Health-care providers leverage next-generation technologies to treat patients
There are few things that seem more of-the-future than robots, particularly when robots start doing things previously performed by humans.
More than 1,000 robotic surgeries have been performed at the hospital since the program started in 2005, when robotic systems were used primarily by urologists. But their usage proliferated into other surgical disciplines, and now are used by 14 doctors in urological, gynecological, colorectal and thoracic surgeries.
The new da Vinci robot replaces the previous model formerly used by the hospital. But before anyone gets the wrong idea, it’s not that kind of robot. It doesn’t walk or move independently, speak, or have a face. It only operates remotely by the direct control of the surgeon’s own hands.
“The biggest thing patients worry about when they hear ‘robotics surgery,’ is that it’s R2D2; that it’s in some way automated. That I’m off drinking coffee while a robot is performing my surgery,” explains urologist Thomas Martin, MD, who heads the hospital’s Robotic Surgery Program. “But once you explain that it’s purely surgeon-driven, and the robot can’t do anything to them without the surgeon telling it exactly what to do, they’re fine with it.”
The new da Vinci machine features four arms, three of which hold and operate the small, flexible surgical tools, while on the fourth arm is mounted a high definition three-dimensional camera.
The surgeon sits away from the machine, using the images from the da Vinci camera to see, and uses small hand controllers to operate the robot. As a safety measure, the machine shuts off if the surgeon’s eyes leave the screen for a second, and the controls even have a threshold for any degree of tremor in a doctor’s hand movement, smoothing them out for added precision.
Martin says operating this way is accurate, and incredibly helpful in cutting down fatigue for the doctor, who otherwise would be standing for any potentially long surgical procedures. It also puts more control directly into the hands of the surgeon as opposed to assistants.
“In most surgeries, there are not a lot of hands in the wound, but instruments that are lengthy and precise,” says Martin. “But absence of tactile sensation with this is well-compensated and more than fairly exchanged for the degree to which the visibility is enhanced. I’m a tall guy, so having a 3D camera image right in front me versus having my eyes three and a half feet from where my hands are is a big difference.”
The new da Vinci robot also has a simulator, which trains surgeons on the machine’s functionality, and offers surgical practice scenarios. A far cry from Martin’s initial training, in which he practiced sewing tubes and pieces of cloth together to get the hang of the robot’s motions.
But most importantly, the machine is valuable to patients. Martin says the accuracy of the machine and the small, flexible tools it operates allow for fewer incisions to be made in the patient, and therefore reduces overall pain and recovery time. The comparison between robotic and non-robotic surgery, Martin says, is not even a fair one.
Dr. Thomas Martin says the minimally invasive robotic surgeries make a "profound difference" in patient recovery time.
In a typical prostatectomy, the operation used to take roughly four hours, and the patient would remain in the hospital for up to four days, and had a 25-percent chance of requiring a blood transfusion. The patient was typically restricted from heavy exertion for a month, with three months elapsing before feeling back to “normal.”
With robotic surgery, Martin says operating time is cut to three hours, the patient has only a one-percent chance of requiring a blood transfusion, and is sent home after one overnight at the hospital. Heavy exertion is typically limited for just a week, and he says most patients are back to normal functionality in a month.
“It’s really a profound difference,” he says.
Martin says similarly beneficial results can be seen for the many surgeries the da Vinci performs, including hysterectomies, thymus removal, kidney and fibroid operations, and colon and bowel procedures.
The use of robotics in surgery, he says, is applicable across many disciplines, but not so much yet with cardiac or brain surgery, due to the high risks involved. But as technology further advances, and tools become more flexible, robots in the operating room could become even more common.
“Fifteen years ago, if somebody had described to me when I was a resident doing the surgery that we do now robotically, I’d laugh,” Martin says. “It would be stupid to even think of. And here we are.”
Kurt Roberts, MD knows a thing or two about minimally invasive surgery.
In fact, he’s pioneered procedures at Yale-New Haven Hospital that have patients back on their feet in almost no time.
Roberts is the only surgeon in Connecticut to practice Natural Orifice Translumenal Endoscopic Surgery (NOTES) in women, or, abdominal surgeries such as gall bladder removal, appendectomies, and hernia operations conducted trans-vaginally, with no external incisions in the patient’s body.
Roberts, an assistant professor of gastrointestinal surgery at the Yale School of Medicine, says this is far more beneficial to the patient in terms of recovery; he says the only incision made is on the uppermost section of the vagina to access abdominal organs.
“There are no scars, less pain, and faster recovery. All the pain fibers are in the muscles, and when you go through them, that’s when it hurts,” Roberts says. “The recovery is faster because you have no pain to bother you, so you can go back to regular activity.
“One of my first patients had the surgery on a Friday, she was at home vacuuming for guests on Saturday, and went to a parade on Sunday with no issues. That wouldn’t have been possible with a regular operation.”
A prototype model of the yet-unnamed NovaTract surgical retraction device, designed to aid in minimally invasive surgery. The device could be in use by the end of the year.
The procedure is still relatively rare in the U.S. — Roberts says there are between 300 and 400 NOTES procedures performed each year, and he’s done 88 of them — but is more common in Europe. He saw this first-hand since he grew up in Germany, and went to medical school in Austria. He went on to residencies in Baltimore and Seattle before coming to Yale in 2005.
He said his NOTES procedures are slowing gaining ground, with about 75 percent of patients offered the surgery accepting it.
But since he doesn’t want to be a “one-man show” in Connecticut, Roberts is teaching a CME course in May to train other surgeons on the procedure, and is a program chair at this year’s International NOTES Summit, organized by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR), in July.
Roberts’ research in minimally invasive surgery, such as single-port access surgery, in which doctors can operate via a single incision by the patient’s navel, led to the founding of a medical device startup, Science Park-based NovaTract Surgical, in 2010.
The company is expecting to have its first product, an as-yet unnamed surgical retraction device, in use this year. Roberts explains that the device uses strings and a pulley system to move organs inside a surgical cavity, requiring fewer incisions and therefore less pain for the patient.
“Usually you make four incisions — one for a camera, one for cutting and other fine work, and two others for holding organs aside. You can say you won’t need those two anymore,” Roberts explains. “It works on an internal pulley system with strings that go through the first two ports, and we can pull and retract like a puppeteer with a marionette to move things around.”
NovaTract founder and CEO Eleanor Tandler says the device is currently going through final design stages, with early adopters using them in humans by the fall, and commercial availability by the end of the calendar year. The target, she says, is for gynecological and abdominal surgeries, including gall bladder, appendectomies, hysterectomies, bariatric surgery and colorectal surgery.
“There are still many multi-port surgeries in the U.S.,” she says. “We see this as a tool in helping patients have surgery with fewer incisions, and faster recovery, and less post-op pain.”
She says NovaTract sees big opportunities for distribution in Europe and Japan further down the line.
Meanwhile, Yale pediatric surgeon Christopher Breuer, MD is in the process of conducting Food & Drug Administration-approved clinical trials on children with congenital heart defects to build new vascular grafts using cells from the patient, eliminating the need for synthetic materials.
And more so, since the new tissues are made of living cells from the patient’s body, they have potential to grow.
“Children can outgrow a graft like they outgrow shoes,” Breuer says. “So putting in a graft that can grow is the distinct advantage for use in children.”
To get blood vessels 15 years ago, Breuer says, he would make a biopsy to extract cells, then use a culture to grow more, at which point they would be ceded to a biodegradable scaffold before being used in the body. But in searching for an alternative, he found that nearly enough cells can be gained from a single bone marrow harvest from the hip bone.
The cells can be harvested, attached to a scaffold and implanted in the patient in a single procedure.
The procedure is currently in the investigative stage and is being measured for safety. (The initial application to conduct the procedures is 3,000 pages long and took five years to complete. “The FDA sets a pretty high bar,” he says.)
His first operation, and the first in the U.S., was performed on a three-year-old child last August. There are two more operations slated for this year, and the new grafts will be monitored for growth activity.
Because of the experimental nature of the procedure, Breuer says he had to standardize the patients; in this case all are afflicted with single-ventrical cardiac anomalies, in which the child is born with one functioning heart ventrical. He says successful tissue growth has been observed in animal tests.
Breuer is also working on creating a disposable system that would allow surgeons to inject bone marrow directly into an apparatus that cedes blood cells to a biodegradable scaffold, avoiding the need for expensive laboratory facilities to do the same thing. He says that product is currently in pre-clinical testing on large animals.
He cites congenital heart disease is an example of an orphan disease, otherwise known simply as a rare disease, that which affects a small percentage of people (fewer than 200,000 people, according to the Rare Diseases Act of 2002). Breuer says the system currently in development qualifies as an orphan drug. The Orphan Drug Act of 1983 eases some restrictions, allowing an orphan drug to be produced faster. The act urges pharmaceutical companies to produce products for such rare diseases, since they ultimately will be less profitable.
“The end goal is to create a better vascular graft that is both safe and has growth potential,” Breuer says. “Most drug and device companies make products based on profitability, and as a result there are a number of problems that don’t get much attention. This makes it easier to bring something from the bench to the clinic.”
|< Prev||Next >|