgeons may seem like science fiction, but they are routinely helping human surgeons perform surgeries across the world, especially North America. Prostate cancer surgery is benefitting immensely from robotic surgeons, since the robots can be more precise in nerve-sparing, allowing men to retain important functions of elimination control and sexual performance that can easily be lost during such surgery performed by a human surgeon.

At the USC Center for Pancreatic and Biliary Diseases, surgeons perform increasingly complex procedures on the liver, pancreas, and associated ductal systems.

The world experience on the use of the Da Vinci Robotic System for surgery on the pancreas, bowel duct, and liver is limited. We have developed experience with this robotic system for the following surgical procedures:

* Bile duct reconstruction
* Hepaticojejunostomy (suturing an obstructive bile duct to the intestine to provide drainage to a bile duct blocked by tumor or other cause)
* Distal pancreatectomy
* Reconstruction of the gastrointestinal tract after a Whipple operation
* Laparoscopic cholecystectomy
* Laparoscopic adrenalectomy
* Pancreaticojejunostomy and the Peustow procedure (suturing the jejunum to the pancreatic duct to provide drainage of pancreatic juice into the intestine in patients with obstruction of the pancreatic duct).

Many more procedures of increasing complexity are being researched for these robotic systems. Read more from "Howstuffworks" and "Futurefeeder":

The first generation of surgical robots are already being installed in a number of operating rooms around the world. These aren't true autonomous robots that can perform surgical tasks on their own, but they are lending a mechanical helping hand to surgeons. These machines still require a human surgeon to operate them and input instructions. Remote control and voice activation are the methods by which these surgical robots are controlled.

Robotics are being introduced to medicine because they allow for unprecedented control and precision of surgical instruments in minimally invasive procedures. So far, these machines have been used to position an endoscope, perform gallbladder surgery and correct gastroesophogeal reflux and heartburn. The ultimate goal of the robotic surgery field is to design a robot that can be used to perform closed-chest, beating-heart surgery. According to one manufacturer, robotic devices could be used in more than 3.5 million medical procedures per year in the United States alone. Here are three surgical robots that have been recently developed:

* da Vinci Surgical System
* ZEUS Robotic Surgical System
* AESOP Robotic System

More at Howstuffworks.

The Da Vinci surgical system has enjoyed a lot of publicity recently. Here is an excerpt from an article in Future Feeder:
. . . In robotic-assisted surgery, the da Vinci robot is an extension of the surgeon’s hands in a way not previously possible with minimally invasive surgery via laparoscopy, he said.

“And that’s the key to its success,” Boggess added. “The robot takes us a big step beyond traditional laparoscopy. It allows us to operate more naturally, the way we do in open surgeries, but still preserve a minimally invasive approach with small incisions.”

As in laparoscopy, robotic surgery involves small incisions of one-fourth to three-fourths of an inch, into which sleeves are inserted as ports for placement of specialized instruments and a video camera.

“Robotic surgery allows us to virtually place our hands inside the patient without the need for large incisions,” Boggess said.

After sleeve placement, the robot, much like a post with three arms, is wheeled over and its center arm docked to a port that holds the camera and the other arms docked to the instrument ports.

However, surgery with the da Vinci does not mean close proximity to the patient. Unlike with laparoscopy, the surgeon is seated across the room from the patient, with arms inserted into the nearby console, fingers on stirrup-like holders and eyes fixed on lenses for sharp magnified images of the surgical site. Focus is adjusted via foot pedals.

While laparoscopy allows manipulation of instruments up, down and side-to-side, surgery with the da Vinci allows more natural wrist movement.

The robot’s arms have wrists with eight degrees of freedom that allow the surgeon “to bend around corners and work in ways that are much more natural,” said Boggess. This allows full range of motion and the ability to rotate instruments 360 degrees through tiny incisions. Direct and natural hand-eye instrument alignment is similar to open surgery, with “all-around” vision and the ability to zoom in and out.

Another advantage with da Vinci is the elimination of tremor. Surgeons can scale, or ratio, their finger movement to that of the robotic instrument. A movement of inches at the console can be scaled down to centimeters in the patient.

So even a surgeon with a tremor can perform flawlessly with the Da Vinci surgical robot. The robot is actually an improvement in many ways, on the natural human surgeon--but it depends on the human surgeon. It is an augment, not a replacement.

These machines are quite expensive, and still experimental for many procedures. Nevertheless, in settings where medical provision is by private pay, these machines should gain in use. In settings of government provided medicine, the machines will take much longer to attain wide use, due to cost constraints.

Eventually, cardiothoracic surgeries and intracranial surgeries will be done routinely by robot, due to the delicate nature of those procedures.

Modern machines are capable of doing things that our grandfathers would not have imagined. Years in the future, our grandchildren will say much the same thing about their machines, referring to us and our own limited imaginations. This technological acceleration can be thought of as an intimation of the singularity.

Update: Here is a buy recommendation from Oneguysinvestments for ISRG, the company behind the da Vinci robot system.
Several new studies were released this year indicating continued improvements in cancer control, continence and sexual function for robotic prostatectomies -- 20% of prostatectomies are already performed with the da Vinci, and I think patient demand should continue to drive that much higher (their goal is hitting 25% this year, which I think is conservative). The only argument against da Vinci prostatectomies is now the high up front cost. It's definitely worth listening to the call (archived on their website) just for the clinical update.

My opinion on the cost issue: In most cases hospitals can't charge more for the robotic procedures than for open procedures, but in the future this might change with the clear benefits to insurers of much shorter hospital stays and better results.

Mitral valve repair, gastric bypass, and "da vinci hysterectomy" can all be significant drivers of procedure growth if the good results we've so far seen continue. The huge gynecological market is just beginning to be tapped and may show growth that compares to prostatectomies in the coming years (but for a much larger market). It took about two years of study before the prostate surgery took off for ISRG, so the gynecological growth may be a year or two from hitting its stride.

Read the whole thing and see what you think. I make no recommendations for investments on this blog.


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