Monday, November 17, 2008
A few feet away from him a 63-year-old female patient lies sedated, pierced by three projections from a 1,200-pound robot, named da Vinci, which towers over the operating bed. The robotic arms move in sync with every movement of Dharan’s hands. One of da Vinci’s arms holds the camera, which magnifies the inside of the human body ten times and projects it in Dharan’s console in 3-D format. The other two arms hold surgical instruments, mimicking human wrist movements.
Monitors all over the operating room capture a 2-D magnified image of the thin robotic arms inside the upper right side of the patient’s body grasping and separating a tumor on her thymus gland. Dharan is removing the tumorous thymus, a procedure called a thymectomy. Thousands of thymectomies have been performed before. But what makes this one special is that a robot is doing most of the penetrative work. And Dharan is enjoying the ride.
“You look like you are having too much fun back there,” says Dr. Barry Gardiner, who has used robots extensively for laparoscopic (abdominal) surgery, as he looks at the screen showing the robotic arms plug away at the tumor, in response to Dharan’s directions at the console.
“I’m like a kid at a Nintendo machine,” Dharan jokes.
Benefits of Robot-Assisted Surgery
One reason for their apparent light-heartedness is the fact that da Vinci has removed the post-operative hassles associated with surgery: massive blood loss that may require a transfusion, pain, slow recovery, infection, injury to other organs and, in the worst circumstance, death. Standard minimal invasive surgical procedures use long, chopstick-like tools mounted with a camera that can view the inside of the human body to assist the doctor in determining where and how to operate. But the image is two-dimensional and consequently not really accurate. The tools function in a counter-intuitive way inside the body – if the doctor moves his hands to the left, the tools move to the right inside the body. Additionally, the tools cannot translate the human wrist movement that the robotic hand mimics.
“It’s a blind operation, you cannot see what injury you are causing,” Dharan says. “For a thymectomy I would have to make a big neck incision to see the whole thymus gland, while now I can make small keyhole incisions in the side of the body, but be able to see the entire gland from the neck downward in 3-D.”
The small incisions reduce blood loss – in this particular operation, the patient lost 50 cc. The amount is so negligible that in surgical terms it is called “bloodless surgery.” Small incisions and less blood loss mean reduced chances of infection and lesser pain. The cumulative effect is that the patient recovers faster. Referring to the patient he just operated on, Dharan confidently says she can go home the next day. This is important not only from the patient’s perspective, but the hospital’s as well. A rapid recovery is crucial to reducing hospital expenses. Insurance companies typically pay the hospital a fixed amount of money, irrespective of how long the patient stays. The hospital, therefore, has to bear the brunt of paying for each additional day. Now, because patients can leave sooner, hospitals save. This is why patients favoring robotic surgery over standard methods will not have to shell out a larger amount of money for choosing an advanced surgical method.
Another of da Vinci’s benefits for surgeons is that small hand tremors are dampened in the circuit. Previously if the surgeon’s hand twitched even slightly, the tools moved as well. Now the vicarious form of surgery dilutes the tremor.
Although in the approximately 15 cases he has performed he has never had to abort the robotic procedure in favor of the open procedure, Dharan says it is essential to understand when one should convert to the regular procedure. Approximately 5 percent to 10 percent of the time surgeons have to convert from the robotic to the manual method. The patient’s safety is paramount and anything jeopardizing it has to be abandoned.
History of Robotic Surgery
The concept of robot-assisted surgery developed in the military to prevent doctors from coming in harm’s way while operating on wounded soldiers in war zones. By no means is da Vinci the first robot used in surgery. But Dharan argues that it is, by far, the most advanced, able to translate a surgeon’s hand movements in a seamless manner. Intuitive Surgical, which builds the million-dollar da Vinci, was founded in 1995 and has more than 200 employees. Jo Anna Takacs, account manager at Intuitive’s Mountain View office, said that the company has invested $100 million to bring the system to its current state. The first surgery using the da Vinci system occurred in Germany.
Training and Preparation
Dharan spent weeks training at Intuitive. Coordination of hand and feet with the surgeon’s eyes is an integral part of the da Vinci system, requiring doctors to spend time in maneuvering the levers effectively. Dharan has also practiced extensively on cadavers and animals before performing the first esophagectomy (operating on the esophagus) with da Vinci after FDA approved it in March. Dharan says the challenge lay in mentally preparing himself to venture down a path that no one, at least in the United States, has taken.
“The hardest thing is not the operating part,” he says, his large, expressive eyes echoing the thought. “I was a little worried and apprehensive because I was taking the leap to do something no one else has done.”
Dharan obtained his master’s in cardio-thoracic surgery in 1988 from the University of Madras. Between June and November 1999, he was a fellow in cardio-thoracic surgery at the University of California at Los Angeles. He has come a long way since the FDA approved the procedure. Gardiner referred to the 42-year-old surgeon as the “prince of robotic surgery.” But Ray Engstrom, a cardiac anesthesiologist, suggested a loftier rank.
“He is a star; hospitals are fighting over him,” Engstrom says, with the knowledge of an insider.
The Road Ahead
Dharan expressed his disappointment at FDA’s delay in approving the use of robots in heart surgery. Germany is already using them and surgeons from the United States have flown over to take part in the procedure there. Dharan, however, has not found the time.
“FDA needs human trials [to approve it],” Dharan rues. “I think they are conservative, and as American physicians we are hurt by that.”
But Dharan hopes that FDA will approve it by the end of next year. Meanwhile, he knows the future is going to be all robotic and spends his time training when not in surgery or doing patient rounds in the hospital. He expects the apparatus to become a little more user-friendly. Although da Vinci is equipped with wheels, the 1,200-pound device is not easy to maneuver. Moreover, children under 11 cannot be operated upon with the da Vinci system because of its size.
A final question crops up. If the robot can mimic the dexterity of a human wrist, why not use it to make incisions before the surgery and sutures after the operation is completed? The operative word is robot-assisted, Dharan reminds.
“It’s got to be your slave and not your master,” he says with a twinkle in his eye. si
