St. John’s adds robot to its surgical staff

June 20, 2018

Last week the St. John’s Hospital Foundation unanimously approved the purchase of a robot to aid surgeons with hip and knee surgeries. The hospital will join a handful of other facilities in the state — like hospitals in Douglas, Casper, Cheyenne and Laramie — with similar robotic-arm-assisted technology.

Some, like Memorial Hospital of Converse County, use a robot for abdominal and OB/GYN surgeries. Others, like Cheyenne Regional Medical Center, advertise their robot as a tool for knee and hip procedures, as St. John’s intends to do.

St. John’s Medical Center plans to purchase the Mako Robotic Arm System by Stryker at the end of the month and have it in service for patients in August. It costs roughly $1.1 million, discounted from $1.7 million normally, and the hospital foundation transferred an initial $550,000 to the hospital for that purpose.

There will also be a yearly operational fee to maintain the robot, renewable in five-year allocations, that’s included in that cost.

While robotic surgery is on the cutting edge of medical advances in the last decade, it isn’t as futuristic as it may sound. A surgeon is still overseeing the robot; the machine isn’t performing surgeries fully on its own.

And patients can still choose traditional surgical techniques if they deem it appropriate for them. Restricting that would be illegal, said CEO Paul Beaupre said.

“Patients always have the right to make a choice on what form of therapy they want,” he said.

Hospital staff and members of the public can view the robot July 10 from noon to 1 p.m. at the hospital. Beaupre said that patient interest generated the purchase in the first place.

“People are calling the orthopedic offices and saying, ‘Do you have this technology available,’” Beaupre said. “And when the answer is no, they hang up and go elsewhere.”

“It’s the next generation of navigation,” Beaupre said of the robot.

When a patient comes in a device will be placed over his or her knee or a hip. A wand touches various quadrants of the joint to project an image, a cut plane and how deep the cuts should be.

Then a disc of those C-T scan images will be fed into the robot. Similar to 3-D printing, the robot will create a 3-D image of the surgery site with the cuts already designed into it. The arm that the surgeon controls is then fed that information.

“Because you do a CT study first of the joint and then marry that to the robot, the cuts are pure,” Beaupre said. “Any bone cut that you make is absolutely done by the robot itself.”

Once the instrument is outside the pre-designed plane it will turn off, so making a too big or too deep cut out of the question.

“So fitting the prosthetic into the joint afterwards is completely scientific,” Beaupre said.

Upsides and downsides

Using a robot for surgical assistance has pros and cons.

On one side, robotic surgeries can result in decreased surgery times, less blood loss, shorter hospital stays and less pain medicine used post-operation.

“With the bigger concern coming out nationally with opioid abuse, we’re looking for absolutely anything where we could bring someone through a major operation and potentially not use any opioids in the post-operative period,” Beaupre said.

On the flip side, numerous studies show that outcomes aren’t any better.

“Many claims of superior safety and effectiveness are misleading,” Dr. Marty Makary, of Johns Hopkins, said in a 2014 AARP story on robotic surgery.

The story said that while over 2,000 surgical robots have been sold in the U.S. in the last decade, “experts attribute the surge to aggressive marketing that plays up the robot’s wow factor.”

The U.S. Food and Drug Administration said it is aware of an increase in the number of medical device reports related to robotically assisted surgical devices, the majority of which were device malfunctions.

“However, the FDA has also received reports of injuries and deaths related to the device,” the FDA’s website reads. “This increase in reports may be due to a number of factors, including an increase in the number of devices being used or surgeries being conducted, better awareness of how to report device issues to the FDA, increased publicity resulting from product recalls, media coverage, and litigation, as well as other influences.”

A study published by the U.S. National Library of Medicine National Institutes of Health looked at 14 years of FDA data on medical accidents. It found that between 2000 and 2013 there were 144 deaths, 1,391 patient injuries and 8,061 device malfunctions.

The report, published in 2016, stated that “despite widespread adoption of robotic systems for minimally invasive surgery in the U.S., a non-negligible number of technical difficulties and complications are still being experienced during procedures. Adoption of advanced techniques in design and operation of robotic surgical systems and enhanced mechanisms for adverse event reporting may reduce these preventable incidents in the future.”

Other studies, like one from Stanford University and Mazor Robotics, looked at the use of surgeries to remove a patient’s kidney and the use of a robotic-guided spine surgery, found comparable patient outcomes, sometimes less risk for a complication, and shorter hospital stays compared with freehand surgery.

Beaupre said he was unaware of any fatalities caused by the robot itself: “I haven’t heard of any. Zero.”

He said any fatalities would likely be caused not by the machine, but instead by a reaction to a blood transfusion or anesthetic, or the buildup of fat tissue lodging within a blood vessel, called a fat embolism. Those are common surgical complications, regardless of the technique.

“You’re mitigating those factors by using the robot,” Beaupre said. “You’re actually improving the outcomes.”

Cost is factor

A potential real con for St. John’s, Beaupre said, is cost. Medicare and Medicaid don’t reimburse hospitals any more for having a surgery performed robotically versus having the operation done under the typical open technique. The only way those costs to the institution will be mitigated, he said, will be increasing the number of joint surgeries performed. There were 190 knee and hip joint replacements at St. John’s in the last four quarters.

“It’s a volume game,” Beaupre said. “If we increase the number of joint surgeries by just about 20 to 22 surgeries a year, this covers the cost of that, and we believe we can do that fairly easily.”

Beaupre said the robot is a fiscally responsible purchase.

“We’re comfortable that what we’re purchasing isn’t going to be obsolete in five years or something like that,” he said.

Patients may be wondering how their doctors will gain the necessary experience to operate a robot. In medicine, surgeons must perform a certain number of procedures a year to keep their skills up — one reason that St. John’s doesn’t perform open heart or brain surgeries.

“There are programs for surgeons who are already in practice to get the appropriate training to be able to utilize this robot,” Beaupre said. “Gus Goetz has been through that program already and received his certificate.”

May help recruit surgeons

The certification program was created by an orthopedic surgeon from the company Stryker who has used the technology for a long time. That surgeon watched Goetz, the doctor who performs approximately 90 percent of St. John’s knee surgeries, as he did his first few robot-assisted surgeries and signed off on his proficiency.

“He has done this procedure on others under direct supervision, much like you do when you’re a fellow,” Beaupre said. “It won’t be his first case here; he’s already done them.”

Goetz will then train other doctors to use the machine. Recruiting new surgeons is another expected benefit of the robot, Beaupre said.

“Fellows that are coming out of these orthopedic programs are now all accustomed to using the robots,” Beaupre said. “If we don’t have the technology here — someday, when it’s time for us to really start recruiting the next group of orthopedists in the community to replace the ones we have — we’re not going to be competitive at all at that point.”