Robotic surgery hailed as a cut above the rest
Published: Saturday, January 21, 2012 at 7:52 p.m.
Last Modified: Saturday, January 21, 2012 at 7:52 p.m.
This surgeon — working at several hospitals in the area — has four arms, can grasp, cut and suture in infinitesimally small areas, and is becoming emblematic of high-cost, high-tech health care that's coming under increasing scrutiny.
Five years since its debut locally, there's no denying that the da Vinci Surgical System has thrust robotics into surgery — in more disciplines than ever.
After being used chiefly in gynecology and then urology locally, robotics has expanded into thoracic, ear, nose and throat, and general surgeries. Robotic heart surgery is coming next.
Once limited to major medical facilities, da Vinci assists in surgeries at hospitals from 70-bed West Marion Community Hospital in Ocala to 790-bed Shands at the University of Florida.
“It's here to stay,” said Dr. Li-Ming Su, who is the chief of the Division of Robotic & Minimally Invasive Urologic Surgery at UF. He also is leading the Multi-Speciality Robotics Program at the UF College of Medicine.
Surgeons wax passionately about the abilities da Vinci gives them and how the system has shrunk surgical incisions to a fraction of what they have been. They marvel at how da Vinci has expanded physicians' field of vision into human innards. Also, patients are being told they can go back to work weeks before they would have been able to previously.
But da Vinci's high costs — as much as $2.2 million to buy and as much as $170,000 annually to maintain, according to its manufacturer — have also attracted notice. An article published in August 2010 in the peer-reviewed New England Journal of Medicine found that robot-assisted surgery added about 6 percent to 13 percent to the cost of a procedure, depending on how you calculate it, even though there was no demonstrated long-term benefit from robotic surgery.
The progress of a generation
Having a robot assisting at her partial hysterectomy at North Florida Regional Medical Center didn't cost Gayathri Shaw, 43, of Lake City any more money than if she had had it done the old-fashioned way — without a robot assisting, said her doctor, Dr. Tony Agrios, a Gainesville gynecologist.
Shaw's mother had a hysterectomy more than a decade ago for the same problem Shaw has been experiencing — irregular bleeding. Her doctor prescribed a partial hysterectomy. Using the robot, the incision was 4 centimeters long (or roughly 1½ inches) through her belly button instead of the incision her mother got — about 8 inches long across her abdomen.
“When he said, ‘hysterectomy,' I said, ‘Oh?' — I knew from what my mother went through it was a pretty major surgery,” said Shaw, a Bank of America employee and the mother of a 17-year-old daughter. “But he told me about minimally invasive surgery — and that's when I read about da Vinci.”
In the operating room
Once the robot's arms were inserted through a platform that leads into Shaw's abdomen, Agrios retreated to a corner of the room and sat at a console. He slid off his clogs and put his feet on the console's pedals. The right pedal controls the electrical current that comes through the instrument that his right hand guides. The left pedal guides the camera and the left hand controls the robot's grasping instrument. The camera's view of Shaw's insides was projected not only in the console's viewfinder that Agrios' head is pressed against, but also on two 55-inch, flat-screen monitors in the operating room.
“Can we get the house lights down a little bit?” Agrios asked the surgical crew.
Since the 12 robotic surgeries that were done at North Florida Regional in 2007, they've been steadily increasing through the years, accounting for 1,472 surgeries last year, hospital officials said. Agrios was the first to do robotic surgery at NFRMC; now he's one of 17 surgeons who do it. At Shands at UF, 15 surgeons are using the robot.
Su at UF&Shands calls robotic surgery the perfect marriage between the best part of open surgery and the best part of laparoscopic surgery.
The robot allows surgeons the same flexibility they would have if they made an open incision, he explained, yet the incision that the robot requires is minimal, like laparoscopic surgery. And unlike the instruments used in a traditional, closed procedure — straight sticks — robot-assisted surgical instruments can move like a wrist.
“It's akin to taking the human hand and miniaturizing it to an 8-millimeter instrument,” Su said.
For Agrios at NFRMC, it's hard to see the downside of less cutting, smaller incisions and more nimble instruments than the straight sticks used in laparoscopic procedures without the robot. But a laparoscopic surgery was not an option for Shaw, Su explained, requiring the precision of the robot.
When Su uses the robot, “it feels like I have my hands in there and my hands are doing the work,” he said.
Dr. Emina Huang, an associate professor and colorectal surgeon at UF&Shands who uses a da Vinci in surgery, said more than a universally utilized surgical tool, she sees the robot becoming a powerful teaching tool for demonstrating human anatomy to trainees. But she said she wouldn't rule anything out for its future.
“It's an exciting time,” she said.
Even though the costs of buying a da Vinci Surgical System are not passed directly onto the patient who has robot-assisted surgery, the New England Journal of Medicine has raised the alarm that the cost increases are coming just as new codes exist for procedures or diagnosis for which robots are used.
“Medicare and private-insurer reimbursement rates are computed on the basis of these charges,” the article reads. “Thus, increases in charges for robot-associated diagnosis and procedures may eventually generate higher payments that are never explicitly linked to robot-assisted surgery.”
Matt Davis, chief operating officer and vice president at NFRMC, said that higher payments were not the goal for the hospital's investment in da Vinci.
“It's our belief that da Vinci absolutely leads to better outcomes for the patient,” he said. “North Florida's commitment is to the advancement of technology for the patient's benefit.”
But for Dr. Gabriel Barbash, one of the authors of the study analyzing robots' cost to health care, one of the biggest indictments of the boom in robotic surgery is that it has happened chiefly in the United States.
There are currently 1,548 surgical robots installed in the United States, compared with 584 systems overseas, according to manufacturer Intuitive Surgical Inc.
“The rest of the world is more cost-aware than the U.S.,” Barbash said.
For Shaw, the after-effects of the surgery were still giving her pain three days later. But she was home the day of the surgery. Had she undergone open surgery, she would have required as long as a four-day stay at the hospital. And she planned to be back at work two weeks sooner than her mother was after her hysterectomy.
She was going a full eight hours without pain medication three days after the surgery.
“I'm probably doing better than she was,” Shaw said.