Robotic Surgery

I watched a lecture yesterday by the head of surgery at Stanford University on robotic surgery. He spoke on the decades long experience with laparoscopy, and the the da Vinci Surgical System.

The latter allows a surgeon in one room to remotely conduct an operation on a patient in another room. Binocular vision is enabled via a binocular eyepiece connected to two cameras mounted on a cable inserted into the patient. Similarly, the surgeon controls instruments from his console that are mounted on the end of cables, and which can be moved with a large number of degrees of freedom to match the motions of his/her hands in the controllers. Very delicate maneuvers of the very small instruments can be made because there is a reduction calculated from the movements of the surgeons hands to the movements of the tiny instruments, while the binocular vision magnifies the images. The system weighs more than a ton, and requires extensive software which is apparently continually being improved and upgraded.

The technology was developed from the aerospace industry with thought to apply it to battlefield surgery or in outer space. But it is being applied to a number of delicate interventions, such as pediatric heart valve surgery. It has been used for some 25,000 operations, including one operation done by a surgeon in New York on a patient in Paris.

The speaker also mentioned the emerging possibilities in new micro0sensors and nanotechnological surgery. Thus one may soon be able to monitor blood pressure within the body; or maneuver tiny antibody loaded particles to cancerous tumors from outside the body using magnetic forces.

I was impressed on the one hand by the discussion of the the historical evolution of this technology which goes back decades (and indeed much longer when the antisepsis and anesthesia are taken into account), and thus seems quite old and established, and on the other hand how very rapidly this is progressing. I can't imagine that 50 years ago anyone would have imagined robotic surgery to be well established today, with some surgeons having performed hundreds of interventions using the technology.

I am also impressed by this as an example of the digital divide. In a world where billions of people have only the most limited financial access to health services, an elite has access to this "space age" care option. The difference between the family who can send their newborn for heart surgery using a million and a half dollar instrument operated by a large and very highly trained team of experts versus the Darfur escapee mother whose child must be dying as I write this for lack of oral rehydration salts and clear water is far more than the distance between those who simply have and do not have access to the Internet.

I was also impressed by the institutional challenges that are soon to be posed by this technology. Certainly one is the reluctance of professionals to accept the new technology. Surgeons have to learn new skills to use the new techniques effectively. There has to be a new relationship formed between engineers, programmers, and the doctors and nurses in the operating suite. Patients have to learn about the technology and its potential risks as well as benefits. Financing agencies and insurers have to develop policies. So to do the schools training surgeons.

We already have medical tourism in which patients travel from developed to developing nations to take advantage of lower cost medical services. What happens when a U.S. hospital outsource an operation in its own surgical suite to a surgeon in India? How is the licensing to be managed? Who has liability? Where is the liability insurance?

Distance education has raised many similar institutional problems, and advances in the application of distance learning that are possible with the available technology are not being fully realized due to our failure to solve the institutional problems rapidly. I suspect that will happen also in the case of ICT enabled medical services -- telemedicine in general and robotic surgery specifically.