Thursday, July 28, 2011

Robotic surgery gains popularity

Patients appreciate faster recovery; surgeons report ability to see better
By Rhiannon Meyers
Corpus Christi Caller Times

Posted July 23, 2011 CORPUS CHRISTI — As the patient lay motionless on the table, her belly exposed and marked for a hysterectomy, Dr. Laura Shelton prepped for surgery.Shelton removed her plastic face shield and pulled off her sanitized surgeon's gown. She sank into a rolling chair, pushed up her long sleeves to the elbows and kicked off her tennis shoes.

For the next hour, Shelton performed the hysterectomy in a pair of pink and gray ankle socks sitting at a console 6 feetfrom the patient.

A live video feed from within the woman's abdomen illuminated Shelton's pale blue eyes as she worked a set of joysticks guiding robotic arms that cut, cauterized and sutured.

This, Shelton said, is the future of surgery.

The growing popularity of this pricey equipment — which can cost more than $2 million, according to some estimates — has sparked a debate on the merits and risks of robotic surgery.

Both local hospital systems now have surgical robots in an effort, hospital officials say, to provide minimally invasive surgery that shortens patients' hospital stays. Christus Spohn Health System bought one last year and Corpus Christi Medical Center added one in January.

Surgeons who use the robots say the technology allows patients to recover quicker because they lose less blood — less than a tablespoon, in some cases — and the incisions are smaller, sometimes less than half an inch.

"We can have them back on their feet in a week instead of six weeks," said Dr. Stan Shoemaker, an obstetrician/gynecologist who operates at Corpus Christi Medical Center. "It's a much more attractive alternative."

Advocates also say robotic surgery causes less physical strain on the surgeon and could lengthen a doctor's career in the operating room. Shoemaker said the robot also allows him to perform more challenging surgeries in a minimally invasive way.

"I'm not nearly as frightened about a tough case," Shoemaker said.

But others argue that the benefits are overstated and driven by marketing, at times by the robot's manufacturer, Intuitive Surgical Inc., which earned $1.4 billion in its last fiscal year.

One recent study suggested there was no solid scientific evidence to back claims that robotic surgery is more precise and results in less pain. The study, released in May by Johns Hopkins University School of Medicine researchers, also argued that hospitals often use Intuitive Surgical's promotional materials and fail to talk about robotic surgery risks, including claims that such surgeries can take more time, causing patients to remain under anesthesia longer, and that they are more costly.

There remains a healthy debate about the merits of traditional surgery versus the robotic procedure, said Dr. Benjamin Lowentritt, a urologist in Baltimore who solely offers robotic surgery.

"I don't think it does anyone any good to declare it as a cure-all and the perfect treatment," he said. "I would not advocate (open surgery) in my practice, but at the same time, I don't fault anyone for making that choice."

Still, Lowentritt said, it's difficult for any hospital to opt against offering robotic surgery because of the strong patient demand.

"I wouldn't want to go to a hospital that didn't have it for my prostate care," he said. "To be a center that provides the full complement of care to your patients, I think it is something that you should have."

Plus, he said, robotic surgery acts as a good recruiting tool for new surgeons.

"As time goes on, hospitals and communities that don't have them will more and more have difficulty attracting newer and recently trained physicians," he said.n n nFor the past 1½ years, Debra Cantu, 34, struggled with near-constant pelvic pain and an overactive bladder. She popped pain relievers at least three times a week and ran to the bathroom once an hour. She woke frequently at night to use the restroom.

Shelton diagnosed her with uterine fibroids, which are noncancerous tumors, and possibly endometriosis, a painful condition where tissue typically lining the uterus grows outside the uterus, becomes inflamed and eventually develops scar tissue and adhesions, which bind organs together and causes pelvic pain, according to the Mayo Clinic.

Shelton recommended giving Cantu a partial hysterectomy using Christus Spohn Health System's da Vinci robot.

The robots are controlled solely by the surgeon, who sits at a nearby console and views the surgery through a viewfinder, where the images are magnified 10 times and appear in 3D.

Robotic instruments, which look like miniature forceps, are inserted through tubes in the patient's body. The surgeon uses joysticks to direct them to pinch, cut and sew.

Using a pedal that looks like a car accelerator, the surgeon can move around a small, lighted camera, usually inserted through a tube in the patient's belly button, to peek around organs and zoom in on blood vessels. The surgeon uses another pedal to deliver bursts of electricity that cauterize, or burn, tissue and blood vessels to seal them and stop the bleeding.

As Shelton worked at the console Wednesday – shoeless, she said, so she could better feel the pedals – she navigated the instruments past organs and blood vessels that filled the flat-screen televisions on each side of the operating room.

Shelton pointed to scar tissue and adhesions that marred the inside of Cantu's pelvis and decided she had to do a complete hysterectomy. It was the only option, she said, that could relieve Cantu of her pain, even though it would force the mother of two into early menopause.

It was an option they had discussed in a pre-operative appointment, but once Shelton saw in excruciating detail the extent of the scarring from Cantu's endometriosis, she said she realized the problem was worse than expected. Cantu's ovaries had adhered to her abdominal wall and scar tissue was tucked underneath her uterus, a typically hard-to-reach area for a surgeon.

Shelton said she wouldn't have been able to see such detail with traditional surgery, which likely would have been more challenging.

"The visualization is key," she said. "I could see exactly where the adhesions were, exactly where to cut."

Lowentritt, who said he was skeptical at first of what he thought would be a gimmicky new technology, said the visualization provided by robotic surgery changed his mind.

"I feel like it has made me a much better surgeon because I could see for the first time in ways I couldn't with open surgery," he said.n n nWhile hospitals nationwide offer robotic surgery for a variety of procedures, from heart surgery to gastric bypass, the local hospitals so far only offer it for gynecological and urologic surgeries, such as hysterectomies and prostate removals.

All surgeons working with the robot must be trained.

Christus Spohn Health System bought its robot for urologists at Spohn Hospital Shoreline, but officials moved the robot in March to Spohn Hospital South so it could get more use, spokeswoman Katy Kiser said.

The hospital system has used it 115 times, and five gynecologist surgeons now operate on it, da Vinci representative Michael Isaac said. Kiser said the hospital system has plans to train more surgeons on the robot and expand its surgical offerings, but no plans to buy additional robots.

Corpus Christi Medical Center bought a newer version of the robot in January and surgeons there since have performed 150 gynecologic and urologic procedures, hospital spokeswoman Lisa Robertson said. Twelve hospital system surgeons are trained on the robot, she said.

Dr. Joseph Wagner, director of robotic surgery at Hartford Hospital in Connecticut, said he considers a robot thoroughly used at 500 cases a year.

He suggests hospitals consider expansion if their robots hit 350 to 400 annual operations, well above the usage level at Corpus Christi hospitals.

Kris Muller, spokeswoman for Corpus Christi Medical Center's parent company HCA, said robotic surgery does not cost patients more than traditional surgery. Some insurance policies cover the full cost, others do not, Shelton said.

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While the debate continues about the cost of the technology and long-term benefits for patients, there seems to be little argument that robotic surgery is better for the surgeon.

Surgeons say robotic surgery leaves them less fatigued, allows them to see better within the body and gives them the ability more easily to suture, or sew tissue, than they could with traditional laparoscopic surgery, a type of minimally invasive surgery in which surgeons work at the bedside using long, slender, chopstick-like instruments inserted through small incisions in a patient's body.

Dr. Alan Nesbit, a urologist who operates at Corpus Christi Medical Center, said the robot is easier on his body than traditional laparoscopic procedures, which left him exhausted.

His knees, hips and back ached after standing for five or six hours at a patient's bedside, his arms positioned in an awkward manner over the patient's body.

"No matter how strong you are, it's a very physical surgery," he said.

Shoemaker said, without the robot, his persistent back pain and arthritis likely would have forced him to take a break from surgery. Robotic surgery allows him to rest his back by sitting in a cushy chair at a console, instead of standing for hours at a patient's bedside.

"It's extended my surgical career by 10 years," he said.

At Cantu's hysterectomy on Wednesday, Shelton chatted easily while she performed complicated maneuvers within Cantu's pelvis. As she flicked her wrists at the joysticks, the robotic instruments pushed a tiny, thin needle with barbed-wire-like thread in and out of the tissue. Shelton said she was operating within a space the size of a pingpong ball.

This is the kind of technique that, if done in a traditional laparoscopic way, would have been more difficult and physically draining, Shelton said.

"I feel like I'm going to go exercise now and I wouldn't have wanted to go exercise had I done it laparoscopically," she said after the surgery. "I would've been too sore. I would've said, 'I've done my exercise for the day.'"

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Experts say robotic surgery is likely to expand in coming years, particularly as the technology improves. Surgeons say they expect the devices will get smaller and eventually provide tactile feedback, giving surgeons back the sense of feel that they traded for the magnified, high-definition vision that came with robotic surgery.

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