Tuesday, April 27, 2004; Page HE05
hree days after a robot assisted with surgery on his heart, James Spaith spoke about his experience from his home in Arlington. Spaith, an information technology manager for The Washington Post, had returned there 24 hours earlier.
Doctors, he said, "got me walking the next day. I'm surprised at how good I feel today."
That's the kind of report that gives minimally invasive surgery a post-op edge over conventional open-heart surgery. In a standard, or "open sternotomy" approach, patients go home after three or four days, "but in a different condition," said Inova Fairfax surgeon Paul Massimiano.
"Different" meaning weaker, in greater pain and far more physically intruded upon.
In the first recorded instance of robot-assisted surgery, a robot arm was used in 1985 to precisely position a biopsy needle inside a brain lesion. Since then, robotically controlled arms have been used in almost every surgical field: neurosurgery, orthopedics, urology, reconstructive-plastic surgery and cardiac surgery. The key technical challenge is getting the machine to faithfully reproduce the trajectory guided by the human hand. Neurosurgeons train themselves to master robotic devices, using a watermelon to simulate a human head.
Linking a CT (computerized tomography) or MRI (magnetic resonance imaging) scan to a robot allows a surgeon far greater accuracy. Once a patient's anatomy is mapped into the robot's software, it helps a surgeon pick out a lesion (a brain tumor or damaged intervertebral disk, for example) and then point the robot's arms to it. The robot lets him use smaller tools, invade less healthy tissue and lock precisely onto the target.
As Massimiano puts it, "You have to know how to do the surgery. The skill set of using the robot is easy."
The Defense Department commissioned some of the earliest work with robotic surgery. "They wanted a robot to be in a forward battle position, not the surgeon," said Massimiano. "That concept didn't work very well, because it's hard to get the robot in, but the possibility remains of having the surgeon watch from a screen and take over from a less expertly trained off-battle surgeon." A non-military license for use was issued in 1995, and Massimiano was the first in the Baltimore-Washington area to use it.
Massimiano credits his partner Ed Lefrak with recognizing the potential of the da Vinci surgical robot and helping to persuade Inova to provide funding. "We had a track record of picking out new devices that seemed to have a future, and the hospital administration has always supported us. They came through for us, and it has been a real reward."
Their first cases were part of a trial to obtain approval from the Food and Drug Administration (FDA) , which was granted on July 11, 2000. That made da Vinci the first robotic system licensed for use in American operating rooms. "People love the idea. They come to me because they want the robot."
Why hasn't robot-assisted surgery become more common? The expense. Said Kevin Cleary of Georgetown's Imaging Science and Information Systems Center, "The price has to come down before they're used more. The medical applications are comparable to the way factories were using robots in the '60s. It's still in the early stages of figuring out cost-effectiveness and just where they fit in."
Insurance reimbursement for mitral valve surgery is the same whether or not the robot is used, so a higher cost-benefit ratio will have to come from shorter hospital stays and improved patient condition with fewer complications.
While part of the problem is quantifying cost-cutting, a larger part lies in making the robots attractive to produce. Says Cleary, "NIH and NSF are geared more towards funding basic research than R&D projects such as this, and manufacturers can't be sure of getting a return on their investment. FDA approval is good and helpful, but they are still looking for more widespread applications of the robot."
