By Angela Spivey

Urogynecologist Anthony Visco, MD, readies a robot for surgery.When he decided to become a surgeon, Anthony Visco, MD, entered one of the most hands-on of professions. But nowadays he does some of his best work when sitting eight feet away from his patient.

To repair pelvic prolapse, for instance, the gynecologic surgeon begins by making dime-sized incisions in the patient's abdomen, through which four hollow instruments called trocars are placed.

He then steers a state-of-the-art surgical robot over to the patient's belly. The robot's four arms are docked -- attached to the trocars -- and then used to insert a camera and specialized robotic instruments such as forceps, scissors, a scalpel, or a needle holder into the patient's body.

Sitting at the robot console, Visco operates the instruments and camera using hand controls and foot pedals. His face rests in a viewer with left and right eyepieces. The views from the robot's two cameras merge to give a three-dimensional view of the operating field that rivals that of open surgery.

"You can zoom in closer than you can with your own eyes," Visco says.

As for the arms, there's little comparison -- the robotic instruments can rotate much like the human hand, but with a greater range of motion and on a much smaller scale, enabling doctors to perform intricate maneuvers through keyhole incisions.

Engineered for dexterity, surgical robots have opened up new possibilities in the OR since they arrived on the scene less than a decade ago -- enabling surgeons to give patients a minimally invasive option for some of the most complex procedures.

Currently only one robotic surgical system is sold commercially in the United States, Intuitive Surgical's da Vinci Surgical System, which was approved by the Food and Drug Administration for use in general surgery in 2000. Since then it's been approved for a variety of cardiac, thoracic, urologic, and gynecologic procedures.

Urology and gynecology appear to be the biggest users of robotics; a 2008 financial filing from the company notes that robotic prostatectomies and hysterectomies make up 79 percent of the procedures performed with its system.

David M. Albala, MDFormer urologic surgeon David Albala, MD, says that data from the company show that in 2007, over 60 percent of prostatectomies in the United States were performed using the robot, up from some 40 percent in 2006.

Robotic surgery has been steadily gaining ground at Duke, too. Since the medical center acquired its first robot in 2002, hundreds of patients have come here from around the state and the country to have robotic surgeries.

Today Duke doctors have the most experience in North Carolina in robotic prostatectomies and the most experience in the world in robotic sacrocolpopexy (the procedure to repair pelvic prolapse).

But surgeons point out that while calling such procedures "robotic surgery" may sound cutting-edge, in truth they are robotically assisted; the robotic arms are just extensions of the surgeon's hands.

"Robotics isn't going to take a mediocre surgeon and make him a great surgeon," says Visco, chief of the division of urogynecology in the Department of Obstetrics and Gynecology.

The field has its critics, too; some surgeons at Duke say that robotics simply isn't for them.

But there's no denying that robotics is making a major impact on the surgical scene -- and at Duke, proponents and skeptics alike are leading efforts to define just what its place should be.

Writing the Book on Sacrocolpopexy

Developed at Duke in the 1960s, sacrocolpopexy, in which a mesh is attached from the vagina to the sacrum, is considered the gold standard for repair of pelvic prolapse -- a sagging of the pelvic floor tissues which can happen after menopause, childbirth, or a hysterectomy.

One of the procedure's progenitors taught it to Visco during his urogynecology fellowship at Duke in the late 1990s; Visco first learned to perform the open surgery, then the laparoscopic technique -- in which surgery is performed through small incisions using specially designed handheld instruments.

"I did a lot of open colpopexies. I believed in minimally invasive surgery. When I was exposed to the robot, it seemed like an obvious extension of what I was already doing," he says.

Now he has literally written the book on performing them robotically -- he authored the colpopexy training manual for the da Vinci system, regularly hosts courses at Duke, and provides live broadcasting of the surgery, so that surgeons and urogynecologists around the country can learn about the technique.

Visco expects the need for sacrocolpopexy to increase as the baby boomers age. And he now considers robotics the gold standard for performing that surgery in a minimally invasive way.

Because colpopexy requires intricate steps such as attaching mesh, the laparoscopic version is just too hard for many surgeons to learn. "There are a limited number of people who can actually perform a laparoscopic colpopexy," Visco says.

Tying knots and suturing is difficult with laparoscopic instruments because they're straight "like a pair of long, skinny needle-nose pliers," Visco says. And they don't bend. Urologic surgeon David Albala, MD, likens using laparoscopic instruments to operating with a pair of chopsticks.

Visco and colleagues have documented that robotic colpopexy does provide the short-term benefits that patients are looking for. They found that compared with the open procedure, robotic sacrocolpopexies provided similar short-term surgical outcomes, but the robotic group had significantly shorter hospital stays (1.3 days on average versus 2.7 days for open), and their blood loss was significantly less (103 ml versus 255 ml).

Duke owns four different robots, two at Duke University Hospital and one each at Duke Raleigh and Durham Regional hospitals, which are used to perform a variety of procedures.

Like Anthony Visco, Duke urogynecologists Alison Weidner, MD, and Jennifer Wu, MD, perform robotic sacrocolpopexy and other robot-assisted procedures, while Cindy Amundsen, MD, offers other minimally invasive options for the treatment of pelvic prolapse.

Gynecologic oncology surgeon Fidel Valea, MD, uses the robot mostly for radical hysterectomy, which requires a lot of dissection. Craig Sobolewski, MD, chief of the Division of Minimally Invasive Gynecologic Surgery, uses the robot mostly for myomectomy (fibroid removal), which involves a lot of suturing.

"If the surgeon is performing intricate steps of a procedure such as tying multiple sutures, the robot is much more capable of mimicking what we do with open surgery.  For me, that makes the robot the perfect choice for laparoscopic removal of fibroids," 
Sobolewski says.

Since he mastered the laparoscopic version years ago, Sobolewski doesn't do straightforward hysterectomies robotically and reserves the robot for more complex procedures. As all these surgeons point out, they don't dabble; for each procedure, most of them pick one method, then perfect it.

In urology, Albala performs nearly all of his radical prostatectomies robotically. Other surgeons who offer the robotic procedure are Phil Walther, MD, Thomas Polascik, MD, Cary Robertson, MD, and Brant Inman, MD.

Combined, these Duke surgeons now perform 300 to 350 robotic prostatectomies per year. Albala trains urologists from across the country in the procedure, helping to disseminate the new approach even more widely.

Climbing the learning curve

All these seasoned surgeons learned robotics in the midst of their careers, most using a training robot. The magnified view took some getting used to. So did keeping all three robotic instruments in view at all times.

"If you can't see one of them, and your hands are in the cradles, you could make it do something you don't want it to," Valea says. Then it's a matter of practice to get familiar with the power and sensitivity of the controls, and to learn to take full advantage of the wristed instruments.

When Visco was in medical school, he would take suture material home and put stitches in his scrubs, to practice tying knots. He and colleagues did the same type of practice with the robotic instruments.

Visco also videotaped his first robotic cases and spent time reviewing them, to find places where he could have tied a knot or made a cut more efficiently.

Though Albala's first few robotic prostatectomies took seven or eight hours, his speed increased as he got his bearings in the magnified view of the operating field. "Now, I feel like I'm in total control during the case. I know my landmarks. Once you learn how the robot moves, I think the surgery is simplified," he says.

Surgeons seem to like the increased autonomy of the console; if they want to cauterize something, often they don't ask an assistant, they just press a foot pedal. And the 3-D, close-up visualization of the surgical field is considered by some to be better than they can get with their own eyes.

"It's almost as if I've stepped inside the patient," Albala says.

First a dry lab, then you fly

When the two robots at Duke University Hospital aren't in surgery, they reside in a hallway outside the operating room.

There, residents use petri dishes of coins and multicolored dollops of silicone to conduct their "dry lab" with the robotic instruments. Valea, who directs the Residency Program in Obstetrics and Gynecology, puts some of the residents through their paces.

"I may tell them, pick up this coin, turn it over, put it in your other [robotic] hand, turn it over again," Valea says. "That's a great exercise because it teaches them transfer and it teaches them rotation of the hand." They'll also practice stitching the silicone dollops together.

In the OB-GYN residency, robotics isn't yet required, but most residents are proactive about learning it, Valea says. They learn to do robotic hysterectomies, myomectomies, and pelvic floor reconstruction.

They take it in small steps, observing or assisting in surgeries first, then, when they've shown proficiency in dry lab, performing part of an operation, such as sewing up the vaginal cuff after a hysterectomy. Once they've shown they can "fly," they move on to perform other parts and then a whole operation under supervision.

"We're not putting first-year residents in there. They will have done the case open many times before they try it on the robot," Valea says.

He doesn't set a certain number of cases as a criterion for moving on; each resident's competency is judged by the faculty, and that is how he or she is deemed proficient. He notes that's a trend in surgical training in general -- using competency-based measures.

In urology, Albala uses a formal procedure to teach robotic prostatectomies. Residents assist a senior surgeon for 10 cases before actually working at the robot console.

For training purposes, the procedure is divided into three parts. Trainees first perform the third part of the procedure, which consists mostly of suturing, for 10 cases or until they become proficient. Then they do the second part of the procedure for 10 more cases, and only then do they take on the responsibility of performing two or more parts of the operation.

"It's very regimented, and I'm in the room monitoring," Albala says.

In a study published April 2008 in the journal Urology, Albala and colleagues found that outcomes -- blood loss and rate of positive margins -- for 383 patients at Duke were the same whether the experienced surgeon performed the robotic prostatectomy or the resident performed it.

"One of the things we're very proud of at Duke is we've trained 16 different surgeons in urology at this point in how to do robotics safely and with good outcomes," Albala says.

Are the benefits overhyped?

Judd W. Moul, MDLike most of these surgeons, Judd Moul, MD, chief of the Division of Urology in the Department of Surgery, sees robotics as part of a trend toward minimally invasive procedures that will only keep growing.

But he expresses concern that some hospitals acquire robots just to keep up with the Joneses, and others hype them so much that some patients think the robot is more than what it really is -- a tool that needs the skill of a surgeon.

In a study published October 2008 in European Urology, Moul and Albala found that patients who underwent robotic-assisted prostatectomy were more likely to report being regretful and dissatisfied, possibly because they had higher expectations that they were receiving an innovative procedure.

The study points to the need for doctors to make sure patients know all the risks and benefits of the procedures they may choose, Moul says. For radical prostatectomy in particular, Moul wants to see more data to show that robotics is superior to open surgery.

For both procedures, the rate of complications, such as incontinence or sexual dysfunction, is the same. The smaller incisions possible with the robot do result in less blood loss, but at Duke it's not enough to cause a difference in transfusion rates, he says.

Moul also points out that the incisions made for the robot are in the abdomen, higher on the body than the incision for an open prostatectomy.

"It's important for patients to understand that the robotic prostatectomy is going through a cavity that wouldn't normally be entered for this surgery," Moul says. "Open surgery stays below the intestines, so there's a slightly lower chance of intestinal injury."

Albala counters that studies from other institutions find that patients who have the robotic procedure show decreased blood loss, decreased transfusion rates, shorter hospitalization, decreased pain, and decreased analgesia use when compared to patients undergoing open procedures.

"It's an evolving field," he says. "There are over a thousand robots in use now, and groups around the world are constantly improving the outcomes. We're continually modifying our practice based on new evidence in the literature."

And he thinks that patients will drive increased demand for robotics. "With a robotic prostatectomy, the patient will leave the hospital the next day. The catheter will stay in place for about a week to 10 days. The patients like that," he says.

Even Moul says the use of the robot has inspired him and other urologic surgeons to refine procedures. "We're a competitive bunch. When the robotic guys came in and said 'We can get patients discharged on day one,' we open guys changed our techniques. We started using long-acting local anesthesia in the incision and tweaked this and tweaked that, and said 'Okay, now we can get our patients out on post-op day one.' It's pushed us to reassess our whole practice pattern for radical prostatectomy and try to do a better job for all patients."

Such efficiency translates into the intangible benefit of a calmer operating room. As with standard surgeries, the robotic operating team is honed so that everyone has a defined role to execute.

"Even though the robot affords a lot of autonomy to the console surgeon performing the operation, it really is a team approach," Visco says. "We owe a lot to the nurses and the OR and anesthesia staff. We've become very efficient at setting up the robot, for example. You need a group of people who are really committed."

Adds Albala, "Duke is one of the few places where everyone in the OR, from the anesthesiologist to the nursing staff, is dedicated to robotic procedures -- so patients are benefiting from having not just an experienced surgeon, but an experienced team."

A Robot for Every OR?

Visco predicts that more and more doctors will adopt robotics because it provides a minimally invasive tool for surgeons who find laparoscopy too difficult. Laparoscopy has been around for more than 20 years, but Visco, Wu, and colleagues reviewed 2003 data showing that only 11 percent of hysterectomies in the United States were performed laparoscopically.

"I think robotics is going to allow minimally invasive surgery to be an option for a greater number of patients," he says. But will robotics completely replace traditional laparoscopy? Duke surgeons aren't sure.

Valea thinks that laparoscopy will remain very popular as the current generation of surgeons with advanced laparoscopic training enters the field. "We're infusing graduates from our training programs who are truly capable of performing advanced laparoscopy," he says.

He also predicts that the cost of the robot (more than $1 million to purchase, plus $100,000 or more in yearly upkeep costs) will prevent it from becoming an everyday tool. "I think hospitals will reserve it for the most technically challenging cases. Otherwise you will need more robots, and that will just drive the cost of medical care even higher," he says.

Open surgery will probably always be around, for several reasons.

Some patients, because of weight or prior complications in the abdomen, aren't eligible for robotic surgery -- although, Albala notes, as surgeons gain experience, they are able to offer the procedure to more and more such patients.

And some hospitals don't have the volume of cases needed to make the expense of the robot worthwhile and to enable their surgeons to become proficient at robotics, Albala says. It takes 25 robotic cases to get really comfortable and maybe 250 to become a master, but a surgeon at a community hospital may perform only 10 prostatectomies a year.

"Many community-based urologists refer patients to us for robotic surgery, and then we transfer them back for follow-up care," says Albala. "Since we were the first in the state to offer robotic prostatectomies, we've been able to build strong relationships with community physicians across the region, and we're grateful for that."

Visco thinks the ideal way to grow robotics is the same way he and his colleagues have perfected their skill with it -- purposefully and carefully. "I think there is probably a pressure to offer this kind of new technique for patients," he says.

"But we still want to do the fundamental things -- take care of patients, get them home in a reasonable period of time, have few complications if any, and give them good long-term outcomes.  "If we can do that with a minimally invasive approach? Great."

Note of disclosure: Visco consults for Intuitive Surgical, manufacturer of the da Vinci Surgical System.

This article was first published in the Winter 2009 edition of DukeMed Magazine.