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Residencies with DaVinci Training?
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On one interview, we got to take a look at a DaVinci robot. They're pretty wild man. Just like a video game. You don't even have to touch the patient, just stare into a big box while seated comgortably. Apparently the robot can tell how hard and swiftly to move instruments based on tactile sensors in the controls.
As far as the data goes, I don't think there's much out there yet since not that many programs even have the robots. They cost a couple of millions if I recall... Also, there is a Davinci and there is one other kind of surgical robot and both are competing so a lot of programs want to wait as long as possible to buy one since they don't want to get stuck with a 2 million dollar betamax.
I would be very surprised if any residency program gave you enough Davince time and teaching to be comfy doing everything davinci when you graduate. We were told on the interview that there will be a lot of fellowships springing up in robotics to give surgeons adequate training to be considered "robotic" surgeons.
As far as the data goes, I don't think there's much out there yet since not that many programs even have the robots. They cost a couple of millions if I recall... Also, there is a Davinci and there is one other kind of surgical robot and both are competing so a lot of programs want to wait as long as possible to buy one since they don't want to get stuck with a 2 million dollar betamax.
I would be very surprised if any residency program gave you enough Davince time and teaching to be comfy doing everything davinci when you graduate. We were told on the interview that there will be a lot of fellowships springing up in robotics to give surgeons adequate training to be considered "robotic" surgeons.
I've been told that it's only been approved for cholecystectomies. Is that so? In Europe they are using them for lots of stuff, including thoracic surgery.
Re: MacGuyver... I'm interested in it because I'm a geek, and well, that's what geeks get into... we like all things related to technology, and the Davinci system has geek written all over it. Bring it on!
Re: MacGuyver... I'm interested in it because I'm a geek, and well, that's what geeks get into... we like all things related to technology, and the Davinci system has geek written all over it. Bring it on!
Medical College of Virginia and East Carolina University both have DaVinci robots. Since I gathered this from interviews, I don't know to what extent they are used in training, but they allowed us to play around with one at the ECU interview tour and it was *extremely* cool.
This interest in robotics seems pretty peripheral to me. There are only a very few instances I can imagine where this technology is going to be of much use to practicing surgeons (beating heart CABG) on any kind of frequent basis. Many of the procedures they have demonstrated that the operations are feasible on just don't demand the kind of precision or (more importantly) capital expenditures neccessary for the purchase and maintainance of these machines especailly when you look @ our health care on a systemic basis. When you don't have the ability to insure large amounts of people, pay for exploding persciption meds, or insure basic health maintainance the idea that you're going to reinvent the wheel with this very expensive technology in search of indications is just ridiculous.
Anyone else have some insight on this? Womansurg, I'd be interested in your perpspective. They just purchased one of the DaVinci's here for cardiac use mainly. There is a ten year old AESOP in a closet here that no one use b/c its a pain in the ass. We also have one of the few operative MRI's in the country here that is still looking for someone to find a way to make it pay for itself. While very attractive from a gee-whiz geek-boy perspective, these state of the art instruments just don't seem like an advance compared to say laparoscopy and endovascular techniques.
The last thing I would be influenced by when you look for a training program would be the presence or abscence of these "latest & greatest" toys
Anyone else have some insight on this? Womansurg, I'd be interested in your perpspective. They just purchased one of the DaVinci's here for cardiac use mainly. There is a ten year old AESOP in a closet here that no one use b/c its a pain in the ass. We also have one of the few operative MRI's in the country here that is still looking for someone to find a way to make it pay for itself. While very attractive from a gee-whiz geek-boy perspective, these state of the art instruments just don't seem like an advance compared to say laparoscopy and endovascular techniques.
The last thing I would be influenced by when you look for a training program would be the presence or abscence of these "latest & greatest" toys
S
Skylizard
operative MRI is an MRI suite that is also an operating room. All the instruments used for the OR are special material to insure no magnet related "accidents". Basically between steps in the operation (generally special & rare neurosurgery operations), an MRI is done to guide the procedure along the way. It is an "almost real-time" MRI guidance to the surgery. There is big marketing (like drug reps but for equipment) for it as one of the Magnets alone is several million dollars and then you basically need a seperate special OR with all special equipment. The environment limits the use of this OR for any other cases as you couldn't use it for a good old lap chole when one of the special cases wasn't using it. The reason being because of the risk of leaving unsafe instruments in the room and having a magnet related "accident". For the "special cases", there are strick selection as you want to be able to demonstrate the multi-million dollar set-up was a "success". Of course, these cases are few and far between and thus will not pay for the...for lack of a better term, the "structure". It is real star wars type stuff and real cool from an academic standpoint. Yet as DrO has mentioned, it doesn't pay for itself and there are very limited numbers of cases out there to justify institutions laying out the millions for this get-up. If you just limited the cost expenses to the hospital itself and ignored the lack of general insurance in the public, I would say numerous people get frustrated with these expenditures. Why? well, in the OR it is not uncommon to have crappy pick-ups, mayos, and other equipment. Budget limits are usually cited for why everyday equipment is not always new and functioning while in the meantime you have a massive chunk of infrastructure that sits in moth-balls nearly 24/7.
I suspect there are generally 2 main reasons why institutions purchase these new gizmos. First, The chair or big wig happens to be a neurosurgeon or CT or Ortho or etc...surgeon and really wants the "toy" to be on the "cutting edge". The second reason which is probably why the first reason succeeds is that the hospital wants bragging rights to claim "theirs is bigger". The hospital often realizes they won't really use the monster but knows that if you use words like "laser" and "robots" and "Operative MRI" and "virtual reality" you get the publics attention. That means patients=clients start wanting to go to hospital X instead of hospital Y because Hospital X must have the best doctors because they are the only hospital in the state with the Robot, laser, operative MRI, virtual reality, etc... That is also why they allow resident applicants to play with the gizmos. they want the top candidates to rank them higher because they have the latest equipment. What applicants need to remember is that when a hospital spends money on these wow devices and buildings it comes from somewhere else...i.e. resident salaries, resident benefits (i.e. 401k & free parking), nursing & ancillary care cuts, upgrades to regularly used equipment, lack of PAs, etc... You need to also remember that with this new technology, your attendings aren't even comfortable with it. This means if the equipment is even used you will generally simply be a spectator. Beware of these big expenditures because they represent a big RED deficit in the program's monetary bottom line. It is a different issue if the program spent a large bundle on new research facilities that will be used or state of the art portable U/S for use in trauma evaluations. It is a matter of good leadership and judgement and allocation of limited resources. Even if your get some wealthy person to pay for it, that is that much charity dollars that will be sitting in moth-balls and not on the mayo stand in the OR or trauma bay. There are only so many dollars out there. If you have real needs to fill and hospitals need upgrading, you need to think very carefully how many flies this million dollar honey will catch? Can you catch flies with a really well used new research facility...I think so. Though it may not be as jazzy in the hospital report/magazine/flyer as some "robot".
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😱 Bamboozled! Again!
🙂
We've had DaVinci for about a year now. One of our pediatric surgeons uses it fairly frequently, usually for fundoplications. In fact, he just did a procedure on the smallest baby ever to undergo robotic surgery - a tiny preemie, about 4 lbs I think, who needed a Nissen. It took him 29 minutes (if you don't count the set up time, which is usually between one and two hours).
We also have a surgical oncologist who has used it for esophagectomies, and a thoracic surgeon who uses it for both intra-abdominal (pisses off our general surgeons...) and intrathoracic antireflux procedures.
There are some very real advantages to robotic surgery, and some drawbacks. Probably the major advantage is the flexibility of visualization and access. In laparoscopy, your instruments and the camera are a straight rod, which limit your ability to see and work in any position which is not on a straight line from your entry point into the abdomen - for instance, the anterior abdominal wall is tough to see and get to, the deep epigastrum can be difficult, and the transhiatal mediastinum is essentially not accessable.
In robotic surgery, the camera and your instruments are 'snaked', so that you can curve them, twist them into right angles and do a 180 degree circle, look backward, skyward, whatever. In a transhiatal esophagectomy, you just 'drive' your camera and instruments right up the hiatus and into the chest, so that you can accomplish the dissection under visualization rather than blindly, as it is typically done. Also, because all of your instruments adjust to align with the camera, this overcomes the phenomenon of working 'backward', which in laparoscopy means that - if your camera is facing backward from the entry point of your instruments and your viewing stance, everytime you move to the right and up, your instrument on the screen moves to the left and down. This is highly disorienting, and the ability to compensate for this is probably the last step that an accomplished laparoscopic surgeon masters. In robotic surgery, you don't have to deal with this.
Also, the head of your graspers, scissors, etc all rotate 360 degrees, in a manner which simulates your wrist, giving you a very natural translation of movement. The robot can be filtered so that large movements in your hands are minimized to tiny movements by the instruments, adding exquisite degrees of fine motor control. Because of these factors, the manipulations in robotic surgery are actually much easier for newbies to master than for laparoscopic surgery (it's far easier to free hand tie suture, for instance).
The major downside is a complete loss of tactile feedback. You have absolutely no clue, aside from the visual cues, how much tension or pressure you are applying to tissue or to instruments. It's pretty common that folks break suture a lot in the beginning, for instance. It makes it difficult to manipulate bowel and other soft tissues, not having any tactile sense of how hard you are squeezing or pulling.
The other major problems include the set up time, which is substantial, and the cost. I do think that there is a genuine utility for robotic surgery in selected situations. I don't believe it will replace traditional open and endoscopic techniques, which are cheaper, easier for hospitals to maintain, and have long histories of proven efficacy.
We also have a surgical oncologist who has used it for esophagectomies, and a thoracic surgeon who uses it for both intra-abdominal (pisses off our general surgeons...) and intrathoracic antireflux procedures.
There are some very real advantages to robotic surgery, and some drawbacks. Probably the major advantage is the flexibility of visualization and access. In laparoscopy, your instruments and the camera are a straight rod, which limit your ability to see and work in any position which is not on a straight line from your entry point into the abdomen - for instance, the anterior abdominal wall is tough to see and get to, the deep epigastrum can be difficult, and the transhiatal mediastinum is essentially not accessable.
In robotic surgery, the camera and your instruments are 'snaked', so that you can curve them, twist them into right angles and do a 180 degree circle, look backward, skyward, whatever. In a transhiatal esophagectomy, you just 'drive' your camera and instruments right up the hiatus and into the chest, so that you can accomplish the dissection under visualization rather than blindly, as it is typically done. Also, because all of your instruments adjust to align with the camera, this overcomes the phenomenon of working 'backward', which in laparoscopy means that - if your camera is facing backward from the entry point of your instruments and your viewing stance, everytime you move to the right and up, your instrument on the screen moves to the left and down. This is highly disorienting, and the ability to compensate for this is probably the last step that an accomplished laparoscopic surgeon masters. In robotic surgery, you don't have to deal with this.
Also, the head of your graspers, scissors, etc all rotate 360 degrees, in a manner which simulates your wrist, giving you a very natural translation of movement. The robot can be filtered so that large movements in your hands are minimized to tiny movements by the instruments, adding exquisite degrees of fine motor control. Because of these factors, the manipulations in robotic surgery are actually much easier for newbies to master than for laparoscopic surgery (it's far easier to free hand tie suture, for instance).
The major downside is a complete loss of tactile feedback. You have absolutely no clue, aside from the visual cues, how much tension or pressure you are applying to tissue or to instruments. It's pretty common that folks break suture a lot in the beginning, for instance. It makes it difficult to manipulate bowel and other soft tissues, not having any tactile sense of how hard you are squeezing or pulling.
The other major problems include the set up time, which is substantial, and the cost. I do think that there is a genuine utility for robotic surgery in selected situations. I don't believe it will replace traditional open and endoscopic techniques, which are cheaper, easier for hospitals to maintain, and have long histories of proven efficacy.
S
Skylizard
WS, if I may ask, how much hands on do the General surgery residents get at your institution with the robot? When you say it is used fairly frequently are you saying a few times/day, a few times/week, few times/month, more or less?
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Only a few cases per month, if that, are performed. They are in the process of formulating the policy about the degree of resident exposure. Currently, the staff have had to learn to use the system themselves prior to being able to proctor someone else in it. Aside from practice ex vivo in a simulation environment, the residents who have been consistently available for the cases in the OR have typically put in some stitches or done some mininal dissection, while the staff perfomed the majority of the case. The anticipation for the future is that, as exposure grows, the resident will perform as primary surgeon in some cases.
I have to admit, I've not been very interested in the process. I doubt that most hospital systems will incorporate this technology, and when and if they do, the learning curve is easily mastered by someone familiar with laparoscopic techniques.
I have to admit, I've not been very interested in the process. I doubt that most hospital systems will incorporate this technology, and when and if they do, the learning curve is easily mastered by someone familiar with laparoscopic techniques.
What exactly are they proposing that you would need it for? Like I said, all the commonly performed laparoscopic procedures just don't need it if you have any chops at all. About the only case I've done that I could imagine it might have helped for was a laparocopic choledocho-jejunostomy for a choledochal cyst, but even I was able to sew that thru a scope. For all the nissens, gastric bypasses, etc... that I see the robotic gurus write about, I (and most other surgeons) just roll their eyes back as the authors just don't seem to be realistic on the prospect of widespread adoption of their work. That being said, its important to push envelopes, but this robotic field seem destined for a very narrow niche in surgery
Ooh, nice case 😉 .
I agree about the limited utility. Our peds guy does undergo some cricticism about doing procedures with it that could be done laparoscopically safely and within half the time. He even did a gallbladder with it once, but the OR put a stop to that (30 minutes lap, vs 2 hours robotic...and three times the cost! Hmm...)
I do think that some of the technology could lend itself to improved laparoscopic techniques though. For instance, the bendable camera and the swivel head on the instruments.
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Trust me on that cyst case.....you do not ever want to do one of those! Exceedingly painful & long🙄
I have no doubt that there are some things simplified with the robot, but like you said the setup for them is quite lengthy. When you can do (when you're good at it) lap nissens & the like under an hour or lap gastric bypasses in 1.5 hours, this stuff just doesn't make sense financially. In addition, a whole OR has to be a dedicated room for one of the machines which is an expensive proposition. If you need the robot to do a pediatric nissen or those other procedures, your skills just aren't up to snuff with the scope I think. Along that line, a number of urologists have been intrigued with the technology for vasectomy reversal & lap prostatectomies. A lot of their interest is due to their fairly poor laparoscopic training (in general) for the field, & the technology lets them do things many would not be able to do otherwise. That seems like an another area that might be benefitted with the robot (the blossoming of laparoscopic GU techniques)
I have no doubt that there are some things simplified with the robot, but like you said the setup for them is quite lengthy. When you can do (when you're good at it) lap nissens & the like under an hour or lap gastric bypasses in 1.5 hours, this stuff just doesn't make sense financially. In addition, a whole OR has to be a dedicated room for one of the machines which is an expensive proposition. If you need the robot to do a pediatric nissen or those other procedures, your skills just aren't up to snuff with the scope I think. Along that line, a number of urologists have been intrigued with the technology for vasectomy reversal & lap prostatectomies. A lot of their interest is due to their fairly poor laparoscopic training (in general) for the field, & the technology lets them do things many would not be able to do otherwise. That seems like an another area that might be benefitted with the robot (the blossoming of laparoscopic GU techniques)
S
Skylizard
First, thank you DrO & WS for your replies, insight, and experience.
I think you do point to probably the most important near application...the spin-off techno. As things miniaturize etc... maybe the robot itself will eventually be broadly used. However, in the near future, I think primarily you will see expanding use of individual "robotic" tools/instruments that can be moved from one OR to the next and do not require an elaborate set-up beyond that used for a basic laparoscopic procedure. This is of course my own opinion.
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That's (2 hrs) pretty cooking I think. I was refering to some of the attendings we work with who can do it laparoscopically in 60-90mins routinely. I haven't done one thru a scope in almost a year & I'm not sure I could approach that kind of technical speed anymore (mostly my intracoporeal knot tying would be out of practice I suspect, the stitching parts pretty easy). Going into plastics I've really not been aggressively seeking out a whole lot of advanced laparoscopy lately.
WS:
We have an attending on staff here that can do them routinely in 1.5 hours, and his record is 1 hour 4 minutes! Granted he does 15 a week, and has a wait list of over 500 patients (and is currently booking procedures for 1/04)!
Watching this guy throw knots laparoscopically is magic.
The bar has been set!
Interestingly, he mentioned the other day that the first he did (nearly 8 years ago) took him 9 hours, after which he converted to an open procedure.
Airborne
We have an attending on staff here that can do them routinely in 1.5 hours, and his record is 1 hour 4 minutes! Granted he does 15 a week, and has a wait list of over 500 patients (and is currently booking procedures for 1/04)!
Watching this guy throw knots laparoscopically is magic.
The bar has been set!
Interestingly, he mentioned the other day that the first he did (nearly 8 years ago) took him 9 hours, after which he converted to an open procedure.
Airborne
Does your guy use endostitch, or does he just pass a suture into the abdomen through the trocar and free hand it? I'm just curious. We've got one guy here who uses endostich; everyone else free ties.
One of our staff was taking an average of six to seven hours to do his, but with practice he's now down to about three. Probably because we do so many lap nissens here, I did my first one in two and a half hours, and have stayed about that range since. The skill set is roughly the same; the steps are different.
One of our staff was taking an average of six to seven hours to do his, but with practice he's now down to about three. Probably because we do so many lap nissens here, I did my first one in two and a half hours, and have stayed about that range since. The skill set is roughly the same; the steps are different.
The Da Vinci robot here is used mostly for prostatectomy and some other urologic stuff. The residents do train on it, but they don't get a whole lot of exposure as only a few attendings use it.
There was one more advantage of the Da Vinci over traditional laparascopic technique that was missed. There are actually two side-by-side cameras and so the surgeon gets a 3D view when they are sitting in the box controlling the robot. Another advantage is that they sits down the entire time. The future of this type of thing is certainly questionable...the setup time alone can take longer than the procedure. But is sure does look cool...
There was one more advantage of the Da Vinci over traditional laparascopic technique that was missed. There are actually two side-by-side cameras and so the surgeon gets a 3D view when they are sitting in the box controlling the robot. Another advantage is that they sits down the entire time. The future of this type of thing is certainly questionable...the setup time alone can take longer than the procedure. But is sure does look cool...
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