Robots Take a Major Hand in Heart Surgeries
A woman lies anesthetized on the operating table. Bright primary colors dominate the room: the brilliant yellow of iodine-scrubbed skin, the red of blood, the green of surgical scrubs worn by all. Medical students flank a far wall, the Greek chorus of the surgical theater. From a CD player in the corner, the Beatles croon softly, “I wanna hold your haaand.”
This looks like any operating room, but this surgery--a heart-valve repair--will be anything but typical. The surgeon, sitting at a console that resembles a virtual-reality game console, will use a robot to operate from across the room.
Doctors hope the robotic Da Vinci Surgical System will make open-heart surgery a lot less open and a lot easier on the heart. Rather than cracking the sternum to allow the surgeon’s hands access to the heart, the largest incision doctors make is an opening, 4 centimeters square, between the ribs. Two smaller incisions give the robot’s two working arms access to the heart.
A major goal in surgery these days is to be “minimally invasive.” The least invasive surgeries thus far have been endoscopic, or camera-assisted. In this method, a camera is guided through the body so that surgeons can operate without having to open up the body. Robotic surgery is designed to improve on endoscopic surgery, which is routinely used for operations such as gall bladder removal. And, for the first time, the robot will make heart surgery possible without a traumatic sternotomy, or cracked chest bone.
Da Vinci has been approved by the U.S. Food and Drug Administration for general and thoracic surgeries, allowing hospitals to use it for surgeries involving the liver, esophagus and lungs. The FDA is considering approving it as the equipment for cardiac surgeries.
Doctors say that such approval should mean faster and less painful recoveries for heart-surgery patients who had access to the robotic technology. But the expense of the machine--about $1 million--will likely limit its use to larger medical centers where such surgeries already are routine.
After all, the robot is only an extension of a highly skilled surgeon. Dr. Vaughn Starnes, a USC professor of surgery, who was among the first surgeons to use Da Vinci for operating on the heart, said the robot’s “hands” work like tiny extensions of his own. The hands move in six different ways, giving them distinctly wrist-like movements. The computer senses the position of the surgeon’s hands 1,400 times every second. And, unlike human hands, the robot’s are not subject to trembling.
The surgeon uses his entire body to control the robot: His head rests on a pressure-sensitive plate, his feet control an array of pedals and his hands move the delicate arms that do the actual work. The interchangeable tools at the ends of the robot’s arms can be used to grip, retract, even burn through tissue.
“Are my eyes in yet?” asks Starnes from the controls. Another surgeon, Dan Schwartz, positions Da Vinci’s central camera arm. On a large monitor above the operating table, a shaky view of the room pops up before the camera delves into the patient’s body, navigating through tissue and past the lungs to the heart.
Until now, endoscopic surgery has been limited by two-dimensional vision. Da Vinci has improved on this by using two tiny cameras, rather than one. The image seen by the surgeon at the console is a three-dimensional view. Traditionally, surgeons wear little magnifying glasses called loupes, which magnify the view of the operation by two or three times. Using the robot, the surgeon’s view is magnified 10 times.
Another shortcoming of endoscopic surgery has been that it requires the surgeon to operate with long tools with moving parts at the ends of the device. Some doctors liken the procedure to writing with a pencil that you hold by the tip, calling it “chopstick” surgery.
The tiny grabbing tools of the robot are more maneuverable. They look like little cooperative penguins, bobbing and diving around tissue, passing the suture back and forth between their “beaks” to repair the heart. The tools appear massive on the monitor, but they measure only a couple of centimeters.
Holly Ciotti, a high school English teacher, had her heart repaired by Starnes using the Da Vinci robot. She remembers when Starnes told her that she was the perfect candidate for robotic surgery. “All he had to say was ‘shorter recovery time,’ and I said, ‘Sign me up!”’ The choice to have surgery with Da Vinci--and without a cracked-open chest--was an easy one for her.
Ciotti’s five-day hospital recovery was not much shorter than usual. But Ciotti realizes that she will reap the real benefits of robotic surgery now that she is back home. The normal recovery from open-heart surgery is long and painful. Patients cannot lift anything heavier than a phone book for months, for fear of popping out the wire stitches that hold the chest together. Ciotti, however, plans to be back to work later this week--less than a month after her surgery.
Officials at Intuitive Surgical, of Mountain View, Calif., say that Da Vinci was developed with heart surgery in mind. Ten U.S. hospitals are participating in clinical trials seeking FDA approval for cardiac surgeries. In Europe, Da Vinci is already approved for cardiac surgery; it is being used there for various heart surgeries, including the beating-heart bypass.
Intuitive’s only competitor, Computer Motion of Santa Barbara, manufactures a surgical robot called Zeus, with capabilities similar to Da Vinci’s. The Zeus device is in clinical trials seeking FDA approval for general and thoracic surgeries. After clearing those hurdles, Computer Motion will also seek approval for cardiac surgeries, company officials said.
Garbo Fichtinger, a robotics expert at Johns Hopkins University in Baltimore, describes two directions for surgical robotics research. The first seeks to extend the abilities of the surgeon with tools like Da Vinci. The other arm of research is aimed at developing the least invasive surgery imaginable: using the body’s orifices to insert cameras and surgical tools without any incisions.
Fichtinger says medical robotics is still in its infancy, and that Da Vinci represents only the first baby steps. Advancements in this area will likely include better sensory capabilities for the surgeon, such as a larger field of vision.
