The Science of Surgery: CoxHealth, St. John's enlist robots for surgery

Patients scheduled for some types of surgery at Springfield's two largest hospitals might think they've entered a science fiction movie set instead of the operating room.

CoxHealth and St. John's are using robot systems called da Vinci to perform certain surgical procedures - prostatectomies, hysterectomies or kidney surgeries - that aren't typically candidates for other minimally invasive techniques.

These robotic systems are akin to oversized video games in many ways, although the equipment in question is much larger - and there's more at stake than top scores.

The surgeon sits at a console across the operating room from the patient, monitoring his work via a camera that's inserted into the patient. Using controls at the console, the doctor directs the da Vinci to perform delicate cutting and sewing work, typically in half-inch incisions.

Doctors who use the da Vinci system say it combines the best of traditional "open" surgery and laparoscopic procedures.

"The robotic instruments are quite a bit more advanced - they actually have joints that can rotate 360 degrees, where laparoscopic instruments don't," said Dr. Howard Follis, a Ferrell-Duncan Clinic urologist who has performed 15 robotic prostate removal surgeries with partner Dr. David Anderson since the unit arrived at CoxHealth in early September. "So with our precision, our ability to control blood loss and to make very fine maneuvers, it really helps good surgeons to become even better."

That precision and maneuverability makes the robot system ideally suited for abdominal and pelvic procedures, which have to work in a narrow space around numerous other vital organs.

"The difficult thing about prostate surgery is that you're in a deep, narrow space and it can be hard to get your hands in. Now you don't have to do that," said Dr. Eric Guilliams, a St. John's Clinic-Urology urologist. "The instrument ... can move in ways that the human wrist can't, so you can manipulate the needle in ways you couldn't without the robotic assistance."

The result - patients who can leave the hospital more quickly, experience less blood loss and pain during and after surgery, and who suffer fewer post-operative complications.

The investment

Robotic surgery is not cheap for the hospital or the doctors who perform it.

Each health system paid $1.65 million to purchase their da Vinci systems, and both had to gain approval from the Missouri Health Facilities Review Committee's Certificate of Need process.

"The state just looks at the purchase process to make sure health care systems aren't duplicating major purchases like that," said St. John's spokeswoman Cora Scott. "Since they approved both Cox and St. John's for this, they obviously felt that there was a need for two of these systems."

Dr. John Duff, senior vice president of hospital services for CoxHealth, said his hospital watched the advancement of robotic surgery for at least a year before moving forward with the purchase. He said the system went through both the hospital's quality resource department and technology review committee before going to the state review committee.

"When it was all looked at, we saw that robotic surgery is moving to be the standard of care for prostate removal and many hysterectomies and removal of kidneys, and it made sense to move forward with the technology," Duff said.

The investment, however, extends beyond the initial purchase. Physicians pay for their own training, which includes both on-site work with the robot and off-site classes, and the hospitals help doctors rearrange their schedules accordingly.

The hospitals also have to be willing to schedule longer periods for surgery. Anderson and Follis said the initial prostatectomy procedures using the robot take six to seven hours compared to an average of two hours for a traditional open prostate surgery. Robotic surgery times, however, should decrease as doctors become more experienced with da Vinci.

Given the costs and time investments, Anderson is impressed with the health systems' decision to bring the robots on line.

"Hospitals have the tendency, when presented with new technology, to be reticent to jump in - especially on a $1.6 million expense," Anderson said. "The numbers with this, because of the steep learning curve, don't initially look that rosy. But eventually, because patients leave quicker and get back to work faster and their overall health is better, it snowballs and (hospitals) do see a positive effect overall."

Adjusting to innovation

Hospitals code the surgical procedure the same way, regardless of whether a robot is used, Ferrell-Duncan's Follis said. That means that the amount hospitals receive from insurance companies is the same whether robotic or traditional surgery is used.

Anderson noted that Medicaid has not set a precedent of paying more to reimburse hospitals that use robots for surgery.

That's not surprising to Follis, who said that larger insurance companies in particular have historically been slow to embrace new procedures and technology without numerical data showing that the new way is better.

"The insurance company cares how much they have to pay out today, but if the employee can go back to work three weeks early, that's a benefit that the insurance company doesn't always take into account - but the employer does," Follis said. "The economic effect of that is hard to quantify."

Doctors, too, can be reluctant. Follis said that not all doctors are cut out to use a robot for their procedures.

"You have to be the kind of person who enjoys learning new things," Follis said. "If (doctors) do it because it makes business sense or because everyone else is doing it, (there) is such a learning curve that those guys will get so frustrated that they won't do a seven-hour case."

Patients, however, are asking for the robotic option; Anderson said that nationally, 65 percent of all prostate removals are being done robotically.

He added that prior to the robots coming to Springfield, he was referring large numbers of patients who requested the robot to St. Louis and Kansas City - and that can be costly to both the hospitals and the local economy.

"An employer, indirectly through the insurance company, will have to pay more to send a patient to St. Louis or Kansas City, because there is no relationship between the insurance companies here and the hospitals there," Hollis said. "It helps the local economy to keep patients here and provide their medical care here; it keeps medical premiums lower."

The hospital benefits, too, from a patient that recovers more quickly, according to St. John's obstetrician-gynecologist Dr. Kent Burk.

"The hospital can be more efficient with nursing resources and inpatient resources," said Burk, who has used the robot for one procedure and has seven more scheduled.

"We're in a nursing shortage, and technology is helping us solve a problem that has nothing to do with surgery - let's use those skilled individuals for something that uses their skills more appropriately."[[In-content Ad]]