As noted previously, robotic assisted surgery was developed to improve laparoscopic surgery. Laparoscopic surgery is a common surgical technique to treat several types of cancers including prostate, colon, kidney and ovarian cancers as well as cancer of the throat and esophagus. Given the ergonomic advantages of a laparoscopic surgery using the da Vinci surgical system, which technique – traditional or robotic – provides the most successful surgeries when treating cancer?
In general, robot-assisted surgery has been associated with reduced blood loss, reduced transfusion exposure, fewer complications, reduced post-operative pain, shorter hospital stays, and reduced recovery times as compared to typical laparoscopic and open surgical techniques . But, given the relatively recent introduction of robotic assisted surgery, there is a lack of substantial medical proof to substantiate these clinical benefits.
For example, according to the Canadian Agency for Drugs and Technologies in Health (CADTH), conclusions regarding the benefits of the da Vinci must be drawn carefully due to the lack of clinical research. CADTH’s literature analysis of current research measuring performance of the da Vinci surgical system for laparoscopic prostatectomy, hysterectomy and nephrectomy (common surgeries to treat prostate, cervical and kidney cancers), which is limited, showed statistically significant benefits. This included less blood loss during the procedure and shorter hospital stays after the procedure when compared to a typical laparoscopic and open prostatectomy, hysterectomy and nephrectomy. But, according to CADTH’s report, research in this area is limited making it difficult to come to any substantial conclusions . With that being said, the research that does exist suggests that some laparoscopic procedures that use the da Vinci may be less invasive and provide several short term benefits.
But what about long term benefits? According to CADTH, there are currently no long term clinical benefits to using the da Vinci. This seems to be one of da Vinci’s largest criticisms because robotic assisted surgery is costly compared to open and laparoscopic surgeries. The da Vinci costs roughly C$2.7 million with annual maintenance costs of about C$186,000. In addition, the average instrument cost per procedure is approximately C$2,600 (many of these instruments are not reusable) . The use of the da Vinci may also require additional operating room time and there is a learning curve associated with effective use the of the da Vinci surgical system – surgeons must perform 150 to 200 procedures to really become adept with the technology . Therefore, when push comes to shove, one has to wonder if it is cost effective to use the da Vinci over traditional surgical procedures. Do the benefits outweigh the costs?
Take prostate cancer as an example. A popular treatment for prostate cancer is a laparoscopic prostatectomy. A da Vinci laparoscopic prostatectomy costs (net cost) roughly six per cent more, or $1,600, not including the robot itself, than alternative procedures . Even though it is more expensive, the da Vinci laparoscopic prostatectomy may offer a less invasive surgical option. This may benefit prostate cancer patients because often times patients choose non-surgical interventions such as “watchful waiting” to avoid the consequences of surgery. But the potential for a surgical procedure that offers a faster recovery time as well as fewer complications during the procedure may encourage patients to opt for a surgical intervention using the da Vinci. The extra cost may be offset by reductions in post-operative hospital costs as patients recover more rapidly from this procedure. But this is all speculation. Time will tell if this is truly the case.
So is laparoscopic surgery using the da Vinci superior to traditional laparoscopic surgery? Preliminary research suggests it may be. But the question remains: is it worth the economic price we pay for the technology?
i Canadian Agency for Drugs and Technologies in Health. (September 28, 2010). Draft report - Robot-assisted surgery versus open surgery and laparoscopic surgery: Clinical and cost- effectiveness analyses. Accessed at http://www.cadth.ca/index.php/en/publication/2682
ii Ibid
iii Ibid
iv Vancouver Sun. (October 2, 2010). Meet Jack the surgical robot: He’s on the cutting edge of cancer treatment. Accessed at http://bit.ly/9f9gE0
v Ibid
vi “Watchful waiting” is a non-surgical intervention for prostate cancer. It involves a regular examination of the prostate and its PSA level. Immediate treatment (surgery or other) is only recommended if signs of cancer appear or change. Prostate cancer is not known to be an aggressive cancer. Some prostate cancers are very slow growing and can be present for years without affecting one’s health.
Friday, March 11, 2011
Thursday, March 10, 2011
Cancer Surgery and Robotics
Cancer is a disease that has plagued the human race for centuries. The world’s oldest documented case of cancer hails from ancient Egypt (1500 B.C.), while the first attempt to treat it surgically dates back to approximately 1600 B.C. Today’s surgical treatments have very little resemblance to the techniques used several centuries ago as our knowledge of the human body, of chronic disease and our technology are much more advanced.
One of the most amazing advancements is cancer surgery has come in the form of a robotic assisted surgery. Robotic assisted surgery was developed to overcome the limitations from minimally invasive surgery. Minimally invasive surgery, known as laparoscopic or keyhole surgery, is a modern surgical technique that is performed by making several small incisions (less than ½ inch) in the abdominal and pelvic regions. By inserting a small camera and tiny surgical instruments into these incisions, the surgeon performs the surgery while watching detailed images on a monitor . Laparoscopic surgery is an effective surgical technique and is mainly used for operations within the abdominal and pelvic regions as well as on the thoracic and chest cavities. This procedure is typically used to treat cancers of the abdominal and pelvic regions including prostate, colon, kidney and ovarian cancers as well as other cancers including throat and esophageal cancers.
Although traditional laparoscopic surgery is a very safe and successful surgical procedure, robotic assisted surgery was developed to improve this technique further. The most known robotic surgical system, and the only one available in Canada, is called the da Vinci Surgical system. The da Vinci Surgical system, owned and designed by Intuitive Surgical, consists of a surgeon’s console (remote control) and a patient side cart (the robot). The surgeon’s console consists of two hand controllers, two foot pedals, and a two-eye viewing screen. The side cart consists of 4 robotic arms, 3 for surgical tools, and 1 for a two lens endoscopic camera.
The surgical procedure using the da Vinci Surgical system is similar to a typical laparoscopic surgery except for one major difference. Unlike a typical laparoscopic surgery where the surgeon operates while standing over the patient, the da Vinci surgical system allows the surgeon to operate by controlling the robotic arms remotely from the console. While seated at the console, normally located in the same room as the patient, the surgeon uses the console’s controllers to manipulate the patients-side carts three or four robotic arms, while looking through the two-eye viewing screen.
The ergonomic design of the da Vinci allows the surgeon to perform the surgery in a much more comfortable manner compared to a typical laparoscopic surgery. The surgeon sits at the console and operates the robotic arms remotely, which come into contact with the patient, while directly viewing the procedure with his/her head rested on the two-eye viewing screen. Instead of standing over the patient using surgical tools while viewing the procedure on a monitor, the da Vinci’s design is seen to reduce fatigue and physical strain on the surgeon.
The design of the da Vinci also has a number of other advantages. This includes the jointed wrist design of the robotic arms, the da Vinci’s ability to translate, filter and scale the surgeon’s movements from the console, and the high definition stereoscopic image provided by the two-eye viewing screen and the two lens endoscopic camera. The jointed wrist design of the robotic arms provides increased dexterity not possible with the human hand. The da Vinci’s ability to filter and scale the surgeon’s hand movements from the controllers enhances the precision to perform complex, delicate procedures and allows the surgeon to operate in a much more graceful manner. The two-eye viewing screen and the two lens endoscopic camera provides the surgeon with a stereoscopic high definition view of the procedure and it provides a much better view of the surgery when compared to the image of the monitor used for a typical laparoscopic surgery.
Although these advantages come from the ergonomic design and the technology of the da Vinci surgical system, the question remains: do they translate into more successful and efficient cancer surgical procedures?
One of the most amazing advancements is cancer surgery has come in the form of a robotic assisted surgery. Robotic assisted surgery was developed to overcome the limitations from minimally invasive surgery. Minimally invasive surgery, known as laparoscopic or keyhole surgery, is a modern surgical technique that is performed by making several small incisions (less than ½ inch) in the abdominal and pelvic regions. By inserting a small camera and tiny surgical instruments into these incisions, the surgeon performs the surgery while watching detailed images on a monitor . Laparoscopic surgery is an effective surgical technique and is mainly used for operations within the abdominal and pelvic regions as well as on the thoracic and chest cavities. This procedure is typically used to treat cancers of the abdominal and pelvic regions including prostate, colon, kidney and ovarian cancers as well as other cancers including throat and esophageal cancers.
Although traditional laparoscopic surgery is a very safe and successful surgical procedure, robotic assisted surgery was developed to improve this technique further. The most known robotic surgical system, and the only one available in Canada, is called the da Vinci Surgical system. The da Vinci Surgical system, owned and designed by Intuitive Surgical, consists of a surgeon’s console (remote control) and a patient side cart (the robot). The surgeon’s console consists of two hand controllers, two foot pedals, and a two-eye viewing screen. The side cart consists of 4 robotic arms, 3 for surgical tools, and 1 for a two lens endoscopic camera.
The surgical procedure using the da Vinci Surgical system is similar to a typical laparoscopic surgery except for one major difference. Unlike a typical laparoscopic surgery where the surgeon operates while standing over the patient, the da Vinci surgical system allows the surgeon to operate by controlling the robotic arms remotely from the console. While seated at the console, normally located in the same room as the patient, the surgeon uses the console’s controllers to manipulate the patients-side carts three or four robotic arms, while looking through the two-eye viewing screen.
The ergonomic design of the da Vinci allows the surgeon to perform the surgery in a much more comfortable manner compared to a typical laparoscopic surgery. The surgeon sits at the console and operates the robotic arms remotely, which come into contact with the patient, while directly viewing the procedure with his/her head rested on the two-eye viewing screen. Instead of standing over the patient using surgical tools while viewing the procedure on a monitor, the da Vinci’s design is seen to reduce fatigue and physical strain on the surgeon.
The design of the da Vinci also has a number of other advantages. This includes the jointed wrist design of the robotic arms, the da Vinci’s ability to translate, filter and scale the surgeon’s movements from the console, and the high definition stereoscopic image provided by the two-eye viewing screen and the two lens endoscopic camera. The jointed wrist design of the robotic arms provides increased dexterity not possible with the human hand. The da Vinci’s ability to filter and scale the surgeon’s hand movements from the controllers enhances the precision to perform complex, delicate procedures and allows the surgeon to operate in a much more graceful manner. The two-eye viewing screen and the two lens endoscopic camera provides the surgeon with a stereoscopic high definition view of the procedure and it provides a much better view of the surgery when compared to the image of the monitor used for a typical laparoscopic surgery.
Although these advantages come from the ergonomic design and the technology of the da Vinci surgical system, the question remains: do they translate into more successful and efficient cancer surgical procedures?
Tuesday, March 8, 2011
The Use of Robotics is Cancer Treatment
There is no doubt that global cancer incidence rates are on the rise. It is estimated that 45% of males and 40% of females in Canada are likely to develop cancer in their lifetime. Here in Ontario, cancer rates have steadily increased since 1996 including here in the Champlain LHIN region . Whether this is primarily a case of an aging population or due to environmental factors related to the food we eat, the water we drink and the air we breath (probably a combination of both), cancer is a growing phenomenon. There is even growing concern, some of it warranted, that cancer incident rates are increasing in younger Canadians – outside of melanoma (skin cancer).
The causes of cancer continue to be hotly debated as the science remains unclear surrounding many of its potential causes and, as a consequence, is creating policy concerns, public confusion and fear. Although this paints a rather bleak but, accurate picture, there is a bright light in the war against cancer – treatment. Cancer treatment has vastly improved over the last number of decades. The odds of surviving many cancers has never been better as cancer treatments such as chemotherapy, radiation therapy and surgery have improved. There have also been several additions to cancer treatment in the areas of complimentary and alternative therapies. But one of the most intriguing advancements in cancer treatment has come in surgery. Over the last number of years, the use of robotic assisted surgery has become more commonplace for the treatment of several types of cancer. The following 4 blog entries will take a critical look at robotic assisted surgery - how it works; how it has contributed to the treatment of cancer; if it makes a difference as compared to more conventional surgical techniques; if the hype surrounding this type of surgery is worth the economic price we pay for the technology; and where in Canada provides access to robotic assisted surgery.
The causes of cancer continue to be hotly debated as the science remains unclear surrounding many of its potential causes and, as a consequence, is creating policy concerns, public confusion and fear. Although this paints a rather bleak but, accurate picture, there is a bright light in the war against cancer – treatment. Cancer treatment has vastly improved over the last number of decades. The odds of surviving many cancers has never been better as cancer treatments such as chemotherapy, radiation therapy and surgery have improved. There have also been several additions to cancer treatment in the areas of complimentary and alternative therapies. But one of the most intriguing advancements in cancer treatment has come in surgery. Over the last number of years, the use of robotic assisted surgery has become more commonplace for the treatment of several types of cancer. The following 4 blog entries will take a critical look at robotic assisted surgery - how it works; how it has contributed to the treatment of cancer; if it makes a difference as compared to more conventional surgical techniques; if the hype surrounding this type of surgery is worth the economic price we pay for the technology; and where in Canada provides access to robotic assisted surgery.
Friday, March 4, 2011
Acupressure & Trigger Point Therapy
Following common cancer treatment, such as surgery and radiation, muscle tension in the affected area may occur resulting in decreased lymphatic flow to surrounding tissue. In turn, this can make it difficult for fluid to penetrate through the tissues. In addition to being prescribed an individualized home exercise program by your physiotherapist, acupressure, or trigger point therapy, may be used during your treatment sessions.
Acupressure is an ancient healing art which was developed in China over 5,000 years ago. Using the pad of the thumb or fingers, the therapist applies pressure to key points on the skin surface. Applied pressure can vary from light to firm. This stimulates flow of the body’s life force energy, or “Qi”, which promotes health and healing. The acupressure treatment technique is rooted in the Traditional Chinese Medicine (TCM) belief that energy flows through meridians, or imaginary lines, throughout the body. In a healthy individual the energy flows freely. However, if the energy flow is obstructed, the blockage of Qi results in illness. It is believed that acupressure releases the active trigger points found on meridians allowing for a healthy flow of energy. Acupressure can also be responsible for relieving stress and strengthening the body’s resistance to disease. Additionally, the stimulation of active trigger points is thought to lead to an elevated level of endorphins. The release of endorphins, a natural painkiller, can allow for overall relaxation and normalization of the body.
By restoring your bodies natural energy flow, and releasing muscle tension, the ability for lymphatic fluid to drain from your affected region may be improved, decreasing one’s risk of developing lymphedema. Registered physiotherapists and massage therapists specializing in cancer rehabilitation are trained to assist survivors in managing muscle tension resulting in improved lymphatic flow.
Acupressure is an ancient healing art which was developed in China over 5,000 years ago. Using the pad of the thumb or fingers, the therapist applies pressure to key points on the skin surface. Applied pressure can vary from light to firm. This stimulates flow of the body’s life force energy, or “Qi”, which promotes health and healing. The acupressure treatment technique is rooted in the Traditional Chinese Medicine (TCM) belief that energy flows through meridians, or imaginary lines, throughout the body. In a healthy individual the energy flows freely. However, if the energy flow is obstructed, the blockage of Qi results in illness. It is believed that acupressure releases the active trigger points found on meridians allowing for a healthy flow of energy. Acupressure can also be responsible for relieving stress and strengthening the body’s resistance to disease. Additionally, the stimulation of active trigger points is thought to lead to an elevated level of endorphins. The release of endorphins, a natural painkiller, can allow for overall relaxation and normalization of the body.
By restoring your bodies natural energy flow, and releasing muscle tension, the ability for lymphatic fluid to drain from your affected region may be improved, decreasing one’s risk of developing lymphedema. Registered physiotherapists and massage therapists specializing in cancer rehabilitation are trained to assist survivors in managing muscle tension resulting in improved lymphatic flow.
Thursday, March 3, 2011
Reducing Your Risk
Once damage has occurred to the lymphatic system, the affected area will be at risk
of developing lymphedema from then on. Fortunately, there are steps one can take to
reduce their risk:
1. Skin Care
- Avoid cuts and scrapes to the skin as much as possible
- Keep skin clean and dry
- Apply moisturizer daily to prevent cracked skin
- Protect skin with sunscreen and insect repellent, or cover skin when outdoors
- Avoid nicks and irritation when shaving
- If possible, avoid injections on the affected side
- Wear gloves and/or long clothing with doing an activity that may cause a burn or
injury, such as cooking and gardening
2. Minimize Constriction
- Do not wear tight or restrictive clothing on the affected area
- Avoid carrying heavy bags or purses on the affected side
- Avoid using the affected arm when taking blood pressure
3. Avoid Extreme Temperature
- Avoid exposure to extreme cold or heat, or try to minimize any exposure to less than
15 minutes
- Avoid direct heat on the affected area, such as hot tubs and saunas
- Wear appropriate clothing in the winter and summer
4. Healthy Body Weight
- Being overweight increases the risk for developing lymphedema, due to an overload on
the lymphatic system
- Consult a family doctor, physiotherapist or dietician for healthy eating and physical
activity guidelines
5. Healthy Activity & Lifestyle
- Exercise does assist with draining the lymphatic system, however excessive exercise
may trigger lymphedema by causing inflammation in the joints and muscles, therefore
leading to an increase in lymph production
- Increase the duration and intensity of exercise gradually
- Rest frequently and avoid over-exertion
- Monitor the at-risk area during and after activity, looking for any change
- Whenever beginning a new activity or an activity not performed in a while (such as
shovelling snow or raking leaves), gradually work up to the activity over a period of
several weeks
Reducing your risk of developing lymphedema may require a slight or major change to
your lifestyle. However, if changes are implemented gradually, it will allow for a simpler
adjustment.
of developing lymphedema from then on. Fortunately, there are steps one can take to
reduce their risk:
1. Skin Care
- Avoid cuts and scrapes to the skin as much as possible
- Keep skin clean and dry
- Apply moisturizer daily to prevent cracked skin
- Protect skin with sunscreen and insect repellent, or cover skin when outdoors
- Avoid nicks and irritation when shaving
- If possible, avoid injections on the affected side
- Wear gloves and/or long clothing with doing an activity that may cause a burn or
injury, such as cooking and gardening
2. Minimize Constriction
- Do not wear tight or restrictive clothing on the affected area
- Avoid carrying heavy bags or purses on the affected side
- Avoid using the affected arm when taking blood pressure
3. Avoid Extreme Temperature
- Avoid exposure to extreme cold or heat, or try to minimize any exposure to less than
15 minutes
- Avoid direct heat on the affected area, such as hot tubs and saunas
- Wear appropriate clothing in the winter and summer
4. Healthy Body Weight
- Being overweight increases the risk for developing lymphedema, due to an overload on
the lymphatic system
- Consult a family doctor, physiotherapist or dietician for healthy eating and physical
activity guidelines
5. Healthy Activity & Lifestyle
- Exercise does assist with draining the lymphatic system, however excessive exercise
may trigger lymphedema by causing inflammation in the joints and muscles, therefore
leading to an increase in lymph production
- Increase the duration and intensity of exercise gradually
- Rest frequently and avoid over-exertion
- Monitor the at-risk area during and after activity, looking for any change
- Whenever beginning a new activity or an activity not performed in a while (such as
shovelling snow or raking leaves), gradually work up to the activity over a period of
several weeks
Reducing your risk of developing lymphedema may require a slight or major change to
your lifestyle. However, if changes are implemented gradually, it will allow for a simpler
adjustment.
Wednesday, March 2, 2011
Lymphedema Signs & Treatment
Early detection is the best defence against lymphedema. Seek treatment promptly from a Certified Lymphedema Therapist if you notice any of the following changes on your affected side:
• Skin tightness
• Feeling of heaviness
• Clothing or jewellery feels tight on affected side
• Aching or stiffness in the area
• Feeling of ‘pins & needles’
• Swelling or increase of size in the area
Unfortunately, there is no cure for lymphedema at this time. However, with appropriate treatment it can be successfully managed. The treatment protocol for lymphedema is termed Complete Decongestive Therapy (CDT). It entails the following:
1) Manual Lymphatic Drainage (MLD)
• This is a form of gentle massage performed by a Certified Lymphedema Therapist. The goal of treatment is to stimulate and direct lymphatic flow towards adjacent functioning lymph nodes.
• The therapist may instruct you on how to perform your own lymphatic drainage.
2) Compression
• Multi-layer compression bandaging and/or compression garments are the most effective ways of reducing lymphedema. This process aids in reducing swelling and assists in the removal of lymph fluid.
3) Exercise
• Muscle movement is a key component in stimulating venous and lymphatic flow. Exercises are aimed at augmenting muscular contraction, enhancing joint mobility, strengthening the limb, and reducing the muscle wasting that frequently occurs with lymphedema.
4) Skin Care
• Skin care is addressed to avoid an overload to your lymphatic system, in regards to the role it plays in immune function.
• Skin tightness
• Feeling of heaviness
• Clothing or jewellery feels tight on affected side
• Aching or stiffness in the area
• Feeling of ‘pins & needles’
• Swelling or increase of size in the area
Unfortunately, there is no cure for lymphedema at this time. However, with appropriate treatment it can be successfully managed. The treatment protocol for lymphedema is termed Complete Decongestive Therapy (CDT). It entails the following:
1) Manual Lymphatic Drainage (MLD)
• This is a form of gentle massage performed by a Certified Lymphedema Therapist. The goal of treatment is to stimulate and direct lymphatic flow towards adjacent functioning lymph nodes.
• The therapist may instruct you on how to perform your own lymphatic drainage.
2) Compression
• Multi-layer compression bandaging and/or compression garments are the most effective ways of reducing lymphedema. This process aids in reducing swelling and assists in the removal of lymph fluid.
3) Exercise
• Muscle movement is a key component in stimulating venous and lymphatic flow. Exercises are aimed at augmenting muscular contraction, enhancing joint mobility, strengthening the limb, and reducing the muscle wasting that frequently occurs with lymphedema.
4) Skin Care
• Skin care is addressed to avoid an overload to your lymphatic system, in regards to the role it plays in immune function.
Tuesday, March 1, 2011
The Lymphatic System & Lymphedema
The lymphatic system is a structure which unfortunately most of us do not fully understand. Yet, it is responsible for numerous essential daily functions within the body.
The lymphatic system has three primary functions:
1. It plays a role in immune system function by destroying pathogens and clearing waste
2. It removes large cells our circulatory system cannot handle such as dead blood cells, toxins and cell debris
3. It works with the circulatory system to deliver nutrients, oxygen and hormones to bodily tissues
A diagnosis of cancer commonly also means that there has been a spread of the disease to the lymph nodes in the affected region. During surgery to remove cancerous tissue, lymph nodes are often removed or damaged in the process. Additionally, common treatment techniques, such as radiation therapy, can cause further damage to the remaining lymph nodes. This damage to the lymphatic system results in an inability to properly drain lymphatic fluid from the affected region, thus resulting in swelling. This condition is termed Secondary Lymphedema.
Primary Lymphedema develops when lymphatic vessels are absent or impaired from birth.
The lymphatic system has three primary functions:
1. It plays a role in immune system function by destroying pathogens and clearing waste
2. It removes large cells our circulatory system cannot handle such as dead blood cells, toxins and cell debris
3. It works with the circulatory system to deliver nutrients, oxygen and hormones to bodily tissues
A diagnosis of cancer commonly also means that there has been a spread of the disease to the lymph nodes in the affected region. During surgery to remove cancerous tissue, lymph nodes are often removed or damaged in the process. Additionally, common treatment techniques, such as radiation therapy, can cause further damage to the remaining lymph nodes. This damage to the lymphatic system results in an inability to properly drain lymphatic fluid from the affected region, thus resulting in swelling. This condition is termed Secondary Lymphedema.
Primary Lymphedema develops when lymphatic vessels are absent or impaired from birth.
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