Ask many recent surgery patients in Idaho, and they will tell you: The days of being cut wide open and operated on by a surgeon’s hands are becoming a distant memory. An increasing number of procedures in Idaho rely on robotic equipment, which doctors say has made surgery safer and ultimately less expensive.
Johnny Green, a general and colorectal surgeon at Saint Alphonsus Regional Medical Center, started out the old-fashioned way, performing surgeries by hand. In the 1990s, he jumped on the laparoscopic-surgery bandwagon, using specialized tools to enter the body through much smaller openings and finding his way with a camera scope.
But in the past 20 years, medical device companies have created surgical robots that offer a much greater range of motion than the rigid laparoscopic tools of the 1990s. The old tools had a range of motion like elbows; the new ones are like wrists whose camera scopes are built to offer depth perception. At least one surgeon in Idaho is using a robot that performs the operation.
‘MAKES ME EVEN BETTER’
Saint Alphonsus in 2003 bought the 60th Da Vinci surgical robot to come off the factory line. The Da Vinci, made by California-based Intuitive Surgical Inc., is a large machine that has arms to which someone can attach surgical instruments. It is a “master-slave” system, meaning that a surgeon sits at a console and uses remote controls to guide the machine through the surgery as the patient lies on a table nearby.
The hospital has since bought a newer version of the Da Vinci and donated the earlier robot to the College of Western Idaho, which uses it to train registered nurses and surgical technology students who are planning to work in the operating room. The students take turns at the console, doing a simulated procedure and learning how each tool works.
Since 2011, Green has used a Da Vinci robot on all colon-cancer and rectal-cancer surgeries and most surgeries involving benign conditions — more than 190 surgeries. Other surgeons use it, too. Urologists have performed thousands of surgeries with it at Saint Alphonsus.
“The robot makes me even better, because I can see better, I have more capable instruments, I have more control, and I also don’t fatigue as fast,” Green says. “It’s taking the brunt of the physical part of the work.”
With fewer incisions, patients usually go home earlier — three or four days after a complicated rectal operation, Green says — and are less likely to develop infections.
David Verst, a spine surgeon in Hailey, began using a robot last summer. His robot, unlike the Da Vinci, acts like a cosurgeon. St. Luke’s Wood River Medical Center’s foundation bought the Mazor Robotics Renaissance System for about $1 million.
Almost all the work takes place “before we even step foot in the operating room,” he says.
A patient goes in for a CAT scan to get a three-dimensional image of a section of the body, such as the back. The doctor then plans the surgery and programs the robot. Once in the operating room, the doctor “pairs” the program to the human body. The programming tells the robot to move its arm to a certain location and insert an implant, take a biopsy or perform another task.
Verst says that in the first three months, he used the robot to put in about 130 screws and other implants on 25 patients.
St. Luke’s Wood River is the only hospital in the region with the robot, Verst says. The nearest Mazor systems are in California, Colorado, Nebraska and Western Washington.
2,471Robotic surgeries done with Da Vinci by physicians at Saint Alphonsus as of Oct. 5.
St. Luke’s Health System CEO David Pate says that if data and evidence show that the Mazor system at Wood River reduces risks and shortens operating time and hospital stays, the health system “would be more likely to pursue this technology at hospitals that do significant volumes of this type of surgery.”
Verst says it can be used for pelvic conditions, joint dysfunctions, fractures and other problems. Where it shines in his practice is in complicated cases, such as scoliosis (where the spine is severely rotated), or when the patient has scar tissue.
Before robots, Verst says, he would make a large incision and remove bone to access parts of a person’s body, then “triangulate in your mind the exact location and trajectory of the implant.” At every step, there was opportunity for human error. The robot has a reduced risk of those errors, he says.
It’s similar to “if you were trying to place a [6-millimeter] nail in a wall, and ... into ... a piece of wood that is about 8 millimeters wide in circumference,” Verst says. “And what you have surrounding that piece of wood is two wires on each side and plumbing that is an inch behind it. If you’re off the stud, and you put it into the wire, you’re electrocuted. And if you put it into the plumbing, you’re going to flood the house.”
The robotic surgery system allows the 6-millimeter nail to hit the 8-millimeter stud, sparing the spinal cord, the aorta, nerves and a large vein that carries blood to the heart.
$1.8 million Price for the first Da Vinci Surgical System in 2003. The price for new systems is about the same.
Green and Verst say neither they nor the hospital get paid more for using the robotic systems.
Verst says he receives no compensation from Mazor to use or talk about the system.
Federal records for Verst show that Mazor Robotics paid for about $1,400 of his travel, lodging and meals last year, as well as an $18 gift.
Green last year received about $20,000 from Intuitive Surgical, the manufacturer of the Da Vinci robot. Those payments were for education, such as teaching other doctors about the system; meals; and travel and lodging.
The surgeries are billed to insurance as plain laparoscopic surgery, Green says. There can be additional costs. With Verst’s system, for example, a patient must get a CAT scan instead of the much cheaper X-ray. (But, he notes, that also means less radiation exposure.)
It can cost thousands of dollars per procedure just to operate the machines, because their tools can be used only a certain number of times. Most of the Da Vinci robot’s instruments — the tools that are attached to the arms to perform tasks like clamping or stitching — can be used 10 times before they are decommissioned, then must be replaced.
The Mazor system’s hardware adds a roughly $1,200 disposal fee to the operating-room costs for each procedure.
But the physicians argue that the robots pay for themselves through savings from shorter hospital stays and fewer complications. Verst says his robot has a 98 percent accuracy rate, and there have been no neurological complications found in 120,000 implant procedures.
“I think in the future, it’s going to revolutionize spine care as it relates to fusion and putting implants in the spine,” he says.
Robotic surgery has its skeptics.
The ECRI Institute, a nonprofit that researches medical products, procedures, devices and drugs, found in 2012 that the Da Vinci was not a panacea for surgery. The institute said the Da Vinci was, at best, equal to traditional laparascopic surgery.
The institute says there have been 144 deaths related to surgical robots. In a small sample of 73 adverse events, more than half of the cases had device failure or device operation/setup as contributing factors.
Using a database of 87,514 gynecologic surgeries between 2009 and 2012, Columbia University Medical Center researchers found in a 2014 study that robotic surgery had a higher complication rate and a higher cost than conventional laparoscopic surgery.
An article in the New England Journal of Medicine in 2010 noted that, based on patterns researchers found in certain prostate surgeries, “robotic technology may have contributed to the substitution of surgical for nonsurgical treatments for this disease.”
That substitution “may have increased both the cost per surgical procedure and the volume of cases treated surgically,” the article says. “However, the evidence suggests that despite the short-term benefits, robotic technology may not have improved patient outcomes or quality of life in the long run.”
The article says a surgeon would become “adept in their use” after doing 150 to 250 robotic procedures.
Green says the Da Vinci is a tool. If he hits his thumb with a hammer, he doesn’t blame the hammer, he says.
He argues that surgeons also need to be aware of their abilities, to take advantage of the Da Vinci manufacturer’s training, and not to attempt a complex procedure with the Da Vinci if it is beyond their robotic skills.
“It is a long learning curve,” Green says.
Who uses Da Vinci robots more than 20 times a year?
Saint Alphonsus Regional Medical Center
St. Luke’s Regional Medical Center
Kootenai Medical Center, Coeur d’Alene
Mountain View Hospital, Idaho Falls
Portneuf Medical Center, Pocatello