BY TIM FOX

In 400 BCE, Archytas of Tarentum, known for inventing the pulley, built a pigeon out of wood and made it fly. The “why” of that invention may be lost, but the human penchant for automation has persisted.

Today, in the 21^st century, the “why” of robotics in health care is evident. Specialists use this technology to save lives.

I’M PERFORMING THE SURGERY; ROBOTIC TECHNOLOGY DOES WHAT I WANT IT TO.

“Using robotic technology in the operating room doesn’t mean that a robot is performing surgery on its own. It means that robotic technology is being used as a tool during surgery,” says Adeel Khan, MD, MPH, FACS, Washington University transplant surgeon at Barnes-Jewish Hospital. During a robotic-assisted surgery, Khan sits in a console situated just a few feet away from the patient. He uses 3D visualization provided by a camera mounted at the head of the robotic instrument and joystick-like tools that work as extensions of his own hands. In this way, Khan says, “I’m performing the surgery; robotic technology does what I want it to.”

Khan says that this technology gives him additional flexibility, dexterity, articulation, visualization and stability, all of which he uses to retrieve kidneys from living donors and transplant them into people in need of a new kidney. Nathaniel Moulton, MD, Washington University pulmonologist at Barnes-Jewish Hospital, relies on those same robotic qualities to perform biopsies of small tumors located deep within the lungs.

Moulton says: “One of the problems with the traditional, flexible bronchoscope we use for biopsies is simply holding the instrument steady. The slightest movement of my hand can take me from inside a nodule to outside it. The robotic tool ensures no movement takes place.”

But the benefits of using this technology in patient care go far beyond improved stability and dexterity. This technology also is helping surgeons like Khan and Moulton address some of the biggest problems in their fields.

More kidneys for more people

As of mid-December 2023, about 23,000 people in the U.S. had undergone kidney transplantation; another 93,000 were on the wait list for a matching organ. Compared with all other transplanted organs, kidneys are most in demand. In fact, kidneys make up 86% of the total of donor organs needed, according to the U.S. Health Resources and Services Administration.

Robotic-assisted surgery is helping to improve these dire statistics, potentially increasing the number of available donor kidneys and the number of transplants that can be performed, especially among certain patient populations.

“Transplant surgery is complicated,” says Khan, “and in a traditional transplant, the incisions used are large.” Consequently, recovery can be difficult for some kidney transplant recipients—many of whom are very sick. Khan notes that, for kidney transplant, the patient population in general is aging and becoming more frail, factors that further complicate transplantation and recovery. “That’s where robotic technology can make a difference,” Khan says, because it allows for smaller incisions than those in traditional open surgery or even laparoscopic surgery, potentially reducing the risks involved in living donor donation and transplantation.

That risk reduction means that a greater number of people have the potential to qualify for life-saving surgery. For example: In the past, many people with obesity were not candidates for living-donor kidney donation nor for kidney transplantation because they were at risk for significant complications. Now, however, with robotic technology, Khan says, “we can use a smaller initial incision and disrupt less muscle tissue, whether we’re retrieving a kidney or transplanting one.”

The use of robotics also eases the discomfort of recovery for donors and recipients, many of whom require less pain control and can leave the hospital much sooner, compared with traditional surgery.

Specialized training helps ensure success

Both Khan and Moulton note that extensive training in robotic-assisted surgery safeguards patient safety. While the technology has been available for about 20 years, Khan notes that it has only recently become part of medical school training programs.

ADEEL KHAN, MD, PICTURED HERE, AND COLLEAGUES PERFORMED THE FIRST U.S. ROBOTIC-ASSISTED LIVER TRANSPLANT IN 2023.

Photography by Katie Gertler

“I learned first-hand from a surgeon who was quite experienced,” Khan says. “Today, robotics is more frequently part of a hospital’s surgical practices, so residents have more exposure to it during their training. And medical students can now graduate as certified robotic surgeons.”

At the Washington University and Barnes-Jewish Transplant Center, robotic-assisted transplant surgeries are performed by the Dedicated Robotic Transplant Team. “We don’t have members of the robotics team rotating to different kinds of surgery,” Khan says. “As a result, we have a highly skilled robotics transplant team in place.”

That team approach includes additional health-care disciplines, such as perioperative specialists who care for patients before, during and after surgery, Khan notes. Led by Jackie Martin, MD, vice president of Perioperative Services at Barnes-Jewish Hospital, these men and women help improve patient outcomes, says Khan.

Robotics and liver transplantation

In May 2023, Washington University surgeons at the Transplant Center performed the first robotic-assisted liver transplant in the United States. Khan notes that liver transplantation is a highly complex abdominal procedure. A diseased liver is prone to excessive bleeding during removal, and attaching the new liver requires sewing tiny blood vessels together.

In the milestone liver transplant, robotic technology allowed the surgeon to use smaller incisions and minimize cutting abdominal muscles. As a result, the patient recovered more quickly, walking easily within six weeks of surgery and participating in more strenuous activities within seven weeks. With traditional liver transplant surgery, patients find it can take longer to simply walk without discomfort.

Khan and colleagues on the multidisciplinary robotics transplant team are working to share their expertise with other transplant centers. They have visited centers to teach and mentor new teams, and they’ve hosted visiting specialists looking to understand the Transplant Center’s process.

Better lung biopsies, longer lives

Moulton’s work using robotics for lung biopsies also requires a multidisciplinary team, and like Khan, his mission is to use technology to push back on some daunting statistics.

More people in the world die of lung cancer each year than any other form of cancer. Nearly a quarter of a million people are diagnosed annually in the U.S. alone, while a significant number of people live with undetected lung cancer. In fact, less than 6% of the 8 million people at high risk for lung cancer are screened—and early detection is critical.

“Time is important; undetected cancerous nodules have time to grow,’” Moulton says. “If we can biopsy a nodule when it’s less than a centimeter in size, the five-year survival rate is 92%, compared to a 77% survival rate for a node that’s just a centimeter larger.”

Lung cancer screening consists of a CT scan, which can reveal the location of a nodule in the lung, says Moulton. If a nodule is found during a scan, the next step often is biopsy, used to determine whether the growth is cancerous. Traditional biopsy is done using a flexible bronchoscopy tool to reach the nodule and remove a section for testing.

“If a CT scan reveals a small nodule located deep in the lung, we may not be able to reach it for biopsy and may have to watch it over time,” Moulton says. He adds: “When we have a lesion that is less than two centimeters, is on the periphery of the lung and does not have an airway leading to it, traditional bronchoscopy may not be effective in detecting cancer. Robotics, however, addresses that issue.”

WE CAN NOW IDENTIFY CANCEROUS NODULES EARLIER, AND START TREATMENT SOONER.

The stability and dexterity of robotic technology allows Moulton to biopsy tumors that are smaller and harder to reach than would be possible with traditional bronchoscopy. Moulton performs biopsies at Siteman Cancer Center, based at Barnes-Jewish Hospital and Washington University School of Medicine.

A robotic-assisted biopsy uses a small catheter that is designed to reach farther into the lung than a bronchoscope can. This technology also uses artificial intelligence and a small, mobile CT scanner to help determine the best pathway through the airways to the nodule. If an airway becomes inaccessible during the procedure, the technology will suggest a new path in real time—just like a car’s GPS system.

That navigation also helps the surgeon determine which approach angle to take—and with robotic technology, angles are virtually limitless. The device can articulate 360 degrees, more than twice the range a human wrist can rotate when performing surgery.

“In addition, if we know we are close to the nodule but still not getting a diagnostic result, the CT scanner can rotate around the body to provide a different visualization of where the catheter is relative to the nodule. That allows us to reorient our approach,” Moulton explains.

“Washington University specialists helped develop the feasibility and safety of robotic bronchoscopy,” says Moulton, noting the work of Washington University pulmonologist Alexander Chen, MD, who also trained him in robotic-assisted bronchoscopy. As a result of the advances made in the field, Moulton adds, “we can now identify cancerous nodules earlier, and start treatment sooner.”

Read more about the first U.S. robotic-assisted liver transplant.