The Robot Is In -- And Ready To Operate

More and more surgeries -- from prostate to heart -- are being performed by doctors remotely guiding robotic arms

You won't see R2D2 wielding a scalpel, but robots are increasingly appearing alongside surgeons and nurses in operating rooms. At a cost of $1.3 million each, a robotic system developed for the military and sold to private industry is helping doctors take out cancerous prostate glands, repair ailing hearts, even perform gastric bypass to help obese patients lose weight.

In such procedures, the surgeon's hands never enter the patient. After the initial incisions are made, robotic arms wielding a tiny camera and surgical tools make the snips, stanch the blood flow, and sew up inside when all is done. The surgeon sits at a console -- usually in the operating room, although the technology would allow a doctor to operate on a patient on the other side of the world -- peering into binocular-like lenses at views provided by the camera inside the patient. The doctor guides the robot's work by twisting his wrists in stirrup-like handles, moving his thumb and forefinger in scissor-like loops, or tapping foot pedals to focus the camera or move a robotic arm.

The most common robotic surgery is prostatectomy, or the removal of the prostate gland located just below the bladder in men. But surgeons also use the system, called the da Vinci by its maker, Intuitive Surgical (ISRG ) of Sunnyvale, Calif., for everything from heart surgery to gynecological and infertility operations. Its use has grown from just 1,500 procedures in 2000 to an estimated 20,000 last year.

Doctors who perform such surgery say they can see better because the smaller incisions mean less blood and the robot magnifies what's shown. They also say the robotic computer's ability to filter out routine hand tremors and scale down movements when tinier cuts are needed means more precision. Apart from smaller incisions and less blood loss, benefits for patients include less pain and shorter recovery times.

An older form of minimally invasive surgery, laparoscopy, also uses miniature surgical instruments inserted through small incisions -- although guided directly via long handles in the surgeon's hands -- and comes with some of the same advantages. But that method provides a two-dimensional view rather than the robotic system's 3-D vision and is harder for newcomers to master, says Dr. Vipul Patel, a Birmingham (Ala.) surgeon and a leader in robotic prostatectomies. Also, with laparoscopy, there's no computer to adjust the size of the surgeon's hand movements or screen out tremors.


Robotic technology doesn't come cheap, which is one reason it's in fewer than 300 hospitals worldwide. But while it might add, say, $1,000 to the surgical cost of a prostatectomy, and $4,000 to a heart mitral valve operation, total costs of around $24,000 (for a prostatectomy) and $30,000 to $40,000 (for the heart procedure) remain about the same because of savings from shorter hospital stays and less pain medication, according to surgeons who use the robot.

More than 8,000 prostate glands were removed robotically last year, up from 36 in 2000. The procedure accounted for more than 10% of the 75,000 prostatectomies done in 2004, says Intuitive Surgical. Surgeons who remove prostates robotically say the method has advantages. Undergoing open surgery may require a transfusion -- which brings a risk, though smaller than in the past, of blood-borne communicable diseases such as HIV. Busy professionals like the fact that they can be out of the hospital in a day, vs. two or three for open surgery, and resume normal activities in one week rather than six.

Cutting nerves around the prostate can lead to incontinence or impotence, so precision is important. Between 25% and 60% of conventional prostatectomy patients suffer from postoperative impotence, says Dr. Patel. Small studies of robotic surgery have shown at least a short-term benefit in terms of impotence and incontinence, says Dr. Kevin R. Loughlin, a professor of surgery at Harvard Medical School. But, he says, the evidence remains inconclusive.

Dr. Lothaire Bluth, of Gilbert, Ariz., opted for robotics when he had his prostate removed in 2003. He had heard about incontinence and impotence after prostate removal. A surgeon himself -- albeit one who operates on eyes -- he knew how to research the options. Bluth called hospitals and scoured the Internet. In the end, he traveled to the University of California at Irvine Medical Center to have his prostate taken out by a robot. Bluth now has four barely visible half- to 1-inch scars rather than a 6- to 8-inch one. And, he says, neither incontinence nor impotence is a problem.

Meanwhile, heart surgeons are using robotic technology to repair valves and bypass arteries without opening rib cages. A patient winds up with three or four half-inch incisions instead of a sawed sternum and an 8- to 10-inch gash. That translates into less pain, blood loss, and trauma, says Dr. Michael Argenziano, director of robotic cardiac surgery at New York Presbyterian Hospital-Columbia University Medical Center. Hospital stays drop from five to seven days to two or three, and time away from work is cut from two months to about one, he says.

Not every patient is a candidate. Complicated cases -- when the patient is very sick, needs multiple procedures, or has had previous chest surgery -- are not suited to robotics, Argenziano says. Nor can a heart transplant or artificial heart implant be done this way.

Naysayers point out that a robotic operation done by a novice can take twice as long as open surgery. (Experts say between 20 and 50 operations are needed to become proficient.). If the unexpected happens, the patient may wind up being opened anyway. Then there's the fact that while the robotic camera may let the surgeon see better, he never feels the tissue he is cutting, which can be helpful in determining how far a cancer has spread.

So patients who want robotics' smaller scars and quicker recovery times will need to ask hard questions. Find out how many times the procedure you need has been done robotically and what the advantages and disadvantages are. Just as important, ask how many robotic surgeries the doctor who will do yours has performed. In real life, you want the force of experience to be with you.

By Carol Marie Cropper

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