Respectful Insolence

The evolution of surgery: robots

I realize this is well over a month old, and maybe some of you have seen it before, but I haven’t. It’s a fascinating look by surgeon and inventor Catherine Mohr at the history of surgery and how it has evolved over the centuries.

One thing that talks like this remind me is just how much surgery has evolved just in the short span of my career thus far, since I went to medical school in the mid-1980s. Indeed, I undertook my surgical training right in the middle of the laparoscopic revolution and experienced some of the disconnect that older surgeons must have experienced. You see, I went into the laboratory to work on my Ph.D. in 1990. A little more than three years later, in 1993, I came back to surgical training as a third year resident. In just that short a period of time, a cholecystectomy (gall bladder removal) had gone from being an case for a second year resident to scrub on that was done the old-fashioned way to all of them being done by laparoscopy. All the third year residents to whose class I now belonged knew how to use the camera and instruments. When I came out of the lab, I did not. I caught up, but the first few months back were very frustrating for me and, I’m sure, for any of the attending surgeons whom I assisted.

Since the 1990s, things have changed even more rapidly. Laparoscopy is used to do more and more procedures, some of which would have been unthinkable when I was a resident. Over the last three years or so, there has even been the development of so-called “natural orifice” surgery,” (natural orifice translumenal endoscopic surgery, or NOTES), in which even the tiny incisions used for laparoscopy are dispensed with and instruments introduced through the rectum, vagina, or stomach using endoscopic instruments. I have to admit, I don’t yet see the utility of NOTES, given that laparoscopy incisions are already quite small and introducing instruments through the esophagus, rectum, or vagina appears likely the risk of infection, namely because it’s impossible to completely sterilize the mouth, rectum, or vagina.

Still, I do sometimes look on in a bit of envy at my surgical colleagues in other fields. Comparatively speaking, breast surgery is still fairly low tech. True, even that low tech has evolved fairly rapidly in my career. When I was a medical student and early in my residency we still did quite a few mastectomies, and every woman got her axillary lymph nodes removed. Now, around 25% of women require a mastectomy, thanks to lumpectomy and radiation (not to mention neoadjuvant chemotherapy), and possibly even fewer require all of their lymph nodes removed, thanks to sentinel lymph node biopsy, the latter of which became standard of care within the last decade or so, almost as fast as laparoscopic cholecystectomy supplanted open cholecystectomy. Most women with breast cancer no longer need to lose a breast, and the rates of lymphedema from lymph node surgery are way down.

Still, sometimes I wish I could figure out a way to use the da Vinci robot to do a lumpectomy. It’s a silly thought, of course, but we surgeons do like our toys.

Comments

  1. #1 Whitecoat Tales
    July 29, 2009

    The da Vinci’s are pretty cool.

    Our Surg Onc/GYN/urology departments share robot time in our main hospital. It’s a pretty sweet setup, the surgeries seem to take more OR time just because of set up/docking/ take down time, and occasionally learning curve time for fellows/residents, but the patients seemed to leave the hospital faster.

  2. #2 storkdok
    July 29, 2009

    Very cool!

    I remember as a senior resident being paged to a LSC tubal ligation I had assigned to a first year resident. The attending, a maternal-fetal medicine subspecialist asked me to teach him how to do laparoscopy.

  3. #3 LC
    July 29, 2009

    Well given the recent advances in tele-surgery, it may not be long before Orac is blogging with one hand and doing surgery with another. As long as he doesn’t mix up the controls and the surgical sutures spell out “Your Friday Dose of Woo…oops…wrong control…crap…”.

    The big advance in AI/robotics which I think most researchers would be after though is a ‘grant writing robot’. Feed it your research data and it conjures up an acceptable grant proposal form in a few minutes, as opposed to a few weeks of pure torture.

  4. #4 JD
    July 29, 2009

    Too bad they can’t use this for SCAD.

  5. #5 Pablo
    July 29, 2009

    One thing that I always wondered about surgeons. Where do they learn/practice very new techniques?

    I would think that a laparscopic surgery would be a completely different ballgame from a scalpel. It’s a different approach that takes very different skills, I would think.

    So if you are a surgeon who trained in the 60s or 70s, where do you get not just someone to show you how to do it, but the practice you need to get good enough at it so that you can do it well? Do you go to a surgery short course at the AMA meeting and practice on cadavers or something?

  6. #6 IBY
    July 29, 2009

    I wish the doctors would have used laparoscopy on my father’s gall bladder. I don’t know how much the doctors in Venezuela keep up, but I would think that they could have done it by then, since it was around 2000-2001.

  7. #7 Alan Kellogg
    July 30, 2009

    Pablo, #5

    You practice first on critters, then corpses, then on study participants who really have nothing to lose, and for whom the current methods are not possible. Finally you try it on people who are feeling adventurous and want to try something new. When you can show that it is more effective, more efficient, and safer than the old method, it enters into general use.

    BTW, doctors no longer automatically pluck gallbladders with gallstones. It don’t bug the patient, let it be. At least that’s what my doctor told me when they discovered I have gallstones.

  8. #8 wfjag
    July 30, 2009

    Stone Lifting Robot Attacks Factory Worker (Apr 27 2009)

    http://www.geekologie.com/2009/04/robot_attacks_worker.php

    It happened in Sweden, so it must be true!

  9. #9 Pablo
    July 30, 2009

    You practice first on critters, then corpses, then on study participants who really have nothing to lose, and for whom the current methods are not possible. Finally you try it on people who are feeling adventurous and want to try something new. When you can show that it is more effective, more efficient, and safer than the old method, it enters into general use.

    No, that is not what I am talking about. I am talking about Joe Surgeon who did her (it’s Josephine) residency in 1975 – 78 doing learning good old slice-em-up technique. Now still practicing, she hears about new laparoscopic methods that are far and away better than her old methods and says, “I need to start doing that. It is safer and more effective than my current methods. However, it is also completely different. The skills it takes to handle a scope are far different from what I am used to. I like to get my hands on things, and I know what things are supposed to feel like. However, with a scope, I don’t have that same feedback. I need to practice this so that I can be as skilled at it as I need to be to make it more effective as my old methods.”

    She learned to do surgery by doing a 3 year residency, where she could do supervised practice. How is she going to learn to do laparoscopy? Yes, someone can teach her “here’s what you do,” but where does she get hands on training?

  10. #10 Todd W.
    July 30, 2009

    @Pablo

    I imagine that there are programs to learn it, and that, like residents, an established surgeon would go through many of the same steps, e.g., working on a corpse before working on a live patient.

    I had a laparoscopic surgery to repair a hernia. The surgeon was easily in his 60s. Not sure where he learned the laparoscopic procedures, but the way he described it beforehand, and the results, made it seem like a breeze.

  11. #11 Capt. Craig
    July 30, 2009

    Hmmm, laparoscopic revolution in the late 1980s to early 1990s? Doesn’t compute. My 26 year old wife was diagnosed with endometriosis in 1970 and Leo Peddle cleaned her up using laparo during which she lost over half of her right ovary and some of the left. The surgery was performed at St. Boniface Hospital in Winnipeg Manitoba. Pregnancy was considered a maybe. Four years later she bore a fine strapping son most likely due to my superior sperm and Leo’s superior surgery. A daughter arrived in 77.

  12. #12 storkdok
    July 30, 2009

    @Pablo

    There are weekend and up to a week long courses on new techniques that use cadavers or animals to learn on. A lot of the surgeons I know that practiced quite a while before LSC was widely used told me they went to courses and then worked with younger surgeons who had the training in residency. I taught a lot of techniques to my partners when I joined the practice.

    The attending who asked me to teach him LSC learned from the residents.