Helping Hand

If you've invested in robots, you might as well let everyone know that your facility offers the most advanced surgical technology. Our hospital, Pascack Valley Medical Center in Westwood, N.J., has done a terrific job marketing our robotic system. Our campaign includes a website, WeGotBots.com, that positions robots as "your surgeon's new best friend," and social and print media that reads: "At Pascack Valley, We've Got the Bots."

American healthcare is big business, a big part of which is marketing. Differentiating yourself in an increasingly crowded and competitive market is crucial. "Minimally invasive" already resonates positively with the population, and now manufacturers and medical centers alike are marketing robot-assisted surgery to consumers.

We've been using robots to assist with surgeries for 20 years, and we've had an excellent experience with them. They help me perform safer, more accurate surgeries. We've seen improvements in care — more efficient OR times, shorter lengths of stay, quicker recoveries, lowered risks of infection, less pain, less blood loss, less scarring and other trauma, the list goes on. Getting better outcomes adds up to significant cost reductions over time. And obviously, the more patients you care for with the robot, the faster you'll make back the initial outlay.

My main hospital, Hackensack (N.J.) University Medical Center, has 5 Intuitive da Vinci robots. We've bought every one of their iterations, and we've gotten very good with them. It's a very refined system. However, as chairman of surgery at one of our satellite hospitals, Pascack Valley Medical Center, I was asked, "What's the next step for us as a hospital? What can we do in terms of tech and being on the forefront?" We could have bought another da Vinci, of course, but we would've been like most other hospitals in the state. We wouldn't be adding anything new. I wanted to try something different to see if we could progress even further.

In March, we acquired the only other FDA-approved robotic system for abdominal surgeries, the TransEnterix Senhance. We're one of the first U.S. sites to acquire one. Over the last several months, we've been trying it for a wide variety of general surgery cases. We've successfully done bariatric procedures, gallbladders, different types of hernias, appendectomies — bread-and-butter stuff.

Just as minimally invasive laparoscopy became a preferred option versus open surgery, robot-assistance is taking us to the next level of care. The Senhance robotic system simply builds upon and refines the foundation of laparoscopy. With laparoscopy, surgeons take handheld instruments and, through the use of trocars, insert them (instead of our hands) into the body. We manipulate the instruments and do the operation — dissection, vessel sealing, and so on. The robot adds a digital interface. We're still putting instruments into the patient, but the way I control them is a bit different.

To me, robots give you several advantages over manual laparoscopy:

• Ergonomics. It's easy to forget the physical toll laparoscopy can take on a surgeon. Using the robot for prolonged cases is far less fatiguing. You're sitting at a console, in a chair, instead of standing at the patient's bedside.
• Visualization. The more visual information available to the surgeon, the better and faster the procedure will go. With traditional laparoscopy, you have a 2-dimensional image on the screen. With the Senhance, I see a 3D image through a pair of wraparound glasses. This has huge advantages when you're doing dissection. Because I can see things like the gallbladder or hernia in 3D, I get the depth perception needed to make fine movements.
• Refinement of techniques. The digital interface of the robot translates your motions and cleans them up a bit. It removes tremors and vibrations that could potentially affect outcomes.
• Theoretical advantages. In traditional laparoscopy, we torque against the patient's abdominal wall, and move the instruments around as we see fit. With the robot, the instrument deploys less torque, which reduces patient discomfort.

The other theoretical advantage involves haptic feedback. In laparoscopy, when you touch tissue you get instant haptic feedback. With previous robots, surgeons rely on visual cues to know they are handling tissue. With Senhance's built-in haptic feedback, you actually feel the resistance as you handle tissue. That's an extremely valuable enhancement.

I really like the modular concept of the Senhance system; I think it's going to be the norm in the future in order to bring costs down and save time. We can grow with the system we originally bought. If a new part comes out, they can upgrade or replace the old part. You don't have to buy a whole new system. That cost savings was a big determinant for us. The other thing I like: You don't have to dispose of the instruments and buy a whole new set after 10 uses; the instruments with the Senhance system are infinitely reusable. If they break, you can repair them.

We've done about 45 Senhance cases so far, and we haven't had to throw away one instrument. That's huge in a healthcare system that scrutinizes every penny spent.

Surgical robots are only going to become more affordable, functional and cost-effective in the future because of increased competition and demand.

Learning curves are getting shorter, too. Because the instruments with this new robot more closely resemble traditional laparoscopic instruments, it doesn't take an experienced surgeon much time to get comfortable with the tech. For the nurses and techs who assist me, it was plug and play, essentially. We've learned how to set it up and clean the instruments very quickly for each case.

The point here is, surgical robots are only going to become more affordable, functional and cost-effective in the future because of increased competition and demand. The technology is always improving based on surgeon feedback and the needs of patients. The da Vinci robots continue to evolve after 2 decades in the field. As with most technologies, it's never, "This is as good as it's going to be." Your first-generation Android phone or iPhone was far different than what you use today. The same applies with these robots.

Robotic-assisted surgery lets us do procedures we couldn't do with traditional laparoscopic means. The classic example is prostate surgery, which used to be a longer operation that had associated known complications. With the da Vinci robot, this operation now takes 60 to 90 minutes at experienced centers. Nerve injuries are far less common, and recoveries are much quicker. The robot has sent that operation to new heights, helping countless patients.

Robots are incorporating a lot of advanced artificial intelligence to act as virtual assistants. Some now integrate CAT scan images or immunofluorescence imaging to help the surgeon do a better, safer operation. That sort of stuff is difficult to incorporate with traditional laparoscopy, but it's coming.

We've found hybrid approaches are possible. We can use the Senhance surgical system for certain aspects of specific operations, while using traditional laparoscopy for others. I extract the advantages of the robot, but can shift to traditional laparoscopy rather seamlessly. Take a sleeve gastrectomy — we can do the dissection, exposure of the anatomy and a lot of other things with the robot. As of yet, there's no stapling platform for the Senhance, so I need an assistant to bring in a traditional laparoscopic stapler. When I convert back to laparoscopy with the Senhance, though, the port placements are very similar to what I'd place in a laparoscopic procedure.

The disadvantages of any robotic system? Certainly, cost — acquisition cost, ongoing maintenance costs, restocking fees, all sorts of things. But here's the thing. Until very recently there's been no competition in this sector of the market. If you wanted to do robot-assisted abdominal surgery, you had one choice. They charged what they charged; if you could afford it, you got one. Now that there's competition with the Senhance system and several others coming in the next few years, it'll drive costs down. Senhance already has an overall lower cost profile than da Vinci does.

Having said that, the Senhance is still a first-generation unit. They've already provided us upgrades, like a higher-resolution monitor, updated eye-tracking technology to move the camera and software upgrades to make motions smoother. More refinements will be made — for example, advanced bipolar electrocautery and articulated instruments. That's the deal with surgical robots — the technology is always advancing to address surgeons' needs and, most importantly, improve patient outcomes. OSM