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Dr. Alexander Vaccaro - "The Use of Robotics in Spinal Surgery" — Transcript

by Rothman Orthopaedics · 3,042 words · 461 segments · language en · Watch on YouTube

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0:00so thank you all for joining us this
0:01afternoon
0:02today's lecture will be given by dr
0:04alexander vicaro
0:06spine surgeon and president of roth
0:08orthopedics
0:09dr vicaro has served as the president of
0:11rothman since 2014 and is the richard h
0:14rothman professor and chairman in the
0:16department of orthopedic surgery and
0:18professor of neurosurgery at thomas
0:20jefferson university
0:22dr pakira sees patients in our center
0:24city office and operates at jefferson
0:27hospital methodist hospital and rothman
0:29orthopedic specialty hospital in
0:31bensalem
0:33good dr picaro
0:35natalie thank you so much it's an honor
0:36to have this opportunity and i think
0:38it's really interesting that we do it at
0:39lunchtime which i think is great i'm
0:41dressed in my little outfit because i'm
0:43between surgical cases and believe it or
0:45not my next patient who's about to have
0:47spine surgery
0:48is most likely streaming this right now
0:50as they get her ready for surgery
0:52after this course so i wanted to talk
0:54about something that we're using a lot
0:56of now and that's using technology
0:59to help us in the operating room and
1:00this doesn't mean it's safer it's just
1:03it's a different way of doing surgery
1:04using a robot that has all the values of
1:07a robot
1:08but it's as you can imagine it doesn't
1:10do the surgery for us it just helps us
1:12do that so i'm going to take us through
1:13a little tour
1:16i have a conflict i do work with the
1:17robotic company
1:19so
1:21we see robots in almost everything we do
1:24i have an electric car it uses
1:27artificial intelligence our smartphones
1:29use robotic technology we use
1:32airplanes and anything we use nowadays
1:34has some sort of automated service using
1:36artificial intelligence which is
1:38fantastic so the robots are here they
1:40just may not look like robots but we're
1:41using it in everything we do
1:44and you see the manufacturers touting
1:46this technology it's safer smaller scars
1:50shorter hospital time lower risk faster
1:53overall recovery
1:55and that's not really true
1:57you can do minimally invasive surgery a
1:59lot easier because instead of using
2:01fluoroscopy and using loops which is
2:03what i use and here's an example this is
2:05what i'll be using today what i operate
2:07the robot sees all these things for you
2:10but we have not been able to translate
2:12that into two things at the present time
2:14one time efficiency
2:16and two improved outcomes
2:19we have decreased radiation for the
2:20patient and the or staff i think that's
2:22true so these are the things that we
2:24have to think about now
2:26you don't have a robot in the operating
2:27room doing the surgery we basically have
2:29a computer assisting us doing surgery
2:32that's all it is basically and there's
2:34three different types of surgical robots
2:36and the fda has approved in spine
2:39surgery a shared controlled spine
2:42we tell the robot what we want to do the
2:44robot tells the computer what it should
2:46do and then we have to be the end
2:48effector we have to actually press a
2:50button watch the robot do exactly what
2:52we want it to do as we visualize to make
2:54sure it's safe we're not
2:56telling the robot to do and sit in the
2:58back of the room that's not what's
2:59happening with the robot now
3:01what does the robot do for us today well
3:03it makes cuts in bone more accurate
3:07it puts screws more accurately we want
3:09to place them and keep in the back of
3:11your mind well then why doesn't everyone
3:13use a robot because putting a screw one
3:15millimeter to the left one millimeter to
3:17the right may not affect the outcome now
3:19what will affect the outcome if you keep
3:21people
3:22under anesthesia less you can get them
3:24up sooner and if you can take a very
3:26complicated procedure with high blood
3:27loss and make it a smaller procedure
3:29with less blood loss and that's
3:31important so for me as an orthopedic
3:32spine surgeon
3:34i don't think it's useful for very
3:35simple cases but i think it's very good
3:37for
3:38revision cases if i have to come back
3:39and do an operation again that someone
3:41else did and there's a lot of scar
3:42tissue if they cut the bone take a look
3:44at this picture this is a really bad
3:45scoliotic deformity three-dimensionally
3:48i'm only looking at a two-dimensional
3:49fluoroscopy when i'm in the operating
3:50room but a robot in their mind can see
3:53things in multiple dimensions and
3:55basically take me to where i need to go
3:57and then i confirm that's the accurate
3:59cut and it goes ahead and does the
4:01accurate cut so that's that's what it's
4:02great for me and this picture just shows
4:04us that like right now when i do
4:06scoliosis you put a bunch of screws in
4:08and you're like oh i got the screws in
4:10now you got to figure out how to push
4:11the spine into the right alignment then
4:13you have to put the rod to attach to the
4:14screws and also some of the screws are
4:16in deeper somewhat less deep some are to
4:18the left the robot basically says all
4:20right fine and the robot tells you how
4:23to make all the screws perfectly aligned
4:25and at the right height so little things
4:27like that
4:28you don't have to do because the robot
4:30does it which i think is is phenomenal
4:31so the robot gives us that now
4:34what's a disadvantage
4:36well it's a robot actually doing
4:38the end effector
4:40maneuver so you're not feeling the
4:42instrument against the human body
4:45you need to train everybody and and by
4:47the way robots are expensive
4:49million dollars for a robot an extra
4:51thousand dollars for every case so these
4:52are very expensive things and and i say
4:54all the time you have to be there
4:57working with this technology
4:59because technology sometimes fails and
5:02you don't want to be in a situation
5:03where you're blind and all of a sudden
5:05your instruments fail and then you don't
5:06know what you're doing so you i always
5:08say you have to train as a traditional
5:10surgeon so you all you have as a scalpel
5:13and a tool and you can do the operation
5:15you don't have to rely on on big
5:17technology now my interest this is a
5:19paper we wrote at the end of the 1990s
5:22looking at the value of using computer
5:25assisted technology we looked at
5:28using the normal way of doing it
5:30we used looking at a cat scan and
5:32fluoroscopy we looked at using image
5:34guidance and what we found was when you
5:35use image guidance
5:37it's more accurate again
5:39not a difference in safety not a
5:40difference in outcome but it's more
5:42accurate and then we did a more recent
5:44study we worked on cadavers then we
5:47worked with the robot we worked with
5:49just using it the way we do it today and
5:51we're using with fluoroscopy and again
5:532020 so this is 20 years later
5:55before we just had a computer assisted
5:57navigation then we had a robot with
5:59computer assisted navigation and the
6:01robot's more accurate and then the more
6:02complicated areas for spine surgery is
6:04like operating on the neck and the
6:06thoracic spine where you have the spinal
6:07cord it's dangerous and if you're
6:08looking i won't get into these studies
6:10but if you look at every study it
6:12basically shows
6:13there's no error or very little error in
6:16the cervical and thoracic spine
6:18so it's it's a great technology now this
6:21is way beyond the scope of this talk but
6:23the technologies that are approved by
6:24the fda is that we use optical tracking
6:28so we have these like little light
6:29emitting diodes that get picked up by a
6:31camera that gets registered to her
6:33computer and it's a real pain because
6:35all the instruments have to have these
6:36diodes and it has to see the camera so
6:38if you put your head in the way if
6:39someone looks over you block the vision
6:41the robot stops
6:42so
6:43we're waiting for bluetooth bluetooth or
6:45electromagnetic we can't use it right
6:48now because it interferes with our
6:50anesthesia machine it interviews
6:52interferes with other things in the
6:53operating room
6:55so it's not there yet but i can't wait
6:56until bluetooth is around because then
6:58you don't have to have line of sight
6:59anymore which would be fantastic so
7:01that's just something interesting
7:02so when i started in the late 1980s and
7:05early 1990s we had very simple
7:07robots that came out not the end of
7:091990s and
7:11the end of the 1980s and i was
7:14participating in a lot of different
7:16catavaric and research studies and now
7:18we've sort of evolved to these complex
7:20robots now we have
7:22robots that can be carried around in a
7:23suitcase and brought to an ambulatory
7:25surgical center which i think is is
7:28phenomenal so i think that is where we
7:30have to be so i just think it's a
7:32wonderful technology that we have
7:34um
7:35so
7:36so that's that's wonderful that was the
7:38anesthesiologist asking when to do and i
7:40said wait until i finish my talk and
7:42then we can put her under so this is
7:44this is the uh the robots we use now we
7:46use robots that have things placed in
7:48the body
7:50that allow us to know that our imaging
7:52is accurate and if you look down here
7:54that little picture you see two little
7:55antennas those antennas have to maintain
7:58a distance and if anything moves like
8:00say you bump something it tells us the
8:02navigational system is off and we have
8:04to stop what we're doing so it's it's
8:05interesting now i'm going to go through
8:07a bunch of papers and i don't like any
8:09details i'm just going to tell you in a
8:11few few words what they say this is just
8:15all the world's literature
8:16looking at the accuracy and if you look
8:18at the numbers anywhere from 92 to 100
8:22which is phenomenal and then i looked at
8:24all the different studies that came out
8:25recently you know 2000 2021 2022
8:29um more accurate than free hand
8:32no difference in outcome basically
8:34radiation is less
8:36another study
8:37more accurate than freehand
8:39superior
8:40violation of structures shouldn't be
8:42violated less with the robot which is
8:43great and then and then what i'd like to
8:46study is i like to study well when does
8:47a robot not work very well well with any
8:50type of
8:51individual that has a large body girth
8:54imaging is difficult and you need to
8:55have imaging
8:56to show the robot where the patient is
8:58in space so it's less accurate in
9:00obesity less accurate when the bone is
9:02not usually visualized if they're
9:03osteoporotic and then if you have really
9:06bad formulate sometimes it's volume
9:08averaging and sometimes the robot can
9:10get confused you have to keep that
9:12in mind and if you look at the more
9:13contemporary um papers that look at
9:15complications the complication rate is
9:17about equal it's really it's really not
9:19that difference between um open and
9:21close which i always thought was uh
9:23interesting
9:25and then i wrote and my powerpoint
9:26stopped okay there it goes the thing i
9:28like the robot the most and i think
9:29patients should like the most is that
9:31you're not using intraoperative
9:33fluoroscopy you're not radiating someone
9:35constantly like minimally invasive
9:37surgery bring the fluoroscopy in ap
9:39lateral ap lateral surgeon's exposed
9:42anesthesiologist exposed patients
9:44exposed with the robot
9:46we're developing mr technology so you
9:48can get a pre-operative mri scan merge
9:50that with the robot and there's no
9:51radiation at all so it's phenomenal and
9:53these are just studies that look at if
9:55you're using traditional minimally
9:56invasive techniques using philosophy
9:58compared to a robot the philosophy is a
10:01lot more radiation so always ask your
10:03surgeon are you doing minimally invasive
10:05surgery are you using any type of method
10:07to minimize my radiation exposure
10:10the other thing which i think is
10:11interesting is we study learning curves
10:13anytime you have a new technology
10:14there's a learning curve and you always
10:16say it's a patient well i don't be part
10:17of the learning curve i want to be when
10:18that surgeon is great and with a lot of
10:21technologies when you learn how to do be
10:23really skillful once you think you
10:25mastered it you haven't mastered it you
10:26need more time because there's always a
10:28peak
10:29and all of a sudden you have problems
10:30and there's a peak i see this in every
10:32learning curve i got it i know i don't
10:34got it and i got so like anything else
10:36make sure your surgeon has a lot of
10:37experience in it and some say you have
10:39to have up to 80 cases before you become
10:42an experienced surgeon now if you look
10:44at operative times i clearly believe the
10:46operative time is increased today for a
10:48robot
10:49because there's a lot of different steps
10:51and we've worked on the accuracy and the
10:52safety but we haven't worked on the time
10:54efficiency so these studies are
10:56published no different but really
10:58in general it's increased time and we
11:01just pulled all of our cases of thomas
11:03jefferson uh together and we compared it
11:05to doing a traditional open way or
11:07minimally invasive way and we basically
11:09said it's the same so there's no so if
11:12if your doctor doesn't have a robot it's
11:14not going to affect the outcome it's
11:15just another tool that that a doctor
11:17uses and then if you look at the cost
11:19effectiveness and these are always
11:20amusing papers to read because you have
11:23to really look at the details
11:25intuitively it's more expensive to use a
11:27robot and until you change the outcome
11:29or until you can do more patients safely
11:32in an operating day it's not going to be
11:34cost effective but if you read the
11:36literature you get confused like this
11:38paper said
11:39once you get to the 254th case it
11:41becomes cost effective this one said
11:43listen you have less or time less
11:46revision rates less length of stay so
11:48it's cost effective you save 2700 a case
11:50which has not been our experience and
11:52then another paper said listen this is
11:55this is great less infection
11:57um quicker instrumentation
11:59better more accurate and this says in
12:01one year you could save more than a half
12:03a million dollars
12:04and but this study basically says and
12:07these are from people who are not
12:08conflicted that says look let's take a
12:10look at everything let's look at robotic
12:11cases look at mis cases let's look at
12:13open cases and basically they look at
12:15cost per quality
12:16a quality
12:18life year i mean we rate we rate
12:20someone's utility that means health or
12:22bad health zero means you're dead one
12:23means you've got great health and then
12:25we look at
12:26what what what would you pay to get a
12:29100 percent uh
12:30great quality of life and you could see
12:32that robotic is actually more expensive
12:34if you use mis techniques it's 116 000
12:37for quality the united states can pay up
12:39to 150 000 per quali great britain will
12:42only pay up to 50 000 for quality but if
12:44you look at a robot it's 593. so
12:47the
12:47the literature is a little bit confused
12:50so in real world i love the robot
12:53um if you have a large body weight it's
12:55more difficult i make sure when i'm
12:58training fellows that they have at least
12:59100 cases under the belt before they go
13:01out and use it you have to make sure you
13:03have the right equipment and you need
13:05the right table you need the right
13:06sterilization equipment you need the
13:08right draping um and then the robot
13:10right now takes a lot of time you have
13:11to introduce the robot to the imaging
13:13system the imaging system has to
13:15introduce the data to the robot and then
13:17you have to confirm that so and then you
13:19have to use the line of sight technology
13:21which we have now so we have gone from
13:23this in assembly lines to this at the
13:25present time and i always laugh how the
13:28car industry and all the other
13:29industries space industry had all this
13:31technology and why did medicine have to
13:33wait and i have no idea but i think in
13:35the future we won't use cat scans we'll
13:38use mri scans we'll have things that
13:40will just be able to use light and look
13:42at the topography of the patient and
13:44then that and that will be
13:46evaluated in light of the imaging
13:48studies before surgery and you'll be
13:49able to take a patient in space
13:51and then merge it with the pre-operative
13:53imaging studies to tell the robot
13:55exactly where it is and we'll have smart
13:56tools that we'll use that can help
13:58navigate to soft tissue so right now the
14:00robot just takes you where you need to
14:01be but if there's a great vessel in the
14:03way if there's a nerve in the way that
14:05can cause a problem but with these
14:07robotic technologies
14:08with smart tools it senses the
14:10difference impedance and tissue because
14:11oh that's a vessel let me move over here
14:13well that's the nerve we don't have that
14:15today but i think we'll have it in the
14:16future
14:17so this was just sort of an introduction
14:19to a really interesting form of
14:21technology that will take us where we
14:23need to go in 10 years we're in its
14:25infancy now we love it at the rothman
14:27institute we're all using it we think
14:29it's great uh but there's more to come
14:32in the future so thank you for your time
14:34i always like to speak sure because i
14:36know you don't have much time for lunch
14:38so i want everyone to eat an extra
14:40sandwich because you have some extra
14:41time
14:42on your plate well thank you
14:44thanks dr vicara and we did record this
14:46so we will send this out so you can
14:48review at a later time
14:51everyone have a great day

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