Paulos Yohannes, M.D. & Ranjan Sudan, M.D.
Creighton University Medical Center
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May 6 , 2003 — Lincoln JOURNAL STAR
In the hands of a robosurgeon
Robotics laproscopy means less pain, shorter hospital stays. It stands menacingly over the unconscious man, its three gangly arms sunk deep into his yellowish, iodine-painted abdomen. Meet robosurgeon. He’s here to help. Fresh from the pages of science fiction, robosurgeon heralds the next stage of laproscopy —surgery through small holes instead of large, open cuts. At Creighton University Medical Center recently, a human surgeon worked the controls of what appeared to be the ultimate Sims Surgery computer game, but it wasn’t simulation. The daVinci robot’s mechanical arms reponded to surgeon’s movements, trying knots and cutting tissue inside the patient. The robot brings these advantages to the task. Its hands never shake, its back never tires, and it can easily sew a perfect stitch deep inside a patient’s body by stretching long mechanical arms through tiny incisions. For the patient this means less pain, quickly healing and a shorter hospital stay. Heart surgery will be the real future of the machine, said Larry Elliott, BryanLGH Medical Center vice president of diagnostic and treatment services. BryanLGH bought a daVinci months ago after the robot received federal approval for heart-value surgery. Elliott expects federal approval of singlevein heart bypass surgery using the robot this fall. BryanLGH Heart Institute surgeons plan to do their first values using the machine in the next two months. “I’m confident we’ll get the learning curve up quickly,” Elliott said, “We’ve been doing several hundred valve cases a year.” Oomaha has two daVinci robots. Creighton’s has been performing limited numbers of urologic and abdominal surgeries since federal approval for those procedures came in 2000. Almost weekly, Dr Paulos Yohannes, 33, sits at the console of the Creighton robot, peering through its binocular eyepieces at a small area of flesh. As Yohannes quickly spins his wrists and fingers, tiny robot pincers inside the patient grasp needles or sew stitches. A different robotic attachment slicecs through connective tissue. Pressing a foot pedal cauterizes the tissue to stop bleeding. Another foot pedal repositions the robot’s camera. Although nearly a foot inside the patient’s abdomen, the image that Yohannes sees appears inches away. The picture is three-dimensional, fully lit and in living color. To the untrained bystander, it seems impossible to distinguish the various organs and features as Yohannes removes the patient’s cancerous prostate. Surgeons removve prostates when the cancer is confined to the gland and the patient can be expected to live another decade. Prostate cancer typically grows so slowly that surgery is otherwise unnecessary. Dr. Ranjan Sudan, one of two doctors assisting Yohannes, sits at the patient’s left side, staring into one of three monitors dispersed around the operating room. Sudan explains the procedure while working suction. Assistants also change tools at the end of the robot arms. Sudan points out the prostat, a shiny bleached white bulb against the pink background of the bladder. This wormlike feature is a vein, he said. There, he said, pointing to a different shade of white is the pubic bone. “It’s very deep inside the body,” said Sudan, who is in charge of developing Creighton’s robotic program. Yohannes speaks to the others via a microphone and loudspeaker. He moves first around the seminal vesicles, which duct semen. Once thosse are free, he tackles the prostate. It rests beneath the bladder, which stores urine. The prostate produces fluid to keep sperm alive. It wraps around a portion of the urethra, a tube that drains urine from the bladder. Removing the prostate will require taking out that portion of the urethra, which must be splice back to the bladder like a piece of a cut garden hose, Sudan said. Cauterizing and burning, Yohannes meticulously peels away the connective tissue around the walnut- sized gland. At one point, he works carefully near a bundle of nerves to prevent functional impotence for the patient. Yohannes has done about 10 prostate robotically. Proficiency comes with practice. The goal is to blur the distinction between thought and machine, so that the robot’s arms will seem to move automatically, like flippers on a favorite old pinball game. “Once he’s done 100 of these,” Sudan said, “he’ll be able to do them in his sleep.” The ends of the robotic arms converge at the prostate, moving through sleeves that protect surrounding tissue. The gap where the tools actually grab and move is smaller that a tennis ball. It would be much larger in a conventional surgery, Sudan said. Surgeons often can do similat things laproscopically, manipulating tools on the end of sticks by using their hands, but there are limits. The big advantage of the robot over laproscopic surgery is the swivel at the end of the stick. Pivoting like tiny wrists, these swivels give the surgeon tremendous ranages of motion. Laproscopic hand tools also exaggerate tremores. It’s like trying to hit the head of a tiny screw with a yard-long screwdriver, bobbing back and forth. Sewing with the robot is much easier, Sudan said. “It can pretty much do with this instrument what the hand can do,” Sudan said. Even beginners can sit at the machine, pick up a tiny needle and pass it back and forth. One of the chief challenges of the robot is developing a team whose movements work harmoniously. Hands that operate suction, tool changes and stitches must work together seamlessly. A 16 inch scar adorns the abdomen of this particular patient. It’s a souvenir from an earlier conventional surgery. this procedure should leave far less scarring. He might even be able to leave the hospital the following day. That explains why Lincoln heart surgeons are now practicing on the robot. As with everything in medicine, economics plays a critical role. Creighton currently loses money on robotic abdominal surgeries, Sudan said. The machine cost $1 million, plus attachments, but hospital reimbursement from Medicare is no different than for tradtional surgery methods. During the learning phase, it also takes longer to do robotic surgeries. “It’s still worthwhile,” Sudan said. Teaching hospitals like Creighton can advance science while making things less painful for the patient, he said. Reimbursement may catch up to the new technology, he said, or it may lead to shorter hospital stays. Short hospital stays is how the robot already may work for hearts. Elliott said BryanGH has been carefully watching the progression of robotic surgery for years. Cardiac surgeon Bruce Jones of the BryanGH Heart Institute said early studies show that patients who receive robotic valve proceedures have good success. “If we do not have to open the chest completely,” he said, “it will alleviate a lot of post-operative discomfort.” Patients undergoing valve surgery now stay in the hospital about five to six days. “If it cuts that down to two days, that will save money,” he said. Across town, Saint Elizabeth Regional Medical Center currently has no plans to purchase a surgical robot. Saint Elizabeth is focused on the completion of its $110 million expansion, said hospital spokeswoman Jo Miller. The daVinci robot is a product of the U.S. Department of Defense. It was born in the 1980s as a way of letting surgeons operate on critically injured soldiers from a safe distance, or of performing emergency surgery on astronauts. Jones believes robots could soon become pervasive, at least for some surgeries. “It’s (still) overkill for general surgery,” he said. By MARK ANERSEN Lincoln Journal Star








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