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TIME MAGAZINE, JUNE 4, 2001, VOL.157 NO.22
Doctor's Little Helper
Robotic devices aren't cutting surgeons out of a job just yet, but they are lending an extra hand, making operations easier
By DAFFYD RODERICK San Ramon
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Mark Richards for TIME.
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With the da Vinci surgical robot, surgeons can control tiny "hands" that perform minimally invasive operations.
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On the outside, the patient's stomach is smeared in yellowy iodine and puffed out from the CO2 pumped in to provide some elbow room. Five "ports" are cut through his side, allowing surgeons to slip mechanical tools into his body. On the inside, it's an unrecognizable mess of viscera, shiny pink surfaces and gloopy fat. Across the room, lead surgeon Barry Gardiner sits at a console with his head pressed into a 3D viewfinder. His fingers, looped into what look like castanets, dart about just above his lap. But the action is taking place inside the patient, where metal robot "hands" inserted through the ports follow every move of Gardiner's: sewing, clamping, cutting. "It's like being able to shrink my hands and put them places they'd never fit," the surgeon says.
Mention robotic surgery and people typically envision a C3P0 in pale green scrubs, leaning over and digitally intoning: "This won't hurt a bit." It's not quite as cool as that. The robot Gardiner uses at San Ramon Regional Medical Center, in a grassy suburb an hour outside of San Francisco, is a gray-and-black three-armed wonder connected to a console that doesn't have anything witty to say. It looks exactly like what it is: a machine. But by allowing doctors to access and see parts of the body as never before—without large, open incisions—this tool is speaking the language of surgery in a whole new way.
The $1 million da Vinci robot, made by Intuitive Surgical, is a modern twist on an older technique known as "keyhole" surgery, in which surgeons use elongated chopstick-like tools teamed with a tiny camera to work inside the body. But "keyhole" surgery is counterintuitive: to move the instrument's tip to the left, the surgeon has to push the handle to the right—and vice versa. Despite the advantages to the patient, only about one-quarter of the 15 million operations performed each year in the U.S. are done this way. The da Vinci takes the tools out of the surgeon's hands and gives him 3D vision. "It's like being able to operate in the same style as open surgery, except the tools are inserted through small puncture wounds," Gardiner says.
The da Vinci is a descendant of a U.S. Department of Defense project in the 1980s to create a robot that would allow surgeons to operate on critically wounded soldiers from a safe distance, or even perform emergency surgery on astronauts on Mars. The scientists envisioned easily deployed surgical units that would save lives. But while the need for careful setup of the patient and machine and the chaos of trauma surgery have yet to make that possible, non-emergency surgery over great distances is already happening. In 1998 a doctor from Baltimore assisted on a robotic operation in Singapore from his library at home. But it's not about to become common. The surgery was a success, but it had its downsides: the cost of involving another surgeon (there has to be a surgical team at the patient's side ready to take over in case of mechanical failure), and "speed of light" issues that caused a lag of one second between the surgeon's actions and the machine's execution. For surgery between Earth and the International Space Station, or for the Mars mission scheduled for 2015, the lag becomes even more considerable.
But while some are excited about the long-distance possibilities of remote-control operations, it's the application for on-location surgery that most excites surgeons, and patients like Valentina Tichtchenko. While visiting her daughter recently in San Ramon, the 69-year-old native of St. Petersburg, Russia, began having difficulty swallowing. It worsened to the point where she couldn't eat at all; she was diagnosed with cancer of the esophagus. Traditional surgery involves an incision from the throat down to the belly button. "It's a very violent operation," says cardiothoracic surgeon Murali Dharan, making a digging motion with his hands. With the da Vinci, Dharan was able to remove Tichtchenko's cancerous esophagus and move her stomach up much higher—to allow her to feed herself minus her swallowing mechanism—through small incisions in her neck. "I'd watched E.R. on TV at home, but I never imagined how fully I'd get to be involved," she says, over lunch three weeks after her operation.
The robot is also being tested on more difficult surgery, including heart bypasses and heart-valve replacements. These procedures are performed through three incisions, each about the diameter of a pen, instead of cracking open the chest. With a less invasive approach, they promise benefits in patient recovery and lower costs for post-op care. The da Vinci's ability to perform precise movements in tiny spaces—without trembling like a tired surgeon might—could allow better microsurgery, preventing debilitating nerve damage.
Despite the rave reviews, robot-assisted surgery is still in its infancy. While the da Vinci does offer realistic "force feedback," similar to a high-end joystick, it isn't developed to the point where surgeons truly get their valuable sense of "feel." Developing teletaction—long-distance feel—has proven to be a slow process, with current prototypes years away from functioning at a useful level. But surgeons are intrigued by the ability of da Vinci and its closest competitor, Computer Motion's Zeus, to spread knowledge. An expert surgeon could be sitting in his office, watching over the shoulder of a novice doctor 1,000 km or more away. "This is a way of putting someone with more experience into the operating room," says Gardiner. A surgeon could even be in several places at once, watching a bank of monitors showing operations all over the world and being a "telementor" for the less-experienced surgeons. "When a pilot wants to learn how to fly a 747, he doesn't just climb into the cockpit and watch the other pilot and eventually take control," says Bill Colman, assistant professor of sports medicine at the University of California in San Francisco, who has developed a simple simulation for knee-replacement surgery that is used in teaching. "They get to try their hand in a simulator and develop their skills slowly."
Researchers at Berkeley's robotics lab are also excited about what they call "Nintendo" surgery. This involves presenting surgeons with simulations of rare abnormalities. "Simulators give you a way to make things go wrong," says Jeff Ustin, a trained surgeon now studying electrical engineering at Berkeley. Further out on the edge is a research project at Yale that is looking at performing surgery in a virtual environment and storing it for future automated use. A team of medical technicians would pop the patient into a surgical machine, something like slotting in a piece of toast, taking him out when he was done. But that's a long time from now, in a galaxy far, far away.
Related Sites
Intuitive Surgical
UC Berkeley Robotics Lab
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Doctor's Little Helper
Robotic devices aren't cutting surgeons out of a job just yet, but they are lending an extra hand, making operations easier
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