STAR-LEDGER, June 8, 1997
ROBOTS IN OPEN HEART SURGERY
ROBOTS IN GENERAL SURGERY
ROBOTS IN LAPAROSCOPIC INGUINAL HERNIA REPAIR.
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The medical robots are busy in the laboratory of Dr. Ralph J. Damiano Jr., chief of heart surgery at the Medical Center of Hershey.
Using gleaming claws, one robot is clasping a curved needle half the gauge of an average fish hook. The other is pulling the sides of a small coronary artery apart to get it ready for a graft.
Together, they make a dozen precise and delicate stitches in the heart before them. A third robot holds a camera steady next to the 'heart so Damiano can watch the surgery on the full-color video monitor in front of him as he gives the robots instructions.
"They are my hands and eyes," Damiano says of his operating assistants.
Devices gain role in surgery
Unlike Damiano's hands, the robotic arms can grasp the handle of an 18-inch instrument probe without causing, even a slight tremor at the other end. Each can also adjust its own degree of movement to a millionth of an inch.
And unlike his own eyes, the robotic camera will magnify the stitches by a power of 16.
Damiano says medical robots will never replace human judgment or the experience of a surgeon, but the medical devices are about to revolutionize the 'treatment of patients.
In five to 10 years, this will change the face of surgery," said Damiano 42, a Westchester native who graduated Dartmouth College and Duke University's medical school.
Pressed by incentives to cut costs, and marketplace competition to make surgery easier on patients, medical and biotech companies are focusing on new tools for "non-invasive" surgery. In some cases, technology developed for space exploration and military use is transported to the medical world.
In Hershey and at two other sites in the nation, surgical robots will begin operating on, humans early next year, as part of a federal Food and Drug Administration trial of their safety and effectiveness. The system is called ZEUS, and it is manufactured by Computer Motion in California.
In New Jersey, the Hackensack University Medical Center has been using a simpler Computer Motion robot system, known as AESOP, for four years. The name stands for Automated Endoscopic System for Optimal positioning, company spokeswoman Leslie Reniley said.
ZEUS doesn't stand for anything yet, they just wanted to keep going with the Greek names," she said. There currently are 280 hospitals using the AESOP system, which costs about $44,600 for the entire system.
Yet to come is a system called "Hermes," which will allow a surgeon to give vocal orders to a battalion of voice-activated medical devices and is described as "the creation of the `intelligent' operating room. It will be unveiled at a convention in Santa Barbara later this month.
The explosion of robots in the operating room , however, has raised some concerns at ECRI, a private non-profit laboratory in Plymouth Meeting, Pa., that tests medical devices and collects data on their safety records.
"Anytime you introduce another machine into the operating room, that's one more place something can go wrong," said Eric Sacks, senior project engineer. But neither ERCI nor the federal Food and Drug Administration had any reports of medical accidents involving Computer Motion's robotic devices.
"Their track record is good. There haven't been any disasters," said Dr. Garth Ballantyne, director of minimally invasive surgery at Hackensack University Medical Center.
In Hackensack recently, surgeon Peter Fan permitted visitors into his operating room to observe AESOP at work on two procedures, including hernia repair.
They were joined by two medical device sales representatives.
One was a camera salesman testing a new laparoscopic system. The other urged doctors to consider a device that uses imaging techniques. It was used on Apache helicopters to detect targets during the Gulf War. The technology had been adapted instead to detect laser-sensitive dye injected into a patient's ureters , the tiny tubes that drain kidneys. Viewed through a special scope, the dye makes the ureters glow flamingo pink. That makes it easy to avoid nicking them, a risk in gynecological surgery.
Ballantyne said the Pentagon is also interested in medical robots. "The military wants to have a system where robots can measure blood pressure, give fluids and use a video camera directed by a surgeon miles away," he said.
The robotic arm used in ZEUS and AESOP was an offshoot of a NASA mission, Damiano said.
In Hackensack, Fan was operating on Howard Walker, a Rutherford sanitation worker who had an inguinal hernia - a tear in the connective tissue of his lower abdomen through which his intestines protruded in a 69-sized bulge.
"It was that washing machine, Wednesday, on heavy trash day," Walker, 31, said in a post-operative interview. "I lifted it and I felt it rip."
Ms co-workers warned him he was in for an ordeal. Traditional hernia surgery requires doctors to cut the abdomen, through layers of skin, muscle and nerves.
"The guys were telling me I'd be in agony," he said.
In the operating room, once Walker was anesthetized, Fan made three incisions. All were three millimeters long, small enough for BandAids. Then, using a headset, Fan began talking to his robot, the system known as AESOP.
A fiber optic camera smaller than a pencil was threaded into Walker's abdomen and was being held by the robot. "AESOP, move left," Fan ordered. The robot chirped in response. "AESOP, stop," Fan said after the robot found the hernia.
"AESOP, get me some coffee," he said, then turned to his visitors. "That was a joke.
The repair was done by done a polypropylene mesh patch, shaped like a hammock through the operating port, placing it inside the abdominal wall. Then Fan stapled the b of the mesh to the pelvic bone and front to the abdominal muscles. " It's like lining the bottom of a boat with a hammock," he said.
There are no nerves in the stapled areas, hence no pain, he said. But in a traditional hernia repair, closing six-inch incision often means accidentally catching a nerve and possibly leaving a patient in pain for months, he said.
Each surgeon cleared to use the AESOP system makes voice recordings. To make AESOP recognize commands, each surgeon has a voice card that is inserted into the robot whenever that surgeon operates.
Usually, the system works fine. The robot might not recognize the voice, if the surgeon's tone that day is different from the recording. But there is a backup system of manual controls should that happen.
The next generation of surgeons may be more at ease with the robotic concept. People who have grown up with video games and virtual reality simulations have an easier time making the transition, said Hackensacks Annette Wasielewski, a surgical in charge of AESOP.
"We had a community demonstration where we let people try the basic techniques, using controls to pick things up," she said. "The kids did it best. I think its because of Nintendo."
Though the technology for single-handed laparoscopic hernia repairs has been available for several years, most surgeons have resisted, Fan said - partly because of the cost, but also because the traditional method is simpler for older surgeons, he said. ' As for Walker, he was up and about the day after Ws surgery. "My friends were amazed," he said.
Fan said the AESOP robot re. places the need to have another doc,tor, usually a surgical resident, hold the camera, a tedious job that the device can do better. "It takes the shakes out of the doctor's hand," Fan said.
"Most everyone is doing gallbladder surgery laparascopically now. The appendix is next," he said.
But adding robots to. the instrument lineup is expected to take surgery to a new dimension, doctors and experts interviewed said. "You can't do the hernia laparoscopically without the robot," Fan said. "I can't operate and hold the camera at the . same time.
Robots are expected to make surgery safer and cheaper, and recovery much faster.
Robots may also eliminate some operating room personnel with the goal being to allow "solo surgery" - a doctor operating with only an anesthesiologist and nurse on operations that now require two or three doctors and several nurses. But mostly the idea is to do surgery with the smallest incision possible, said Damiano.
He predicted the robots will become standard in doing even multiple coronary bypass surgeries and valve replacements. Coronary bypass surgery is done about 700,000 tones a year, and almost always as open-heart surgery.
Both now require a "thoracotomy," Cutting through the chest's bone, muscle, blood vessels, and nerves. The procedure leads to long hospital stays and slow recoveries.
ZEUS is expected to change that, he said.
The first such robot-assisted heart surgeries will require stopping the patient's heart, the same as in conventional bypass. But researchers expect to put computer robotics to work to be able to operate on the moving, beating heart.
"Someday we'll be doing bypass operations as same-day surgery, or outpatient procedures," Darrdano said.
But Damiano doesn't envision a day when robots will rule the operating roost. "Things can go bad quickly and you have to be ready to go in if that happens," he said.
"This is going to be a revolutionary change. As someone who's spent 17 years with his hands in patients' chests, I feel a little strange about that. But this is what the future looks like, he said.