Interview with Craig Peters, MD
Could you first give us some background information about your work?
I am a full time pediatric urologist, dealing with diseases of the genitourinary tract in children and young adults. Most of these conditions are congenital and requires reconstructive surgical procedures.
How did you first become involved in robotic surgery and why did you choose it?
I had been performing laparoscopic surgery for 12 years with frustration at limitations in dexterity in reconstructive procedures. The hospital had a donor willing to buy a robot if there was interest among the surgeons, so we developed a robotics program.
Do you prefer da Vinci to conventional surgical methods for any specific procedures?
It is preferable to nearly all laparoscopic procedures, except those that deal with the undescended testis, as those do not require suturing. The latter is the major advantage of the robotic systems.
What happens if the da Vinci Surgical System mechanically fails during the surgery?
We are always prepared to convert to conventional laparoscopic surgery and all procedures that we do with the robot, I can perform laparoscopically. We have not needed to do this due to mechanical failure.
Many surgeons feel the benefits of robotic surgery are unproven. What is your opinion?
Proof is elusive. It is unproven by many standards and I approach it with a very open mind and if we decided it could never be an advantage, I would abandon it. We have to look at what it represents for future approaches as well as what it does today.
Since robotic surgery is known to take longer on average, what are the benefits for the surgeon of robotic-assisted surgery to counteract this aspect?
The extra time taken is largely a product of not yet knowing the procedures or methods as well as the surgeries we have been doing for 20 years. As we have learned the times are decreasing and in some series are equal or better than open surgery.
Are you required to undergo a training session before using the da Vinci? What training do surgeons need to use the da Vinci? How long?
There is a two day training session to learn the robot. We require mentored cases with the robot before someone is given privileges. There is going to be a learning curve, but it is shorter than or laparoscopic surgery.
Does robotic-assisted surgery cost more than open surgery? What’s the price differential? Do the health funds cover this?
It depends on your accountant. With the cost of the machine, the cost is much greater and it requires a large volume of patients in whom you save money by shorter hospital stays to make it financially viable. It also depends on your insurance payers. Without the cost of the machine, as we have, the cost differential was 20% more in our first 10 cases, largely due to long OR times. That difference is less now.
Do you think telementoring and telesurgery is a good idea?
Yes, they are extensions of surgical teaching, but they need to be strictly monitored and reviewed.
What sort of “test” do you perform on the machine before the surgery to make sure it is functioning properly? How do you sterilize it? There is a basic set-up routine that the machine goes through as a self-check and then we test its responses when we start out.
What makes da Vinci superior to Zeus?
The image quality is better, the smoothness of manipulation, ability to scale and the natural feel of the handling are superior. It is much larger, more clumsy and less easily set-up, however.
Is there any point where the robotic system limits the surgeon’s action to avoid mistakes?
There are limits to pressure exerted and there can be no movement if the surgeon is not viewing the field.
How effective are the anti tremor systems and how noticeable is it while you’re operating?
It is very smooth and helpful, particularly with delicate suturing.
Surgeons lose tactile sensation with robotic surgery. How does this affect the outcomes of surgery?
The inexperienced surgeon will break sutures at first and may put too much stress on tissues, but with time this does not seem to be a problem as one learns to feel with your eyes.
During the surgery there was blood on the eyepiece. Is there a mechanism to clear it?
The optical instrument needs to be removed and cleaned. This is the same as with laparoscopy.
How accessible is da Vinci to new doctors?
Depends on the hospital system. Many are now available.
How many doctors use it? Is it on a regular basis?
I don’t know. The company may have that information.
What are the patients’ initial impressions/concerns when they first hear about robotic surgery?
They wonder if the robot is doing the surgery. Obviously that is not the case. Most are very intrigued and want to see it. How often do patients need a follow-up operation after robotic surgery because of complications?
There has been no specific change in follow-up due to using robotic surgery as the complication rate is essentially what we see with laparoscopic and open surgery.
If the patient needs follow-up surgery, is it usually done using the robot or conventional means?
We have performed re-do operations with the robot and they work well. One was from a prior robotic case.
Are there times where you use robotic surgery to follow-up a conventional operation?
Would you recommend robotic surgery to all eligible patients over traditional surgery? If not what are your criteria?
In cases we have established as effective in early data, yes. The family has to express an interest and they are always given a choice.
What are the average costs for the procedure you normally perform?
The total costs are well over $10,000 but this includes all facets and these numbers are a bit imaginary, as what is billed is never what is paid.
What improvement would you like to see in robotic and imaging technology?
Smaller size and footprint, more pediatric-built instruments, smaller cameras.
During the surgery, there was a considerable amount of switching from the cauterizer to the suction-irrigation instrument on the right robotic arm. How great of a hindrance was this?
It takes some time to switch back and forth, but we have developed an efficient routine for doing this so it is not that big of a hindrance.
There is now a new fourth arm for da Vinci. Would you consider purchasing it to save time on instrument switching? We do know about it but are not looking into buying it. It would save time but children have smaller cavities so room is limited.
Which field of surgery is digital surgery most used for currently? Which field will have the most benefit?
“Digital” surgery is not a term I have heard before, but if you mean computer assisted, then urology is at the forefront since it is being used for a large number of prostatectomies for cancer in adults.
What are some of the major hurdles that will delay this system from becoming a more prevalent technology?
Size, cost, inflexibility, resistance to change.
How do the hospital administrators look at and feel about da Vinci?
It can be a money loser, but can also serve to enhance the image of a hospital as being on the cutting edge. Many hospitals have bought them simply to stay up with competing hospitals.
What are the maintenance costs and what has to be maintained regularly?
There is a maintenance contract and it is about 50K per year. Software and the working arms are included.
Do you enjoy playing video games?
Yes, but I lose terribly to my son.
Where do you see robotic surgery 20 years from now?
Very widely used, flexible small systems with very different control systems that may be built into operating rooms. They may be used for a wide variety of applications that require delicacy and minimal access.