RoboDoc and a hospital revolution

22/01/2011, The Advertisertiser
By Robert Mayne

ROBOTS are helping surgeons do quicker and less intrusive operations.

I’d like you to meet my doctor. His name is Vinnie and he’s pretty good at what he does. Just a little while ago he removed my prostate gland. It was cancerous, and it would eventually have killed me. Vinnie is so good at what he does that just hours after this normally major abdominal operation I was eating, talking, walking and generally happy. And Vinnie won’t accept a dollar in reward for his remarkable achievements, performing this feat endlessly and without complaint at the Royal Adelaide Hospital.

That’s because Vinnie is a robot. His full name is da Vinci and he hails from the Silicon Valley area of California. His birth occurred around the time of the first Gulf war in the early 1990s. Americans were expecting heavy casualties among the ground forces lined up against Iraq’s Saddam Hussein, and they were keen to be able to apply the highest level of American surgical skills to the battlefield.

Vinnie (that’s what his users call him) was one answer to the call. He would be operating in or near the battlefields of the Middle East, but the surgical skills would com by satellite by remote control from one of the big teaching hospitals in the US. Vinnie was the “doctor” at the rock face, but fortunately they didn’t need his full range of capabilities because casualties were light.

But the possibilities of robot surgery were not lost on da Vinci’s maker, Intuitive Surgery Inc., nor on other potential users and makers. Intuitive named its robot after painter and inventor Leonardo da Vinci who envisaged a robotic human substitute five centuries ago. Da Vinci’s vision has been rebuilt in recent years and was displayed at the Sydney Town Hall (the “mechanical knight”) last year.

Today we are seeing the US military’s same incredible technology used in South Australia, including on me. Prostate cancer is to men what breast cancer is to women. Each year more than 20,000 Australians are diagnosed with it, and almost 3300 die. Until recently, a prostatectomy (removal of the gland) involved significant surgery: a 20cm cut in the abdomen creating a big scar, loss of blood, pain and discomfort. Patients having the open cut can expect to spend five to seven days in hospital.

In my case the disease was discovered because I had a PSA test (Prostate Specific Antigen), the usual indicator of serious warning signs. My level was 10, enough to send me off to the Repat General Hospital for a biopsy, which confirmed the cancer. No one knows why prostate cancer is so prevalent. Western lifestyle is one of the possible contributors. Other pointers include vasectomies; men over 50 are at risk for the disease and risk increases with age. As studies into ageing continue, scientists may find that the ageing process produces biochemical reactions that contribute to abnormal cell growth. After my diagnosis, removal or radiotherapy was recommended, and the open operation suggested. However, I’d heard of the robotic procedure, and asked to be referred to Dr Peter Sutherland, 59, a member of a distinguished Adelaide medical family and head of urology at the Royal Adelaide Hospital.

The only downside to the robotic procedure, he told me, was the cost of private treatment. In the end, after fund rebates, it cost about $2000, but it was worth it for the lack of pain, discomfort and rapid return to normal. As a public patient the cost would be completely covered by Medicare.

Come with me, then, to Theatre 5 on the third floor of the RAH where I have been trollied at 2pm on the day of my surgery. I’m left to wait just outside da Vinci’s theatre, named for its benefactor, South Australan developer and philanthropist Gordon Pickard. Some time ago he went to Melbourne for a robotic prostatectomy because there was no machine in Adelaide. Delighted with the result, he decided on the plane on the way home to provide the RAH with one of the machines, at a cost of about $3 million; the State Government covers the $100,000 annual cost of maintenance and operation of the machine.

I am given a sedative, so I don’t remember much beyond the surgery doors. This description was helped by a video of the event and Dr Sutherland’s comments afterwards. First the anaesthetist, Dr Peter Devonish, takes me in hand. Beside him is the senior theatre assistant, Registered Nurse Julie Bowd. There is another theatre nurse and an assistant surgeon who helps with the robot. Not far away is the console where Peter Sutherland directs its robotic arms.

The machine has four arms, three of which can be equiped with disposable “fingers” that cut, slice, pull and stitch. A 3D camera enables the surgeon to see what he is doing in high definition. By now I am asleep, and six small cuts are made in my abdomen, which is also distended with carbon dioxide to give the surgeons more room to see and work. They must manoeuvre around my bowel and bladder to get at the cancerous prostate gland. Da Vinci delivers exceedingly precise movements to the surgeon. I can’t say that I had nightmares about it going mad, but I’m reassured by Dr Sutherland and the makers that it takes the tremors out of microsurgery.

So I pass out with these thoughts going through my brain. Oddly, I also recall a news report that said the Chief of the Defence Forces, Air Chief Marshal Angus Houston, 63, is having the same procedure that very day, though his was the conventional open cut operation. Having made the incisions, the robot’s arms are inserted in my abdomen. They cut through the flesh and fat. There is some blood loss but this is quickly cauterised by heat via the robot “hands”. One of the advantages of these is that they can, unlike human hands, rotate through 360 degrees.

The robot cannot, of course, think for itself, which is why the controls are operated by Dr Sutherland, sitting at a control console 2m away. He is one of 10 specialist doctors in SA trained to use the robot, and five of them use it regularly. Dr Sutherland has done hundreds of cases. He says da Vinci’s advantages are that it allows surgeons to operate through several small incisions about the size of a 10c piece, and that because of the smaller incision, patients experience less scarring, shorter hospital stays and less post-operative pain. Unlike the average week-long hospital stay for open surgery prostatectomy patients, those undergoing robot-assisted operations can go home in 12-36 hours. Air Chief Marshal Houston, for example, was off work for three weeks.

All of these advantages were evident in my case. So why aren’t more operations conducted this way? The main reason is the cost of the equipment. Another is the reluctance of the insurance companies to help hospitals cover the extra cost necessary to buy and operate the robot. But it increasingly seems to be the way of the future, providing better results for patients in areas such as bladder cancer, coronary artery disease, throat cancer, thyroid cancer and gynaecological cancer. In throat cancers, for example, the da Vinci arms can get in to operate via the mouth, obviating the need to cut the throat open.

The da Vinci procedures may be only the beginning. Villis Marshall, Professor of Urology at the RAH’s Hanson Cancer Centre, says: “The da Vinci robot is part of an emerging suite of technologies that will continue to improve outcomes and also reduce length of stay and a more rapid return to normal function for patients. This includes lasers, focused ultrasound and other less invasive technologies such as transluminal repair of aneurysms and cardiac valves. At the present time they often have a high initial cost and consumable cost and this does create a problem for the health delivery system as the greatest benefits occur in the recovery phase, but this is rarely factored into the health budget as it is an ‘out of hospital benefit’.”

Watching the video of my own operation (not pleasant, though gruesomely fascinating) amazes me. The operation took almost two hours, and the camera takes me right into the centre of my abdomen as the robotic arms snip and tear through the tissue. When the surgeon finds the prostate he starts to isolate it, cutting away the links with the rest of my body. I can see the tube of the catheter, and see the delicate needle and thread work as my urethra is re-joined. This is the really delicate part of the operation, partly because it enables me to urinate successfully and also because some of the nerves associated with sexual arousal are necessarily damaged.

With the prostate gland cut away, Dr Sutherland moves Vinnie’s arms to pick it up, put it in a plastic pouch and pull it through the surgical incision in the centre of my abdomen. It’s sent for biopsy (the results are reassuring … the cancer appears to have gone).

When it’s all over the small incisions on my belly are stitched up and I am wheeled out to recovery. I wake some hours later, ravenous, and wolf down some chicken and salad. I remember very little, other than I’m alive.

Less than 24 hours later I walk out of the hospital. While I do not feel absolutely comfortable, I am certainly getting better quickly. Within a few more days I am striding 4km to the library every morning.

Vinnie, I’m completely sold on your skills, and that of your operators. You are another modern marvel, a product of this incredible age in which we live; lucky for humans like me, at least.

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