Robotic Debate

Last updated on May 13th, 2019 at 02:36 pm

Thousands of surgeries were done last year in the United States with the aid of a robot. However, the use of robots for cardiac surgery is still fairly rare. St. Luke’s Medical Center cardiac surgeon Dr. Daniel O’Hair is the only surgeon in the state who uses robots for cardiac surgery. Dr. Michael Savitt, a cardiothoracic surgeon who practices at St. Luke’s and at Columbia Hospital in Milwaukee, moved to the area last year after performing about 50 cardiac surgeries with a robot in Portland, Ore. He has not performed one here, yet.

Surgeons who use robots for cardiac surgery say it is a less-invasive procedure and patients recover faster. Instead of cutting a large incision through the sternum to gain access to the heart, cardiac surgeons with robots only have to make a few small incisions.

"That is the key to the whole thing," O’Hair said. "The patient recovery is dramatically accelerated."

Patients who undergo cardiac surgery with a robot typically do not have shorter hospital stays than patients who undergo the standard operation, but they do tend to resume normal activites faster and go back to work sooner, Savitt said.

"The one true advantage that we found in robotic surgery is how quickly the patient recovers," Savitt said.

However, other surgeons dispute that the use of a robot for cardiac surgery provides any benefit to the patient.

"There’s currently no clear advantage to using the robot," said Dr. Alfred Nicolosi, an associate professor of surgery at the Medical College of Wisconsin who practices at Froedtert Memorial Lutheran Hospital and the Clement J. Zablocki VA Medical Center. "There’s not even a hint of an advantage of using a robot at the present time."

Dr. Paul Seifert, a cardiac surgeon who practices at Waukesha Memorial Hospital and the Wisconsin Heart Hospital, said patients recover fairly quickly from the standard cardiac procedure that involves cutting the sternum. It takes about six weeks for the bone to heal, he said.

"I’ve been impressed with patients that don’t seem to require a lot of pain medication afterwards," said Seifert, who does not use the robot for cardiac surgery. "They complain of pain, but it’s not excruciating. It’s a tolerable experience."

"The pain from an incision is not dependent on how long the incision is," Nicolosi said. "The notion that patients recover quicker, I don’t think there is any data to support that."

In 2001, St. Luke’s purchased the da Vinci robot system, which costs about $1.3 million and is manufactured by Sunnyvale, Calif.-based Intuitive Surgical Inc. O’Hair has done about 240 cardiac surgeries with the robot. He performed some of the first trials of the procedure in the nation.

To use the robot, a surgeon sits a few feet away from the patient. Small incisions are cut into the patient’s chest and the surgical instruments are inserted. The surgeon looks into the machine and can see a 3-D image of the patient’s heart, and the surgical instruments. The surgeon places his or her hands into controllers and moves the controllers to direct the surgical tools.

The robot can be used for heart bypass surgeries, valve repair, valve replacement, fixing holes in the heart, pacemaker installation and tumor removal from around the heart, O’Hair said.

It takes time and training to learn how to use the robot for cardiac surgeries, cardiac surgeons said.

Some surgeons, particularly older doctors, may be reluctant to try a new procedure that they are not as skilled at instead of sticking with a procedure they have done well for years, some heart surgeons said. They may also hesitate to try a new procedure if they are not convinced it will provide obvious benefits for the patient.

Some surgeons who do not use a robot for cardiac surgeries point out that the surgery with a robot lasts longer, which can require a patient to spend more time on a heart-lung machine.

"I never heard a patient  complain," O’Hair said. "Nobody complains about being asleep for another two hours."

However, some patients hooked up to a heart-lung machine during cardiac surgery suffer complications, such as a stroke.

"An operation that takes two to three hours longer than the standard way, using the heart lung machine, can’t be called less invasive," said Seifert.

Patients undergoing valve surgery must be kept on the heart lung machine. Patients undergoing bypass surgery can be operated on with a beating heart. O’Hair said he has done some beating heart bypass surgeries with the robot, when appropriate for the patient.

Dr. Husam H. Balkhy, a cardiac surgeon at the Wisconsin Heart Hospital, Community Memorial Hospital and St. Joseph Regional Medical Center, said less invasive valve surgeries can still be done with small incisions without the robot.

"There are other ways to do less minimally invasive surgery without the robot," he said.

However, O’Hair said the robot allows more complex maneuvers than typical endoscopic surgery, and the robot allows surgeons to get a 3-D image inside of the patient instead of a 2-D image with typical endoscopic surgery.

The robot technology is a huge leap forward, but it still has less range of motion than the human hand, Savitt said.

"Very few people can do a multi-vessel coronary bypass with the robot and do it well," Seifert said. "We have the robot. It’s used more by the urologists. It’s very good for prostate surgery. As a cardiac surgeon, I think I’m waiting for the technology to catch up with the complexity of the operation."

"I still think it’s very cumbersome to do," Balkhy said.

Many new health care products are over-hyped by their manufacturers, some cardiac surgeons said. Health care providers need to carefully consider if those products will benefit their patients.

"Heart surgery is being driven by companies inventing new technology," Nicolosi said. "It is not really being driven by common sense."

However, even the heart surgeons who do not use the robot say it should still be studied and further developed.

"I think the robots need to be looked at," said Dr. Curtis Quinn, a cardiac surgeon at Waukesha Memorial and Community Memorial who does not use the robot. "I think they will be used in the future. At this moment in time, they don’t lend an advantage to cardiac surgery. I am not pooh-poohing technology. Technology is a great thing. But some technology hasn’t benefited us yet."

Balkhy said he would use the robot some if the hospitals he practices at had one. However, the technology must improve so the robot has even more range of motion and is even less invasive, especially for bypass surgeries, he said.

The robot is an important part of the future of cardiac surgery, Balkhy said, but the technology must be improved. For now, minimally invasive valve surgery can still be done just as well without the robot, he said.

"It’s very important for us to develop robotics in cardiac surgery, but there are also other ways," Balkhy said. "Robotics, I think, is here to stay in cardiac surgery. The ball is rolling."

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