A Brief History of Surgery
Surgery, like humankind, has evolved throughout the ages. The earliest known form of surgery dates back to nearly 12,000 BC. Prehistoric skulls found on the bank of the Dnieper River and a burial site in France show holes due to trepanation, the process of drilling through the skull to relieve intracranial pressure. Very early surgeons had only rudimentary surgical tools, such as small copper knives, obsidian scalpels, and chisels.
While these techniques and tools seemed to suffice for early civilizations, they are a far cry from what is available in the modern era of surgery. Solutions to the three major issues with surgery in the past – bleeding, infection, and pain – have been found with the introduction of methods such as cauterizing (the burning of tissue to stop blood loss and further damage), ligatures (material that ties closed a severed blood vessel), sterilization of surgical instruments, usage of sterile gloves, aseptic hospital conditions, and anesthesia.
Even greater refinements in surgery occurred in the second half of the twentieth century. In 1953, a German optics company named Zeiss introduced the first surgical microscope, which improved illumination and magnification, allowing for microsurgery. In the 1970s, the development of laser surgery permitted the repair of very delicate body parts.
Now, at the start of the new millennium, robotically assisted surgery promises to usher in a whole new era of medicine.
The da Vinci Surgical System
The da Vinci Surgical System, manufactured by California-based Intuitive Surgical, Inc., is an innovative robotic surgical system designed to perform complex surgeries while being minimally invasive. One of the most groundbreaking aspects of this system is that its precise surgical tools are controlled by remote access. The surgeon, sitting at a console located several feet from the patient on the operating table, uses hand controls and foot pedals to control the system.
Using three or four interactive robotic arms that can be locked in place or moved in real-time, the surgeon can use multiple tools at once. The machinery includes an arm with a scalpel, a pair of scissors, a bovie (which is an applicator of a high-frequency electric current that can cut, coagulate, desiccate, or fulgurate tissue), and various other electrocautery instruments. The last arm, controlled by the surgeon’s foot, is an endoscopic camera with two lenses. This allows for full 3-D stereoscopic vision of the procedure.
Robot-assisted Surgery at Yale
A leading research institution, Yale was certainly not slow in adopting this new surgical method. In 2006, Yale-New Haven Hospital became the third medical center in Connecticut to acquire the da Vinci Surgical System. The $1.8 million machine was first used by Dr. John W. Colberg, Associate Professor of Surgery (Urology) and Director of the Yale Uro-Oncology Program, to perform a robotically-assisted prostate surgery.
Colberg has performed thousands of open prostate surgeries in his career, and since the advent of the da Vinci Surgical System, he has performed over 100 laparoscopic robot-assisted prostatectomies. Though the pre-operative preparation work, such as anesthesia, X-rays, and blood work, is similar for both methods, Colberg speaks enthusiastically of the da Vinci System’s assistance in the procedure itself. “It is the same anatomy, just with different tools,” he says. “It’s actually a lot of fun.”
Patients seem to be attracted to robot-assisted prostate surgeries as well. In fact, Colberg notes that the market for robot-assisted surgeries is very patient-driven. Before Yale-New Haven Hospital acquired the da Vinci System, patients would often opt to have their surgeries at the Hospital of St. Raphael, the location of Connecticut’s first robot-assisted surgical system.
Dr. Adam Hittelman, Assistant Professor of Surgery (Urology) and of Pediatrics, is another surgeon trained to use the da Vinci System. His specialty is pediatric urological surgery, and he said the most common procedure that he performs using the da Vinci System is pyeloplasty.
This procedure, which involves reconstruction or revision of the renal pelvis to drain and decompress the kidney, is usually performed to treat uretero-pelvic junction (UPJ) obstruction. Hittelman performs one to two robotically-assisted pyeloplasties a month, and in most cases, the patient has requested the robotic method. Indeed, more and more patients are viewing robotic surgery as an enticing alternative to traditional open surgery.
The da Vinci System offers many advantages over open surgery for both the surgeon and the patient. For the surgeon, the robotic arms offer greater mobility since their range of rotation is not constrained like the human wrist’s. As a result, an action like cutting off tissue can be performed smoothly with one stroke instead of multiple jerky movements. The robotic arms are also capable of removing human tremors: large movements are converted into small movements by the computer, and minute twitches and shakes are almost completely eliminated. The four arms of the da Vinci System also enable more multi-tasking during the procedure. The camera probe allows for not only 360 degrees of vision, but also for 3-D spatial viewing and 8 to 10–fold magnification.
Colberg spoke highly of the increased accuracy and efficiency of prostatectomies with the da Vinci System. For example, blood transfusions have become very rare with the usage of the new technology. Moreover, the handy electrocautery instruments minimize bleeding during the procedure, allowing for a cleaner surgical site and thus a clearer view for the surgeon. According to studies reported on the da Vinci Prostatectomy website, the estimated blood loss for a da Vinci prostatectomy (dVP) is only 109 mL, compared to 380 mL for a laparoscopic prostatectomy and 1355 mL for an open prostatectomy.
A dVP is minimally invasive. Only five small incisions are made, mere millimeters in size, for the four arms and the camera. An open prostatectomy, on the other hand, involves a single large incision in the abdomen. Chances of infection are therefore much lower when the robotic system is used. The suture of the urethra and bladder is also cleaner, and incidents of leakage in the bladder are rarer.
In the past, typical prostatectomies took five to five and a half hours. With the da Vinci System, however, the same procedure can be done in less than two hours. The patient’s recovery time is also reduced from nearly a week to only one or two days.
Finally, studies have shown that a dVP leads to four times fewer major complications following surgery. The statistics for minor complications are similar, with only 3.7% of patients experiencing them after a dVP compared to 12.6% after an open prostatectomy. Recovery of full urinary and sexual function also tends to occur faster after a dVP.
As with any new technology, robot-assisted surgery is not without its flaws. First, the machines are not cheap. Intuitive Surgical currently has no competitors, and the robot itself costs $1.8 million.
In addition to the fixed price are other variable costs. Colberg estimated that disposable parts for the system are between $1200 and $2000 per case, meaning that the price of the procedure is quite high for the patient. As Hittelman explained, “Physicians have to be more cost-conscious as everyone in the medical field has to be. The robot is an expensive way of doing things, though justifiable in many cases.”
The da Vinci System may also not prove advantageous for all surgeons. Colberg and Hittelman both pointed out that while the majority of surgeons can perform faster using the robot, this depends on the skill level of the surgeon. For some, the extra degree of freedom provided by the da Vinci System might be superfluous. Surgeons who have decades of experience with open surgeries and laparoscopic procedures, for example, may work just as fast or perhaps even faster without the da Vinci System.
Robot-assisted surgery is also not for all patients. Although the ports of the robot that are inserted into the patient are not that large, they can cause problems when used to operate on infants. Hittelman, who works with children of all ages, often opts to use laparoscopic procedures instead of robot-assisted surgery on his younger patients, as the port size is 2 mm compared to the robot’s 5 or 8mm. Usually, patients between the ages of three and five are ready to be considered for surgery with the da Vinci System.
Another shortcoming is that arguably one of the most important aspects of surgery, especially urological surgery, is not accounted for with the new system. That aspect is the sense of touch. Surgeons who use the da Vinci System do not have tactile feedback when in the remote console. Irregularities of texture and density, often characteristic of cancerous tissue, cannot be detected and thus may be overlooked during the procedure.
As a result, some members of the surgical field – particularly older ones, noted Colberg – are more reluctant to transition to robot-assisted surgery, as they claim the system does not and cannot fully present the whole picture.
The advent of the da Vinci System may also prevent new and upcoming surgeons from performing open surgeries. While many are trained during their residencies to use the da Vinci System, open surgeries are being performed less and less. Since successful open surgeries require more technical skill and experience than robot-assisted surgeries, newer doctors may find themselves ill prepared to switch spontaneously to an open-procedure if complications arise.
Future of Robotics in Surgery
Yale continues to purchase newer and smaller ports for the da Vinci System, and as newer models are coming out, Hittelman mentions that Yale may consider purchasing another machine. A greater variety of surgical procedures are now being performed with the da Vinci System, including hysterectomies, bladder removal, and even appendix removal through the vagina.
It is also theoretically feasible for the da Vinci System to be operated over longer distances. Some hope that surgeons in developed countries may eventually be able to perform “telesurgeries” on patients in third world countries.
Despite its drawbacks, the motto of Intuitive Surgical says it all: robotics in surgery will soon be “taking surgery beyond the limits of human hands.”