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"More than this being a hard technique to learn," says Massimiano of Inova Fairfax Hospital, "it requires adjusting your approach to the surgery and your way of thinking. The robot is your assistant now, and that takes some getting used to."

Chitwood agrees. He says, "There is a mental challenge of moving from a large incision where you can directly see things and touch the patient to operating through small incisions with less direct control. But I tell surgeons they have even more control because the robot is more precise. It's a matter of accepting that you don't have to see with your eyes directly. You can look through a scope."

Because of limited data, it is hard to convince doctors of this, Chitwood adds. "We teach that if you do this and become uncomfortable, you can always go back to a conventional approach."

Chitwood's center at East Carolina University was the first U.S. site to formally train surgeons in clinical robotics and has trained more than 170 surgeons. They use a curriculum that trains surgeons for two to three days in cardiac, gallbladder, and gastric reflux surgery. The center is developing similar programs for gastric bypass and gynecologic operations.

When it comes to training heart surgeons in robotic surgery, Zenati calls it "uncharted territory." Surgeons in disciplines that have commonly used endoscopy and young surgeons, who are most likely to have experienced laparoscopic or video-assisted thoracic training in residencies, may have an easier transition to robotics. Most cardiac surgeons have no experience with endoscopic techniques. "So is this going to become mainstream for us or will just a small subset of doctors continue to do this?" Zenati says. "It's too soon to know."

Toward the Future

Zenati says the current robotic surgical systems are just the beginning, "like Model Ts," he says. The products will likely evolve to correct their limitations. For example, da Vinci and ZEUS have "force feedback" for gross movement, but not fine movement.

"If you use an instrument and touch tissue, you feel a different resistance," Zenati says. "Without force feedback, you can push but you don't know how hard you are pushing with the robot." Often sight can compensate for touch, but force feedback remains an area that needs more attention.

Starnes of USC says the drive toward wider use of robotic surgery won't come from doctors, many of whom are used to doing surgery the traditional way. And the cost of the systems also may affect which hospitals can adopt the new technology. The da Vinci sells for about $1 million; ZEUS is priced at $975,000.

"Over time, I think patients will demand it," Starnes says. "A lot of patients getting mitral valve operations are in their 40s and 50s, and they are usually very concerned about recovery and getting back to work."

Massimiano says in his experience, patients have been enthusiastic about robotic surgery. "They perceive new devices as being better."

Anita Veltman, 66, of Sterling, Va., says she had laparoscopic gallbladder surgery and knew the benefits of minimally invasive surgery. So she felt comfortable about having the da Vinci robot successfully remove her mammary artery as part of preparation for bypass surgery at Inova Fairfax Hospital in October 2001. "I was not afraid of it," she says. "I asked for the robot. All I could do was put my trust and faith in the doctors."

Robotics and Telesurgery

The da Vinci and ZEUS make it possible for surgeons to perform robotic surgery across long distances. Surgeons from the European Institute of Technology used ZEUS and high-speed telecommunications to perform the first complete long-distance robotic surgery last year. According to an article in the Sept. 27, 2001, issue of the journal Nature, the surgeons worked from New York to remove the gallbladder of a 68-year-old woman in Strasbourg, France.

The mean total time delay was 155 milliseconds, so surgeons could see the result of their commands a little more than one-tenth of a second later. The time to set up the robot was 16 minutes and the gallbladder was dissected in 54 minutes without complications. This is similar to the time it takes to perform standard laparoscopic gallbladder surgery. Mount Sinai Medical Center in New York and the Department of Electrical Engineering at the University of California participated in the study. Researchers first practiced the procedure on pigs.

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