Robotic surgery is safer, more precise and the best way for patients in remote places to receive proper health care, argues Richard Satava, a Professor of Surgery University at the Washington Medical Center. New innovative types of surgery will change how we look at doctors and the tools they use to heal the sick.
This is the fifth and final article in a series of Celebrity Guest Writers offering their insight into issues close to their experiences. See below to check out what other topics these guest contributors investigated and discussed.
See part one, by Lieutenant Governor David Onley, at this link
See part two, by former police officer Jack Cole, at this link .
See part three, by online video producer Miles Beckett, here
See part four, by Lavalife CEO Marina Glogovac, at this link.
by Richard M. Satava
In 1995, the first surgical robot was commercialized by Intuitive Surgical, Inc. This is a tele-manipulation system, based upon the research system developed by SRI, International called the Green Telepresence Surgery System. Today there are hundreds of surgical robots around the world, with tens of thousands of operations performed annually. The fundamental principal of the surgical robot is to reproduce the hand motions of a surgeon with greater precision, speed and with reduction of hand tremor. It also wants to provide 3-D high-definition video images which are much clearer than simple human 20/20 vision in order to perform a delicate surgical procedure with accuracy beyond that of human control. The system has certainly succeeded in this goal.
An added benefit is that, by reproducing the surgeon’s hand motions from the computer to the surgical instruments, it is possible to perform surgical procedures at remote distances. To demonstrate this capability, in 2001 Dr. Jacques Marescaux of Strassbourg, France performed an operation upon his patient in Strassbourg while sitting at the surgical robot workstation in New York City. Although this required a very expensive, dedicated telecommunication connection between the two points, the demonstration clearly proved that such remote surgery is a possibility. However, many non-technical factors, such as cost, lack of reimbursement to the physician, resistance to change by healthcare professionals, has limited the widespread use of telesurgery.
Currently experiments are ongoing by the military and by NASA, investigating issues such as time delay in hand motion and correct communication bandwidth. By operating on manikins in their underwater research facility 60 feet below the waters off Key West from a surgical console in Toronto, Canada, Surgeons David Williams (a Canadian NASA astronaut who has flown on three space shuttle missions) and Mehran Anvari of McMaster University in Toronto have conducted two such operations called NASA Extreme Environment Medical Operation (NEEMO). They want to prove that we can do telesurgery, even to the most remote places on Earth, in preparation for the days we may need such capabilities for space missions.
Even more important is the concept behind robotic surgery – the fact that the surgical console takes the hand motions of the surgeon and converts them into information (electrical signals) which are sent through a computer to a remote instrument. By going through a computer, it is possible to enhance the motions well beyond human physical limitations. In addition other information can be brought into the computer at the same time. The actual 3-D body scan of the patient can be displayed and the surgeon can do a ‘surgical rehearsal’ simulation of the operation, and if any mistakes are made the patient does not suffer. The surgeon can practice until he has that patient’s operation perfected, then do the operation on the patient (not the simulation) without mistakes. This is done in very few procedures, such as complex liver surgery, but will eventually be able to be done on literally any operation, making surgery even safer.
It is also possible to bring in other information and images (in addition to the video image which the surgeon uses to perform the operation), such as X-rays and CT scans and overlay the X-ray on the video to give the surgeon “X-ray vision” to see structures under the surface which are not visible to the unaided eye.
Finally, there are new types of surgery which are being explored that will eventually be conducted from a surgical robotic console. The difficulty is in manipulating long, flexible instruments or catheters – a skill that takes a great deal of training such that a very limited number of physicians can perform them. If it is possible to connect these to a robotic surgical console, literally any doctor would be able to perform such procedures. For example, a current alternative to open surgery is the “endovascular” approach, where a long catheter is inserted into a blood vessel such as the femoral artery, and advanced with a balloon to dilate a narrowing of heart (coronary) or brain (carotid) arteries. Or it can use a catheter with a stent to bypass an aneurysm rather than conducting a very difficult and dangerous open repair of the problem.
There is also the new Natural Orifice Transluminal Endoscopic Surgery (NOTES), which is taking long flexible tubes (endoscopes) traditionally used to look inside the stomach and colon, and poking through the stomach to go into the abdomen and remove organs such as appendix, gallbladder, etc – without ever making an incision on the patient’s abdomen. This is called “incisionless surgery” because entry to the abdomen is through the stomach, a natural orifice. This extraordinarily difficult procedure takes hours instead of minutes to perform because of the difficulty in controlling such a long and flexible instrument – this is a task that is very simple for a robotic system. There is research in both of these areas (endovascular and NOTES) to use the robotic workstation to make the procedure available to any surgeon.
Still in the laboratory is yet another futuristic surgical opportunity – the possibility to operate inside an individual cell. Using the tools of cell biologists like high power scanning microscopes and femtosecond lasers, doctors are making incisions into the cell membrane and delicately operating on the internal structures such as mitochondria and even inside the nucleus on the chromosomes and genetic material.
Today, “genetic engineering” is accomplished by using harmless viruses to which strands of genes are connected and then injected into the blood stream to take the new genetic material to cells. This is very imprecise, with about a 15 per cent chance of success; imagine that it might be possible to actually operate directly upon the cell to change the very genes, reversing diseases by surgery rather than x-ray or drugs. This type of surgery is so new that it is not possible to see where it will eventually succeed; however, in order to conduct such procedures on individual cells requires the precision that only a surgical robot can deliver.
Previously, it was inconceivable to operate upon a cell. Today it is in the research laboratory, and who knows where it will be in the future – all because of surgical robots.
Richard Satava, MD FACS, is currently Professor of Surgery at the University of Washington Medical Center, and Senior Science Advisor at the US Army Medical Research and Materiel Command in Ft. Detrick, MD. Prior positions include Professor of Surgery at Yale University, Professor of Surgery (USUHS) in the Army Medical Corps at Walter Reed Army Medical Center and Program Manager of Advanced Biomedical Technology at the Defense Advanced Research Projects Agency (DARPA). During his 23 years of military surgery he has been an active flight surgeon, an Army astronaut candidate, MASH surgeon for the Grenada Invasion, and a hospital commander during Desert Storm, all the while continuing clinical surgical practice.
