Surgical robots have been around for more than a decade, but it has not been until recent years that surgeons have begun using them for minimally invasive surgery. An article in the February 1, 2002 issue of Forbes estimated that approximately two percent of facilities that perform minimally invasive surgery make use of surgical robotics. The article speculated, however, that the figure could jump to as high as 10 percent within five years. Although investing in robotic technology is not a realistic option for every facility or every procedure, a growing number of hospitals in the US and abroad have been able to put robotic technology into their ORs.

The facilities that invest in these systems typically view them as long-term investments because the cost is inevitably steep. "The most advanced systems can cost $1 million, and that does not include upgrading such things as imaging and auxiliary equipment to get the most out of the technology," says Ken Stahl, MD, a cardiothoracic surgeon and chief of thoracic and cardiovascular surgery at the Cleveland Clinic of Florida in Weston, Fla.

For Dr. Stahl's facility, as well as the others that invest in this technology, the real payoff is being on the cutting edge of surgery. "The most important factor is the opportunity to expand the parameters of minimally invasive surgery," says Dr. Stahl. "Those who got on board with the technology earlier will lead the way in advaning surgery further in the near future."

Outpatient Surgery spoke to surgeons from facilities that have utilized three of the better known surgical robotic systems. We asked the surgeons to describe their experiences with the system: how they work, what they can do with them, whether they have improved outcomes, and whether they're pleased with their investment from both a medical and economic standpoint. Here are their stories.

Case 1: Zeus at the Cleveland Clinic of Florida, Weston, Fla.
The Cleveland clinic uses the Zeus system, manufactured by Computer Motion. According to Dr. Stahl, the robotic system has been used in for about 500 cases, primarily inpatient cardio cases as well as plastics. Other common minimally invasive endoscopic surgical applications for the Zeus robot include nissen fundoplication, hernia repair, outpatient cholecystectomy, GYN reanastomosis, and even plastics cases. The Cleveland Clinic also uses the Aesop system (also manufactured by Computer Motion), a robot equipped with voice recognition software that moves an endoscope according to the surgeon's voice commands.

The Past, Present and Future of Surgical Robots At the present time, surgical robots can roughly be divided into two basic types: telemanipulators and image guided localizers. Telemanipulators, which have gained a foothold in laparoscopic surgery, provide the surgeon with a robotic arm that can be controlled directly by the surgeon's hand or head movement. Alternatively, the arm may be remotely-controlled by a joystick-like device or interfaced with other devices as part of a voice-controlled system. Image-guided localizers, which are primarily used in orthopedic and neurosurgery, relate a physical point on the patient to a corresponding point on an image screen. Localising robots are programmed pre-operatively and enable a surgeon to implement a precisely defined intervention to the area he or she indicates. The robot then navigates precisely to the target by the specified trajectory. Sal Mesiano, MD, assistant director of the Robotics and Guided Surgery Research Institute at Carnegie-Mellon University, says that, clinically speaking, there are three general benefits to using robots in surgery, regardless of the system. The first is the precise localization of surgical targets, which allows for smaller incisions. The second is that a robotic hand, unlike a human one, remains completely steady, which can reduce the risk of collateral damage. Finally, the robotic arm allows for complex maneuvers to be performed, pitching and rolling with instruments in ways that are not possible for the surgeon. This creates the potential for refining existing procedures or developing completely new ones. Additionally, long-term studies are underway to determine if the risk of operative infection is significantly decreased in cases that utilize robots to work in the surgical field. The main disadvantages are that there can be a significant learning curve in using the robot-for example, when using an image-guided robot for cutting, the surgeon loses the tactile cues that he typically uses when assessing the progress of the cutting operation. Secondly, although it is expected that in the future, robots will reduce OR times, that is not usually the case today. Dr. Stahl foresees a very bright future for robotics. He says, "In the here and now, I think we have turned a corner. Our case times are still longer than traditional endoscopy but recovery times are shorter. Robotics and telemonitoring technology has numerous benefits for all those involved. First and foremost is the patient, for whom these advances are geared in the first place. Secondly, surgeons benefit. Speaking from personal experience, I can say that becoming involved in robotic surgery validates the very reason I pursued a surgical career. It presents the opportunity to learn new and innovative ways to carry out operations with less invasiveness, best practice techniques, and improved outcomes for those whose lives are entrusted to us. Intellectually, it's fascinating. It combines the mental challenge of computer applications and engineering to surgery. It creates increased discourse and exchange of ideas with surgeons from around the world. The telesurgery technology that has been developed creates a huge margin of safety for the patients of the less experienced surgeon and it enables surgeons from around the world to teach one another more about their profession. Our center has gained a reputation of being a springboard for innovation and knowledge and we provide a service to the community. I don't think the value of any of those things can be quantified in dollars and cents."

How the system works
Dr. Stahl says that Zeus uses a rather elaborate setup. "The robotic device has to be placed at exactly the right angle because the instruments that the robot moves pivot on a fulcrum point. The system features three robotic arms that the surgeon operates from a control panel. The function of the first arm, which is controlled by voice command, is strictly to move the endoscope. Rather than looking at a video monitor, which is what the surgeon does during traditional endoscopy when he is positioned beside the patient, there is a computer screen that renders the image from the endoscope. One really useful feature of the system is that the image can be rendered in a two-dimensional perspective-which is what you get with typical endoscopy- or a three-dimensional image. The surgeon can switch back and forth if he so chooses."

The other two arms, which the surgeon operates from a control panel, operate the surgcial instruments, and the controls themselves are designed to look and feel like surgical instruments. Says Dr. Stahl, "It's not identical, but reasonably close."

Set up and learning curve
Dr. Stahl says that the biggest challenge for surgeons is the initial training with the system. The surgeons most likely to master robotic surgery are those with extensive endoscopic knowledge. He notes, "One of the big learning challenges is also one of the big advantages. The human hand can be articulated in seven different positions. When you are doing open surgery, you have a full range of motion. When you are doing endoscopy, however, you are basically limited to four movements with the instruments. With the robot, as you manipulate the controls, the robotic arm can move in six directions [the company calls this a robotic "Micro-wrist"]. So the main challenge for surgeons is to re-learn how they do the procedure. It takes a fair amount of repetition to feel comfortable at the controls."

Dr. Stahl notes that the setup and instrument sterilization also take a bit longer than traditional surgery. "Figure on an extra twenty minutes between cases. The robotic arms need to be positioned and the surgeon has to be set up at the console. The instruments that the robot uses are smaller and thinner than the ones human hands use-they have about a five millimeter diameter-and we have to take the utmost care when we are sterilizing them between cases. It's worth taking the extra time because if the instruments are damaged, we're out of commission with the robot until we can get a replacement instrument. If this were to happen, the facility would be looking at losing at least a full day of cases, even if the company rushes a replacement. Given the nature of the cases we do here, it is even more important that we make sure everything stays in working order."

Case outcomes
Dr. Stahl says that his facility has noticed two very encouraging trends in their patient outcomes. "The incisions are tiny and the robotic arm is so precise that there is almost no collateral tissue damage. There is also less bleeding. The result has been that patient complaints of post-op discomfort can be as much as 50 percent lower than when we do the cases the traditional way. Patients are not only ambulatory after the procedure, but they also return to full activity as much as a few days faster. We've had patients come in for hernia surgery and go back to work two days sooner than with the average laparoscopic hernia repair."

Case times, however, are not faster. "Overall, we can run about a half hour to forty minutes slower, so several fewer cases can be scheduled in a day as compared with traditional surgery," says Dr. Stahl. "On the other hand, post-op recovery tends to be faster."

Conclusions
Dr. Stahl notes that his facility is providing a service to the public, as it is the only hospital in that region of Florida that boasts the technology. "The cases that don't go to Pensacola come here. So far, we've applied the robotic technology selectively, but in the not too distant future, I think we will be using it to develop all new procedures. I think that the field of robotics will only continue to grow."

Case 2: daVinci at San Ramon Medical Center, San Ramon, Calif.
The San Ramon Medical center uses the daVinci system, manufactured by Intuitive Surgical. According to Barry Gardiner, MD, director of minimally invasive surgery, the robotic system has been used in many laparoscopic GYN cases and hernia repair. Dr Gardiner helped in the initial the testing and development of daVinci.

How the system works
Explains Dr. Gardiner, "The surgeon is seated at console, looking at a 3-D screen that sits on a cart. In layman's terms, it works sort of like a video game, in that there are instrument controls below the display screen. The surgeon's wrists, however, are at eye level. With his fingertips, the surgeon controls pencil-sized instruments in the operative site. The robotic arm moves the instruments by command."

Set up and learning curve
According to Dr. Gardiner, one of the hardest aspects of using the robotic system is the process of getting ready to use it-both before and after you get it in the OR.

Dr. Gardiner notes that the learning curve for using this system is fairly steep. "In traditional laparascopy, surgeons are moving elbows and shoulders. With the daVinci system they are mostly positioning their wrists and fingertips to make the robotic arm roll, pitch, and grip the instruments. For a lot of surgeons, it's a fairly intuitive system, but it's not something you can get familiar with in a two-hour seminar."

Surgeons are trained in the use of daVinci by clinicians who have worked extensively with the robot. Even with this high level of training, Dr. Gardiner says that it takes several training sessions before surgeons are ready to consider using it in live cases. "Some surgeons are still more comfortable doing laparoscopy the way they learned it," he says.

Getting the system set up also takes a while. Says Dr. Gardiner, "The setup involves positioning the console and instruments properly and making sure the surgeon is physically comfortable at the controls. Initially, the setups were even longer; it could take an extra 15 minutes of down time between cases as compared to the turn-around time in between typical laparoscopy cases. It still runs longer but not as dramatically. The difference is manageable."

Case outcomes
According to Dr. Gardiner, the outcomes with the daVinci system have been excellent. "The precision in the operative field is extraordinary. The system scales the surgeon's hand and finger movements down to a microsurgical level-in other words, there is exact precision in the surgical field with no hand tremors. That means you can work through tiny incision ports because you can get to the exact spot you want to operate on. Also, with traditional laparoscopy, the video screen is the operative field. The surgeon loses the depth of perception that you have in most types of surgery. The DaVinci system is superior in that the surgeon is working with a three-dimensional view, which is like being inside the operative field. Patients tend to recover a little faster on average and get back to their normal routines a little sooner. The infection rate has been miniscule in robotic surgery, although laparascopy infection rates have been improving, too."

While the outcomes have been very encouraging, the cases have taken longer to complete. Says Dr. Gardiner, "Although one of the areas that has people excited about robotics is the possibility of shorter case times, case times have been longer for most users. This is typical of any developing technology, however. When surgeons initially use the system, including set-up and actual operating time, cases can take about 50 minutes longer to complete. As you gain experience, you can trim about 18 minutes off that time, but there are still the issues of longer times for setting up the equipment, performing the cases, and getting ready for the next case as compared with traditional laparoscopy cases."

Conclusions
Dr. Gardiner believes that the daVinci system has been benefcial in two ways. "First, we are at the forefront of actually doing surgery with the technology. We've seen that they work and patients have benefited. Secondly, those who have already gained the benefit of that experience, both the surgeon and the facility, are on the cutting edge of the medical community. The level of both professional and layperson interest in the technology and the number of patients who inquire about it are increasing at a steady rate."

Even though the systems, due to their high cost, tend not to be profitable from a strictly economic perspective, Dr. Gardiner says that few who are interested in robotics expected a quick economic boost from it, and they plan to get more use out of it in the near future. "For example, surgeons can do some gastro procedures that we couldn't do before and with more and more experience, we are refining and adding to our repertoire," he says. "Robotic systems are a long-haul investment in your patients that could pay other dividends over time. Overall, I am very pleased."

Case 3: Socrates at Sentara Norfolk General Hospital, Norfolk, Va.
The newest trend in robotic surgery has been the use of telesurgery. This techology allows a surgeon to "link" to a patient in another OR; even if the patient is halfway around the world. The first telesurgery was performed in New York and Paris in September, 2001. More recently, Michael Fabrizio, MD, utilzed the Socrates teleconferencing system (Computer Motion) in Norfolk to assist in a urology procedure in Berlin, Germany on a 66 year old prostate cancer patient.

How the system works
Explains Dr. Fabrizio, "What the system does is function like a super high-tech teleconferencing system. But rather than just seeing and hearing each other, the robotic instruments are also linked in real time. I did the procedure collaboratively with Dr. Ingolf Turk in Berlin via Socrates, which has a telestrator on the video link. Via the telestrator, I outlined the steps of the procedure to Dr. Turk from my office and I controlled the Aesop robot in the Berlin OR. Dr Turk did the actual surgery, however."

Set up and learning curve
Says Dr. Fabrizio, "The big challenge, of course, is that there are not yet many facilities linked this way. From a surgeon's perspective, assuming you already know how to use the robotic equipment, the main adjustment is that you are far removed physically from the surgery, so you rely completely on the equipment to keep you in contact with the other OR. It's crucial that you stay linked in real time and the two surgeons can see and hear clearly. The technology really does have to carry the day."

Case outcomes
Says Dr. Fabrizio, "I was able to view the procedure as if I were actually in the OR in Berlin and Dr. Turk and I communicated very effectively. The patient recovered with no complications, so it was a complete success."

Conclusions
Dr. Fabrizio says that telesurgery is a tool that can be used anywhere that robotic surgery is used. "It enables surgeons trained in robotic surgery to deliver care anywhere in the world. It allows surgeons to plot out surgical strategies and best practice techniques during a live case. All barriers of both time and distance are removed. As the field of robotics grows, I think telesurgery will be a major asset."