Robotic Heart Surgery and its Benefits - Research Paper Example

Robotic Heart Surgery and its Benefits to Health Care in America Introduction and Thesis Statement The recent passage by the Obama Administration of the Health Care Reform Act is a landmark event with serious implications on health care practitioners, from caregivers and nurses to doctors and hospital owners, managers and administrators. While the many provisions of the 2,000-plus page bill that was eventually signed into law were controversial to most, no matter on which side they stood on the debate everyone agreed on a few basic points (Pelosi, 2010). First, the new legislation would grant improved health care access to more Americans. And second, costs would be a major factor when considering health care interventions. This means that the adoption of new technologies would play an important role in the over-all goal of balancing the increased volumes of health care beneficiaries with the need to control costs. After all, the perceived increase in financial burdens a more universal health care bill would place on the public – higher taxes, higher costs for businesses, higher co-pay fees, etc. – was a main argument used by the strongest opponents of the bill (Hossain and Quealy, 2010). Implementing change, especially in health care, is always difficult to accomplish for several reasons. As Underdahl (2009) argued in a study, even a seemingly simple procedure as getting a signed informed consent form from a patient can be a tough challenge even in a health care system where the major players are educated and informed professionals. When the change is a new technology, the resistance to change and the difficulty in adapting becomes an even greater challenge, especially when surgeons are involved (Geer, 2000). This is the case with Robotic Heart Surgery or RHS, a new technology that has received mixed reactions from all sectors of the health care field. The purpose of this paper is to show that RHS, one of the “relatively recent” variations of Minimally-Invasive Cardiac Surgery or MICS, is a beneficial and viable alternative that can help meet the goal of the Health Care Reform Act of 2010: better and affordable health care for more Americans. This paper will show that RHS is better, safer and more acceptable to patients and a new breed of heart surgeons. In addition, despite its high initial costs, RHS can be more economical in the long run and make heart surgery affordable to more patients. These developments would also have an impact on the work of health care professionals. In view of the benefits of RHS, and despite initial opposition of many to the new technology, its wider acceptance must be promoted and steps must be taken to prepare health care practitioners for the potential increase in the number of people availing of the procedure. Conquest of Heart Disease: A Short History Well into the end of the 20th century, after the discovery of antibiotics that eliminated infectious diseases from viruses and bacteria as the primary cause of morbidity for thousands of years, the Centers for Diseases Control and Prevention or CDC reported that heart disease continued to be the biggest cause of deaths in America (CDC, 2009). The increasing incidence of obesity in America continues to make heart disease not only the number one killer but also one of the most common factors for the rising cost of medical and health care in the 21st century (Carter, 2006). Aside from congenital heart defects, heart diseases such as high blood pressure, cardiovascular diseases, stroke, angina (chest pain), and heart attack brought about by changes in the lifestyles and diets of Americans were a major factor in made finding a cure for heart diseases one of the major medical challenges in the past century. Several developments in medical and health care interventions since the middle of the 20th century greatly contributed to the decline in morbidity from heart diseases (PBS, 1997). U.S. Army surgeon Harken successfully performed surgery on a beating heart to remove shrapnel embedded in the hearts of wounded soldiers through a hole on the patient’s side. In 1948, Philadelphia-based surgeon Bailey followed the same procedure to repair a defective mitral valve (Westaby and Bosher, 1997). Closed-heart surgery pioneered by Harken and Bailey were limited to relatively minor procedures needed to repair wounds or simple heart valve defects. This procedure proved inadequate to repair congenital heart defects and rheumatic fever effects that led to stuck heart valves. The solution, doctors and medical scientists discovered, was to resort to open-heart surgery. This led to a new set of problems that needed breakthrough solutions. The first problem was concerned with how to stop the patient from bleeding to death from the surgical wounds to the heart and the surrounding tissues, and second, how to save the patient from the fatal effects of oxygen deprivation. The solution to the first problem was to stop blood circulation in the body, but doctors discovered that the human body could do without oxygen for only four minutes. Going beyond this time limit would starve the brain of oxygen and lead to coma or death. The solution to the second problem came from the Canadian surgeon Bigelow while at the University of Minnesota. He discovered that bringing down body temperature extended that four-minute window of surgical opportunity to ten minutes. Two other discoveries by the British surgeons Gibbon, who devised a heart-lung machine that allowed the circulation of oxygenated blood during surgery, and Melrose, who discovered a way to temporarily stop the heart from beating, gave surgeons more time for cardiac procedures (PBS, 1997). Many subsequent discoveries made open heart surgery a viable option not only to fix defective hearts ravaged by atherosclerosis or congenital heart defects, but also allowed the transplantation of hearts or heart parts from animals and humans. As Westaby and Bosher (1997, p. 663-5) chronicled, there were several other scientific and technological innovations that lessened the rate of rejection of transplanted organs and implanted devices, allowing for higher success rates from cardiac surgery. Despite the increase in the frequency and success of open-heart surgery, opening the chest to expose the heart entailed tremendous amounts of pain for the patient, especially after the surgery itself, since the sternum had to be cut open. On top of the surgical trauma, there was a danger of infection from exposure of internal organs to bacteria that often proved fatal for the patient. Thus, with the complexities of cardiac surgery and the need to address the onset of post-operative infectious diseases, cardiac surgery was also a costly procedure that burdened America’s health care system (PBS, 1997). A new solution had to be found that entailed minimal invasive procedures that had an impact on the care of cardiac surgery patients and, at the same time, address the issues of pain, surgical complications and the high cost of medical intervention. The solution was minimally invasive cardiac surgery or MICS that eventually led to the discovery of Robotic Heart Surgery. Minimally Invasive Cardiac Surgery (MICS) Open-heart surgery is painful, exposes the patient to health complications and is costly. While the success rate of the procedure has improved due to advances in medicine and health care, many patients are still apprehensive about the idea of having a surgeon cut their chests open and perform medical magic on their hearts and its parts. Up until recently, some open-heart procedures done through sternotomy, such as redo mitral valve surgery had high mortality and morbidity rates (Onnasch et al., 2008). These multiple concerns led to innovation of minimally invasive cardiac surgery or MICS, which has as its main characteristic that of performing cardiac surgery without having to do a sternotomy, a painful procedure in open-heart surgery that requires cutting the sternum and clamping the rib cage wide open to allow cardiac surgeon access to the heart (Mack, 2001). Figures 1.a. and 1.c. show how a sternotomy looks like. Instead, surgeons performing MICS cut tiny openings in the chest and use thin surgical instruments, miniature cameras, laparoscopes and robotic devices to access the heart (Figs. 1.b. and 1.d). The surgeons view through monitors the part of the heart to be operated and control the instruments the same way one plays computer games: with the use of a set of joysticks or robotic arms. MICS can be performed for a wide range of heart diseases, such as repair and replacement of heart valves to restore valve function, coronary artery bypass grafting (CABG) to improve blood flow to the heart and reduce chest pains, correction of atrial fibrillation, the implantation of ventricular heart devices to boost the pumping action of the heart in heart failure patients, and the treatment of congenital heart conditions such as atrial septal defects. Since the mid-1990s, MICS has substantially evolved from its applications in catheter-based interventions for coronary revascularization, valvuloplasty, and congenital defect closures (Shennib, 1999). MICS: Advantages and Disadvantages Manipulating surgical instruments through these tiny openings is a highly specialized skill. The wide applications of MICS have diminished the painful effects on the patient, but it has become more demanding on the surgeons. The tiniest finger tremor may prove fatal to the patient. In addition, the image is two-dimensional, requiring the surgeon to have good spatial abilities accurately manipulate the surgical instruments in three dimensions (Satava, 2002). Like any other medical procedure, MICS has advantages and disadvantages. Among the major advantages are reduction of post-surgical complications and infections due to the absence of sternotomy, less pain and damage to tissue and muscle, decrease in risks of neurological complications and stroke from the non-use of the heart-lung bypass machine, lesser blood loss and scarring due to smaller incisions, faster recovery period for the patient to less than two weeks instead of four to six weeks, shorter hospital stay and lower hospital and health maintenance costs. Aside from these advantages to the patient, the hospitals and surgeons also benefit from faster patient turnaround time. Besides, insurance companies prefer MICS due to lower long-term costs associated with longer hospital stays and surgical complications. These advantages of MICS dovetail into the goals of the Obama Health Care Reform Act, such as greater access to health care and lower over-all health care cost. Among the major disadvantages of MICS, aside from the one already mentioned above concerning the spatial skill needed on the part of the surgeon, are the high initial investment cost of equipment that would, at least initially, lead to higher costs for the procedure, the amount of time it takes for surgeons to be trained to an efficient and effective level of surgical skill and performance, the longer operating period required at the start until high levels of skills and proficiency are attained, and the resistance to change on the part of surgeons and patients who find it difficult to entrust a critical procedure to unfamiliar technologies. These disadvantages, however, could be addressed with better education, improved accounting and costing, and long-term economies of scale. As more surgeons and patients learn about MICS and its advantages, more would demand MICS from health care providers. The cost of equipment would also go down as more are made. This would allow costs to be spread over a larger base of beneficiaries, bringing down these costs that as Poston et al. (2008) recently argued is already taking place in American hospitals. The innovation, however, did not stop with MICS and its application to a wider range of cardiac surgical procedures. While most of the disadvantages of MICS could be addressed with time, as more surgeons and patients go through the procedure the costs would drop, the technical problem of minimizing the technical imprecision resulting from the direct manipulation of surgical instruments by the surgeon in three-dimensional space but based on a two-dimensional TV monitor image. This led to later innovations in Robotic Heart Surgery. Development of Robotic Heart Surgery Robotic Heart Surgery or RHS is a form of MICS where a robot or an electromechanical device is used by a surgeon to perform the surgery, providing the procedure with improved precision and eliminating the critical disadvantages arising from the direct manipulation of the surgical instruments (Lanfranco et al., 2004). RHS eliminates the technical and mechanical disadvantages of MICS: loss of haptic feedback, demand for excellent hand-eye coordination and manual dexterity, dangers of physiologic tremors in the surgeon, and the restricted degrees of motion in laparoscopic surgical instruments. Lanfranco et al., in their comprehensive chronicle of RHS, argued that these limitations made “more delicate dissections and anastomoses difficult if not impossible” (2004, 14-15). RHS addresses these and expands the benefits of MICS. An additional advantage of RHS is telemedicine or surgery by remote control. Whereas MICS required that the surgeon be in the same room as the patient because of the need for direct manipulation of the surgical instruments, later developments in RHS already allow the surgeon or a team of surgeons, each one in different parts of the world, to operate on a patient even from thousands of miles away (Eadie et al., 2003). The two major surgical robotic systems are the DaVinci System by Intuitive Surgical Inc. and the Zeus System made by Computer Motion Inc. (Lanfranco et al., 2004, 17-18). Figures 2 and 3 show how these two systems look like. While both the DaVinci and Zeus systems are similar in their capabilities, they are different in their approaches to robotic surgery. In the DaVinci System, the three-dimensional image on the monitor is above the hands of the surgeon, giving the illusion that the instruments are an extension of the control grips and the surgeon is in the operating room. In the Zeus System, the surgeon is seated in front of the video monitor and the instrument handles are positioned ergonomically to maximize dexterity and allow complete visualization of the operating environment (Lanfranco et al., 2004, 17-18). According to Lanfranco et al. (2004, 19-20), RHS has advantages and disadvantages. Among the advantages are increased dexterity, proper hand-eye coordination, greater comfort for the surgeon and the surgical team, better visualization, and the possibility of doing surgery by remote control, making surgeries previously technically difficult to be performed with a higher degree of success. Aside from the cost (a RHS system cost $1 million in 2004) and the other disadvantages of MICS, the equipment for RHS has a larger footprint, requiring bigger spaces where the surgeon can perform the operation. Conclusions Recent articles by the two opposing camps relative to RHS provide a summary of the latest discussions on this new health care technology. On one side are those who support RHS and are optimistic that, given more time, exposure and adjustment to change, RHS would become more widely accepted and that its disadvantages would be overcome (Chitwood, 2004; Sloane Guy and Tseng, 2008). On the other side are the skeptics, surgeons who think that new technologies and the benefits to the patient are not worth the high investment costs needed (Robicsek 2004; Robicsek 2008). Those who oppose RHS argue that despite its advantages, the number of surgeries using the new technology as a proportion of the total number of heart surgeries has flattened out and, given this trend, costs would only continue to go up. The supporters of RHS argue, on the other hand, that in terms of absolute numbers, RHS is gaining wider acceptance and, given more time, costs would go down as more innovations enter the market. Looking at the advances in medical and health care technologies in the last twenty years (Hughes, 2010), this writer is of the opinion that the supporters of RHS are right: that the number of RHS patients and procedures would lead to more innovations that would, in turn, bring down the cost of equipment and the cost of health care. With the added pressure of government and insurance companies for lower costs, and the increase in the number of health care beneficiaries as a consequence of Health Care Reform, there would be more innovations in this field. The law of supply and demand in economics would exert pressure in the market to such an extent that the prices of a good, such as cardiac surgery, would settle at an equilibrium level, provided of course that the health care market is subjected to market forces of supply and demand. The concerted efforts of RHS equipment manufacturers, surgeons, hospitals and insurance companies, with additional pressure from the American government and its recently-passed Health Care Reform Act, would push the costs of RHS technology to fall. There have been precedents in the field of health care, e.g., kidney dialysis, elementary surgical procedures, imaging technologies such as Magnetic Resonance Imaging, and even cardiac surgery among others, which prove that safer and more convenient technologies that improve health care attract more users and become more affordable especially for the insurance companies that pay for them (Finch et al., 2006). Cardiac surgeons will adapt to the new technologies as more of them become familiar with it. RHS would be no exception. Illustrations Figure 1. Types of Incisions for Cardiac Surgery Fig. 1.a. Sternotomy in Open-Heart Surgery (Pick, 2008) Fig. 1.b. Small incisions made for MICS (UMMC, 2010) Fig. 1.c. Open-heart mitral valve surgery (Chitwood & Nifong, 2003, Fig. 44-5(A)) Fig. 1.d. Sample of DaVinci instruments used in MICS (Chitwood & Nifong, Fig. 44-3) Figure 2. Da Vinci system set up (Courtesy of Intuitive Surgical Inc.) Source: Lanfranco et al. (2004) DaVinci Robotic Heart Surgery Equipment (UMMC, 2010) Figure 3. Zeus system set up (Courtesy of Computer Motion Inc.) Source: Lanfranco et al., (2004) Reference List Carter, M. (November 1, 2006). Heart disease still the most likely reason you’ll die. CNN.com. Retrieved May 11, 2010, from: http://edition.cnn.com/2006/HEALTH/10/30/heart.overview/index.html Center for Diseases Control and Prevention (2009). Leading causes of deaths in the U.S. National Center for Health Statistics. Retrieved May 11, 2010, from: http://www.cdc.gov/nchs/fastats/lcod.htm Chitwood, W.R. Jr. (2004). An epistle to Dr. Robicsek. Journal of Thoracic and Cardiovascular Surgery, 127, 945-6. Chitwood, W.R. Jr. & Nifong, L.W. (2003). Minimally invasive and robotic valve surgery. In Cohn, L.H. & Edmunds, L.H. Jr. (Eds.). Cardiac surgery in the adult. New York: McGraw-Hill, Chapter 44, 1075-1092. Eadie, L.H., Seifalian, A.M. & Davidson, B.R. (2003). Telemedicine in surgery. British Journal of Surgery, 90 (6), 647-658. Finch, T., May, C., Mort, M. & Mair, F. (2006). Telemedicine, telecare and the future patient: Innovation, risk and governance. In A. Webster (Ed.) New technologies in health care: challenge, change and innovation. London: Palgrave Macmillan. Geer, H. (August 21, 2000). Inside the OR: Disrupted routines and new technologies. Harvard Business Review. Retrieved May 10, 2010, from: http://hbswk.hbs.edu/item/1654.html Hossain, F. & Quealy, K. (March 21, 2010). How the health care overhaul could affect you. New York Times Online. Retrieved May 11, 2010, from: http://www.nytimes.com/interactive/2010/03/21/us/health-care-reform.html Hughes, J.E. (January 28, 2010). What is the future of health care? In many ways, the future is already here. University of Phoenix Knowledge Network. Retrieved May 12, 2010, from: http://www.phoenix.edu/uopx-knowledge-network/articles/industry-viewpoints/is-future-of-health-care-already-here.html Lanfranco, A.R., Castellanos, A.E., Desai, J.P. & Meyers, W.C. (2004). Robotic surgery: A current perspective. Annals of Surgery, 239 (1), 14-21. Mack, M.J. (2001). Minimally invasive and robotic surgery. Journal of the American Medical Association, 285 (5), 568-572. Onnasch, J.F., Schneider, F., Falk, V., Walther, T., Gummert, J. & Mohr, F.W. (2008). Minimally invasive approach for redo mitral valve surgery: A true benefit for the patient. Journal of Cardiac Surgery, 17 (1), 14-19. Pelosi, N. (April 2, 2010). “Affordable health care: Key provisions that take effect immediately.” Office of Speaker Nancy Pelosi, Washington, D.C. Pick, A. (2008). “Open Heart Surgery Diagram After Chest Incision And Sternotomy.” The patient’s guide to heart valve surgery blog. Retrieved May 11, 2010, from: http://www.heart-valve-surgery.com/heart-surgery-blog/2008/02/12/open-heart-surgery-diagram-after-chest-incision-and-sternotomy/ Poston, R.S., Tran, R., Collins, M., Reynolds, M., Connerney, I. et al. (2008). Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques. Annals of Surgery, 248 (4), 638-646. Public Broadcasting Service (1997). Cut to the heart: Pioneers of heart surgery. Nova Online. Retrieved May 11, 2010, from: http://www.pbs.org/wgbh/nova/heart/pioneers.html Robicsek F. (2003). Robotic cardiac surgery: Quo vadis? Journal of Thoracic and Cardiovascular Surgery, 126, 623-4. Robicsek, F. (2008). Robotic cardiac surgery: Time told! Journal of Thoracic and Cardiovascular Surgery, 135 (2), 243-246. Satava, R. M. (2002). Surgical robotics: The early chronicles. A personal historical perspective. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 12 (1), 6-16. Shennib, H. (1999). Evolving techniques and technology in cardiac surgery. Annals of Thoracic Surgery, 68,1473-1474. Sloane Guy, T. & Tseng, E. (2008). Robotic cardiac surgery: Give it more time! Journal of Thoracic and Cardiovascular Surgery, 136, 237-8. Underdahl, L. (April 14, 2009). Implementing change within health systems: A case study. University of Phoenix Knowledge Network. Retrieved May 10, 2010, from: http://www.phoenix.edu/profiles/faculty/louise-underdahl/articles/implementing-change-within-health-systems-a-case-study.html University of Maryland Medical Center (UMMC) (2010). Totally endoscopic, minimally invasive coronary bypass surgery (TECAB): High-precision robotic surgery without any opening of the chest. UMMC Heart Center. Retrieved May 11, 2010, from: http://www.umm.edu/heart/tecab.htm Westaby, S. & Bosher, C. (1997). Landmarks in cardiac surgery. Oxford: Isis Medical Media. Read More