Robot surgeon’ may improve results, quality
Patients find procedures less painful
Brigham and Women’s Hospital in Boston has seen the future of cardiac surgery — and it’s a robot. The facility currently is using a robot called da Vinci to handle fine-motor surgical activities such as snipping and suturing. It has "assisted" in coronary bypass surgery and mitral valve repair, making incisions that span 2 inches instead of the usual 12.
"It’s really a merger of several different technologies," says John Fernandez, vice president of surgical services. "Computer graphics are used to enlarge the objects in the field; there are two handles for the surgeon, who makes his usual motions, which are then duplicated by the machine inside the patient. [Another component] is battlefield technology, which spurred the ability to perform surgery from remote locations," he says.
In practice, the system works like this: The surgeon makes the initial, small incision, into which the robot’s arms are inserted. The surgeon then looks through a binocular-like eyepiece onto a large computer screen that can zoom to a field 200 or 300 times normal and performs the surgery, adjusting the "zoom" setting as required.
Advancing techniques
There were three main reasons for making the da Vinci investment, Fernandez says. "One, we wanted to continue to advance our minimally invasive surgical program," he says. "It was felt by both clinical and administrative leadership that if we wanted to do that, this was one of several things in which we’d have to invest."
In addition, he says, Brigham and Women’s was in search of avenues through which it could continue to differentiate itself from other providers. "The best way to do that is to provide something that patients would see as a better, less-painful service. The hospital’s chief of cardiac surgery was aware of the use of robots in cardiac and abdominal surgery and became a leader of the program. "He recognized that if we didn’t have to have a sternotomy, this could benefit a whole lot of people in a big way," Fernandez explains. "It also offered a spin on the market differentiation concept for cardiology."
Various systems were researched, tested, and compared with each other. Once da Vinci was selected, surgeons had to be trained in its use. "The training time seems to be shortening, but it’s generally a couple of days of formal training, then practice on cadavers, and then observation by one of their trained colleagues," he says.
"For the general surgeon who already does laparoscopy, the training primarily involves minor adaptations to what we already do," adds David Brooks, MD, who has used da Vinci to remove gallbladders and perform pelvic, bowel, pancreatic, and esophageal procedures. "For the nurses and scrub technicians, learning how to set up and service the device is a major undertaking, which adds incredibly to the complexity of the OR."
Improved quality anticipated
While the system is too new to have meaningful data, Fernandez is confident it will significantly improve quality of care and patient satisfaction. "There are German studies that show patients have less pain and don’t stay in the hospital as long," he reports. "Our own chief of cardiology has been doing minimally invasive valve surgery [prior to da Vinci], which does not involve cracking the sternum. Patients want it; it reduces pain and length of stay. One of the big, harsh realities of cardiac surgery is that sternotomy is unbelievably painful."
While the hospital’s thoracic surgeons already have found out how to work through minor incisions on the side of the chest, "They figure if they can have a little hand inside somebody’s chest, it’s that much better," Fernandez says. "With da Vinci, the surgery is even less invasive, whether you’re talking about cardiac or general surgery." In addition to the aforementioned quality advantages, "One could assume less blood loss and fewer comorbidity factors like infection due to body trauma," Fernandez says. "It’s all part of the theory of not having a big incision."
A major investment
At the present time, da Vinci is not for everyone, or for every budget. It comes with a cost of about $1 million, and that’s just for the hardware. "Operationally, it represents a fair amount of expense per case in terms of product and instrumentation," Fernandez says. "We hope over time the operating costs will come down, as happens a lot with technology." Does he see the overall cost coming down to a point where most hospitals could afford it? "My guess is the use may become more widespread, but it may not be like laparoscopic surgery," he predicts. "There’s a massive technology transfer in human terms."
As for Brigham and Women’s, administrators view da Vinci as a long-term investment. "Over time, we see it as a big plus in patient care; attracting more patients will make this a worthwhile multiyear investment," Fernandez asserts. "We took a long view on [our return on investment], because we knew that in the first or second years, we might not have 150 patients who wanted the new technology," he adds. "We also felt over the long haul that part of our mission is to teach the next great people, so we’re making an investment now that will give us the lead in this area in the future."
For more information contact: John Fernandez, Vice President of Surgical Services, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. Telephone (617) 732-7716. E-mail: [email protected].
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