Surgery Of The Future: The Ultimate Remote Contro

Douglas Boyd, a heart surgeon at London Health Science Centre in Ontario, is doing amazing things in the OR these days. Sitting across the room from the operating table, Boyd is using a surgical robot to perform bypass operations on patients without opening their chests (save for five tiny incisions), while their hearts continue beating. He's done 68 such procedures since the fall of 1999, with no deaths and far fewer post-op complications than he encounters in conventional operations. It's real state of the art, whiz-bang stuff, especially when compared with the controlled gore of standard bypass surgery, in which the chest is sawed open and the heart is stopped for the duration of the procedure, while the surgeons work with their hands deep in the chest cavity. But to hear Boyd tell it, his current OR feats and those of his fellow first-generation robosurgeons are not so much technological triumphs as they are, basically, successful experiments, a mere beginning. As good as they are, he says, the million-dollar machines they're operating with today are "like the Model Ts of robots," destined for the junkyard, or maybe the Smithsonian, as more sophisticated systems take their place. And while the operations they're doing are indeed remarkable, they are but the first small steps in a long journey to a boundless future where, says Boyd, "the only limitation is going to be people's imagination."

Robotic surgery is a reality. Today, just over three years after the first systems reached the market, more than 400 surgeons around the world are using surgical robots to fix hearts (valve repairs as well as bypasses), remove gallbladders, repair fallopian tubes and remove prostates, among other procedures. (In the United States, many of the operations being done are part of FDA clinical studies.) Nearly bloodless and almost eerily precise, robosurgery makes some of today's standard operations seem nearly as quaint and crude as the early days of neurosurgery in the 1880s, when doctors operated in street clothes and scooped out brain tumors with their fingers. The pioneer robosurgeons are establishing the ground rules for the nascent field, figuring out the best way to use the technology. Practical by nature, disciplined by training, they are hyperfocused and locked into the present, making their way methodically through each operation. But, like Boyd, they are also dreamers, looking ahead to a time when almost anything will be possible, even long-distance surgery.

Robosurgeons don't have to wash their hands before they operate. That's probably the most telling detail about the entire process, the surest indication that this is a whole new way of doing things. They don't have to perform the ritual scrubbing (although they do wear scrubs, surgical masks and head coverings in the OR) because they don't touch their patients during surgery. Instead, the robosurgeon sits at a console a few feet away from the operating table, watching a color video monitor and manipulating two control instruments. A computer links the controls to instruments held by robotic arms, which do the actual cutting and sewing inside the patient (graphic). The monitor is connected to a tiny camera that is also held inside the patient by the robot, enabling the robosurgeon to see what he's doing. The instruments and camera enter the body through incisions as small as the width of a pencil. A second surgeon, scrubbed and gowned in traditional fashion, is at the table, changing the robotic instruments when necessary, ready to take over in the event something goes wrong and the robotic procedure has to be aborted.

"Scale means nothing to the machine," says Dr. Eugene Grossi, director of the Cardiovascular Research Laboratory at NYU Medical Center, as he conducts a lab demonstration of the Zeus Robotic Surgical System that he and his colleagues use to repair damaged heart valves. (The Zeus, manufactured by Computer Motion, and the da Vinci, made by Intuitive Surgical, are the two main robotic surgical systems currently in use.) What Grossi means, and enthusiastically explains while deftly using the robot to tie knots barely visible to the naked eye, is that surgical robots can do things humans can't because, well, they're not human. They have an array of built-in features that make them ideal for minimally invasive microsurgery. A computer program filters out the natural tremor that afflicts even the best surgeons. "I can have five Starbucks and be rock steady," jokes Boyd. Another program scales down the surgeon's motions, so a two-inch movement of the control instrument becomes, for example, a two-millimeter movement of the instrument inside the patient's body. It can also amplify range, so a 45-degree twist of the control becomes, say, a 90-degree twist of the operating instrument. And tiny endoscopic cameras with up to 25X magnification give robosurgeons microvision far greater than conventional surgeons wearing magnifying eyeglasses.

It's too soon in the history of robosurgery to say for certain exactly how or how much the high-tech operations benefit patients. At this point, the primary benefit seems to be less trauma to the body because of the minimally invasive procedures. This feature, which is also a benefit of laparoscopic surgery (in which surgeons stand at the table and manually operate long instruments through tiny incisions), usually results in faster recovery time. Boyd's robotic bypass patients spent an average of 2.8 days in the hospital after surgery, compared with an average of 6.8 days for patients undergoing conventional bypass. Such reduced hospital stays represent substantial savings for any health-care system and may prove to be one of the long-term benefits of robosurgery. Boyd says his robotic surgery patients also required one tenth as many blood transfusions and had far fewer post-op episodes of irregular heartbeat than conventional patients.

Right now in the United States there are seven FDA clinical studies of robotic surgery systems underway, five involving the Zeus and two involving the da Vinci. The studies are designed to assess the safety and effectiveness of the robots for a variety of operations, including heart bypass. Intuitive Surgical's da Vinci has already been approved by the FDA for use in general laparoscopic procedures, such as gallbladder removal, and several other operations. Computer Motion expects to receive some FDA approvals for its Zeus system by the end of the year. Both systems have full clinical approval in Canada and Europe, where the regulatory environment is less constraining than it is in the United States.

While it might take years before enough clinical studies are done to establish the true benefits of robosurgery, heart patient Richard Rome already knows everything he needs to know. "I would recommend this to anybody," says the 50-year-old photographer from Lynbrook, N.Y. "I feel great, my energy levels are awesome." Rome had the faulty mitral valve in his heart repaired last summer by Dr. Stephen Colvin, chief of cardiothoracic surgery at NYU Medical Center. Colvin, assisted by Grossi, used the Zeus to perform the delicate job through an incision just three fingers wide in Rome's chest. "I didn't feel like having my chest bone cracked if I didn't have to," says Rome, who first read about robotic surgery in 1999 in Popular Science magazine. The operation was part of an FDA study being done by Colvin and Grossi. Rome had no qualms about having the robot come between him and his surgeon. "That didn't bother me in the least," he says. "If you have faith in the doctor, that's the bottom line." Rome was out of the hospital in four days, walking comfortably in a week and cutting his own grass again in three weeks.

Perhaps the most intriguing aspect of robotic surgery is the potential for tele-surgery--performing operations over long distances. "As soon as you're eight feet away you could just as easily be 80 feet or, with fiber-optic cable, 8,000 miles," says Boyd. Long-distance robotic surgery has been proposed as a way to treat patients in remote locations, like Antarctica, or in more populated parts of the world where surgeons are scarce. In the latter case, a regional surgical center would be set up and outfitted with the working end of a robotic surgery system. Telesurgery faces lots of obstacles, including the technical problem of signal lag, those critical milliseconds between the movement of the control instrument and the movement of the operating instrument. Any delay exceeding 200 milliseconds, which can happen when the signal travels long distances, is considered a risk to the patient, since it decreases the surgeon's control. There are other questions about telesurgery as well. Is it ethical for a surgeon to operate on a patient in another city, or even another country, with no way to physically intervene if something goes wrong? And if something does go wrong--power failure, loss of signal transmission--who will the patient blame, and sue? The surgeon? The company that made the robot? The company that operates the communications system, the phone lines or cable? Can a surgeon operate by long distance in a place where he isn't licensed? And if a procedure takes place in two jurisdictions and there's a problem, where are the lawsuits filed?

One person who thinks about these thorny issues a lot is Dr. Michel Gagner, chief of laparoscopic surgery at Mount Sinai Hospital in New York. Gagner, a general surgeon, is working with Prof. Jacques Marescaux at the University of Strasbourg in France on plans to perform transatlantic telesurgery. "It can be done," he says. They have already conducted a lab experiment with the Zeus in which they simulated a transoceanic signal transmission. "The results were conclusive and positive," says Gagner. The legal and regulatory issues are daunting, however, and Gagner cannot say when, or if, they will ever be able to carry out their plans. But his confidence in the equipment is total. "If you don't do anything crazy with the machine, nothing crazy is going to happen on the other end," he says. "The output is going to be exactly what you put in."

As their specialty evolves, robosurgeons are more likely to find themselves assisting or overseeing other surgeons from long distance, rather than operating themselves. Telementoring, as it's called, will exploit the power of the robotic surgery systems while sidestepping many of the issues associated with long-distance surgery. In one scenario, the robosurgeon of record (and a scrubbed assistant) is at the console in the OR with the patient while the teacher or specialist observes and advises from another location via his or her own control console, which is linked to the system in the OR. If the robo-surgeon on site is doing something wrong, or having difficulty, the specialist can help him through the crisis. In another, more complex example, the specialist would have the power to override the on-site surgeon's console and take over the procedure. For Dr. Richard Satava of Yale, the second scenario brings to mind what he calls "Sears-catalog surgery." Satava, a member of the American College of Surgeons' Committee on Emerging Surgical Technology, played an important role in the development of robotic surgery technology in the early 1990s as a member of the government's Defense Advanced Research Projects Agency. "You can picture a warehouse with hundreds of surgeons reporting for work every morning and they just sit down and plug in and you call up and order your operation," he says.

Satava suspects there are too many non-technical issues involved--such as liability--for his catalog vision to become reality. But he and others in the field are confident there will be other, equally extraordinary developments in robotic surgery in the next 10 to 20 years. The key to many of them is "data fusion," which will merge the robotic surgery systems with diagnostic technologies, like MRI and CT scan. "Surgeons are used to seeing with their eyes, but there are other ways to see," says Grossi. He expects robosurgeons will eventually operate while looking at real-time diagnostic images of the patient's anatomy, and that the instruments will also have haptic feedback, a computerized sense of touch, so the robosurgeons will be able to "feel" the tissue they are operating on. Data fusion will also enable robosurgeons to load a patient's diagnostic imagery into the robot and practice the operation in advance, in a virtual dry run. Satava theorizes that data fusion will eventually lead to robotic systems "that can do pre-op diagnosis and pre-op planning." He also thinks robosurgeons could well end up supervising surgical robots, rather than operating them. The machines will be so sophisticated, they'll be able to do most of the work automatically. "You set everything up, push the button and only interrupt if something goes wrong," he says.

Though he dreams of performing trans-oceanic telesurgery, Gagner sometimes worries that the distance between surgeon and patient has gotten too great. He recalls the old way of removing gallbladders. "You put your hands in the patient's body," he says. "And they spent seven days in the hospital recovering, so you really got to know them." And as he speaks, another future development suddenly looms, an affliction unique to robosurgeons, an occupational hazard they'll just have to learn to deal with--nostalgia for the human touch.


ENDOSCOPIC INSTRUMENTS: The long, thin tools used with surgical robots

DA VINCI SYSTEM: The surgical robot made by Intuitive Surgical. There are 52 in use around the world.

DATA FUSION: The merging of diagnostic imagery, like MRI, with robotic surgical systems

HAPTIC FEEDBACK: A computerized sense of touch. Will enable future robo-surgeons to 'feel' the organs they operate on.

HARMONIC SCALPEL: Essential tool for robotic surgery. High-frequency vibrations cut and cauterize tissue.

MINIMALLY INVASIVE SURGERY: Robotic surgery is a form of this. Much less traumatic than open surgery.

MOTION SCALING: A robotic function that reduces the size of a surgeon's hand movements, making them more precise

TELEMENTORING: Long-distance teaching or assisting. An ideal application of robotic surgical systems.

TELEPRESENCE: The fundamental concept behind robotic surgery. The surgeon is present via signal transmission.

TELESURGERY: Robotic surgery performed over long distances

TREMOR REDUCTION: A robotic function that filters out hand tremors

ZEUS SYSTEM: The surgical robot made by Computer Motion. There are 48 in use around the world.