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Remote-Control Surgery
Hi-Tech Robot Gives Surgeons a Hand

by Jeff Worley

Star Wars surgery is now available in Kentucky. A four-armed robot, under the command of Stephen Strup, an associate professor of surgery at the University of Kentucky, successfully removed the cancerous prostate of Tony Curtsinger, 66, of Lexington. This robot is part of the $1.3 million computer-assisted technology called the da Vinci Surgical System, which expands a surgeon's ability to operate within the human body in a less invasive way.

Photo of da Vinci Surigcal System © Initutive SurgicalUK's hospital was the first in the state to purchase and use the da Vinci system, which a surgeon controls from a console near the patient. Da Vinci allows surgeons to make smaller incisions, which reduce patients' pain, blood loss and recovery time. Four UK surgeons are currently using this system.

© Initutive Surgical

But wait a minute. You may have already seen this system in action. In the James Bond film "Die Another Day," which hit movie screens in 2002, the da Vinci Surgical System landed an unlikely supporting role. In one of the earliest scenes, at St. Mary's Hospital in London, the machine scans Bond's body and takes a blood sample, which turns out to be a vital action. Bond subsequently pursues questionable characters from Korea to London to Cuba.

Doctors at St. Mary's who use this system say da Vinci performed well in the role. And Sarah Robinson, product placement coordinator for the movie, echoed that view. "Both the producers and director thought this machine was fantastic. It's a very important part of the film."

The da Vinci system is, literally, cutting-edge technology, a tool for surgeons to do less invasive surgery, says Strup, who serves as the director of minimally invasive urological surgery in UK's College of Medicine. "When we can make smaller incisions, this significantly reduces the patient's pain, blood loss and recovery time."

Excizing a Cancerous Prostate

"When you can have an operation like this, go back to the doctor within a week, have the catheter taken out, and go back to work the same day, that’s incredible and speaks for itself," says Tony Curtsinger, who owns a truck and trailer sales business in Lexington. "I was given pain medicine after the operation, but I never felt like I needed to take it." Now, over a year after the operation, Curtsinger says he has "absolutely no regrets" about choosing to be operated on by a robot.

"Dr. Strup was personable, open and honest, and it probably helped that I’m a mechanically minded person. I never had any fear." He adds that he talks freely with friends and acquaintances who are considering prostate surgery, sort of as an unofficial counselor. "I tell them the robot’s the way to go."

According to the American Cancer Society, there will be about 233,000 new cases of prostate cancer in the United States in 2005. Over 30,000 men will die of this disease. Prostate cancer is the second leading cause of cancer death in men, behind only lung cancer.

Prostate removal is the most common procedure performed on men with prostate cancer. The operation has been typically performed through large, open surgical incisions, which often result in lengthy and uncomfortable patient recovery. Not so with da Vinci. Using this system, surgeons make four or five, 1-centimeter incisions, through which an optical system and highly specialized instruments are slipped in. The optical system and the robotic arms are connected to a computer-driven mechanism controlled by a surgeon sitting at a console near the patient.

Photo of different pincers for the da Vinci system © Initutive SurgicalThe specialized technology of the da Vinci System transfers the surgeon's exact hand movements at the console to the extremely precise micro-surgical movements of the three robotic pincers ("hands") inside the patient's body. The surgeon can rotate the instruments 360 degrees through the incisions.

© Initutive Surgical

The surgeon looks through what appear to be binoculars inset in the console and views the magnified, three-dimensional surgical field. The operator then places the thumb and ring finger of each hand in plastic loops below the console. Specialized technology simultaneously transfers the surgeon's exact hand movements at the console to the extremely precise micro-surgical movements of the robotic pincers ("hands") inside the patient's body. The surgeon can rotate the instruments 360 degrees through the incisions. The patient is under general anesthesia during the operation, which usually takes from two-and-a-half to four-and-a-half hours.

"The optical system provides high resolution and excellent depth perception. The picture is sharp and clear, and the tools allow you to do things that you can't do with straight instruments," says Strup, whose affable enthusiasm is infectious. "Using the robotic fingers, you can spin, rotate and bend, just like you move your wrists, so you have multiple, seven-degrees-of-freedom movement with your wrist. When you do a traditional laparoscopic operation, all that wrist movement is outside the patient on the end of an instrument." Laparoscopic surgery refers to any procedure that utilizes a laparoscope—a fiber-optic instrument inserted through an incision and used to guide surgical procedures within the abdomen.

"The robotic system takes that movement and puts it a centimeter away from where you're working. This is one of the beauties of the system. When I'm working laparoscopically without the robot and using a straight instrument, if I need to go up 30 degrees into a corner, I have to move the whole instrument there. With the da Vinci system, I can just bend my wrist and grab and manipulate what I need to. I can work around corners. That's the advantage you gain."

And this robotic system can be used for more than prostate surgery. More than 60 types of operations have been performed with the system, including abdominal, general thoracic, cardiac, and urological surgeries. Da Vinci has also been used to prepare internal mammary arteries for coronary bypass surgery and for operations on the stomach to stop severe heartburn.

"Minimally invasive surgery, which is what we're talking about with the da Vinci system, is the wave of the future. It's become more and more popular exactly because it's so patient-friendly, and that's why we're focusing our efforts on that here at the university," says Strup, who has done a dozen prostate operations so far at UK using the da Vinci. "There's no reason now that you need to carry around an 8-inch scar like a war wound."

Making Friends with a Robot

Strup says the da Vinci system is fairly easy for surgeons to get the hang of, but admits he had some special challenges when he sat down to learn to operate it.

"Actually, of the group of us in 2003 who went for training in Nashville, where the da Vinci system is built, I probably had the most experience doing laparoscopic surgery—I probably had done 200 laparoscopic procedures by that time—and that put me at a disadvantage in learning the da Vinci system." Strup explains that before he could learn how to successfully operate da Vinci, he had to un-learn techniques and moves that had become second nature to him.

"As a surgeon, I've lived for the last 15 years in two dimensions. Along the way to being certified in laparoscopic surgery, I had to learn how to angle a needle and hold an instrument in a certain way to reach tiny areas, for example. But the da Vinci system is a three-dimensional world, so I had to adapt the vision of my mind."

Photo of Stephen StrupStephen Strup, director of minimally invasive urological surgery at UK, says that minimally invasive surgery is the wave of the future. "It's become more and more popular exactly because it’s so patient-friendly."

Strup says that once a surgeon "gets it," though, and becomes comfortable working in 3-D, doing laparoscopic surgery is almost easy. "That's where I see this type of robotics going, because you can take a surgeon that has very little, if any, laparoscopic training and teach him in a short time how to do these surgeries."

Strup adds that another big plus of this system is that, because a surgeon’s sight is so enhanced, learning how to operate da Vinci involves only a short learning curve. "Surgeons don't have time to do 100 operations using some new technology in order to pick up all the subtleties of how to use it effectively, which is good because learning this system doesn't take dozens and dozens of hours." But he adds that this relatively easy learning process is a two-edged scalpel. "I do worry a little bit about this ease of learning, because I don't know whether we're skipping over skills that are valuable for surgeons to master. We can't trust this system so much that we forget how to pick up the standard laparoscopic instruments and do a procedure the 'old' way."

Strup admits that although the da Vinci system might seem, to some, like something out of a science fiction novel, technology has a way of turning sci-fi into reality. "You could have said the same five years ago about cell phones or palm pilots. The da Vinci system is an amazing advancement, but, you know, it's already five or six years old. And with the advances in computing and engineering within the last few years, the next platform that comes out will be more refined, even smarter."

Strup digresses slightly to explain that the original idea of creating such a system dates back to the Vietnam War. The idea then was to build units that could be ushered into the battlefield so that wounded soldiers could be operated on almost where they fell. He paints an image of this system bolted to a cart and wheeled right up to the front lines. The idea of a surgeon rolling a robot onto the battlefield never materialized, but the concept lingered and was reincarnated as da Vinci.

So what is the future of this robotic system? Is it possible that surgeons will one day use it to do long-distance procedures?

"Oh, it's already been done," says Strup nonchalantly. "A year or so ago, using this system a surgeon in New York performed gall bladder surgery on a patient in Europe. There's enormous potential to take this onto hospital ships and into underserved areas all over the world, and ultimately that's where this technology will go."

Photo of Paris operating room © Initutive SurgicalThe da Vinci Surgical System in action in a Paris hospital

© Initutive Surgical

You Can Go Home Again

After earning his doctorate of medicine at the Indiana School of Medicine in 1988, Strup went to Thomas Jefferson University in Philadelphia, where he honed his skills in laparoscopic and laser surgery as an intern, and then as a resident. After his cancer fellowship at the National Cancer Institute, he returned to Philadelphia. A combination of things led him to UK in 2003.

"The medical climate in Philadelphia is a really tough one right now. I had a huge practice, but the cost of doing business was just rising through the roof due to the total lack of malpractice control. I was paying roughly five times more there than what we pay here in Kentucky."

He adds that his 70-hour weeks completely eroded time for journal reading, writing and teaching, and, worse, severely cut into time with his family—his wife Sue and their children, Spencer and Sydney. These were all "push factors," Strup says, making it easier to think about going elsewhere; and Randall Rowland, chairman of the UK urology department, was a strong pull factor.

"In April 2002, Dr. Rowland invited me to come to UK to do grand rounds, and I did. I knew he was looking for somebody with a background in laparoscopic surgery, and I was thoroughly impressed with the quality of the residents. Also, Dr. Rowland and several hospital administrators said they would definitely consider purchasing the da Vinci system [which happened in January 2004]. So I went home and told my wife we ought to go to Lexington and have a look around." They did and they were sold. "My wife and I are from the Midwest [they met at a John Mellencamp concert], so it was a homecoming for us, really. Dr. Rowland is an outstanding leader and personality, and it was a nice opportunity for me to come into an area that didn’t have a lot of minimally invasive surgery, a chance to make an impact."

Taking da Vinci to the Heart

Chand Ramaiah, an assistant professor in UK’s cardiothoracic surgery division, recalls the exact moment he discovered his life's calling: his first day in medical school, when a cadaver convinced him to become a surgeon.

"This was in 1984, in an anatomy class at Bangalore Medical College in India. The professor held up a scalpel, gestured toward the cadaver, and said, 'Who wants to do some surgery?' Everybody kind of took a step back, so I took the knife from our professor and started in. I felt comfortable with this, and it was easy to project the good that could come from such work. I knew right then that doing suregery was how I could best help patients."

Photo of Chand RamaiahChand Ramaiah, an assistant professor in UK's Division of Cardiothoracic Surgery, specializes in off-pump bypass, esophageal, lung cancer, and cardiothoracic surgeries.

Ramaiah graduated from Bangalore five years later, then spent a year there as a rotating surgeon. After two more years of a residency at a New Dehli institute, he came to the United States and wound up at the University of Kentucky.

"During my residency in India, I met a young woman from Chicago. We wanted to get married and live in the U.S., so I started looking around for a place where my skills would fit, and a place we would like," says Ramaiah, an engaging, friendly man who also serves as director of minimally invasive cardiac surgery at UK. He came to Lexington in 1992 because a good friend of his was at UK.

His friend introduced him to someone in the Ph.D. program in neurosurgery who was looking for a postdoc who knew some biochemistry, somebody who could "cleanly take rat brains," says Ramaiah, smiling at the obvious oddity of the phrase. So, armed with a background of nearly two years in neurosurgery, Ramaiah took the job. A short while later, he was accepted by the UK College of Medicine as a resident in general surgery.

His curriculum vitae now lists half a dozen "special interests," including off-pump bypass, esophageal, lung cancer, and cardiothoracic surgeries. And he's one of four surgeons at UK who use the da Vinci Surgical System.

Ramaiah agrees with Stephen Strup, director of minimally invasive urologic surgery at UK, that working with a robot has many important advantages: faster recovery time for patients, less loss of blood, a "magnificent view" of the operating field, and the advantage of making small incisions rather than long abdominal cross-cuts. This last plus is especially important in thoracic surgery.

"In traditional thoracic surgery you have to split the sternum—right in the middle—and then spread the rib cage to see the field of operation. With the robot, we can do the same operation with just three small cuts. Patients experience less back pain and side pain because we don’t have to crank their chest open."

Ramaiah cites a couple of other advantages of working with the da Vinci robot. He's right-handed, and so favors his right hand when doing surgeries; however, when he's sitting at the console and directing da Vinci, he becomes ambidextrous. In addition, the robot's "hands," the pincers, are always steady—so there’s no possibility of hand tremor.

He does admit that robotic surgery has some downsides. The surgeon has no tactile feedback, he says, and there are some surgeries the system can't handle. Da Vinci can't be used for certain operations on the heart, like aortic valve replacement, and isn't practical to use to do heart transplants, since with transplants the chest has to be open anyway.

"But look at what it can do!" says Ramaiah, who has so far used the robot for 12 operations. "You'll be hearing a lot more about the da Vinci robot as time goes on."

Photo of Daniel Beals and Joseph IoconoDaniel Beals (left) and Joseph Iocono have teamed up to do four pediatric surgeries using the da Vinci system—three operations for gastroesophageal reflux disease and one thoracoscopy for removal of an esophageal duplication cyst. Beals is an associate professor in pediatrics and Iocono an assistant professor of surgery and pediatrics, and associate director of the Minimally Invasive Surgery Center at UK.