The robots are coming; these New Mexico surgeons are ready for it

Apr. 13—Dr. Luis Cerda wasn't always sold on the concept of robots in surgery.

"I used to see this as a gimmick," said Cerda, a cardiothoracic surgeon at Lovelace New Mexico Heart Institute/Lovelace Medical Group. "I believed in open surgery at first. ... We didn't think there was a need for something better."

But a man can change.

Cerda, who was born in Nicaragua and trained at facilities in New York and New Jersey, said his perspective shifted as he witnessed improved outcomes for patients who underwent less-invasive robot-assisted surgeries than those who had traditional procedures — less pain, for one, and therefore less need for narcotics, Cerda said.

Now, the 41-year-old Rio Rancho resident, who moved to New Mexico last year as Lovelace sought to expand its minimally invasive surgery service, is breaking new ground for his employer. Cerda in March performed a robotic pleural biopsy using a Da Vinci Xi robotic system from California-based manufacturer Intuitive, a procedure used to retrieve a tissue sample for testing. It was a first for Lovelace, which has used that model of robot in surgeries for years, but never in a thoracic procedure, Cerda said.

"The cases they were doing, they were doing it by a traditional opening, thoracotomy, so the incisions are a little bit bigger than what I do," Cerda said. "So it's a little bit more pain for the patient, a little bit more risk of having complications — bleeding, infections, things like that."

Today, the use of robots in surgery is only accelerating across the country. A study published 2020 in the medical journal JAMA found a 13.3-percentage point increase in the number of surgeries that used robots from 2012 to 2018.

The trend is happening in New Mexico too, local health care leaders say.

Lovelace today, for example, has four Da Vinci robots, regularly used for general surgery procedures like appendectomies or to treat hernias, said Charlie Lucero, Lovelace Medical Center's administrative director of surgical services. The hospital system also has three Mako robots from Florida-based manufacturer Stryker, which help orthopedic surgeons make extremely precise cuts, and a Globus Medical device for spine procedures.

The University of New Mexico Hospital, too, has a small but growing fleet of robots — three Da Vinci Xi's and a Da Vinci Ion, as well as a robot used for neurosurgery from United Kingdom-based Renishaw, said Kevin Sinclair, the hospital's associate chief operating officer.

"The landscape's totally shifted," said Dr. Jay Zhu, a University of New Mexico Hospital assistant professor of surgery and chair of the hospital's robotics steering committee. "... The volume of robotic surgery, I think just over the last eight months or so, has gone up."

After two of those Da Vinci Xi's arrived last year, Zhu said, the hospital tallied about 350 surgeries using robots in a single quarter — about 53% higher than the same timeframe last year.

These toys don't come cheap.

The Da Vinci Xi model, a multi-piece behemoth that sprawls throughout the better part of an operating room, typically retails north of $2 million — and manufacturers are constantly working on the next generation.

"Every generation of robot is actually better than the previous one, and not only by a small amount," Cerda said. "It's a significant amount of changes."

The Da Vinci Xi offers an improvement over a nonrobotic but still-minimally invasive and widely used camera procedure in that the robot offers a three-dimensional look at a mass rather than a two-dimensional image, Cerda said.

But the new Da Vinci 5 model — which Lovelace has on order and UNMH is considering acquiring — goes even further.

"It's actually capable of providing some tactile feedback," Cerda said.

Sinclair said UNMH owns one of its Da Vinci Xi robots, but has something akin to a lease agreement for two others in which the hospital pays based on use and gets faster access to swap out new technologies when they become available.

"As technology advances, these devices turn into paperweights in the long term, because they just don't turn into that same capability," Sinclair said. "Honestly, surgeons want to use something that's more state-of-the-art and makes their job easier."

Despite the high price tags, there's an argument to be made that robot-assisted surgeries actually save money in a few ways, Cerda said: Fewer complications mean fewer average hospital stays. Less pain for patients means less need to prescribe narcotic painkiller, which not only saves on drug costs but can minimize the risk of a patient developing addiction.

"I do not remember the last time I prescribed a narcotic to anybody," Cerda said.

Robots can also provide a valuable diagnostic tool that can save patients significant time searching for answers. For example, Cerda's patient who underwent the robotic pleural biopsy had a mass that evaded diagnosis with a needle and a can. Taking the biopsy with the robot allowed Cerda to provide that woman with something concrete.

"The diagnosis unfortunately was cancer," Cerda said. "But at least she had a diagnosis. She had an answer that she didn't have before."

The ultimate goal, Lucero said, is to catch those diagnoses as early as possible.

"If you get it at Stage 1, cancer is very treatable," Lucero said.

While the up-front costs are high, Lucero said, those benefits make the investment well worth the money, especially considering that hospitals in other states also have those tools available.

"I live in this community. My family lives in this community," Lucero said. "The last thing I want is for one of my family members to have to leave the community because there's not a service we provide."

Preparing for surgery's more robotic future doesn't just involve major capital investments, Zhu said. It requires a mindset shift he's already observing in young surgeons he trains.

"For folks that trained maybe 20, 30 years ago, the expectation was that what you learned, you can come out and practice fairly consistently, potentially over the course of a career," he said.

That's just no longer true, though, Zhu said, due to the rapid pace of not just robotics but in all sorts of tools and supplies a surgeon might need to use.

Cerda said the pace of robotic advancement could radically alter how surgery and medicine look in the future — perhaps even to the point where surgeons don't need to be in the same hospital or even in the same country as their patients.

"With time, this technology is going to improve even to the point we cannot even imagine right now," he said.

Zhu said he jokes with his residents that at some point surgery might look like dropping robotic spiders into patients' bodies and use a remote control to perform a procedure.

That may be a ways away. But, he said, a generation ago, nobody could imagine how computers might be used in the future.

"For learners today, the goal is not to become expert at a single technology," Zhu said. "The goal is to become expert in the diseases and how to treat patients, and then figure out how to utilize whatever technology's available."