The robot will see you now

The next time you need surgery, a complex piece of machinery might be holding the scalpel

Published: 10/14/2007 7:02 PM

You wouldn't know these people have just had major surgery.

Men who've had a double bypass walk out of the hospital carrying their own luggage. Women go grocery shopping two days after hysterectomies. Prostate cancer patients golf within a month. It's hard to find their scars.

The fast recoveries come thanks to a robot that's becoming the darling of local surgeons. Over a dozen Chicago-area hospitals have purchased Intuitive Surgical's da Vinci robotic system, and they're using it for everything from radical prostatectomies to complex abdominal surgeries.

The minimally invasive approach promises smaller incisions, less blood loss and shorter hospital stays.

In the operating room, a multi-armed robot hovers over the patient. A few feet away, the doctor sits at a console to control surgical instruments attached to the robot's arms. Video screens give him a three-dimensional view inside the patient.

Doctors who use the robot say the magnification lets them see better than in open surgery. The instruments have wristlike hinges, making them more flexible than traditional laparoscopic devices. The robot also allows for tiny, precise movements; its hands have no tremor.

In some fields, the da Vinci has already transformed medical practice. Since it won FDA approval in 2000, the da Vinci has come to dominate prostate surgery. Roughly 65 percent of the 90,000 prostatectomies performed in the U.S. each year are done robotically.

Urologists expect that number to climb even higher. At some hospitals with the $1.5 million da Vinci system, nearly all prostate surgeries are done via robot.

"I bet in five years, any hospital that doesn't have a robot will have a hard time attracting surgeons graduating from residency programs, especially in urology," said Dr. Arieh Shalhav, a urologist who specializes in robotic surgery at the University of Chicago Medical Center.

The robot is particularly good in reconstructive work, including the delicate sutures required in prostate surgery, Shalhav said. Studies show men regain continence a little faster after a robotic prostatectomy. Some doctors believe the robot preserves sexual function better than open surgery, though there's no good proof of that, Shalhav said.

Men lose about eight times less blood with a robotic prostatectomy, so they feel stronger and have more energy afterward, Shalhav said.

"When we do it with a robot, they're bouncing back much quicker," Shalhav said.

Robotic revolution

The next big frontier for robotic surgery could be gynecological procedures, where traditional laparoscopic techniques are so difficult to learn that few surgeons perform them. It's an even bigger market than prostate surgery, with over 600,000 hysterectomies performed annually in the U.S.

Dr. Karen Fish, a gynecologist at Advocate Lutheran General Hospital in Park Ridge, switched from laparoscopic hysterectomies to robotic ones. She predicts more gynecologists will adapt to the robot as a minimally invasive option.

"The difference is amazing," she said. "You go from standing by the patient looking at a flat screen, to a sensation like you're sitting inside the pelvis when you're operating."

Mary Lockhart of Batavia chose a robotic hysterectomy last December. Lockhart, 39, had large uterine fibroids that caused constant pain and heavy bleeding. Fish persuaded her a robotic procedure would result in a faster recovery.

"I didn't want to have the traditional hysterectomy line across my stomach," Lockhart said. "I didn't want to be laid up a lot."

Lockhart went home the day after her surgery, taking only ibuprofen for her pain. Two days later, she went grocery shopping.

"I was back to my full aerobics class three weeks after the surgery," Lockhart said. "I felt awesome. I did not realize the amount of pain I was in until after the surgery."

Other than transforming her belly button from an outie to an innie, Lockhart has little outward sign of the surgery. Her scars are tiny, she said.

Hospitals are expanding the range of surgeries they offer via robot.

Advocate Good Shepherd Hospital in Barrington is using its da Vinci robot to remove cancerous bladders and kidneys with much smaller incisions than traditional surgery. All but a few of the hospital's prostatectomies are now done robotically, said Dr. David Goldrath, chief of surgery.

At Condell Medical Center in Libertyville, surgeons are using the robot for mitral valve replacements, colon resections, gastric bypass and prostate removals.

Some of the larger medical centers in the Chicago area are developing multi-specialty robotic programs. At the University of Chicago, for example, doctors are using the da Vinci robot for cardiac surgery, to remove bladders, repair vaginal prolapse, perform hysterectomies and repair aortic aneurysms.

Advocate Lutheran General Hospital in Park Ridge just bought its second da Vinci robot and recruited two Italian doctors to help expand its program. Doctors Fabio Sbrana and Pier Cristoforo Giulianotti specialize in surgeries of the pancreas, liver, stomach, lungs and esophagus.

Earlier this year, Giulianotti performed the Midwest's first robotic Whipple procedure at the University of Illinois Medical Center in Chicago, where he is also on staff.

That's a challenging cancer surgery that involves removal of the gallbladder, bile duct, part of the stomach and duodenum and the head of the pancreas. It usually requires a long abdominal incision. With the da Vinci, Giulianotti operates through a few small slits.

"In my opinion, it's the surgery of the future," he said. "If you think about lung cancer, you have the possibility to remove a whole lung or part of a lung without fracturing the ribs."

Learning curve

Not every experience is so laudatory. The da Vinci robot has a learning curve; even experienced surgeons need to learn new skills.

A woman whose husband died after a doctor using the da Vinci robot accidentally cut two of his main arteries sued the Florida hospital, alleging he lacked experience with the device.

For the most part, cardiac surgeons have been reluctant to convert their programs to robotic procedures. While the robot offers a way to avoid splitting open a patient's chest, it takes longer to do a coronary artery bypass graft with the robot, especially as a doctor is learning the technique. Surgeons complain it lacks the tactile sense of open surgery.

Central DuPage Hospital in Winfield trumpeted its robotic heart program in 2004, but no longer uses the robot for heart bypass. Only one doctor was trained in those techniques, and he moved out of state. Now the hospital uses its da Vinci mainly for urology and gynecology procedures.

At other Chicago-area hospitals, cardiac surgeons use the robot to replace heart valves or harvest arteries to use in a bypass, but not for an entire bypass graft surgery.

The University of Chicago Medical Center is purposefully bucking that trend.

"We're one of 75 open heart programs in the area. You need to differentiate yourself," said Dr. Valluvan Jeevanandam, chief of cardiac and thoracic surgery at the hospital.

The hospital recently recruited Dr. Sudhir Srivastava, a surgeon from Odessa, Texas who has performed 300 bypass operations with the da Vinci system. University of Chicago already attracts "Hail Mary" cases turned down by other doctors; it also wants the minimally invasive market, Jeevanandam said.

"If you have an executive who wants to do this and go back to work or play golf in a week, this is the only way to have cardiac surgery," Jeevanandam said.

With the da Vinci robot, Srivastava operates through four or five dime-sized incisions. He operates on a beating heart, so patients don't go on a heart-lung machine. The result is lower mortality and fewer transfusions, Srivastava said.

"Because there's less trauma, these patients experience very little pain," Srivastava said. "A lot of our patients go home on Tylenol."

Right now Srivastava is the only surgeon at U of C performing heart bypasses with the robot. He plans to train others, but doesn't expect cardiac surgeons to switch to the robot as rapidly as urologists did.

"Because cardiac surgery is a life-or-death situation should certain complications occur, I think people are more careful," Srivastava said. "Not all surgeons have gotten on board."

Competitive edge

Hospitals are competing for patients who demand cutting-edge medicine, and some doctors say hospitals without the robot will be shut out of certain procedures.

In the short term, at least, low-volume robotics programs are probably losing money. Insurers don't pay higher rates for a robotic prostatectomy than a traditional one, despite the $1.5 million investment in equipment. If these surgeries take longer to do, a doctor will have time to do fewer procedures.

"Only when you use a robot six times a week, then it becomes financially sound," Shalhav said. "If you don't do six cases a week, you're actually going to lose money."

But hospitals are jumping on board. Intuitive Surgical has sold over 650 of the da Vinci robots.

Other local hospitals with a da Vinci robot include Northwestern Memorial Hospital in Chicago, Loyola University Medical Center in Maywood, Rush University Medical Center in Chicago and Weiss Memorial Hospital in Chicago.

Some hospitals are doing robotic prostatectomies and little else. But they expect their programs to grow.

At Condell, Valerie Sosnowski, director of surgical services, agrees the da Vinci is a "necessity" for a hospital to attract patients and surgeons. Since they got the robot last year, Condell surgeons have done 61 operations -- mostly prostates, but also mitral valve replacements, colon resections and gastric bypasses.

"We really need to get out there and market it," Sosnowski said.

Lutheran General more than doubled its volume of robotic surgeries in the past two years, with about 170 surgeries in the past 12 months.

Surgeons at Northwest Community Hospital in Arlington Heights used the da Vinci about 50 times last year; the hospital expects to double that this year, said Linda Page, robotics coordinator.

"Patients are a lot more savvy than they used to be, and they're investigating all their options," she said. "They'll be seeking out the hospitals that have the technology, and I think the hospitals that don't will find they may suffer in patient volumes."