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PROVO — Robotic surgery is becoming more prevalent, though human surgeons have yet to be replaced by video menu prompts and voice commands.
Dr. Richard Rassmussen, of Utah Surgical Associates and the bariatric surgery director at Intermountain Health's Utah Valley Hospital, most often recommends robotic abdominal procedures.
"By using the available technology, I'm a better surgeon," he said.
Endoscopy, the ability to diagnose disease and injury with minimally invasive cameras, was first discussed more than 100 years ago, according to the National Institutes of Health. The first endoscopic procedure was performed on a dog in the 1960s.
A German doctor, Kurt Semm, began exploring and discussing the possibility of laparoscopy — using minimally invasive surgical instruments in combination with endoscopic cameras — to revolutionize gynecological and abdominal surgery in the 1970s. In 1981, he performed the world's first laparoscopic surgery on a human, an appendectomy.
Instead of being praised for advancing surgical techniques, Semm faced ridicule and accusations of being an unethical doctor. His attempts to submit his findings to medical journals were often rejected, according to the NIH.
Nonetheless, laparoscopy was gradually accepted and became the standard for improving patient recovery time and surgical outcomes for many procedures.
Robotic surgery is the next evolutionary step in minimally invasive surgical procedures. According to the Journal of Visceral Surgery, the first robotic techniques were developed as early as 1995. The United States Army began experimenting in combat zones with remote telesurgery soon after.
A watershed moment happened in 2001 when American surgeons from New York performed remote surgery for 54 minutes on a patient in Strasbourg, France. While less than ideal, the delay in commands from New York and surgical outputs in France could be measured in milliseconds.
The third-generation robotic surgery system in use at Utah Valley Hospital in Provo is called da Vinci and was developed by Intuitive Surgical in California. The first-generation system was first available for use in Europe in 1999 and received FDA approval in the U.S. in 2000.
The da Vinci improves upon laparoscopic surgery in several ways, according to Levi Brito, of Intuitive Surgical. He said the surgical instruments are more articulated than more rigid laparoscopic instruments — much like a human wrist can rotate and move up and down and left to right.
The cameras and monitors used in laparoscopic procedures provide a two-dimensional image for the surgeon to work from, while da Vinci offers a three-dimensional image.
Magnification improvements also offer surgeons more accurate margins when working with cancerous tissue removal, for example.
The fact that the surgeon sits at a console approximately 10-15 feet away from the patient, after having made the necessary incisions in the patient, means everything is less crowded around the operating table. Surgical assistants are at the side of the patient and are still available to adjust or switch out instruments and cameras as necessary.
According to Brito, the fourth generation of da Vinci, now in development and testing, will bring about haptic feedback so surgeons can better feel the impact of instruments on the patient and provide a feel for the various pressures involved in grabbing or cutting tissue.
Unlike what many may assume, nothing about da Vinci is preprogrammed or predetermined. Every move is dependent upon inputs from the surgeon at the console.
The console provides Rassmussen a view of the cameras inside the patient's body. Two arms on the console are then manipulated by the surgeon to move surgical instruments. Different instruments can be added or removed, as needed, depending upon what functions the surgeon requires, grasping, cutting, or cauterization, for example.
Michelle Cahoon, a recent patient of Rasmussen's, entered the operating room anesthetized and only learned of the exact operating room layout — the fact Rassmussen is facing away from her at a console 15 feet away — while being interviewed for this story. Cahoon had approximately 2 feet of her colon and lymph nodes removed robotically.
Rather than being concerned about the somewhat remote nature of the surgery, Calhoon marveled at how smoothly her recovery was. Rassmussen discussed both laparoscopic and robotic procedures with Calhoon before surgery and recommended the robotic procedure, based in part on a speedier and more comfortable recovery.
"I literally experienced no pain following surgery and only needed Tylenol in the days afterward," said Calhoon.
She was relieved to not have needed opioid painkillers and was up and walking soon after surgery, and her bowels were working normally ahead of the expected time line. She felt as though her expectations, based upon Rassmussen's recommendations, were exceeded in every way.
Contrary to what many may assume, robotic procedures take more time than open or laparoscopic surgeries. The surgical setup takes longer, and because surgeons can be more thorough and detailed using robotics, time is added to most procedures. That added time can lessen post-operative bleeding, for example, though, as a surgeon can see more vessels in greater detail and cauterize them.
In addition, robotic surgeries are more expensive than standard procedures, in part because the robotics themselves aren't cheap.
Mandie Allred, a registered nurse and operating room manager at Utah Valley Hospital, said the cost difference between equipping a laparoscopic operating room and a robotic operating room will exceed $1 million. That's on top of some equipment the two types of procedures share that would not typically be found in an open operating room.
With higher costs and lengthier surgeries, it would seem disadvantageous for hospitals and surgeons to invest in robotic equipment and training.
Rassmussen disagreed, and said, "It's all about patient outcomes — less pain, less downtime, far fewer complications and follow-up surgeries, everyone wins in the long run."
Jared Parrotti, another recent patient of Rassmussen's, had a severe case of gastroesophageal reflux disease — or GERD — and needed gastric bypass surgery. He also had a hernia repaired.
Parrotti had a prior laparoscopic procedure that had offered some relief, and he had long hoped to avoid bypass surgery. A robotic option provided confidence that this more invasive procedure would go more smoothly than it would have in the past. He had done considerable research as far as the procedure and operating room layout and could imagine Rasmussen being less fatigued, as well, by being able to sit for the four-hour surgery.
"In my case, since Dr. Rassmussen had operated on me prior, I could compare the two experiences, with the robotics being the variable, and my recovery was so much easier and pain-free than I expected — walking around the day of surgery even," Parrotti said. His extreme case of reflux was resolved the morning after surgery.
His wife also noticed his snoring had disappeared.
