THE DA VINCI TOUCH
WHEN it comes to making decisions, there is nothing to match human ingenuity — but try slicing skin, navigating a path through vital organs or stitching a wound and you can’t beat the precision of mechanics.
So, anything a doctor can do, a robot can do better, right? Not quite. Brains still trump brawn, but a growing number of medics are handing over the blood and guts side of their work to robots controlled from computer consoles.
Among them is Dr Barry O’Reilly, consultant in obstetrics and gynaecology at Cork University Maternity Hospital (CUMH), the only hospital in Europe to perform both cancer and non-cancer procedures using advanced robotics.
Dr O’Reilly is among the vanguard of surgeons who operate without handheld scalpels or cutting tools. For him, there is no comparison between robotic technology and the conventional method of bending over the operating table while wearing a powerful headlamp to light up the patient’s insides.
The exact, tremor-free movement of the robot means less stress for both patient and surgeon.
“It is a very precise surgical tool,” Dr O’Reilly says. “I compare it to the way you might eat your dinner. You could eat it with a shovel, which approximates open surgery, or you could use a knife — a bit like keyhole surgery. This is more like dining with chopsticks — precise, clinical, delicate.”
This is the 21st century world of robotic surgery but don’t imagine that surgeons are for the scrapheap. The most important tasks, like diagnosis and decision making still depend on brain power.
In any event, the machine has no life of its own and can only do what the surgeon instructs it to do. A good outcome still needs a skilful surgeon and, for all its sophist-ication, the robot is just another medical tool.
CUMH has been designated the First European Robotic Gynaecological Epicentre. While three other epicentres in Europe perform either benign gynaecological or cancer surgeries, CUMH is the first to offer both, under the directorship of O’Reilly and his colleague, fellow obstetrician Dr Matt Hewitt, who specialises in gynaecological oncology.
They use the da Vinci Surgical System. Named to celebrate the famous Renaissance painter and inventor, it enables surgeons to perform complex surgery using a minimally invasive approach. In that respect, it is a 21st century application of the 5th century BC Hippocratic injunction: “First, Do No Harm.”
The da Vinci system uses up to four arms and flexible wrists on which are mounted miniaturised tools and cameras controlled by the surgeon.
The robots are used mostly for hysterectomies, fibroid removal and other gynaecological procedures, but have lately begun to make inroads into other areas like heart valve replacement and kidney and prostate surgery.
One of the most successful robotic procedures deals with female prolapse, a condition where organs, such as the uterus, fall down or slip out of place and can result in an extension of the womb into the vagina. It affects 50% of women some time in their lives and, up to now, this unpleasant, embarrassing side-effect of childbirth and ageing has been treated using the proverbial shovel.
O’Reilly prefers the chopsticks: “Traditional surgeries have been very invasive procedures, involving big, abdominal incisions from the ribcage to the pubic bone. When an operation is done through an incision of that size, it takes the patient a long time to recover. With the robot system, there is far less cutting.
“The procedure is less invasive and the recovery time is far shorter. It is also more comfortable for the surgeon. It is more ergonomic and means you are not bent over the patient all the time. You are not scrubbed up for surgery either, and you can get up and have a stretch if you need to,” Dr O’Reilly says.
Robots can also protect surgeons from physical stress and exposure to X-rays that may force them into premature retirement.
The da Vinci System’s high-resolution, 3D, stereo viewer is designed to provide surgeons with an immersive experience — and it certainly is. It is a bit like playing a video game or watching a 3D movie where you feel you are part of the action. The anatomy appears at high magnification, in brilliant colour and with natural depth of field.
Operating through a few small incisions, the surgeon uses the console’s controls to manoeuvre the robotic arms which hold the instruments and endoscopic camera.
Dr O’Reilly is particularly taken with the instruments’ multi-jointed wrist design, which follows the natural range of motion of the human hand. “The robotic instruments are called endo-wrists. They move like your wrists do, with great precision. The old, standard keyhole surgery was known as straight-stick surgery, with the instruments capable only of moving up and down, whereas this system mimics the full range of the surgeon’s hand.”
CUMH established its Gynaecological Robotic programme in 2008, having performed the first robotic gynaecological surgery in Britain and Ireland in 2007. It is now the centre of a European-wide study to investigating robotic surgery for female prolapse.
As part of that, CUMH has just been given funding for the provision of the first international Fellowship in Robotic Pelvic Floor Reconstructive Surgery. Dr Lorenzo Dutto, a consultant urologist from Rome, who was selected to undertake the one-year fellowship, is only in Cork a few wet days — literally — but the horrible weather has not dampened his enthusiasm.
“This is a very important study and, although you can learn a certain amount by watching video, you really need to be in situ, so I am delighted to be here. You need to get a real feel for this kind of surgery, with proper coaching and mentoring,” Dr Dutto says.
While observing the procedure being performed by Dr O’Reilly from a viewing monitor, he explains the wonders of the da Vinci system and the importance of human skill.
“This is a fantastic system, but there still remains the difference between a good surgeon and an ‘oops’ surgeon. The good surgeon will plan the procedure carefully and avoid any pitfalls that may occur. The ‘oops’ surgeon won’t, and that is how complications in surgery can arise.”
We watch in wonder as Dr O’Reilly finishes the procedure. Dr Dutto points out that there has been no bleeding, a sign of great skill. So did that mean that Barry O’Reilly was a good surgeon and not an ‘oops’ surgeon? “Absolutely,” says Dr Dutto. “One of the best.”
The da Vinci system does not come cheap, with each machine costing an average of €2 million each — not to mention additional charges of tens of thousands of euro annually for training and replacements for tools disposed of after a certain number of procedures. But, according to Dr O’Reilly, it offers good value for money.
“If you take into account that the procedure is far less invasive, less painful or debilitating for the patient than conventional methods, it stands to reason that far less time is spent in hospital,” he says. “With traditional methods, a patient could be in hospital for weeks and out of work for up to three months. With this system, he or she can be allowed home within 24 hours and be back at work within two weeks.
“That means a saving not just for the health service, but for business as well, so you cannot simply look at it in terms of how much each machine costs.”
There are other advantages too, as Mary O’Conor, from Rathgar in Dublin, found when she had a robotic procedure for a prolapse in May of last year.
“I had undergone conventional surgery for my problem a couple of times and they were not all that successful and I knew it was not a good idea to keep having the same procedure over and over again.
“I was not in pain, but I was very tired and uncomfortable and I didn’t know what to do. Then my niece, who is a doctor, went to Cork for her internship and she told me about Barry O’Reilly, so I went to see him.”
Mary, who works as a sex therapist in Dublin, was relieved when Dr O’Reilly said he could help her, but nervous about undergoing the robotic procedure.
“I was terrified, to be honest, but I need not have been at all. It didn’t feel like major surgery. There were only three tiny wounds and hardly any bleeding. The most amazing part of it all was the recovery time. Usually, after surgery, I am whacked for months, but two nights later I was having dinner in Ballymaloe. I was back to work much more quickly and back playing golf within a month. It is a year later now and I feel fine. I would recommend it to anyone.”
Catherine Siggins, a mother of six from Cork, is hoping for a similar outcome. She underwent a similar operation yesterday and, like Mary O’Conor, had already gone through a conventional procedure. Although that operation went well, the prolapse recurred after a few months.
Unlike Mary, she was full of beans in advance of her operation and felt little or no qualms about the use of a robot, although reserving her praise for the human element. “I have great faith in the staff here,” she said. They have always been very good to me.”
JUST like the internet, medical robotics was first intended for the battlefield. The Pentagon in the US funded research in the 1980s and early 1990s to design robots capable of tending to wounded soldiers in combat conditions.
The unmanned medical treatment systems, known as trauma pods, would administer life-saving medical and surgical care and help to stabilise the conditions of injured soldiers within minutes of them becoming a casualty.
Early systems proved bulky but recent developments, using satellites, allow doctors to operate on a wounded soldier from a remote location.
In 2005, the Pentagon awarded $12m (€8.5m) to researchers at SRI International, the company that developed the da Vinci system, to build a robot that could perform surgery on the battlefield. In turn, last April SRI adapted technology it originally developed for the da Vinci system to create a bomb-defusing robot called Taurus.
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