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June 13, 2006

RoboDoc

Roboandme Last night Mary and I went to a reception – actually a fundraiser – for a robot. I’m the one in the tux; he’s the tall one with all the arms.  His name is da Vinci and you can buy one of his clones from Intuitive Surgical for about $2 million.  He’d be cheap at twice the price.

Robots like da Vinci are already disrupting the traditional practice of medicine with very positive results both for patients and those docs and hospitals who are employing the technology.

Actually, “robot” is somewhat of a misnomer.  Da Vinci doesn’t operate autonomously; he is a tool used by a surgeon to perform operations. Da Vinci’s incredible articulating hands, arms and wrists,  are guided by the surgeons hands and fingers. Da Vinci’s cameras are controlled by the surgeon in the driver’s seat (see Mary in the driver’s seat below) and, since there are separate screens for each eye, the cameras provide the surgeon with a very effective three dimensional image of the inside of the patient.

Marydriving

The three major advantages of da Vinci use so far are tiny incisions, great visibility inside the patient, and the ability to do “scaled” operations – a one inch move of the surgeon’s hand can be scaled to a tenth of an inch motion by the instrument.

Without a tool like da Vinci, a surgeon has to make a big hole in you so that she can get her wrists inside and so that she can see what she’s doing.  The deeper in you the problem is, the deeper the hole that has to be cut.  Yuk! Recovering from the incision is often more difficult and more dangerous than recovering from the actual repair that was made. Da Vinci only needs a tiny incision to get his pincers in.  The pincers have fiber optic cameras and lights so the little holes provide the doc with visibility as well as access.

The predecessor technology to da Vinci uses the pincers-like tool pictured here and a small television camera for laparoscopic surgery. 

Pincers

The instrument provides approximately three times scaling of the surgeon’s movement and the surgeon operates by watching a two dimensional image on a TV screen.  Very twentieth century.  As part of our test drive of da Vinci, the demonstrator switched it from two dimensional to three dimensional mode.  Incredible difference.  I was instantly ready to try some DIYS brain surgery.

The scaling allows tiny repairs of tiny things – mitral valves for example.  And no need to saw open the breastbone to get at the heart.  Even the valves of babies or fetuses are operable with da Vinci.  Prostate surgery can be done more precisely with less risk of incontinence or impotence; myomectomies can often be substituted for hysterectomies.  When a hysterectomy is needed, use of da Vinci makes it minimally invasive and less risky.

It’s all cool engineering but some of the features are enough to make any nerd sit up and take notice.  My favorite: an infrared beam scans the doc’s eyes in the scope.  If the eyes move away, all motion of the robotic arms is frozen.  So someone says “hey, Doc” and the doc looks up.  “The Met’s won again.” No danger that his twitch of delight will snip something off inside the patient.

In the current setup, the controls, the rack of equipment, and da Vinci and the patient are all within a few feet of each other as you see here. 

Broadview

You don’t need to be a futurist to understand that the communication between the surgeon and da Vinci is all electronic.  The doc could be half way around the world (as long as no geostationary satellites are in the data path).

The ability to remote robots surgeons may well turn out to the most disruptive aspect of this technology.  It’s an unquestioned good that the most capable surgeon for a particular operation will be able to operate on patients anywhere from anywhere (licensing permitting).  It is inevitable, says I, that this will also lead to international outsourcing of medical operations after a huge fight to prevent this through application of obsolete local licensing rules.  A very real question we will have to deal with is how should licensing and liability work when surgery is done remotely and internationally.

My guess is that Andy Kessler will have something to say about all this in his about to be published book The End of Medicine.

But meanwhile Vermont is one of the three states in the country without this capability.  Hence the fund raiser.  It was sponsored by Dr. Samuel Trotter who’s Chief of Urology at Vermont’s Fletcher Allen Health Care and Dr. Richard Daum who’s an Attending Physician in Cardiology and Medicine there as well as my doctor (see this post).  Dr. Melinda Estes, President and CEO of Fletcher Allen, talked persuasively not only of the immediate benefits to patients of having one of these here but also of the better job Fletcher Allen can do as both a teaching and a research hospital if it has current equipment.

I’m convinced.

Full disclosure:  I currently have both a prostate and mitral valves. Who knows?

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