- Associated Press - Saturday, November 19, 2016

CHATTANOOGA, Tenn. (AP) - Is there a robot in your surgical future?

Area doctors say improvements in cameras, mobility and size are making the high-tech devices much more useful for surgeons in many more specialties than before.

Dr. Lee Jackson, who has done more than 1,500 prostate surgery operations at CHI Memorial, recently took robotic gear to a monthly show-and-tell meeting with primary care and family doctors. They needed to see what the gear looked like, Jackson explained, because more and more of their patients will see it if they need surgery.

“It’s kind of like the iPhone - when it first came out, it was a novel thing, but people weren’t sure how one would use it,” said Dr. Amar Singh, a urologist who since 2003 has used every generation of the gear at Erlanger hospital.

“The cardiac (heart) guys were among the first to utilize it, and then the urologists took over and we did one operation, a prostatectomy (removing the prostate)” he said. “Now if you look simply in urology, there is a ton of kidney cancer work, female reconstruction, bladder reconstitution. Now there are bariatric surgeons doing obesity surgery. Our hospital is a leader in doing colon surgery. Physicians are using it for throat, and you have general surgeons doing gall bladder and liver work.”

The machines are expensive. Erlanger’s board of trustees just approved spending more than $1 million over the next four years to lease a robotic unit for the use of Dr. Larry Shears, its new heart surgeon.

But they allow surgeons to make tiny incisions, insert miniature tools and operate in small spaces inside the body.

“It allows you to put the equivalent of a hand into the pelvis to do surgery,” said Dr. Rena Azar, a sole practitioner board certified in female pelvic medicine and reconstructive surgery who operates at Parkridge hospital. “I can go into much smaller places with robotic equipment than with my own hand, 30 times smaller.”

Calling the machines robots is a bit misleading. They do not move at all unless a surgeon is guiding their arms. But they definitely appear space-age, with a 3-D screen, a tiny high-definition camera, state-of-the-art monitors and up to four arms that can hold a variety of tools.

The surgeon sits at a console in a corner of a darkened operating room, 20-30 feet away from the operating table. With two fingers and a thumb placed inside two controllers, and foot pedals on the floor, the surgeon can move the camera to see inside the body and maneuver tools to move organs aside, cut tissue, sear blood vessels shut, staple tissue together or hold needles to sew up an incision.

A first assistant stands beside the operating table, using hand tools to suck fluids from the body, remove bits of flesh after they have been cut off, clean the lens as needed, or push in small needles the surgeon can then grab with a robotic arm. A nurse typically is on the other side of the operating table, handing tools to the assistant.

Most surgeons who use robotic gear keep the same assistant for years. Jackson’s has been with him for 21 years, Singh’s for 10, and Shears said the freedom to bring his assistant with him was a major reason he came to Erlanger.

“That was one of my big concerns about ever leaving (my previous job), how easily will this be transferable,” he said. “But we were up and running right away.”

Newer tools give the surgeon even greater insight.

“If you go to the latest machine, we can inject medication and use fluorescent vision to see what is cancer in the lymph node and what is not,” Singh said.

Minimally invasive surgery has been around since miniaturized video cameras appeared in the early 1990s, but Azar said the tools were difficult to control, the equivalent of a rigid pole with a tool on the end. “There was no equivalent to the wrist movement that surgeons have on their body.”

The robotic gear fixes that and does even more.

“It allows you to go around corners,” Singh said. “You can come from any angle because you have 360-degree freedom of movement.”

“You can get the camera much closer, and just the nature of the technology allows better imaging,” Azar said. “So you can do really meticulous dissection between critical organs like the bowel and bladder, and minimize the chance of a mistake.”

The machines are made by one company, Intuitive Surgical, which calls them the da Vinci Surgical System. Erlanger has four of them, CHI Memorial two and Parkridge, which installed the first system locally back in 2002, has three.

Critics have questioned whether robotic gear is worth the extra cost, and even its proponents emphasize it’s not the choice for every surgery.

“There is a medical technology Cold War where if I buy one robot, you buy two, I buy this generation, you buy the next and put a billboard out there,” Singh said. “If you don’t have a high volume of operations, you will go bankrupt chasing this technology. It’s like buying a car every month that you don’t need to drive.”

Some studies have shown using robotic gear can add $3,000 to the cost of an operation. That means surgeons must decide carefully whether using the gear is warranted.

“You have to become not a blind follower, but more like an astute user of this technology,” Singh said.

But besides helping surgeons perform complicated operations, minimally invasive surgery also reduces recovery times significantly, cutting costs and reducing the risk of infection.

“Most (traditional) bypass patients will stay in the hospital almost six days. That is the average,” said Erlanger’s Shear. “With robotics, they go home in two to three days.”

“Cost is a tricky question,” Singh said. “What’s a person getting back to work, back to the gym, a day or two early worth, how do you put a number on it?”

But for the doctors who use it, there is little debate.

Said Azar, “It’s irresistible for an advanced surgeon.”

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Information from: Chattanooga Times Free Press, https://www.timesfreepress.com

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