Robots in the Emergency Room

Metro Detroit hospitals are driving revenue and profits by drawing patients from around the world to their robotic surgical systems

The da Vinci Surgical System includes a 3-D stereo viewer, along with hand controls that connect to robotic arms nearby. Illustration by Garth Glazier

It’s 7:40 a.m. on a Tuesday and a 55-year-old man with prostate cancer is fighting for his life in a surgical suite at Detroit’s Henry Ford Hospital. But there’s none of the usual organized chaos that marks most operations. There’s no popping of latex gloves as nurses slap scalpels and scissors into surgeons’ hands from long trays of instruments. There’s no blood spattered on the floor or on the doctors’ and nurses’ scrubs.

Instead of the usual huge overhead lights illuminating a body cavity as bright as day, this operating room is cool and dimly lit. And you have to look hard to find the patient, who’s almost completely swathed in plastic and lying next to a gently rising and falling respirator presided over by an anesthesiologist.

Instead of the patient being surrounded by medical personnel, just one doctor sits next to him, talking softly to the rest of the team as he inserts and removes short lengths of tubing from the patient’s body. The surgery itself is actually being conducted by Dr. Mani Menon, a urologist who’s seated a dozen feet away at a da Vinci Surgical System, a device that resembles a video-game console-cum-jukebox.

Menon, a pioneer in robotic surgery, looks into the view window and grasps two hand controls that are connected to robotic arms on a cart next to the patient. The system uses computers to translate the surgeon’s hand, wrist, and finger actions into precise movements of the surgical instruments in the tubing. In fact, the surgeon never actually touches the patient.

And instead of requiring a long, gaping incision in the patient to make room for the surgeon’s hands, as is still common in many types of surgery, the tubing and robotic arms are inserted through incisions about the width of a pencil.

Perhaps equally amazing, a camera inserted through a slightly larger incision shows the operation 35 times normal size, and in 3-D, on several big-screen TVs on the wall, as well as on the da Vinci console. Everyone involved in the operation wears special 3-D glasses.

As the surgery begins, thin surgical threads look as thick as steel cables, and the patient’s walnut-sized prostate is clearly visible as the robotic cutting arm snips away flesh and reveals the cancerous tumor. Occasionally, the 3-D screens are obscured by smoke and steam as the heat element on the robot cuts away flesh. “This is a revolution in surgery for the prostate,” says Menon, still hunched over his small da Vinci screen in the shadowy room. “But it may be a revolution for all surgery in the next five to 10 years.”

The da Vinci system, which is now used throughout the world, was originally developed for heart surgery. But its widest use, for prostate operations, “all started in Michigan at the Vattikuti Urology Institute at Ford Hospital,” says Menon, who is director of the institute. “We got funding to try it and it worked.”

Every year, more than 200,000 American men are diagnosed with prostate cancer. But unlike many other cancers, there’s a reliable blood test — the PSA test — for prostate cancer, which is highly curable if detected early, Menon says. “This [patient’s] cancer was caught early, and the chance of recovery is almost 100 percent.”

The da Vinci system is on the cutting edge of what’s come to be known as laparoscopic, or minimally invasive, surgery, which causes minimal damage to the body. Doctors like Menon, and the da Vinci’s maker — Intuitive Surgical Inc., of Sunnyvale, Calif. — say there are many benefits for the patient, including significantly less pain, less blood loss, less scarring, and a shorter recovery time.

But some doctors lament the disadvantages of the da Vinci, such as the initial cost — $1.4 million to $1.6 million per unit, plus annual maintenance. Other issues include a long learning curve for using the device, the lack of a hands-on feeling during surgery, and the limitations of the da Vinci, which isn’t appropriate for all types of surgery.

Currently, 26 hospitals in Michigan use the da Vinci. Four of the systems are at the Henry Ford Health System and three are at the University of Michigan system, according to Intuitive Surgical. Other metro Detroit hospitals that use the da Vinci include Royal Oak-based Beaumont Hospital and the Mount Clemens Regional Medical Center.

As part of a trend dubbed “medical tourism,” patients have come from 49 states and more than two dozen countries to undergo the procedure at Henry Ford Hospitals. Menon estimates that since the first robotic prostate operation in 2001, he has performed more than 3,000 procedures.

Steven Whitty, a 55-year-old truck driver from Macomb Township, came to Henry Ford after he was diagnosed with prostate cancer. “When I found out, I talked to doctors at other hospitals and to my family doctor,” he says. “My doctor said, ‘If it were me, I’d go to the Vattikuti Urology Institute at Henry Ford.’
“I went online [and learned that] Menon was the best in the world. I also met guys from Dubai and Maine who were to have it done.”

Menon operated on him last fall.

Whitty, an athletic man who bicycles about 5,000 miles a year, has had 11 different surgeries in his life. This one, he says, was the easiest. “I went into surgery at 11:45 a.m. and woke up at 4:30 p.m. I went back to work after 20 days. But if I had a desk job, I could’ve gone back to work two days after the operation. Psychologically, the mention of cancer had brought me down. I didn’t know if it had spread, but they got it all. It lifted all the weight off my shoulders, [and] I feel great.”

In Ann Arbor, Dr. Arnold Advincula, a professor in the obstetrics and gynecology department at the University of Michigan’s medical school, has been using the da Vinci for gynecological operations, including reproductive surgery, since 2000. “It’s the only Food and Drug Administration-approved surgical robot for humans,” he says. “It’s given us the ability to overcome limitations — going from two dimensions to three dimensions.”

Where the old instruments were rigid and restrictive, Advincula says, the robotic system has allowed him to treat more patients. He now performs 70 percent of his operations using the da Vinci, but it’s no panacea. “Size is still an issue,” Advincula says. “It takes up a big footprint in the operating room. And at $1.6 million for each [unit], cost is a problem.”

Dr. Mani Menon, a urologist at Henry Ford Hospital in Detroit, has performed more than 3,000 procedures with the da Vinci.

Learning to use the da Vinci can also take time for doctors. In addition to his initial training, Advincula says it took him about 20 cases before he completely understood the mechanics of the device. There’s also a competitive “we have the latest technology” marketing aspect to the da Vinci. “A lot of hospitals use the system,” Advincula says, “but a lot of it is market-driven. Sometimes it ends up in places where it’s not fully utilized, but used for marketing” to attract patients. The maker of the da Vinci doesn’t see that as a problem.

“The continued adoption of da Vinci surgery as a new standard of minimally invasive surgical care is reflected by the growing number of hospitals and patients in Michigan,” says Nora Distefano, a market-development specialist for Intuitive Surgical. “We envision a future in which every hospital in the country will offer the improved clinical outcomes and reduced surgical traumas enabled by [our] system.”

The device, of course, is named for Leonardo da Vinci, who is said to have designed the first robot — a humanoid automaton — around 1495. The design notes for his robot appeared in sketchbooks discovered in the 1950s. It’s not known whether an attempt was made to build it.

The prototype of the da Vinci system was developed in the late 1980s at the former Stanford Research Institute (now SRI International) under a contract with the U.S. Army. The robot is apparently able to make several human-like motions, including sitting up, as well as moving its arms, neck, and anatomically correct jaw. And it’s partially Leonardo’s anatomical research that led to his highly accurate three-dimensional sketches of the human body. Stanford’s initial work was aimed at developing a system for performing battlefield surgery remotely. Intuitive Surgical was founded in 1995 to develop broader commercial uses.

The FDA approved the da Vinci in 2000 for general laparoscopic surgery and, subsequently, for cardiac, urological, and gynecological procedures. Laparoscopic surgery (also known as keyhole or pinhole surgery) is notable for its tiny incisions, as opposed to the larger openings employed in traditional surgery. According to Intuitive Surgical, there are more than 1,000 da Vinci systems installed in hospitals around the world today, from Japan to Saudi Arabia, although most are in the United States.

The da Vinci, however, may not be useful for all types of surgery, the company acknowledges. Heart surgery, at which the da Vinci was first aimed, requires an excellent view of the chest cavity. Surgeons have historically split the chest open with a foot-long incision and spread the ribs, which allows more room for the surgeon’s hands and instruments. And that practice continues.

“I shot at the heart,” says Intuitive Surgical CEO Lonnie Smith, “[but] I hit the prostate.”

Nationally, the majority of prostate cancers are now operated on using the da Vinci, Menon says. Henry Ford Hospital has also begun employing it for kidney surgery. Menon acknowledges that it can “take days to get comfortable” with the da Vinci. He compares the training to practicing in a flight simulator. Surgeons can “easily have 400 hours of virtual-reality training before touching a patient,” he says. “It’s like playing golf — before you can become a pro, you have to play for a long time.”

Some of the advantages of the da Vinci include far better vision and maneuvering in close quarters. Recuperation times are far shorter, and bleeding is reduced by up to 90 percent. There are also fewer problems with infection, incontinence, and erectile dysfunction.

Dr. Robert Welsh, chief of thoracic surgery at Beaumont Hospital in Royal Oak, likes the “greatly magnified field of vision” and depth perception offered by Beaumont’s three da Vinci units. He says the robotic arms offer a range of movement that mimics a doctor’s own hand. But he, too, sees some disadvantages.

“You can’t tell if you’re holding something — there’s no tactile feedback, no sense of the force being applied,” he says. “You can stretch or break tissue.” But such problems, he says, are “very rare.” Welsh also points out that the robotic arms have to be replaced after 10 or 12 uses, to ensure the reliability of the instruments. Welsh says it’s hard to estimate any overall cost savings with the da Vinci. But reducing patient discomfort and shortening the length of most hospital stays from two or three days to one day is a major advancement.

When Carol Gee, of Sterling Heights, was told she needed a hysterectomy, her first thought was that she “didn’t want to be opened up.” She had undergone several other surgeries as an adult — including two Caesarean sections, a tubal ligation, and gall bladder and appendix removal — and was concerned about additional scarring from traditional surgery. “My doctor told me about da Vinci surgery and said I was a good candidate, that it was more accurate,” she says.

Gee had her da Vinci hysterectomy at Henry Ford Macomb Hospital last July. “I’m still amazed,” she says. “There wasn’t a lot of pain, and I went home the next day.”

Back at Henry Ford Hospital in Detroit, Menon peers into his da Vinci view screen in the operating room. He turns his thumb and finger slightly, and the robotic pincer on the 3-D screen drops Steve Whitty’s cancerous prostate into a bag for extraction. Menon then begins suturing the patient.

“It’s always an amazing process,” he says. “It’s minimally invasive, but still a big operation. It makes a huge change in people’s lives.”

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