Ceilidh

Michael Zey
futurist3000@aol.com

--------------------------------------------------------------------------------

Authors:                  Bernard Wysocki Jr.

Pagination:               B.1

ISSN:                     00999660


Abstract:

Even proponents, however, worry about the steep price tag. "The cost has
to come down or it could become like the Concorde" supersonic transport,
which stopped flying in November, says Mani Menon, chairman of urology
at Henry Ford Hospital in Detroit, where he and his colleagues used the
da Vinci robot in more than 400 prostate removals last year. But the price
won't be brought down by intense competition anytime soon; Intuitive Surgical
bought its chief rival in the robotic-surgery marketplace last year.

Most of the time, however, the mitral-valve repair goes like clockwork,
as it did last Monday when 65-year-old William Ogden, a Wilmington, N.C.,
retiree was wheeled into the operating room. At the console, the "remote"
surgeon sees the heart and his robotic instruments in three dimensions,
magnified 10 times. The surgeon uses thumb, forefinger and normal wrist
movement to manipulate the robotic arms, which have tiny knives or forceps
at the tips. The surgeon manipulates the camera from a foot pedal. A fourth
robotic arm is available, but unused by Dr. [W. Randolph Chitwood] in these
operations. In a typical case last week, the operation took a bit over
two hours, about a third of that time spent cutting and rebuilding the
damaged heart valve.

The big costs of da Vinci go beyond those of the hardware itself and include
the extra training of doctors and staff. Procedures often take longer than
traditional "open" surgery, especially at first. And typically, the robotic-assisted
procedure requires more medical personnel in the operating room, raising
costs to doctors and hospitals at a time when nursing staff is in short
supply and insurance reimbursements are usually fixed, and don't always
cover costs. The company says, however, that some postoperative hospital
costs are lower after robot-assisted surgery, such as nursing time, since
patients generally recover faster.
Copyright (c) 2004, Dow Jones & Company Inc. Reproduced with permission
of copyright owner. Further reproduction or distribution is prohibited
without permission.

Full Text:

A FOUR-ARMED surgical robot costing $1.2 million is becoming a fixture
in a growing number of hospital operating rooms. But is it the next wave
in minimally invasive surgery, or technological overkill at an exorbitant
price?

The da Vinci surgical system has been on the market since 2000, but its
sales have taken off only in the past year or so. Regulators have cleared
the device for a lengthening list of surgical operations, and the robot
has won a following among several prominent surgeons. Among them are urologists
who use it for prostate removal in cancer patients, and cardio-thoracic
surgeons who deploy the robot to assist in heart-valve repair.

Made and marketed by Intuitive Surgical Inc., of Sunnyvale, Calif., the
company has installed just over 200 of these robots world-wide, with 61
sold last year, about 70f them in the U.S. The company has also installed
systems in Canada, Europe, Japan and Australia.

In operating the device, a surgeon sits at a console a few feet from the
patient, peering into a high-powered camera while guiding the robotic arms,
inserted into the patient's chest, to perform cutting and stitching deep
inside the body.

"This is the most expensive pair of scissors you could ever buy," says
W. Randolph Chitwood, chairman, department of surgery, at East Carolina
University in Greenville, N.C. He has performed about 130 mitral-valve
repairs on patients using the da Vinci robot and is a strong advocate of
the device, saying it provides unmatched precision for delicate operations.

"For the patient, there's less pain, less blood loss and faster recovery
time," he says. Conventional open-heart surgery requires much larger openings
in the chest cavity, longer hospital stays and a greater chance of needing
blood transfusions.

Even proponents, however, worry about the steep price tag. "The cost has
to come down or it could become like the Concorde" supersonic transport,
which stopped flying in November, says Mani Menon, chairman of urology
at Henry Ford Hospital in Detroit, where he and his colleagues used the
da Vinci robot in more than 400 prostate removals last year. But the price
won't be brought down by intense competition anytime soon; Intuitive Surgical
bought its chief rival in the robotic-surgery marketplace last year.

Despite the high cost, hospitals may feel compelled to buy a da Vinci system
because some patients are starting to demand it. "If you can't offer this,
you are going to lose your patient base," says Edward Janosko, chief of
urology at East Carolina University, part of the North Carolina state system.

Although it is less invasive than traditional forms of surgery, the robot-assisted
procedure are still complicated and delicate. In a mitral-valve repair,
the patient's heart is stopped for about two hours, with bypass machinery
in the operating room taking over the heart's function. A pair of robotic
arms are inserted through the chest wall. The operation also requires a
2-inch incision opening up the heart, enough room for a second surgeon
to do hands-on collaboration and for an endoscopic camera.

Earlier this month, one patient told Dr. Chitwood the day before the procedure,
"I was surprised to hear that they would have to stop my heart." Dr. Chitwood
told the patient that he couldn't guarantee 100uccess, but that of more
than 125 previous cases, none had died from the procedure. (Two patients
died months later from other complications.) In this case, the patient
had a successful operation but had an allergic reaction to medication after
surgery and died a few days later.

Most of the time, however, the mitral-valve repair goes like clockwork,
as it did last Monday when 65-year-old William Ogden, a Wilmington, N.C.,
retiree was wheeled into the operating room. At the console, the "remote"
surgeon sees the heart and his robotic instruments in three dimensions,
magnified 10 times. The surgeon uses thumb, forefinger and normal wrist
movement to manipulate the robotic arms, which have tiny knives or forceps
at the tips. The surgeon manipulates the camera from a foot pedal. A fourth
robotic arm is available, but unused by Dr. Chitwood in these operations.
In a typical case last week, the operation took a bit over two hours, about
a third of that time spent cutting and rebuilding the damaged heart valve.

Advocates say that in complex surgery, the robotic assist is more precise
and more practical than "keyhole" surgery, which uses small incisions to
insert long lighted, laparoscopic instruments. Moreover, both of these
techniques -- long instruments or robotic arms -- are far less invasive
than traditional open-heart surgery, still used for some operations.

But the device poses risks -- potentially fatal -- in the hands of inexperienced
surgeons. In December, the family of a Tampa, Fla., man filed suit against
St. Joseph's Hospital in the 13th Judicial Circuit Court, Hillsborough
County, Fla., charging the hospital was negligent in allowing two doctors
lacking experience and training to use the robot in a 2002 procedure. The
patient, a 53-year-old high-school teacher, died in the aftermath of an
aborted robotic kidney removal.

At the time of the incident, St. Joseph's issued a statement calling it
a "tragic isolated accident that does not jeopardize future care" but required
all of its surgeons wishing to use the robotic system to take additional
training courses. The hospital has since filed a motion to dismiss the
case, which is pending. No charges were brought against the doctors, nor
were charges brought against Intuitive, the maker of the robot.

The big costs of da Vinci go beyond those of the hardware itself and include
the extra training of doctors and staff. Procedures often take longer than
traditional "open" surgery, especially at first. And typically, the robotic-assisted
procedure requires more medical personnel in the operating room, raising
costs to doctors and hospitals at a time when nursing staff is in short
supply and insurance reimbursements are usually fixed, and don't always
cover costs. The company says, however, that some postoperative hospital
costs are lower after robot-assisted surgery, such as nursing time, since
patients generally recover faster.

At East Carolina, surgeons say that the hospital gets paid a fixed fee
of about $25,000 for the total costs of each heart-valve repair regardless
of whether robotics are used. That figure includes the hospital stay and
other costs and is enough for East Carolina to make a small profit. The
procedure, with or without robots, is covered by Medicare and private insurers.

At present, only a tiny fraction of surgeries involve robotic assistance.
About 3.4f radical prostate surgeries in 2003 were performed using robotics,
says Eric Miller, senior vice president at Intuitive Surgical, although
the rate is rising fast. Using the da Vinci system for such surgeries will
be a hot topic at the American Urology Association meeting in May, says
Dr. Janosko. And while the number is rising, and clinical results are impressive,
there's still debate among surgeons over whether it's really more precise.
The stakes are high: In such a delicate operation, a surgical mistake can
leave the patient impotent or incontinent for life.

Reproduced with permission of the copyright owner.
Further reproduction or distribution is prohibited without permission.

PHOTO: Dr. Randall Wolf exhibits the da Vinci robot arm Friday at University Hospital.