An eight-year-old girl lies in an operating room in Children’s Hospital Boston, propped up on one side, ready for surgery. She had been complaining of pains in her side, and a scan revealed a blockage in her left kidney.
In most hospitals, she’d get a six-inch slice down her abdominal wall, giving surgeons access to her kidney during open surgery, and would then spend four to five days recovering in the hospital. But this Monday morning she is about to undergo a robotic surgical procedure. In about three hours, she’ll leave the operating room with a one-inch incision covered by a regular Band-Aid. She’ll most likely return home the next day.
Surgeon Hiep Nguyen, a specialist in pediatric urology and robotic surgery, says the da Vinci robot has greatly expanded the complexity of the minimally invasive surgeries he can perform. It offers three-dimensional vision and articulated tips on the surgical tools that go inside the patient, which allows for smaller, finer movements than traditional laparoscopy. At a recent talk in Boston, Nguyen described complex reconstructive surgeries–fashioning a urethra from an appendix, for example–that just a few years ago would have required open surgery.
But after the talk, rather than expressing wonder or hope over these new surgical possibilities, many of the surgeons, scientists, and engineers in the audience focused on their frustration with the technology. The group had varying concerns–if and when the robot will outperform traditional laparoscopy; the learning curve associated with the technology; whether it allows less experienced surgeons to perform more complex surgeries. But everyone agreed on two points. The technology isn’t advancing fast enough or dropping in price quickly enough. “The system is very expensive because only one company makes it now,” says Nguyen. “We need more competition to drive down price.”
The da Vinci robot is made by California-based Intuitive Surgical, the only big player in the robotic surgery arena (some other companies make robotic systems for eye and brain surgery). The company, founded in 1995, adapted technology originally developed for long-distance surgery–an application quickly abandoned–and created a broad patent portfolio around robotic surgery. It bought up early competitors, garnering Food and Drug Administration approval for its surgical system in 2000. And that’s largely where things have stood for the last decade.
“People have been disappointed in how slowly the robot is evolving,” says Jon Einarsson, a gynecological surgeon at Brigham and Women’s hospital in Boston. “There hasn’t been a lot of evolution or improvement in the articulation at the tip of the instrument.” Some innovations that Einersson would like to see are haptics–a sense of touch that can be translated from the robotic instruments to the surgeon–and a way to incorporate data from magnetic resonance imaging.
Some surgeons and engineers argue that a much smaller and cheaper device could provide the same visual advantages and flexibility, but that no one has been able to move this forward. “The da Vinci robot looks like it was designed to make automobiles–it’s great big clunky gear,” says Kirby Vosburgh, an engineer with the Center for Integration of Medicine and Innovative Technology (CIMIT), in Boston, who previously designed medical technology for General Electric.
Although Intuitive’s robotic surgery technology has grown in popularity, especially among gynecological and urological surgeons, it has also come under increasing scrutiny. While it seems beneficial for the complex pediatric surgeries that Nguyen specializes in, it’s not yet clear whether the robot improves outcomes for simpler surgeries that can be performed using more traditional laparoscopic procedures, such as hysterectomies. Other potential benefits of robotic surgery are more subtle and difficult to assess–whether it helps surgeons by making the procedure less physically demanding, or allows less experienced surgeons to do more complex surgeries. For example, Nguyen says only a few highly skilled surgeons could perform today’s surgery laparoscopically.
Nguyen talked Children’s Hospital into buying the latest version six months ago–for $2.5 million–after his analysis showed that the shorter hospital stays after robotic procedures would make up for the cost over time. (He receives no funding from Intuitive.) But he agrees that Intuitive’s monopoly has stalled the field. “People are afraid to challenge Intuitive because they are such a big company,” says Nguyen. “But now we’re starting to see a rebellion from physicians on the price, especially in the context of the discussion on how to cut down costs. That will motivate more people to consider coming into the market.”
Dennis Fowler, one of the surgeons in the audience at Nguyen’s talk, has experienced this first-hand. His team developed a snake-like laparoscopic tool with two cameras, which provides stereoscopic vision like the da Vinci. But he says his tool doesn’t require the large viewing console that Intuitive’s does. “We learned after we developed the camera that Intuitive had 286 patent claims related to this type of device,” says Fowler, a pioneer in laparoscopic surgeries who recently moved from Columbia University to CIMIT. “That’s the major impediment. Right now it’s an academic endeavor.”
With funding from the National Institutes of Health, Fowler and collaborators are now working on adding grippers and cutters to the device. The tools are cleverly built into the same laparoscopic cord as the camera, making the assembly resemble a Swiss Army knife. This design would reduce the number of incisions required during surgery. Once inside the body, the device unfolds like a flower. But the device is still early in development; they have built a prototype, and Fowler is now applying for a grant to test it in animals.
It’s too early to say how Fowler’s robot would perform in comparison to the da Vinci or other robotic technologies, but “even the initial prototype has numerous advantages,” Fowler says. “It will be less invasive, with one incision instead of three or four; it is vastly smaller; it will cost a small fraction of what da Vinci costs; and it will be much easier to maintain.”
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