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TMCNet:  Robot surgeon starts work at AUBMC

[July 29, 2013]

Robot surgeon starts work at AUBMC

BEIRUT, Jul 30, 2013 (The Daily Star - McClatchy-Tribune Information Services via COMTEX) -- The latest addition to the surgery department at the American University of Beirut Medical Center isn't a specialist surgeon or a new set of operating tables. It's a robot. The AUMMC's new Da Vinci robotic operating system was used for the first time earlier this month to conduct a pelvic lymphadenectomy on a 76-year-old patient with prostate cancer.

The robot uses small keyhole incisions to operate, employing cameras to relay a view of the procedure to the surgeons seated several meters away. "There are two surgical approaches to do a procedure," explains Dr. Faek Jamali, chairman of the minimally invasive and robotic surgery committee at AUBMC.

"You can either do it laparoscopically or open ... The robotic operation is basically a minimally invasive approach, very similar to the laparoscopic approach. It's all done through small key incisions, but it adds a lot of precision [and] dexterity and it increases the ability of the surgeon to do more complicated things." The robot, which is made of three components -- the arms that carry out the operation, a tower that houses the camera and other equipment, and the consoles from which the surgeons control the procedure -- is primarily of use to urologists -- who operate on the kidneys, bladder and tracts -- and gynecologists, Jamali says, but it can also be used for specific operations in general and cardiac surgery.

While Jamali explains that 90 percent of the robots, which have been on the market for around a decade, are controlled by one surgeon at a single console, the AUBMC chose to purchase the rarer dual console system, called the Da Vinci Si, which allows two surgeons to operate at once, each controlling two of the robot's four arms.

"This gives you more expertise and more safety," he says. "We chose the Si because we want to approach this as a team ... and because we are an academic medical center we have residents to train, and so it offers us the opportunity ... to be able to train our residents in robotic surgery using the second console, so they would be side-by-side with the surgeon, seeing what he is seeing." One of the major advantages of the robot, Jamali explains, is that it allows the surgeons to view the operations in three dimensions, as though they were performing open surgery, whereas traditional laparoscopic surgery employs cameras that show everything in two dimensions, meaning surgeons must judge depth purely by feel.

In addition, the tools the robot uses are articulated, allowing them to be angled inside the patient's body with a versatility and precision impossible to achieve with the straight, chopstick-like tools used in a traditional laparoscopy.

The surgeons can set the robot to mirror their movements exactly or to scale them down to one-third, allowing them to perform incredibly precise procedures. It can also be linked up to a patient's ECG machine during cardiovascular surgery.

This allows the surgeon to make the gesture to place a suture at any time, knowing that the robot will wait until the heart has stopped between beats to carry out the procedure.

On the downside, Jamali admits, there is a loss of tactile sensations with the robot. Usually when a surgeon squeezes on an instrument during laparoscopic surgery there is sensory feedback. "An experienced laparoscopic surgeon can appreciate how much force is being exerted and what the resistance of the tissue is," he explains.

"Unfortunately, with the robot, you're sitting at a console away from the machine. So when you squeeze and the robot closes you have no feedback whatsoever, so you have no idea how much pressure you're applying." Another disadvantage is the cost. Jamali says it's unlikely that the AUBMC will recoup the $3 million spent to purchase the robot, added to which is the cost of the instruments used in surgery, which have to be replaced after a limited number of uses. The average cost for these instruments is around $2,000 per patient, the physician explains, although around $500 is saved by negating the need for the instruments that would be used in a traditional operation.

"Who covers this cost is the biggest issue of debate," he says. "Insurance companies are a little bit worried about having to cover this extra cost because the medical literature is not very clear yet that the robot really decreases length of stay.

"We're in the process of negotiating with them and we may be able to come to an agreement. In the worst case scenario ... the patient will have to pay something in the range of $2,000 to have their case done robotically, which we think is a reasonable amount of money." Patients in need of an applicable operation are given the choice between open, laparoscopic or robotic surgery, explains Jamali, and currently the hospital is not charging patients anything extra if they elect to use the robot.

Since the first operation was successfully completed on July 9 the hospital has completed 10 other surgeries, and is currently averaging about one operation per day using the robot. Jamali expects the volume to double once all the interested surgeons have completed their training.

There are currently four stages of training for surgeons interested in learning how to operate with the robot, which teach the user the necessary dexterity. "A surgeon is a surgeon, they know how to do the operation," clarifies Jamali. "What I'm trying to teach them is how to do it with this technology ... They know how to do the operation with their eyes closed. Now it's just a matter of how to use the robot to do it and to do it better." ___ (c)2013 The Daily Star (Beirut, Lebanon) Visit The Daily Star (Beirut, Lebanon) at Distributed by MCT Information Services

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