Interview with Dr. del Nido
Can you first give us some background information about yourself?
I do cardiac heart surgery in children. So mainly repairing birth defects of the heart.
How did you first become involved in robotic surgery and why did you choose it?
Well, we started about 8 or 9 years ago. We started what we call minimally invasive surgery in stead of open heart surgery in which you have to open the chest somehow either from the front or sometimes from the side, in order to get access to the heart or the major blood vessels which is the conventional way of doing it. We started to work on ways to do it without opening the chest but through a small incision where we introduce a telescope with a camera at the end so that we can actually look inside the chest. And through other smaller incisions we could put in instruments that would allow us to do surgery. And that’s how we got started. It is called minimally invasive surgery. What we found is a limited amount of work you can do, the best analogy is sort of working with chopsticks. You have the straight long instruments that have very limited motion on the tips and you’re trying to do these complicated maneuvers and sometimes its frictionally impossible to do. We got farely far, but we realized that we were limited for complex reconstruction because the instruments were what we basically call “dumb instruments.” They had one purpose, one motion and that was it. And if limited it us quite a lot. And so I found out that there was a robotic system, actually at the time there were two robotic systems, that had a real wrist type mechanism. In other words 7 degree of freedom (DOF) that your own wrist has except that they were very small and you can put them in these small openings in the chest so that you can introduce these instruments to the chest and then through this remote council control the movements. Its like your own wrist; you can do sutures; you can do all kinds of complex maneuvers. You do it on a council which basically looks at and reads your movements and translates it to the movements of the robotic arms which are inside the patient. And that’s when we got interested in robotics. We were able to get the machine and we started to do laboratory work first to get experience with it and then we moved to the clinical arena. And so we’ve been doing the clinical for probably about 3 years.
Is there something you can do better with your hands than a robot?
Well right now with the current robot, you can do things better with your whole hands. The difference is you have to have the chest open or the abdomen open in order to be able to put your hands inside and use your hands. The robot gives us almost as good motions which is a major drawback though. But, it is almost as good of motion and control except that you’re doing it through these tiny holes. So that’s the major advantage. It’s not that it is better than your hands its just that you’re hands are pretty big, whereas for the robot, it’s diameter is 5mm or 8 mm depending on the type of robot, which is pretty small.
What are the major drawbacks?
The biggest drawback is that you don’t have any sense of feel. You have no sensation. The robots have no sensors on it. So if you’re putting your hands into a box, and you know that there are things inside, you can feel around with your hands and get a pretty good sense of what’s going on and what’s in there. The robot gives you no tactile feedback. You’re basically going by visual to what you’re doing to the tissue and that’s the biggest drawback.
What happens if the DaVinci Surgical System mechanically fails during the surgery?
Well it depends on why it failed. If it failed because I was misusing it than obviously it is my fault. If it failed because of some defect in the design or the production than it is the company’s fault.
Does the Hospital or Doctor benefit economically from using this system rather than doing surgery with their hands?
If you mean, do we get paid differently for using the robot? No, no we don’t. We obviously get paid for doing an operation. You do not get paid any more for doing it with a robot versus without a robot. No there is no difference
How many operations can be performed each year with a robot?
The total number of operations we do here is about 1100 a year. Robotic cases that we do is probably about 30-40.
How long does each one take?
Most of them take about 2-3 hours.
Do you think that the low number of times that you do robotic surgery offsets the cost of the machine?
The machine wasn’t bought in order to…you can’t think of it as a business plan, you put out so much money to buy its capital equivalent and it allows you to get reimbursed differently and somehow payback for the machine. It doesn’t work that way. We don’t get paid any extra, the hospital doesn’t get paid any extra for using a new technology. But what you’re suppose to be doing as a hospital is providing the latest and most optimal care. I guess something analogous is lets say that I had a CT scanner that took about half the time and half the amount of radiation to give me the same image. If I did a CT scan on you and I billed for it, I would get paid the same whether I use the old machine or the new machine. There’s no new fee schedule that I would add to it that would reimburse me for having bought the new machine. But clinically we know that if I was able to do the same study except get half the radiation, that’s got to be better. So, the obligation of the hospital, despite the fact that there not going to get reimbursed for that, if the think it’s technology that is going to make a difference to the patient, is to go ahead and get it anyway. Hopefully, with whatever gains you get from other sources will cover the cost. That is basically how it works. Here at the Children’s Hospital, what happened was, the robot, the machine itself, was paid for by a philanthropic donation. Someone donated money to purchase the machine, the upkeep, the service contract, and so forth at the responsibility of the hospital. But they provided the initial funds to actually purchase the machine.
What training do surgeons need to use the da Vinci? (how long?)
There’s a training session that the company does that was just two days. They show you how the machine works and how to basically turn it on, work the instruments such as the camera, the counsel, and so forth. During that time they also have you do procedures. And then what most of us did on top of that was that actually went and worked with it on a phantom until you get accustomed to working with it. Then we started with a human study. The training last for a very short period. Once you do about 3-5 procedures, you’re essentially up to speed. The machine is built and designed in a way that it functions very much in way you would when doing normal sutures. So most of the moves and most of the maneuvers aren’t any different than what we do for our regular conventional procedures. So it makes it pretty easy to learn how to use it.
How many people do you have in the operating room while you’re doing the procedure?
We have two surgeons, two nurses, and usually two anesthesiologists. So about six people. Sometimes there will be a third surgeon if it’s someone assisting or just watching
Is there any training that they have to go through to?
The nurses have to go through training program as well just like the doctors do, because they also have to know how to run the machine as well. The only ones who really need are the nurses and the surgeons who are actually going to be using it. The anesthesiologists don’t need to.
Do happen to know the cost and demographics of the robotic assisted surgery?
Well it depends on what procedure you’re talking about. The machine itself cost a little over $1 million, and that’s for the buying of the machine. The service contract is about $100,000 a year.
How specific is your criteria for patient selection?
Well, they have to be a candidate for doing a procedure thorascopically. And if they’re candidates for that they have to be a certain size because the robotic instruments are bigger than thorascopic instruments. For us, it is basically children above a year and a half of age.
What are some other therapies that you would like this technology to be used for and what type of therapy do you think will benefit the most from robotic surgery?
Well it is clear that the robotics for certain procedures have made a huge difference. They have enabled operations to be done closed other words through ports that wouldn’t otherwise be done. The biggest, best example is probably prostatectomy. So in that sense those are the procedures that have made the biggest impact. The robot system was built really for adults. We’ve been using it on older children and we do have smaller instruments now, but it is still a machine that is quite large. So I would like to see is a robotic system that is smaller and easier to use and shorter set up time, the time that it takes to get the machine in position before you actually start the procedure
Are there any other areas of improvements that are needed in robotic surgery and how would you address them?
As I said before, the biggest obstacle for robotics right now, except for size, is the lack tactile of sense, lack of ability to sense what you’re doing to tissues. So that would help quite a bit. The size of the instruments and the size of the machine is also another. There are a number of groups that are working on that and basically there is technology that would allow you to feel and sense. But, it is not fully developed and is basically a commercial venture at this point which companies will have to pursue. There is some work being done in research laboratories. But because it is such an expensive technology, and in order to bring it to the market, to the critical applications, these things will have to be developed by the companies.
Do you think robotic surgery lacks the federal funding to move the industry forward?
Well actually there is quite of bit of funding that is going into surgical robotics. But it is going to build through the next generation of robots. There is quite of bit of funding that is going into it already. I don’t know that more funding would make it any better. I think the biggest push tends to be on the manufacturing, business, and production side of a getting a company to make it financially valuable…for them to develop a system, manufacture it, and sell it.
How long do you think it will before the da Vinci will need to be upgraded?
Well I think it needs to be upgraded now. But how long it will before it gets upgraded?....I have no idea. My guess is that it’s going to be another five years before the new generation comes up.
Do you foresee the usage of robots rapidly increasing as time progresses, across the country and the world?
Well, already has increased a lot. And I think now its going to begin plateau. I think they have something like 1100 centers using robots in North America. So it really exploded over the last five years. Now I think that its beginning to saturate the market. I don’t see it blowing a whole lot higher than that. I think that maybe when the next generation of robots come around then if they’re easier to use, if they’re a little more versatile, than I suspect that it will be even more widespread. But right now, that’s what has been happening; they’ve pretty much saturated the market with their machines.
Does robotic surgery adjust your approach to the surgery and you’re way of thinking? The fact that you have the robot as your assistant, do you think that takes some time to get use to?
Not really. It really doesn’t take that long for people to adapt and incorporate the robotic system into their general usage. If a new system came along, I don’t think it will take very long for people to start using it either. Technology and surgery always changes and so part of staying up to date is learning to use new equipment, new machines, and so forth. So I don’t think it will take very long
Because of the size of the machine, do you think there is a certain age group that the robot system is most often used on, in terms of the surgery that you do?
The machine is designed for adults so we don’t really use for kids that much. But no, it doesn’t make any difference if you use it for younger patients or older patients.
Are younger surgeons using the robot system more than the older surgeons?
Usually its been the younger surgeons who are trained to do the thorascopic procedures and they’re more familiar with it. They’re the ones that have taken up the robotics. It’s rare to see older surgeons using it.
About how many people turn to robotic surgery when given the option?
I don’t think it makes a whole lot of difference for most people. What does make a difference is the fact that it is minimally invasive and that you’re not opening the chest, but you’re opening the abdomen. That’s what really makes the difference, whether you use the robot or not for most people doesn’t make a whole lot of a difference. If it’s because of the robot that you’re doing minimally invasive procedure than, sure, it makes a huge difference.
How noticeable are the filtration systems built into the device that prevents any accidental movements by the surgeon?
I don’t think they have any real filtration system. They have a tremor filtrate. Those are for fine tremor. But if I wanted to suddenly move my hand in a weird direction it would follow what I did. It is a total slave system. So it doesn’t stop you from doing something potentially harmful.