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by DrRich

In the June, 2001 issue of the ©


 , encouraging results have been reported from the first
pilot study in the United States aimed at evaluating robotically-assisted coronary artery bypass surgery.
One year after having the robotic bypass performed, all 19 patients included in the study remained free
of complications and of angina.

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Robotically-assisted heart surgery is the latest advance in trying to move open heart surgical procedures
to the category of minimally invasive surgery - that is, to minimize the extent and the trauma of cardiac
surgery as much as possible.

Most minimally invasive surgery is performed by passing an endoscope (a small tube containing an
advanced optical system) through a tiny incision. Surgical instruments are then passed either through
the endoscope tube itself, or through an additional tiny incision. While visualizing the surgical area
through the endoscope, the surgeon manipulates the surgical instruments to complete the operation.

Such endoscopic surgery works well for several types of operations (such as gallbladder removal and
knee repairs,) where the part of the body to be operated upon is motionless, and the surgical
maneuvers that need to be performed are relatively simple. But moving the surgical instruments
manually during endoscopic surgery can be difficult - the length of the instruments is far longer than
normal, and the "feel" of these long instruments is non-intuitive to the surgeon. Long instruments also
exaggerate normal hand tremors. Thus, endoscopic surgery has achieved only limited success in more
complicated operations such as heart surgery, where the heart is beating and the necessary surgical
maneuvers tend to be complex.

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  is aimed at making endoscopic heart operations feasible.
With this technology, the surgeon manipulates the surgical instruments with the help of a computer. An
endoscope is passed through a tiny incision in the chest wall, and two surgical instruments are passed
through additional tiny incisions. The surgeon views the image provided by the endoscope on a
computer screen. Instead of manipulating the surgical instruments directly, the surgeon manipulates
them via a computer console - similar to manipulating a gamepad to play Ninetendo. The computer
interprets the surgeon's hand movements and causes the surgical instruments to respond accordingly.
This system addresses the major disadvantages to moving the long surgical instruments manually -
computer control of the surgical instruments essentially eliminates the tremor effect, and also the non-
intuitive feel of maneuvering such instruments.

While it takes special training to become adept at using robotically-assisted instruments, most surgeons
who have had such training report that they feel quite comfortable maneuvering surgical instruments
via a console instead of directly.

 
    


Much of the early work with robotically-assisted heart surgery has been with bypass surgery. So far, this
technique has been limited to single bypass grafts in the left anterior descending coronary artery (the
LAD). The LAD is located on the front of the heart, and therefore is relatively accessible. It is predicted
that with advances in technology, multiple grafts with robotic assistance will be possible, at virtually any
location on the heart.

Early efforts have been made at extending robotically assisted surgery to other kinds of heart surgery.
Robotic procedures have been successfully performed, for instance, in mitral valve repair, in repairing
atrial septal defects (ASD,) and in repairing patent ductus arteriosus (PDA.) It is expected that as
experience and technology advance, robotic procedures will be applied to most other forms of heart
surgery.

Two robotic surgical systems are currently available, both developed and manufactured in the U.S.
However, while both robotic systems have been approved for use in Europe, both remain experimental
in the United States. It is not likely they will be approved in the U.S. until randomized clinical trials are
completed that convincingly demonstrate their safety and efficacy.

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The chief advantage of such surgery is that the incisions that are made are tiny, and therefore recovery
from surgery is extremely quick. Rapid recovery from cardiac surgery is not only better for the patient,
but it is less expensive for society.

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The chief disadvantage at this point is that the technology is new, and (despite early encouraging
reports) is still evolving. Its efficacy and safety have not yet been proven sufficiently to allow the FDA to
approve it for widespread use.

Another disadvantage is the expense of the robotic systems. They cost between $750,000 and
$1,000,000, and it is unlikely that most hospitals will be able to afford purchasing the robotic systems for
operations they are performing "just fine" today without the robotic equipment.

The bottom line: it is likely to be several years before robotic heart surgery is widely available.

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There are at least two that come to mind.

1) Not all surgeons think robotic surgery is a great idea. While most agree that robotic surgery is
feasible, many question whether it should be pursued at all. They cite the expense of the equipment,
and the success they are currently having with today's methods of doing surgery. Such arguments
against new technology date back at least to Gutenberg, of course, and are easy to counter. One
suspects that those surgeons betraying a Luddite opinion might have other fears in mind - such as a
complete disruption of the practice of surgery. It is easy to ask why, for instance, if a surgeon can
perform a heart operation while sitting at a console 15 feet away from the patient, then why couldn't
that surgeon perform the same operation while sitting 1500 miles away from the patient? In other
words, competition for patients would occur on a global scale instead of a local scale. (And   
could be operated upon by only the very best surgeons.) If such a notion does not disrupt the practice
of surgery, DrRich doesn't know what does.

2) Insurers and the government (the two entities that pay for most of health care) understand
something that most of the public does not, to wit: the introduction of any successful minimally invasive
procedure - while it may reduce the expense of caring for an individual -

 increases the total
expenditures within the health care system. This is because when a minimally invasive procedure is
available, suddenly the number of patients who "need" to have that procedure expands exponentially.

A good example is endoscopic gallbladder surgery. In the past, it was extremely difficult to recover from
gallbladder surgery. Such surgery required extensive hospital stays, and resulted in significant and
protracted misery on the part of the patient. But with minimally invasive gallbladder surgery recovery
is rapid and suffering is minimized. Most people go home the same day or the next day (and as a result
the expense of the procedure for each individual is far less than it used to be.) precisely because the
surgery is now so benign, far more people (people who, in the old days, would reasonably conclude that
suffering in relative silence was the wisest course of action) are choosing surgery. The total cost to the
health care system has exploded. The same, of course, can be predicted to happen when robotic heart
surgery becomes widely available.

As a result, there will be a tension between innovative companies and surgeons on one hand, and
insurers, regulators, and Luddite surgeons on the other. Robotic heart surgery will not be accepted with
open arms by everybody, even if its efficacy and safety are proven beyond a shadow of a doubt.