Wednesday, August 19, 2009 - The doctor makes a movement and the knife slices fluidly through the muscle, parting the tissue as easily and cleanly as scissors cut silk. The movements go on like this, and the surgical tool is wielded confidently, efficiently, never shaking or deterring from the path it is supposed to take as the procedure continues on video.
Except that the surgeon is sitting in the operating room a few feet away from the patient, and the movements are generated through the video console. It's the surgical arm, the robot, that does the actual cutting and remains oblivious to any potential mistakes that would otherwise run through a human mind.
The robot is the da Vinci Surgical System, manufactured by Intuitive Surgical, Sunnyvale, Calif., essentially the only such robotic arm on the market. It's not new, the da Vinci system has been around for the past decade and has been installed in more than 850 hospitals, but despite claims by many doctors that the robot makes minimally invasive surgeries easier to perform, providers aren't clamoring to use them.
Part of the reluctance is on the part of surgeons who aren't sure about learning to use a machine when they can perform the procedures well using their own hands. St. Joseph's Hospital of Atlanta is stepping in to help smooth out what might be considered a daunting learning curve for some.
Back to school:
The 410bed hospital launched the International College of Robotic Surgery earlier this year as part of its effort to meet a demand for training. While Intuitive has previously established centers, typically done in partnership with various hospitals, including Saint Joseph's, to train physicians on the surgical system, Saint Joseph's college wants to take that basic training to the next level.
The college, which is starting with cardiac surgery but plans to expand into other types of procedures, hopes to train surgical teams on advanced, minimally invasive robotic techniques using customized education modules based on various levels of expertise and need. The curriculum includes Internet course work, quizzes and cases to complete in order to “graduate.”
The college offers interactive, online and remote guidance to teams from around the world interested in learning about robotics. Medical teams are invited to travel to Atlanta and attend sessions in person as well.
Saint Joseph's experts also will visit a team's site to provide follow-up support and training.
Costs for the training can range anywhere from $4,000 for online courses up to $100,000 for the full, one year curriculum, based on how many people are in the surgical team, whether they want to visit in person or take virtual lessons.
Using a combination of hands on, virtual classes and videoconferencing, the doctors at St. Joseph's who lead the college hope to be what they themselves didn't have: mentors.
It's difficult not to sense Sudhir Srivastava's excitement about the college or commitment to robot-assisted, minimally invasive surgery. The cardiothoracic surgeon was brought on board in February by St. Joseph's to be one of two surgeons who lead the college and conduct training. Srivastava serves as President of ICRS and Chief Scientific Officer for cardiac Revascularization. His counterpart, Douglas Murphy, also a cardiothoracic surgeon, serves as Chief Scientific Officer for intracardiac robotic surgery for the college and Chief of cardiothoracic surgery at Saint Joseph's, Atlanta.
Several components are involved when learning how to use the robot, says Srivastava, who has performed more than 1,000 robotic cardiac surgeries since 2002. About a third of those were conducted on beating hearts, a procedure that demands a level of skill that can only come with significant practice, he says. By using the latest technologies and techniques, that's the level he and Murphy hope to bring to others faster through the college.
“We went through a lot of learning curves,” Srivastava says. “People don't have to go through that extended learning curve or frustration.”
The college is approaching robotics training from the team standpoint because robotic surgery “is truly a team effort,” Srivastava says. There is the surgeon at the console, watching the video and manipulating the controls that tell the robot's arm how to move. And there are the nurses at the patient bedside, monitoring the patient and performing tasks to keep the surgical site clear for the robot.
The training is as much about learning how to work well as a team as it is about learning how to manipulate electronic controls, he says. The surgeons are learning hand motions via remote visual cues through a computer screen, but everyone also is learning how their team members function and communicate, especially if there are any disruptions or problems that arise during surgery. “In three months or so we can get people comfortable.”
Getting comfortable is just the beginning, however. After learning to control the machine and improving team communications through simulations, the college recommends doing as many cases with patients as possible to understand how the machine and patient interact, it's much like going through clinical training all over again, Srivastava says. He and Murphy will follow up with teams that have come through the college in their facilities in the first year. “We want to see what they've accomplished,” he says.
Since opening in January, the college has had about four to five teams come through for training, both virtually and in person, each month. Some have come from as far away as Shanghai to spend a week. The college is working to update its Web site with more content and training modules. Srivastava says he would like to eventually see the college training eight to 10 groups each month.
Srivastava is certain that robotics surgery will grow, as more patients demand the procedures that get them in and out of the hospital more quickly, and as providers see the benefits of having such machines.
“I think surgeons will be almost forced to learn this,” Srivastava says. “The technology is continuing to get better and be more surgeon-friendly.”
A growing market:
According to market research conducted by BCC Research, Wellesley, Mass., use of medical robots and computer-assisted surgical equipment is growing in the U.S. The market was worth about $648 million in 2008 and is projected to reach $676 million in 2009, up 4.3%. By 2014, the market will be worth $1.5 billion, according to the report, up about 130% from 2008. Surgical robot systems were the largest product in that market as well, accounting for 54% of the market share. That share is expected to increase to 65% by 2014, according to the BCC report.
With that growth occurring, the design of training remains critical. And it's an issue that has been a concern among physicians for some time. There are a range of surgical opportunities that open up through the use of robotics, writes Richard Satava, a physician who is a professor of surgery at the University of Washington, Seattle, in a 2007 article. His column was published in the Bulletin of the American College of Surgeons, where he discussed the need for the right kind of training.
The robotics console “is the overall architecture that will provide even greater capabilities in the future, and this is just the beginning,” Satava writes. But without first incorporating education that matches high-tech surgery, robotics can't reach its full potential. “Thus, it is necessary to incorporate the basic principles of adult education, curriculum design, setting of quantitative performance metrics for outcomes and validation of the curriculum,” he writes.
Murphy, with the robotics college, agrees. “Robotics surgery is still in the pioneer stage,” he says. There is a deep body of knowledge about robotics that hasn't been available to all physicians, and there wasn't a way to be trained. He views his role and his colleague Srivastava's role at the college as being one of leaving a legacy. “We wanted to put some of our effort into teaching other people rather than just do a bunch of cases,” he says.
The college Web site has a full curriculum, including its daVinci Connect program to broadcast presentations into hospital conference rooms; practice laboratories; and the teaching of small procedures that focus on gaining proficiency with the technology, he says.
Beyond just training, there are other obstacles to adding robotics to surgical programs, Murphy says. The hospitals have to be willing to pay more than $1 million for the system, plus maintenance fees, and surgeons need time to access the systems. Also, while doctors are learning how to use the machines, their productivity drops, Murphy says. “It takes real institutional commitment to have a robotics team.”
Still, it's worth it, Murphy says, a point he hopes to help drive home through the robotics college. Being proficient at using the robotic system has enhanced doctors' technical abilities and has allowed them to perform safer surgeries on patients who didn't have the minimally invasive option before, he says.
Patients who are obese, who have thicker muscular structures and broader chests, or patients with abnormal skeletal structures would have required open surgeries, because doing minimally invasive surgeries on them is too difficult, Murphy says. With the robotics involved, doctors can gain access more easily.
Financial incentives also play a role. “You don't get paid more for doing the surgery robotically,” Murphy says. At the same time, a surgery using the robotic arm can cost $12,000 to $15,000 less than a typical surgery, with fewer complications and a shorter length of stay, he says.
Those metrics alone should make providers consider robotic surgery with more enthusiasm, says Julian Schink, chief of gynecologic oncology at 787 bed Northwestern Memorial Hospital in Chicago, which has had the da Vinci equipment since 2007. Schink has not undergone robotics training through St. Joseph's college, but has been trained through the da Vinci system's manufacturer, Intuitive.
Patients experience less bleeding, less pain and are back to work faster after procedures done robotically, which saves costs for hospitals, Schink says. Once his team demonstrated that the number of hospital days among oncology patients was down 60% to 65% over a year, it was easy to get a buy in from the hospital, he says. “It was absolutely astounding” data.
The same resolve should start to apply to doctors, as well, Schink adds. As patients start to learn more about the advantages of robotics and demand more minimally invasive procedures, doctors will have to become proficient. “That strikes me as the future of medicine,” he says.
St. Joseph's already understands the business case for robotic surgery and views the college as a strategic move forward in surgical services, according to Kirk Wilson, president and CEO of St. Joseph's. In addition, the health system is planning to develop a total of five surgery rooms designed especially for robotic surgery. St. Joseph's is finishing the plans now and needs regulatory approval before starting to build, which is expected to take about a year.
Initially, robotic surgery is not more profitable than traditional surgeries, but the cost per case is starting to decline, Wilson says. “In our view it can only get less costly.”
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