Surgeon + robot: A collaboration

Who’d have thought that a boyhood fascination with Voltes 5 would lead to a stellar career in cutting-edge surgery?

Growing up in the 70s, Jason Letran would rush home from school to catch the 6 p.m. robot shows, which his parents allowed as an exception to the “no TV during study period” rule, as long as he stayed on the honor roll. Aside from that “precious half hour” of TV time, he was rewarded for his good grades with die-cast metal robot toys, all “still standing proudly in my display cabinet today.”

Today, Letran is the country’s leading robotic surgeon. He performed the country’s first robotic surgery, on a patient with prostate cancer, in 2010 – a “milestone moment, having realized my childhood fantasy of being the person behind that battlefield robot, except this time, it’s a battle against disease rather than enemy beast fighters.” A product of the UST Medical School and UST Hospital, Letran did trainings in urologic oncology in Seattle, Washington and advanced endourology in Shizuoka, Japan and has been training in robotic surgery since 2005.

“Robotic surgery is not the future – it’s the present,” he tells me. Currently, four hospitals in the National Capital Region – Philippine General Hospital, St. Luke’s, Medical City and Chinese General Hospital – do robotic surgery; Makati Medical is set to do so this year.

Robotic surgery is, in a sense, a step up from laparoscopic surgery, which has become quite common. In both procedures, small cuts are made in the patient’s body and a camera is inserted to visualize the area to be operated on.

But there are differences, Letran explains: “In laparoscopic surgery, the surgeon uses long-handled instruments inserted through small incisions in the patient’s body. These instruments are rigid and controlled directly by the surgeon’s hands. In robotic surgery, the surgeon sits at a console and operates robotic arms with miniature instruments. The surgeon’s hand movements are translated into precise movements of the robotic arms, allowing for greater dexterity and precision.”

Robotic-assisted surgery is particularly advantageous for procedures requiring precise movements in tight and narrow spaces, such as prostatectomies (the most common), hysterectomies and colorectal surgeries. However, Letran cautions, it may not be suitable for every type of surgery, especially “those where access to the surgical site is limited or restricted, such as in patients with severe scarring due to previous abdominal surgeries or anatomical abnormalities.”

Thus, he stresses, “it is important to know the limitations.”

Robotic surgery has its beginnings in the US military, developed to minimize casualties to its medical personnel while affording critical care to troops in the battlefield. The Da Vinci surgical robot is the most widely-used all over the world. Manufactured by Intuitive Surgical based in Sunnyvale, California, over 10 million surgeries worldwide have been performed on Da Vinci systems since its introduction in the late 1990s.

While robotic surgery does cost more than traditional or laparoscopic surgery due to the initial capital investment required to purchase (a unit now reportedly costs around $3 million) and maintain the robotic system and the disposable instruments used in each procedure, factors such as shorter hospital stays, quicker recovery times and lower rates of complications may offset some of the additional costs in the long run. “Furthermore, the faster recovery may allow for an earlier return to usual activities and an earlier return to work, thus minimizing income loss,” Letran explains.

The robotic system consists of three parts – the surgeon console, the patient cart and the vision cart. Sitting at the console, the surgeon views the surgical area in 3-D and, through two arms with slots for his thumbs and index fingers, manipulates the robot which moves like extensions of his arms, but with greater range and motion.

The patient cart is the actual robot, with four arms that hold instruments as small as 8-10 millimeters (like dollhouse utensils), allowing the surgery to be done through incisions of only 5-12 mm. The actual motions of the robotic arms inside the patient can be seen on the screen mounted on the vision cart.

Recently, Chinese General Hospital (CGH) took things a step further by introducing the country’s first dual console robotic surgery system. Surgeons can work side by side in real time, enabling collaboration and sharing of expertise, a very important factor in complex procedures. It allows surgeons from different fields to work together and, when needed, enables the surgeon at the second console to seamlessly and without delay transition into the procedure with a simple flick of a switch, rather than one surgeon having to vacate the console for the other to take over.

The dual console system also enables more effective mentoring and training, whereby surgical residents or surgeons in training can witness and monitor actual procedures and, in some cases, may be allowed to participate in the procedure under strict supervision of the attending surgeon.

“This is in keeping with our commitment to delivering the best patient care while ensuring the adequacy of health care for future generations through better training and research,” says Dr. Samuel Ang, medical director of CGH.

How far can robotic surgery go? “In the future you may have an expert or specialist in another country actually do the surgery from where he is, without having to fly him in to Manila,” Ang enthuses.

Letran is equally optimistic about its potentials. There is the possibility of remote surgery, citing cases of telesurgery, such as the first one in 2001 done on a patient in Strasbourg, France by a surgeon in New York City.

That, however, Ang points out, is only possible with reliable and strong internet connections. Alas, with the state of connectivity in the Philippines, that is still far into the future.