New techniques coincide with recent surge in tongue and tonsil cancer
By Daniel Leaderman
The Daily Record Newswire
BALTIMORE — Treating tongue and tonsil cancer with surgery used to be so invasive, it was hardly ever done.
The procedure often involved a large incision in the neck, a tracheotomy to enable breathing, and a long and difficult recovery for the patient, said Dr. Jeremy Richmon.
Now, as doctors see an increase in those cancers, there’s a surgical procedure that can be done in a couple of hours, with a much shorter recovery time, said Richmon, director of head and neck robotic surgery program at Johns Hopkins Medicine.
While radiation and chemotherapy used to be the most common way to treat those cancers, the computer-assisted surgical system known as the da Vinci — in which the surgeon controls a group of mechanical arms that manipulate the instruments — has prompted an increase in surgical treatment, he said. The new techniques coincide with an increase in tongue and tonsil cancer due to the human papillomavirus, or HPV, he said.
Surgeons say the da Vinci system can make some aspects of operations easier on doctors, but that the robotic arms can’t do everything human hands can do – yet.
In bariatric surgery, particularly cases involving heavier patients with a lot of fat tissue in their abdomens, the da Vinci doesn’t get tired.
“It takes a lot of energy and strength to move instruments [in those cases],” said Dr. Christopher You, a bariatric surgeon at MedStar Franklin Square Medical Center. “With the robot, the load is borne by the machine.”
You said he finds the robotic system useful when operating on patients who have had previous surgeries because the robotic system makes it easier to cut through existing scar tissue.
The pros and cons
Like laparoscopic surgeries, procedures done with the robotic system are minimally invasive. They make smaller incisions than open surgery and can offer patients shorter recovery times, less pain and less risk of infection.
But laparoscopic surgery is difficult to teach, which can make it a challenge for patients to find specialists who can perform the procedures they need, said Dr. Vadim Morozov, an OB-GYN and chair of robotic surgery at the University of Maryland Baltimore-Washington Medical Center.
The robotic system is different: Almost anyone can be taught to use it, he said.
The da Vinci system can also show surgeons a 3D image of what’s happening inside the patient, and entire operations can be performed while the surgeon is sitting in relative comfort at the controls, several feet away from the patient.
“In essence, it’s like playing a very sophisticated computer game,” Morozov said.
But surgeons say there are some drawbacks to using the robots, one of them being the cost. The machines can require a capital investment of more than $2 million, plus ongoing service contracts and the cost of disposable instruments.
There’s also the lack of haptic, or tactile, feedback. In breast cancer operations, for example, surgeons traditionally rely on their fingertips to feel the borders of a tumor, Morozov said.
With the robot, it takes time — and experience — to learn to interpret how tissue responds by sight; for surgeons just beginning to use the robot, the lack of tactile sensation can pose an additional challenge, Morozov said.
This may be less of an obstacle for a new generation of doctors who are using the robot as they learn to be surgeons, said Dr. Mohummad Minhaj Siddiqui, director of urologic robotic surgery at the University of Maryland Medical Center.
“It’s like learning a language as a native speaker,” Siddiqui said. Even if you can’t touch the tissue, you develop a sixth sense for how the instruments are responding, he said.
Next generation of robots
While the market is currently dominated by the da Vinci, several other companies are working on the next generation of surgical robots; those machines will likely have haptic feedback systems and will bring healthy competition to the market, said Morozov.
Researchers at Eindhoven University of Technology in the Netherlands, for example, have been developing a system — nicknamed “Sophie” — that changes the level of resistance surgeons feel at the controls based on the amount of pressure the instruments exert on the patient’s tissue.
But some advantages attributed to the robotic system have actually been advantages of minimally invasive surgery in general, including laparoscopic procedures, said Dr. Martin Makary, chief of minimally-invasive pancreas surgery at Johns Hopkins.
A 2011 study co-authored by Makary found that in the years following the da Vinci system’s approval by the U.S. Food and Drug Administration in 2000 many hospitals claimed on their websites that the robots were superior and led to improved cancer outcomes without citing a comparison group.
Makary also believes that there must be more thorough reporting of robotic surgery outcomes and complications to more thoroughly track whether the system provides an advantage to patients, and under what circumstances.
A 2013 study he co-authored found evidence that complications from the machines were being underreported.
“There’s not enough research,” he said.
