
Machines offer precision, extended reach
Transcript
Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.
More and more these days, patients who have surgery, particularly surgery on the prostate, will have their operations done with the help of a robot.
Today I am talking about the advances in this field with Dr. Seetharam Bhat. He's an assistant professor of urology at Upstate.
Welcome to "The Informed Patient," Dr. Bhat.
Seetharam Bhat, MBBS: Thank you for having me here.
Host Amber Smith: Let's start with some history about the use of robots in surgery, starting with: How do you define robot? What is a robot?
Seetharam Bhat, MBBS: So the term "robot" is actually from a Slavic root word. It basically means "associated with labor." So any machine that can perform complex tasks, that is considered a robot. So that's where it all began.
Slowly, we introduced these machines into medical field, and right now, we're at Gen (Generation) 1. So we have robots that actually mimic the surgeon's motion, but it helps us to perform surgeries in places that we cannot access with our regular hands and with our regular tools.
Host Amber Smith: So how many years ago did surgeons start using robots?
Seetharam Bhat, MBBS: So in the true sense, if you look at devices as such, so the neurosurgeons actually used it in 1908 where they used stereotactic surgery. So stereotactic surgery is a procedure where you could actually use images and precisely deliver an instrument to a point.
Either you can do manual procedures or you can actually deliver radiation to a particular point in the body using images and coordinates. So this is where it all began. That was the primitive form of robotic surgery. And then eventually we moved on, and in 1980, the orthopedicians (orthopedists) started using a device called RoboDoc, where they were able to perform orthopedic procedures.
Then the general-use robot came in in around 2000 when DARPA, which is the defense institute of the U.S. (Defense Advanced Research Projects Agency), and Stanford Research Institute, they coordinated with each other, and they were trying to build robots to be used in battlefields.
And that's when the robotic surgery actually took off, and then it was commercialized and entered into medical field.
Host Amber Smith: So a lot of times when I think about robotic assistance for surgery, I'm thinking it has to be laparoscopic, where you're not opening the patient up in a traditional way, you're just using the small incisions.
Is that the case, or do you also use robots for open surgeries?
Seetharam Bhat, MBBS: If you look at devices as such that we use currently, the robots used by the orthopedicians are kind of like open procedures, though they make tiny incisions.
So there are two kinds of robots. One is telepresence robot and the other is where you have laparoscopic instruments. So you use a regular laparoscopic instrument, and you use robots to guide and move those instruments.
The problem with those instruments is that they have no wrist in them. So the movements are not like your open procedures. While the current robotic systems that are used, the daVinci system, it's got an end-of-wrist technology, so basically it's got a wrist, so it can move in seven different directions, and you can actually mimic your movements outside, inside the patient's body.
Host Amber Smith: So if I understood you correctly, the daVinci robot has, like, an arm, like a human, and it can twist like a wrist can, in multiple directions and angles?
Seetharam Bhat, MBBS: Correct. That was a limitation with laparoscopic surgeries where we couldn't move a wrist. So we had to modify our technique in performing laparoscopic surgery. So the difficulty was in doing suturing. So that's where the wrist plays a big role. And suturing is a basic part of any surgery.
Host Amber Smith: Well, are there any other terms or milestones that we need to know about robotic assistance in surgery before we move forward?
Seetharam Bhat, MBBS: Right now, what we have is a genuine robot, so that's like a master/slave robot, where, a lot of concerns which patients have, we see day to day, is that, "Are you going to be doing the surgery, or is it the robot that's going to be doing the surgery?"
That's the biggest concern which people have. The current robotic systems, it's all us doing the surgery. We control it. The robot just does the motion inside patient's body. In the future, maybe we'll have autonomous robots, so that's where we are heading, too. So we right now have a genuine robot called STAR (smart tissue autonomous robot) robot, which can perform specific tasks, but again, we control the robot.
When we say, yes, go ahead, that's when that particular robot will perform that surgery. But that's, again, in trials. It's not in clinical practice yet. So all the robotic systems that are available in clinical practice are us who are doing it.
Host Amber Smith: Are there procedures today that have better outcomes because of the robotic arms and cameras giving a better view than maybe the human eye has or being able to reach areas that it was difficult to reach compared with the traditional surgery?
Seetharam Bhat, MBBS: Yeah. The biggest example is robotic prostatectomy (whole or partial removal of the prostate). So previously for prostate cancer, people were being pushed towards radiation, and prostate surgeries were complicated because the surgeon has to reach the prostate. The outcomes weren't that great. People were leaking after the surgery. They had erectile dysfunction after the surgery.
But with the advance in the robotic technology, we are able to perform prostatectomy. And if you look at the numbers, when the robot got introduced into the market in early 2000, within two to three years, the number of robotic prostatectomies skyrocketed.
We were performing thousands of surgeries every year, while prior to the robot, we were performing like hardly 500 to 600 surgeries in a year. So this particular procedure actually benefited from the robot.
Host Amber Smith: Are there particular surgeries that just physically couldn't be done because human hands were too big to get into the space before the robots were available?
Seetharam Bhat, MBBS: Yes. Some procedures by the cardiothoracic surgeons, where they couldn't put their hands in the chest, we were using robots. Cardiothoracic surgeons also were using robots to harvest LIMA -- LIMA is "left internal mammary artery." So they were able to harvest that, which they physically were not able to do with the hands.
Host Amber Smith: Do surgeons miss out on anything by not being able to feel the way they would have if they were doing the surgery with their hands? They're not able to feel things, right, if the robot is doing that part?
Seetharam Bhat, MBBS: That's called haptic feedback. One of the biggest criticisms was, in the initial generation of robots, there was no haptic feedback, so we cannot feel stuff.
But as surgeons, we've learned how the tissue moves, how the tissue behaves with the regular instruments, and that itself was a feedback. So we've got visual feedback from the way the tissue handles, so it's really not a problem, but yes, there is a newer system called TransEnterix robot that has this feedback where you can actually feel the tissue. They have sensors at the tip of the instruments, which the surgeons can feel.
Host Amber Smith: Wow. Now, let me ask you about sterilization. Is it easier to sterilize robot hands than human hands?
Seetharam Bhat, MBBS: In fact, it's actually better. It's easy to sterilize. You can put your hands through multiple other sterilization techniques, but it's pretty easy to sterilize robotic hands.
We use ethylene oxide. You can also put through Sterrad (a sterilizing device) and many other devices to sterilize these instruments.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.
I'm talking about the use of robots in surgery with urologist Dr. Seetharam Bhat.
In a lecture recently, you said that the prostate saved robotic surgery.
What did you mean by that?
Seetharam Bhat, MBBS: Initially, when the robot was introduced, it was introduced to be used in cardiothoracic surgery, but then the cardiothoracic surgeons were using it to harvest LIMA, that is, the left internal mammary artery, and then they were performing open surgeries on the heart. And for some reason, they did not adopt the robotic surgery.
So most of these robots were just lying in these universities without being used. That's when a urologist, Dr. Mani Menon from Vattikuti (Urology) Institute (in Detroit), decided to use this robot in prostate surgery.
So it was not initially FDA (Food and Drug Administration) approved for prostate surgeries, and most of these centers were not using them. But once he showed how prostatectomy can be done with this robot, there was a quick adoption of this technology, and multiple centers started doing robotic prostatectomy, so that's why we say that robotic prostatectomy saved the robot technology, and there was widespread adoption.
And we have like 3,000 installations currently in the country, more than 3,000 installations.
Host Amber Smith: Why are robotic prostatectomies performed five times more than traditional open surgeries?
Seetharam Bhat, MBBS: It's the technical challenge. The prostate is an organ that sits below the bladder in the patient's pelvis, so pelvis is the bony cage which protects your bladder and the prostate.
In order to reach the prostate, we have to dig our hands underneath the bladder and reach the prostate. And prostate is often a walnut-size organ. It's tiny. It's tough for us to see it. Tough for us to feel it. Tough for us to dissect it. With the robot, we have 10 x magnification. You see things clearer, things are magnified, the instruments are more precise. We can perform the procedure more precisely.
Host Amber Smith: It sounds like there's a lot of advantages. Are there ever patients for whom a robotic procedure is not recommended, where you would say they really just need an open surgery?
Seetharam Bhat, MBBS: Right now, the indication for robotic prostatectomy is widespread.
So you can pretty much offer it to all the patients. Before, there was a limitation. Obese patients were not being operated upon, but we found that robotic surgery safe in them.
The only instance where we probably would not consider robotic prostatectomy and try to do a perineal prostatectomy is in patients who've had multiple surgeries in the past.
With multiple incisions in the abdomen where you expect a lot of scar tissue, a lot of bowel adhesions (bands of scar tissue), then we change our approach. We don't go through the abdomen, we go through the perineum, which is behind your scrotum and in front of your anus. So we make an incision and reach the prostate via that particular route.
Host Amber Smith: There's multiple companies that make surgical robots today. Is there any standardization between them?
Seetharam Bhat, MBBS: The daVinci robot, which is the current existing system, most common system that we use in the U.S., had all the patents for it, and now it's been 20 years, and the patents are kind of expiring, so we see all these other companies bringing in their own versions of the surgical robot.
What did daVinci achieve? It showed us that the robot has a use in medical field, and it proved that robots are safe. These were the two values which daVinci did in the last 20 years.
Now since, the patents have expired, there are many companies that are bringing in. There is a company called CMR Robotics, which has its own version of robot. They're based out of London. Medtronic, which is a huge medical company in the U.S., they've brought their own robot.
They all have similar principles in the way they operate, but they're slightly different.
Like, daVinci is a single robot where all the arms come out of a single pole, while Medtronic's robot, the arms are individual, so you can position them at different spots, so you can configure how the robot works. Same with the CMR. The arms are different, so you can place one arm at the head, one arm at the leg of your patient, one arm at the side, but in the daVinci, it's a single pole, and then multiple arms come out of the single pole.
Those are minor differences, but they all have risk. They all have similar instruments. Nobody's going to change the technique just because you have a new company releasing a new robot with fundamentally different design. So designs are almost the same. It's just that they're a little different.
Host Amber Smith: I see. Now, we talked about prostate, we've talked about cardiac. What other types of surgeries lend themselves to being done with robotic assistance?
Seetharam Bhat, MBBS: Right now, almost all general surgeons are using the robot: cholecystectomy (gallbladder removal), they're doing bowel surgeries. Rectal surgeries, again, rectum is an organ that's in the pelvis, that's behind the bladder, so those surgeries are performed using the robot. Thoracic surgeons use it to perform lung surgeries. There are different models of robot used by the orthopedicians. There is Mako robot that helps in arthroplasty (restoring a joint). We can replace hips with that. You have some robots that are specifically designed for the spine.
There are multiple other companies with different designs for other surgeries, too. So more or less, all the surgical procedures now have a robot attached to it.
Host Amber Smith: Are robots being used in brain surgery?
Seetharam Bhat, MBBS: The stereotactic surgery is actually a robotic surgery. In the true sense, they're not using the daVinci robot for brain surgery, but stereotactic surgery is a robotic surgery where, right now, they basically feed MRI scans into the machine, and the machine guides those instruments. If you want to ablate (remove) a lesion in the brain, they can actually precisely make a burr (drilled) hole and put those instruments directly in that particular spot and ablate that using ultrasound waves or radio frequency ablation.
They can use multiple other techniques to do that. So they are doing it. I mean, they were the ones who first started it.
Host Amber Smith: Are we looking forward to a day when the robots do the procedure entirely?
Seetharam Bhat, MBBS: That is where it's heading to. Right now, if you look at the autonomy of the robot, autonomy is where you let the robot perform tasks by itself, there are levels of autonomy. We got this concept from self-driving cars.
Right now, all the robots that are available are Level 1 robots, where it's a master, that is, us, surgeons, who are operating the robot. And the robot will kind of mimic our actions.
The Level 2 autonomy is when you have specific tasks, which the robot will perform. They don't perform the entire operation, but we give them permission, and they would perform a particular task, like either suturing or cutting a particular tissue or making an incision in the abdomen. So it'll perform a specific task.
In Level 3 autonomy, we expect the robot to perform more complex tasks, but it's us deciding whether the robot performs it. So it can perform the entire operation, but it's us saying, OK, go ahead. And we have a level of autonomy, meaning we kind of control these robots, and we can override these robots.
Level 4 is when they do it all by themselves, so we have no control. So they make the decision. If the patient has to undergo the surgery, they will perform the surgery, and then they will manage the outcomes and everything. So it's all done by them, and we cannot override them. So this is Level 4 autonomy. Right now, we are at Level 2. We have robots that are being trialed to perform specific tasks.
Host Amber Smith: What is augmented reality in relation to surgery?
Seetharam Bhat, MBBS: So if you look at augmented reality in general terms, it's basically you're using computer-generated simulation and using it in real world.
So there are now multiple companies with different products where we can use patient's images intraoperatively and overlaid on the surgical field. So there is a company called Ceevra. So what it does is, they use patients' images, create a 3D model of, say, for the prostate, the surrounding structures, the lymph nodes around the prostate. And you can use these 3D models in the current robotic system, and you can kind of superimpose them side by side and know patients' anatomy.
Again the TransEnterix robot, which I told you, they have tools where they can superimpose these images onto the patient. You can actually measure stuff inside patients' bodies. So they actually have a ruler, and you can measure, say, I have to go 5 centimeters towards the prostate. I can measure how far I'm moving using those rulers.
So it's heading towards that. It's basically like using Google Maps inside the patient. You know how to do, where to go, how to find the anatomy, how to perform the operation.
Host Amber Smith: Well, how would you like to see robots evolve in the field of medicine?
Seetharam Bhat, MBBS: Well, I am a fan and a skeptic both together at the same time.
I like the fact that we are having so many other tools that will enhance our ability to perform procedures. But at the same time, I worry about patient safety.
Like, for example, right now, AI (artificial intelligence) is a big thing. People are talking about AI. When ChatGPT was launched, it was able to answer almost all the questions with accurate answers, so it could solve a math problem with 98% accuracy, but over time, now the accuracy is going down because it's learning all the other stuff on the internet. So recently they published a paper where it could only accurately solve a problem about 2% of the times.
So this can happen even with the surgical robot. If you have a new surgeon or a trainee resident trying to perform surgeries, and the machine learns that, over us, there is no control as to what the machine is learning. That's the problem with AI. You just feed large data sets to the machine, the machine learns. It cannot pick and choose which is right, which is wrong. It just learns based on what is being fed to it.
So that's where I think the patient safety has to be taken into consideration, and we still have to have some control. The Level 4 autonomy is something that scares me.
Host Amber Smith: I was going to ask if you would be comfortable having a robot do your surgery on you at a Level 4 status or whatever.
Seetharam Bhat, MBBS: If you speak to the scientists who are actually supporting AI, they will tell you it's the same question with self-driving cars. You can use self-driving cars as an example in surgical robots. Would you let a car drive you home?
But they would support self-driving cars with data. They're saying the number of accidents are lesser when the car is driving itself rather than human beings driving the car. So the human error forms a big part in this. The same thing with the surgery, too. The idea of using autonomous robots is to eliminate human error. That's when I think experience comes into play.
This is a little bit nuanced. You need to have experienced surgeons performing surgery, so the surgical error is much lesser. That's why we have tools like proctorship (monitoring and evaluation), we have training, we have to undergo training for almost 10 years before we actually can start performing surgeries on the patient.
That's the difference. I'm skeptical about the future with regards to patient safety. At the same time, I am excited about all these technologies.
Host Amber Smith: You've given us a lot to think about. I appreciate you making time for this interview, Dr. Bhat.
Seetharam Bhat, MBBS: Of course. Thank you.
Host Amber Smith: My guest has been Dr. Seetharam Bhat, an assistant professor of urology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.
Find our archive of previous episodes at upstate.edu/informed.
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