Advances in surgical technology spotlight changes in medicine, business
Robotics and automation on the factory floor are transforming the way people manufacture goods, while comparable technology in cars could soon transform the way we drive.
They also are transforming the way we heal the human body. Like advances in commerce and transportation, the developments bring efficiency and productivity not just to the practice of medicine, but also to the business of medicine.
The technology is more expensive, but advocates say the expense is offset by better patient outcomes and shorter healing times, both of which help lower costs overall.
PinnacleHealth System in Harrisburg has been using the da Vinci Surgical System for minimally invasive robotic surgery since 2005, and it recently acquired the latest version of the technology, which gives surgeons greater precision and access to the human body through use of robots and 3D-HD imaging.
In York County, West Manchester Township-based Eyes of York now offers ReLEx SMILE, the latest laser vision correction treatment for myopia, commonly called near-sightedness.
Experiences at PinnacleHealth and at Eyes of York illustrate not just the clinical benefits of evolving surgery techniques, but the considerations doctors and hospitals must make when making such investments.
“Although our technology was very good, we always like to be current with everything,” said Eyes of York founder Dr. Denise M. Visco.
How it works
Minimally invasive surgery refers to procedures in which doctors use small incisions and a variety of technologies to perform operations with less cutting than in traditional, or open surgery. Not all invasive surgery is robotic. Endoscopic surgery, for example, allows surgeons to operate using small flexible tubes that carry tiny video cameras and surgical instruments into the body through a small incision or existing orifices. The video feed allows the surgeon to see the organs while physically maneuvering the instruments.
Robotic surgery techniques also give access to the body through small incisions, but instead of handling the surgical implements themselves, surgeons operate using a computerized console that moves the instruments using robotics.
PinnacleHealth first adopted an early version of the da Vinci robotic equipment in 2005. Since then, the organization has performed more than 6,000 procedures and has robotic surgery capabilities at Community General Osteopathic, Harrisburg and West Shore hospitals.
A second generation of equipment followed before the newest version, da Vinci Xi, arrived in April 2016, said Dr. John F. Lazar, thoracic surgeon and medical director of the PinnacleHealth Robotics Institute. Two more of the Xi machines arrived this spring.
Smaller camera lenses are the major benefit, Lazar said, along with streamlined integration of add-ons and communication between the surgeons’ console and the robots.
The da Vinci technology helps surgeons treat a range of health issues — from benign conditions to complex surgeries such as thoracic, cardiac, colorectal, hernia, gynecology, head and neck cancer, and urology — with greater precision.
The surgeon is completely in control of the robotic-assisted da Vinci System, which translates hand movements into precise movements of instruments inside the patient’s body.
“It allows you to work in tighter spaces with greater freedom, and better visualization than you could with traditional minimally invasive surgery,” Lazar said.
“Even if you’re a great surgeon, at a very minute level, you’re still going to have a tremor,” he added. “This eliminates that.”
At Eyes of York, meanwhile, Visco and her colleagues now have a powerful tool that can create clearer vision — or eliminate the need for glasses and contact lenses — and which is less invasive than LASIK eye surgery.
With LASIK, a 20-millimetre flap is made on the surface of the eye, while a second laser reshapes the cornea to improve vision. With ReLEx SMILE, a laser is used to create a thin contact-lens shaped layer below the surface of the eye. A small laser opening of 6 millimeters or less is then created through which the disc-shaped layer is removed, correcting the patient’s vision.
Both procedures allow for a rapid return to daily activities, but SMILE typically results in less discomfort and dry eye after the procedure.
The technology was developed in Europe in 2006, but only approved by the U.S. Food and Drug Administration in 2016. More than 700,000 procedures have been performed internationally. Eyes of York is the first Pennsylvania practice to offer it, Visco said.
“It’s such an exciting procedure,” she added.
Making a case
Such advanced equipment carries a high price tag.
The VisuMax femtosecond laser used to perform SMILE treatments retails for between $425,000 and $450,000, Visco said. On top of that, the practice must pay the company a fee for each use.
California-based Intuitive Surgical, which produces the da Vinci Surgical System, sells them for between $600,000 and $2.5 million, according to a report they presented to investors this year. On top of that, hospitals pay between $700 and $3,500 for instruments and accessories per procedure, as well as $80,000 to $170,000 per year in service fees.
“There is an upfront cost with robotics. It is definitely more expensive,” Lazar said,
That expense is balanced by other benefits, he suggested. In addition to the smaller incisions and greater surgical dexterity, healing times are typically shorter, so patients spend less time hospitalized, Lazar explained. Smaller incisions also reduce pain and discomfort for patients, which help reduce the need for pain medications — given the nation’s epidemic of opioid abuse, any chance to minimize dependence on such drugs is beneficial, he added.
For Eyes of York, the SMILE machinery is the practice’s third technological upgrade since 2000.
“When you invest in a technology, it’s not just an upgrade. You’re also making a bet, or a risk,” Visco said. “I’ve always looked at the worst-case scenario. If it fails, and I have to make my payment on this every month, can I?”
In the early days of the practice, which was founded more than 20 years ago, there were times when she went without a paycheck.
When Visco bought her first LASIK equipment, however, “it really took off.”
Such procedures are not considered medically necessary, however, and demand is market-driven. When the economy faltered in the late 2000s, so did the demand for LASIK.
“It was fortunately a seven-year loan and it was paid off,” she said of the LASIK equipment.
As the economy improved, Eyes of York was able to invest in new cataract laser equipment. Now that loan is nearly paid off, and Visco said the investment in new SMILE equipment is comparable.
No hands needed?
Automation in the manufacturing world has reduced the number of bodies needed to produce goods, which has eliminated some jobs and generated controversy and political debate. Could it do the same in the medical world?
Visco stressed that it’s important for doctors to be guiding robotic technology through procedures, even if their physical contact with patients evolves or declines.
“You still need a surgeon who knows how to operate it,” she said. “If you have complications, for example, that’s where the importance of having someone who’s trained in all of those things comes in, as opposed to someone who is just a technician.”
Visco also recognizes that many doctors can benefit from a better grounding in business principles. That’s why she began studying for an MBA about a year ago.
“The market is so complicated, that I felt that I owed it to everyone who worked for me, to become a better manager,” Visco said of her studies.
She and her business partner, Dr. Jerome Benz, employ about 40 people.
Lazar pointed out that technology used at PinnacleHealth is not automation, but robotics controlled by humans. Still, he said some in his field are concerned that automation could reduce the need for surgeons.
His response? Be educated, and be in contact with researchers and with industry — for patients’ benefit, and to emphasize the importance of ongoing human involvement.
Both are critical. As good as the current technology is, he said, it will eventually become obsolete.
“Something else is going to be catching the next wave,” Lazar said. “I want to be on the crest of that wave.”