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I, robot, MD

Early adopters of robotics in the operating room, the School of Medicine’s surgeons and researchers are expanding Yale’s footprint with new technology.

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Surgical robot

In August 2006, John Colberg, MD, HS ’90, used a surgical robot for the first time at Yale to remove a patient’s prostate. With its camera and mechanical arms and hands that swivel 360 degrees, the machine offered unprecedented access, dexterity, and visibility. By the time Colberg first used the robot, he had performed thousands of procedures through traditional open surgery. Since then, the professor of urology and director of urologic oncology has used robotics at least 500 times. In fact, he barely recalls the last time he performed a prostatectomy via open surgery. “It’s rare that we do an open surgical prostatectomy—one in five years, that’s probably a lot,” he said in a recent interview.

Indeed, studies have shown that about 90% of prostatectomies around the country are done through robotics. At Yale, robotic systems are now used in mitral valve repair and coronary artery bypass surgery; hysterectomies; treatment of lung cancer and cancers of the head and neck; and surgeries involving the stomach, small bowel, and colon. That first surgical robot, the da Vinci Surgical System, has been joined by eight other devices at Yale New Haven Hospital, with others in place throughout the Yale New Haven Health System in Bridgeport, Greenwich, and New London. Yale New Haven Hospital was the third in the state to acquire a robotic system. Now, said Colberg, many hospitals in Connecticut have them. When it comes to urologic surgeries, Colberg said, “We are never going back to open surgery. As far as pain, blood loss, time in the hospital [is concerned], robotics is so superior.”

The first surgical treatises date from 2,000 BCE in India, but evidence of trepanation—the drilling of a hole in the skull to release internal pressure from a head injury—goes back to 12,000 BCE. Since those early surgeons began opening up human bodies to make repairs, the practice of surgery has inflicted collateral damage. To reach diseased or damaged tissue and organs, surgeons have had to inflict even more injury as they cut through skin, flesh, and bone. Robotic surgery is the outgrowth of a trend toward minimally invasive surgery that dates from the late 20th century.

Arthroscopy, first used in Japan as a diagnostic tool for knee joint injuries in 1919, emerged as a surgical technique in the 1970s with advances in fiberoptics. The 1980s saw the advent of laparoscopic surgery. In both arthroscopic and laparoscopic procedures, surgeons make small incisions of about half an inch, through which they insert a camera and surgical instruments. The small incision minimizes trauma and leads to reduced blood loss, less pain, shorter hospital stays, and faster recoveries.

In the 1980s and 1990s, robots began assisting in laparoscopic surgeries; and in 2000, the Food and Drug Administration approved the da Vinci devices, made by Intuitive Surgical in California. The company has dominated the market ever since, installing more than 2,900 systems in the United States. “Any reasonable-size city with a reasonable-size hospital probably has a robotic system in place,” Colberg said.

He now uses an upgraded version of the system that he first used 14 years ago. “Technology has gotten better,” he said. The new system has four arms instead of three, and a second control console for training, although only one surgeon is in charge at any given moment.

Colberg sees the da Vinci machine as a vast improvement over laparoscopic surgery. “Laparoscopic is sometimes hard to do, harder than robotics.” Among its advantages, the surgical robot eliminates hand tremor, and allows greater visibility and freedom of movement. And unlike humans, it doesn’t get tired.

There are caveats, and there is a spirited debate within medicine about the value of robotics. Robotic surgeries can add thousands of dollars to the cost of a procedure. Although outcomes are the same in urological procedures, that’s not the case across all surgical specialties. And in some cases, laparoscopic surgery leads to better outcomes. Robotic surgery is a relatively young field, and some surgeons think that more studies need to be done to gauge its efficacy and safety.

Nevertheless, Colberg sees it as the wave of the future, and recent studies show its growth. A study published in JAMA Network early this year found that the use of robotics in general surgery went from 1.8% in 2012 to more than 15% six years later. Another study found that robotic-assisted surgery for kidney operations went from 1.5% in 2003 to 27% in 2015. “As more and more time goes on, more surgeries are going to be done robotically,” Colberg said.

Brian Scassellati, PhD, the A. Bartlett Giamatti Professor of Computer Science & Mechanical Engineering & Materials Science, has been studying artificial intelligence and robotics for years but cautions that those in the field still struggle to define what a robot is. That said, he cites certain essential attributes. The robot must be aware of its surroundings and able to respond to them independently without human intervention. So those machines patrolling supermarket aisles checking for spills and inventory are in their limited tasks robots. A surgical robotic system, however, is not.

“When we think about robotic surgery, we’re not talking about autonomous robots. We’re talking about things that are directly controlled by human surgeons,” Scassellati said. “It’s a way for surgeons to do things with finer control and finer precision than they can do with their own hands. But it is not autonomous.” Colberg agrees. “It doesn’t do anything we don’t tell it to do,” he said.

On a broader scale, Scassellati compares the current state of robotics to the advent of the personal computer in the late 1980s and early 1990s, when technology allowed mass production of PCs and made them affordable. Now, our laptops, tablets, and cell phones have become essential tools of our daily work and personal lives.

“Robots used to be things that only existed in very tightly controlled factory floors, much like the computer labs of old, and now they’re becoming safer for people to have around. They’re becoming more pervasive in the kinds of applications they have,” Scassellati said. “The range of places where these things are going to be applied? The short answer is everywhere. They’re going to change the landscape in the same way that the introduction of the personal computer was hard to perceive. We’re in a golden age of robotics right now.”