Robotics in Surgery: Coming to an Operating Theater Near You
Thursday April 1, 2004
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proving its benefits outweigh its costs.
Margaret M. Sloane, RN, BSN
At first glance, you might think the only thing missing in today's ultra-high-tech OR is George Lucas directing a cast of sci-fi robots battling mortal threats to humankind. In reality, an impressive robotic assistant named the da Vinci Surgical System is inspiring oohs and aahs in the field of minimally invasive surgery (MIS) for its ability to replicate and enhance surgeons' movements while working through tiny incisions. The da Vinci also gets two enthusiastic thumbs up for speeding patient recovery and shortening hospital stays.
Two years ago, Miami Cardiac & Vascular Institute at Baptist Hospital performed its first cardiac surgery using da Vinci, which was developed by California-based Intuitive Surgical. According to staff nurse Florida Mutawakkil, RN, a 20-year cardiac surgery veteran, the future depends on technology. Robotic surgery is exciting considering that cardiac surgery has gone from making a huge incision, cracking the sternum, and using a heart-lung machine to making tiny cuts to accommodate robotic arms - with no need to divert blood flow, she says. "The whole idea is to be able to operate on a beating heart using MIS - really fantastic stuff!"
The most dramatic aspect of robotic surgery is improved patient outcomes. Because the robotic arms require only modest openings, patients experience less bleeding and trauma, less pain and scarring, and a quicker return to daily activities. What's more, operating on a beating heart and eliminating the heart-lung machine reduce the risk of infection.
The da Vinci has several components designed to give the surgeon's hand-eye coordination a thorough workout. Among them are a console that stands about 10 feet from the operating table and a patient-side cart with three arms for instruments and a camera. Two of the arms accept instruments designed with seven degrees of motion to mimic the human wrist's flexibility. One arm acts as an endoscope to provide depth of field, magnification, and high resolution for transmitting 3D imagery from the operative field to the surgeon console. Looking somewhat like a kid playing a video arcade game, the surgeon sits at the console; straps the master controls onto the fingers; uses foot pedals for display control; and begins clamping, cutting, and suturing with the robotic arms.
According to Intuitive Surgical, the da Vinci isn't a robot in the strict sense because it doesn't display in virtual reality - nor is it programmed to operate and make decisions. Instead, it's a computer-enhanced system that connects the surgeon's hands to the instruments, operating in real time.
Rave Reviews
Human surgeons must cope with the tremor effect when making the cut. Not so with the da Vinci robotic arm, of course; and that makes for fluid motion on the operative field - the instrument holds a vessel perfectly steady during suturing. Not only that: The surgeon can zoom in for 10 times the magnification using the powerful display console, and the da Vinci's wristlike action gives the surgeon access to previously unreachable areas.
Baptist Hospital uses the da Vinci for patients needing a single coronary artery bypass. The surgeon harvests the internal mammary artery for cardiac bypass using the da Vinci on a beating heart; then the robotic arms are removed from the ports, and the surgeon finishes the procedure. The hospital's next goal is to train urologists and general surgeons to use the equipment for additional procedures that have US Food and Drug Administration (FDA) approval.
In May 2002, St. Joseph's-Baptist Health Care became the first hospital in the Tampa Bay, FL, area to enter the robotic surgery arena. There the da Vinci is being used not only for single cardiac bypass surgery, but also for urological and general surgery procedures like hiatal hernia repair and cholecystectomy.
According to Lisa Lockhart, RN, BSN, CRNFA, St. Joseph's charge nurse for surgical services, surgical robotics is a progressive process. A certain level of mastery, she says, is required before moving to the next level. The hospital's ultimate goal in cardiac surgery is to go from the single bypass to mitral valve repair, which recently won the FDA's OK.
But what's really exciting, says Lockhart, is the impressive results that robotic surgery is getting with prostatectomies. "The big thing for this surgery is the nerve-sparing aspect," she says. "Because of the small port sites, the improved manipulation of the surgical instruments, and the increased optics, we can see the nerve more easily - and avoid it."
Vicki Runyon, RN, MSN, director of surgical services at Regional Medical Center Bayonet Point in Florida, says in her 30 years of OR experience she never dreamed she'd see such amazing equipment. "We're blown out of the water with this technology," she says of the da Vinci's capabilities.
Runyon thinks urological and general surgeons are particularly well-suited for the da Vinci's complexities. "They already have advanced laparoscopic skills with well-developed hand-eye coordination compared with cardiac surgeons who are used to an open-chest operative field," she says.
Most healthcare professionals familiar with robotic surgery agree one of the drawbacks to the new technology is the learning curve. Moreover, surgical procedures often take longer with robotics because surgeons are still perfecting their techniques. In general, though, most feel that with more experience, operating times will shorten.
Learning the Script - Again
The cost to acquire the equipment and learn to use it is also a challenge. Lockhart says that initially the million-dollar investment was overwhelming. "It was a lot of equipment and technology, and there it was on our doorstep. We needed to learn how it all worked," she says. So St. Joseph's sent two teams of nurses, technicians, and physicians to an Intuitive Surgical facility for training in equipment preparation and intraoperative/postoperative system management.
Bayonet Point's surgical teams attended the company's training programs, as well; and the hospital has established strict credentialing criteria owing to the complex nature of robotics. For example, says Runyon, in the 1980s surgeons trained in laparoscopy with instruments that produced motions opposite to what might be expected - "If you wanted to move up, you pressed down on the controls." Today, it's intuitive - no pun intended. "With the da Vinci," she says, "the actual movement is what you get." But while the new technology may seem easier, the process must still be relearned.
In terms of nursing care, not much will change. The focus is still on patient safety and quality of care, says Baptist's Mutawakkil. "The key is learning how to position the equipment around the patient."
Lockhart says robotic surgery will ultimately make the nurse's job easier, reducing the number of people needed to pass instruments or manipulate tissue. Also, patient recovery time will be significantly shorter. "With MIS, you don't have to put the patient to sleep as deeply as with open chest," she says. "They awaken and can be extubated more quickly."
The Sequel
Sarasota Memorial Hospital, in Sarasota, FL, is using an investigational robotic system called Zeus, developed by Computer Motion, that's similar to the da Vinci. And besides the latter system, Baptist Hospital is using FDA-approved components of Zeus that provide voice-activated control for an endoscope on a robotic arm.
"St. Joseph's already has 10 surgeons in three different specialties using this robot," says Lockhart. "We can't begin to imagine how this is going to impact the way we do laparoscopic surgery in the future."
Runyon points out computers weren't around when she was growing up. Nowadays, though, 2-year-olds are glued to computer screens, playing games with the same intensity she used to devote to dolls, cutouts, and crayons. That prompts her to reflect on the future: "This next generation will be so adept at using this technology that the sky's the limit when it comes to robotic surgery!"
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