Photograph by Anna Summa
These large robotic arms deliver tiny tools inside the chest to do the delicate microsurgical labor of coronary bypass. “Working inside the closed chest is completely different,” says cardiac surgeon Douglas Boyd. “It’s mission critical like NASA. You have to have backup because of the possibility of bleeding inside a closed chest. Everything must be very controlled.”
Heart surgeon Ralph Damiano's hands move with practiced precision as he prepares to open the chest of 62-year-old David Jones for a double-bypass operation. Damiano makes a 12-inch incision between Jones's neck and abdomen with a scalpel, then cuts through Jones's sternum with an electric saw and cracks the bone apart to expose the diseased heart. To create a clear field for his surgical maneuvers, he inserts a drainage tube into the right atrium and diverts theflow of blood to a heart-lung machine the size of a truck engine. "OK, we're going all the way," Damiano says. He injects a mixture of blood and potassium--which alters the flow of electrochemical impulses--into the heart, causing it to stop. An amplified pulse monitor, sounding steady beats, goes silent, and the operating room is quiet except for the whirring sounds of the heart-lung pump motors. On the video screens, multicolored lines measuring electrocardiograph activity are flat. Jones's burly chest is still.
Time is now of the essence. The longer Jones remains attached to the heart-lung machine, the greater the risk of postsurgical complications like strokes. Damiano deftly sews a piece of healthy artery harvested from Jones’s left arm above and below one blockage, completing the first bypass.
Then he does something completely out of the ordinary for a heart surgeon: He unhooks the power to his forehead light, takes off his magnifying glasses, leaves behind dozens of scalpels, scissors, and clamps, and walks away from his patient.
A few moments later, he settles into an office chair in front of a squat black-and-gray computer console positioned five feet from the operating table and dons an unsterilized headset equipped with a microphone. “Left,” says Damiano.
By practicing with items like this tiny toy star, surgeons can achieve dexterity in manipulating robotic tools.
So goes an endoscope—a camera attached to a robotic arm and inserted in Jones’s body before the operation—scanning to the left, illuminating for Damiano a brightly lit landscape of pink, glistening flesh magnified 10 to 12 times on the computer monitor. As he watches the screen, Damiano then grasps the silvery ends of elbowed computer joysticks, which allow him to maneuver two additional robotic arms that hover over the operating table like brooding black cranes. As Damiano manipulates the joysticks like a master puppeteer, a pair of surgical graspers and the needle driver he will use to help sew the second bypass graft loom into view on his monitor.
This is no fantasy; this is real. It is the operating room of the future.
Damiano, the chief of cardiothoracic surgery at Hershey Medical Center at Penn State University, is one of a handful of doctors using computer assistance and robotic tools in an attempt to revolutionize heart surgery. “For the first time in history we’re interposing a computer between the surgeon and the patient,” says Damiano, 45, a tall man with thick eyebrows, a mustache, a ready smile, and thoroughgoing optimism. He believes these robotic tools will set a new standard in minimally invasive surgery—and eliminate a good deal of the terrible physical trauma associated with opening the heart. If the technology fulfills its promise, there will be no need to cut the sternum and no need to stop the heart. Patients may leave the hospital sooner, wearing three Band-Aids instead of a long line of heavy metal staples.
‘There could be a day when you could operate on individual cells’
For now, because the Food and Drug Administration considers computer-assisted bypass operations experimental, doctors in the United States are also required to open the patient’s chest and hook him up to a heart-lung machine so that the surgery can be completed by hand if something goes wrong. But last September, Canadian surgeon Douglas Boyd provided a glimpse of the future of computer-assisted surgery when he inserted tiny robotic tools through four keyhole-sized ports in a patient’s chest and successfully performed the first closed-chest, beating-heart bypass operation without the aid of a heart-lung machine.
Photographs by Thomas Hart Shelby
“A lot of surgeons feel that the real essence of surgery is getting your hands on the tissue, having your hands inside someone’s body. Robotic surgery is different from regular surgery,” says cardiac surgeon Ralph Damiano, “but I’ve done it enough now that it doesn’t feel unnatural.” Damiano practices at least twice a week on pig hearts.
Boyd and Damiano both use a computer-driven robotics system called Zeus, which was developed and manufactured by Computer Motion in Santa Barbara, California. The computer hardware that drives Zeus is modest. “It requires about the same horsepower as a high-performance home desktop,” says Computer Motion founder Yulun Wang. And yet commands travel from the console to each robotic joint at a rate of up to 400 times per second. The power of Zeus lies in its software—the 200,000 lines of computer code that harness the machine’s processors to pick up the hand movements of the surgeon as he handles the computer joysticks.
Instantly, the circuits sense and filter out tremors, the nemesis of every microsurgeon. “The system smoothes out my hand motions in much the same way you can filter an image in digital photography and make it perfect,” says Damiano. And a brilliant surgeon who develops a hand tremor might not have to quit operating.
The system is also capable of scaling hand movements down to whatever size the surgeon chooses. “If I tell you to move a foot,” says Damiano, “it’s easy. But try to move one sixteenth of an inch, and you’d have to spend time moving carefully to get it right. It’s much easier to move things in gross distance than to work on a microscopic scale. On the console, I can make very big motions, and the computer will scale it down. There could be a day when you could operate on individual cells.”
The potential benefits of the technology provided by Zeus and similar systems may be extraordinary, but learning how to use them is a challenge. Surgeons accustomed to saving lives with conventional instruments are bound to feel awkward when they start to manipulate these tools. “It’s like the first time you shot a basketball or threw a football,” says Robert E. Michler, chair of cardiothoracic surgery and transplantation at Ohio State University. He recently started using a tiny wrist at the working end of a robotic arm in a system called da Vinci, made by Intuitive Surgical of Mountain View, California.
After practice operations on 25 cadavers, Michler was pleased to discover some unexpected advantages: “I’m right-handed, but with the system I use my left hand a lot more. It’s as if you become ambidextrous. If the situation dictates the use of my left hand to place a suture in a certain position, it’s much easier to do that with the robot than using a freehand instrument.”
Michler’s equipment also offers a three-dimensional view of the magnified operating field. That means that even the two-millimeter distance between the top and bottom of a severed artery registers as nearer or farther away. “Phenomenal,” he says. “It makes everything seem so much larger—or us so much smaller.”
Full text of this article appears in Discover magazine.
For more information about the Zeus robotic system, see www.computermotion.com. For more information about the da Vinci robotic system, see www.intusurg.com.
For a technical paper about robotic surgery coauthored by Ralph Damiano, see www.hsforum.com/vol2/issue1/1999-6462.html.
For more information on robot-assisted surgeries, see www.lapsurgery.com/ robotics.htm.