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Robotics in Cardiothoracic Surgery: Its Effects and Implications in the Philippines

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Through its intricate mechanisms and unyielding thirst for innovation, the human mind was able to create a revolutionary age where we mingled with technological creations that traverse boundaries and limitations with their remarkable capabilities. Robotics, one of man’s greatest inventions, became a popular advent of curiosity due to its diverse functions in several aspects of man’s professions. Its A. I. (artificial intelligence) and reflexive, automated parts allow the success of delicate tasks and procedures. In relation to such, I aim to provide insight on robotics’ significance, necessity and applications in cardio-thoracic surgery and how these factors would affect the Philippines. Cardiothoracic surgery is the specialty involved with the treatment of diseases affecting organs within the thorax (the chest), principally the heart, lungs and esophagus. It is a young specialty which has grown rapidly since the Second World War.

Procedures are often lengthy and complex, requiring support from advanced forms of technology during surgery and intensive therapy for the patient after surgery. It was the first specialty to use outcome measures to analyze and improve techniques and procedures, largely due to the fact that cardiac procedures carry a definite risk of death (“Cardiothoracic Surgery”). Unlike in Europe and in the United States, the specialty of thoracic surgery did not initially find fertile ground in the Philippines. The first recorded thoracic operation in the Philippines covered only two pages in the September 1925 issue of the Journal of the Philippine Islands Medical Association (Danguilan S613).

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In 1946, Dr. Serafin Menes of the Department of Surgery of the University of Santo Tomas (UST) Faculty of Medicine cited some of the following reasons: “lack of a systematic campaign to educate the people and give them reassurance that most surgical chest diseases can be cured if discovered and operated on early; failure of the family physician, internist and. . . lack of properly trained personnel to administer intratracheal anesthesia and lack of proper surgical instruments for major thoracic work” (S614). According to The Society of Thoracic Surgeons, the following are the common types of cardiothoracic illnesses that require major procedures: Coronary Heart Disease (blockages of the arteries in the heart), Thoracic Aortic Aneurysm (abnormal enlargement of the arteries), Congestive Heart Failure and Lung Cancer.

Subsequently, the Department of Health has included heart diseases and illnesses of the vascular system among the leading causes of death in the Philippines in 2013. The first scientific definition of robotics appeared in 1972 from the Robot Institute of America, which was, “A reprogrammable, multifunctional manipulator designed to move materials, parts, tools, or specialized devices through various programmed motions for the performance of a variety of tasks. ” Several years later, in 1978, the PUMA (Programmable Universal Machine Assembly) was developed by Victor Scheinman. PUMA was used for the first time in 1985 in the field of medicine when it was used to direct a needle to undergo a brain CT-guided biopsy. 3 This stereotactic brain biopsy achieved an accuracy of 0. 05 mm. With such an astounding execution, this robot-assisted surgical procedure paved the road for robot-assisted surgery. (Abdul-Muhsin and Patel 5). The most common applications in cardiac surgery are for mitral valve repair (MVP) and endoscopic coronary artery bypass grafting (CABG) (Modi et al. 500). 4 John Hopkins Medicine describes mitral valve repair as ‘one of the first cardiac surgical operations performed with the robot and for which FDA approval was obtained’. On the other hand, CABG is defined as ‘a procedure used to treat coronary artery disease’.

Over 1,700 robotic cardiac operations are performed in the USA per year with an increase of about 400 cases, or about 25% growth per annum (Modi et al. 500). The ‘da Vinci Si’ robotic surgical system is the latest advancement in minimally invasive surgical techniques, a procedure that only requires four small incisions (each around 5-12 mm in diameter, less than the width of a pencil) on the patient’s abdomen. Presently, there are two of these robots in the Philippines; both of which are in St Luke’s Medical Center Global City. Dr. Dennis Serrano, chief of St. Luke’s Robotic Urology section, brought the first da Vinci Si robot back in 2010. “Since then, more than 150 robotic radical prostatectomy procedures have been done in the institute,” he said (Montenegro). Surgeons develop their prominent skills through numerous kinds of cases; each one quite different from the other. They compile the bits and pieces of information into concrete ideals that determine the success of every procedure. However, even with man’s ability to rationalize in precarious events, robots hold a certain advantage that man doesn’t possess— the inability to feel. Some of the viable examples of human limitations are imprecision, limited dexterity, susceptibility to tremor and fatigue and inability to use quantitative information easily. In contrast, the robots’ capability in stability and accuracy, diverse sensors and optimized software would be able to balance the natural weaknesses of man (Camarillo et al. 3S).

In terms of automating surgery— Duke University in the USA, for example, is developing a robot arm that is controlled by a computer program on the basis of ultrasound data with the aim of guiding a biopsy plunger device to take samples. Ultimately, this could prove to be more economical, and could reduce waiting times by enabling such routine operations to be performed without surgeon fatigue (Sharkey 288). In the journal article entitled, Impacts of Robotic Assisted Surgery on Hospital’s Strategic Plan, Charalampos Platis and Emmanuel Zoulias mentioned that “using robotics to aid in surgical procedures would result to a reduced trauma to the body, reduced blood transfusions, less scarring and a faster rate in the patient’s healing process”— all of which would guarantee safer precautionary measures for patients (323). It has been noted that use of the ‘da Vinci’ system increased by 400% in US hospitals between 2006 and 2010. ‘There’s a medical arms race’, according to Phil Levy, executive of Beth Israel Deaconess Medical Center in Boston. The marketable aspect of robotics sends hospitals into a widespread frenzy, with each vying for a distinct feature that would attract patients to their doors.

A systematic analysis of 400 randomly selected US hospital websites in June of 2010; 41% of hospital websites described robotic surgery, 37% of these had robot surgery on their homepage with 33% including links to the manufacturer’s website. Jin et al. (qtd. in Sharkey) stated that “as many as 86% of the websites made statements about the clinical superiority of surgical robotics” (281). Therefore, it is logical to assume that the presence of robotic tools and equipment directly increases the number of patients and surgical procedures being performed in the hospital setting. The increasing use of robots could reduce the amount of human contact experienced by patients. The families of patients might increasingly opt for virtual rather than real visits. Parents might stop sleeping by their child’s bedside, and use a robot to check in with them. Patients might not even have the small human contact afforded by the hospital cleaner, or porter if such tasks were performed by uncomplaining, and unpaid robots (Sharkey 288). Health facilities in the Philippines include government hospitals, private hospitals and primary health care facilities. The hospitals are classified based on ownership as public or private hospitals; with around 40 percent being public. Out of 721 public hospitals, 70 are managed by the DOH while the remaining hospitals are managed by LGUs and other national government agencies.

At present, Level-1 hospitals account for almost 56 percent of the total number of hospitals which have very limited capacity, comparable only to infirmaries (Chapter 1: The Philippine Health System at a Glance). The hospital sector in the Philippines is highly segmented in nature. People with PhilHealth insurance are more likely to be confined in a private hospital (56%), than those without PhilHealth insurance (28%). Similarly, patients living in urban area (52%) and belonging to the richest quintile (74%) are also more likely to be confined in private hospitals (Chapter 1). In September 3, 2018, Rappler released a news article—Job losses seen under lower proposed DOH budget— which tackled the budget slash to DOH’s funding for 2019. The DOH’s Health Human Resources Development (HHRD) saw a huge cut in its funding; from 6. 9 billion pesos dwindling to an estimated amount of 1. 2 billion pesos.

In a statement, House majority leader Rolando Andaya said that ‘the lower funds may lead to the possible job losses of about 6,755 contractual nurses’ (Tomacruz). The smaller budget would also see a lesser number of doctors, dentists, and midwives deployed to rural areas. From 293 doctors, there would be about 243 deployed. Dentists would go from 324 to 241 deployed, while midwives would go from 4,000 to 3,650 deployed. A decrease in the number of health care providers would limit the number of patients from rural areas; thus, the use robotics in surgery may be used by those concentrated in the urban setting. Having specialized tools isn’t enough to ensure a smooth operation— a surgeon’s training regarding the use of robotics is a huge factor that will determine the success rate of the procedure. Training programs must be conducted in formal training centers and will consist of didactics, familiarization with the system and then practice on inanimate objects, cadavers and live animals (Modi et al. 503). With the expense of further training aside from the cost of robotics—its warranty period, possible malfunction risks— it may be mostly found in private hospitals because of “higher percentages of funding compared to public hospitals”, as stated by Lavado et al. (qtd. in Chapter 1) (8).


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