Black Pean - Darwin information #4

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The path to modern robot-assisted surgery: its difficulties and real conditions

This time Dr Watabane, who could be called the pioneer of robot-assisted heart surgery, will tell us about how he acquired and learned to use the Da Vinci robotic surgical system and key points about how it reached its current situation.
In reality, surgical robots are often misunderstood as machines anyone can use just by pressing a button, but there are a surprising number of difficult points.

What was the first obstacle? (Acquiring the robot)

The first obstable to starting robot-assisted surgery was actually acquiring the machine. Although it was acknowledged that this machine dramatically reduced the burden on the patient, and other factors such as non-technical costs and organisational consensus had been agreed on, at that time actually getting hold of a machine was already a big obstacle. There are many hurdles when you want to bring something new into a university or organisation. There are a lot of new things that doctors from various departments want, and they have to be listed by priority. Also, as an expensive medical device, the cost was an even bigger obstacle.

After getting past those issues and finally getting hold of the robot, of course there were more advantages. Even so, we have had even more problems getting to where we are now.

How was it to start with?
Medical advantages: difficult operations became easier

On a basic level, there are many advantages to using the robot. It is notably easier than using endoscopy. In other words, difficult operations became easier. The robot has joints, so it is much easier to move. For example, robot-assisted surgery for prostate cancer quickly became widespread in urology departments for this reason.

With heart surgery, we really felt that advantage when doing bypass surgery. Because the surgical field can be seen more easily, you can do good work using the jointed arms. Also, you can see what you're doing as if you were looking from behind it, so you can even reach places that were previously unreachable or on the reverse side. Being able to overcome obstacles and operate further in was another great advantage.

Difficulty 1: technical difficulty

On the other hand, when using a new machine, all your previous experience comes to nothing. To use a simile, it's like switching from walking to driving. Being able to handle it properly is the most difficult part. When using your hands, you can feel the elasticity of something being caught or stretched, but with a machine you have no sense of touch. That means you can only rely on your sight. Because of that, you have to learn to use your intuition. That means you need a lot of practice and experience. I finally felt like I could "see" it after about 100 cases. I'm almost at 500 cases, but I'm still making a lot of discoveries like "so this way of suturing is better!"

Difficulty 2: financial issues are also important

Next, even though it was good that we'd bought the robotic surgery system, there was still the question of how to control it and how to put it into practical use. Before it was covered by insurance, the biggest difficulty was deciding who would be responsible for paying for this treatment.
I would have to say that robot-assisted surgery is expensive. Just using it means staff fees, consumables and maintenance fees, so if we don't charge for treatment then that would be a loss. However, there's no point in buying something and not using it, so either the hospital has to pay the fees or the patient has to pay it alone, and we went ahead by trial and error. In the end, before it was covered by insurance, we managed by treating patients as research subjects or by classing it as a "highly-advanced medical treatment" (it is now classed as "advanced medical treatment").
The self-payment period was very long, so I feel like that was the biggest problem.
Meanwhile, robot-assisted valvular surgery has been covered by insurance since this April, which I think is very meaningful.
If we look at America and Europe, where it is an accepted medical treatment, some might be impressed and think "they're doing it right", but it does take a long time to build up 300 cases of a single disease. In some fields, researchers have to find about that number of cases. In Japan, it has only just been accepted for insurance coverage, so we're at the starting point!