Docteur Charles-Henri Rochat, Chirurgien responsable d'urologie au Centre romand de chirurgie laparoscopique robotisée, Membre du Conseil et Directeur de projet à la Fondation Genevoise pour la Formation et la Recherche Médicales, Président de la Société Médicale de Beaulieu, Clinique Générale de Beaulieu :
Présentations et "abstracts" concernant la chirurgie robotique :
=> L ’image en chirurgie : le robot Da Vinci®
=> Prostatectomie radicale laparoscopique "robot assistée"
Par : P. Dubernard, R. Gaston, C.-H. Rochat
=> Robotique en urologie (abstract)
=> Présentation du système de chirurgie assistée par ordinateur
Da Vinci® (vidéo)
=> Chirurgie laparoscopique robotisée
=> Présentation du système de chirurgie assistée par ordinateur
Da Vinci® (présentation sur PowerPoint, Juin 2005)
Toutes ces présentations sont à télécharger à l'adresse suivante :
http://www.gfmer.ch/Formation_Fr/Rochat.htm
Présentations:
=> Création d’un centre multidisciplinaire en chirurgie robotisée :
Aspects financiers - C.-H. Rochat
=> L ’image en chirurgie : le robot Da Vinci®
C-H.Rochat
=> Prostatectomie radicale laparoscopique "robot assistée",
P. Dubernard, R. Gaston, C.-H. Rochat
=> Retrograde Extraperitoneal Laparoscopic Prostatectomy (R.E.L.P.):
The Lyon technique – Results in 204 cases, P. Dubernard,
P. Chaffange, B. Cuzin, C.-H. Rochat
=> Robotique en urologie (abstract), C.-H. Rochat
Vidéos
=> da Vinci® prostatectomy (low band-width) / (high band width)
=> Excision d'une tumeur rénale (low band-width) / (high band width) C.-H. Rochat
=> Laparoscopic prostatectomy. The intraperitoneal approach in 2005, C.-H. Rochat, J. Sauvain
=> Néphrourétérectomie par dissection robot assistée, C.-H. Rochat, J. Sauvain
=> Présentation du robot, C.-H. Rochat
=> Prostatectomie laparoscopique (low band-width) / (high band width), C.-H. Rochat
=> Prostatectomie robot assistée : évolution 2005, C.-H. Rochat,
J. Sauvain
=> Radical laparoscopic robot-assisted prostatectomy with nerve sparing (Da Vinci) (low band-width) / (high band width), R. Gaston, C.-H. Rochat
Manifestations
=> European Robotic Urology Symposium - Geneva, February 24-25, 2005
Toutes ces présentations sont à télécharger à l'adresse suivante :
http://www.gfmer.ch/Formation_Fr/Chirurgie_laparoscopique_robotisee.htm
Source :
gfmer.ch
Yahoo! Message Boards: Intuitive Surgical ISRG
==> Access the Yahoo! Message Board: click here.
The Yahoo! Message Board about this Robotic Surgery Blog:
==> click here.
On thursday, Dr. Domenico Zavatta sent me an e-mail:
Associates in Urology LLC's Blog :
A Blog about Robotic Surgery in Urology:
==> Click here.
Robotic Surgery at Newark Beth Israel Medical Center,
New Jersey:
==> click here.
The Yahoo! Message Board about this Robotic Surgery Blog:
==> click here.
On thursday, Dr. Domenico Zavatta sent me an e-mail:
Your site looked good, except that I can not read French.
I thought I had the worlds first robotic blog, but you beat me. Congrats.
Good luck and check back. I will be adding new video of new procedures I develop and comments on my blog. Thanks from NJ,
Domenico Savatta, MD
Associates in Urology, LLC
741 Northfield Ave.
West Orange, NJ 07052
Associates in Urology LLC's Blog :
A Blog about Robotic Surgery in Urology:
==> Click here.
Robotic Surgery at Newark Beth Israel Medical Center,
New Jersey:
==> click here.
CATEL Télésanté
==> accès au site internet de CATEL Télésanté
Spécialités médicales, Technologies associées, Territoires :
==> cliquer ici
Adhérents depuis mars 2005 au CATEL:
Dr. Adrian Lobontiu - Intuitive Surgical Inc., Abdelkrim Samiri - Medica Systems, Stéphane Rivière - Aide au montage de projets de téléchirurgie.
Spécialités médicales, Technologies associées, Territoires :
==> cliquer ici
Adhérents depuis mars 2005 au CATEL:
Dr. Adrian Lobontiu - Intuitive Surgical Inc., Abdelkrim Samiri - Medica Systems, Stéphane Rivière - Aide au montage de projets de téléchirurgie.
Daily Double: Intuitive Surgical
How did it double?
"Robotic arms in an operating room seem like something out of Star Trek or pre-Annie Hall Woody Allen. However, Intuitive Surgical® (Nasdaq: ISRG) is the real deal. Its da Vinci Surgical® System has taken hospitals by storm, assisting in performing minimally invasive procedures and simplifying more complicated applications.
The real beauty of watching Intuitive Surgical® over the past few quarters isn't just watching the new installations grow. It's seeing the rest of the company's business growing even faster. With instruments, accessories, maintenance, and training zooming ahead at warp speed, the hospitals that are using da Vinci are clearly using them more often. That has led to a company that has consistently blown past Wall Street's profit targets."
Business description
"Taking surgery beyond the limits of the human hand™-- that's the company's motto. Robotic prostatectomies and open heart surgeries may seem like risky maneuvers, but Intuitive Surgical®'s systems have proven to be safe for patients and lucrative for hospitals.
But surgeons aren't becoming obsolete. Instead of using their own human hands, they man the four robotic arms through a separate console and oversee the process. Perhaps the company's promotional video would help explain the process better than words.
How could you have found this double?
As Stephen Simpson pointed out when reviewing the company's stellar third-quarter results last month, shares of Intuitive Surgical® had provided investors with buying opportunities during three distinct trading dips over the past two years.
The fact that Intuitive Surgical® has a history of bouncing back and blowing analysts away should have made the entry points inviting. If not, perhaps the stock's recommendation in the April issue of Motley Fool Rule Breakers should have tipped you off. The stock has risen by more than 160 per cent since that pick went public eight months ago.
Where to from here?
No, Intuitive Surgical® isn't cheap. Then again, it may not have seemed cheap at lower levels, either, and look where we find ourselves now. With the successful market debut of iRobot (Nasdaq: IRBT) earlier this month, robotic applications are as popular as ever -and this time they're not simply the work of sci-fi.
Analysts expect Intuitive Surgical® to earn $1.69 a share this year but only $1.47 a stub come 2006. Yes, the company has been known to blow past its targets, only to leave the market setting up higher projections. Earlier this month, the company was only expected to earn $1.25 per share this year and $1.08 in profits per share next year.
Let's hope the trend continues, because while growth investors may not balk at paying 69 times this year's profits for a dynamic growth company like Intuitive Surgical®, they may think twice if a bottom line dip prices the company at nearly 80 times forward earnings.
So let that robotic arm scratch your chin and your head. You may not find a more dynamic technology story than Intuitive Surgical®, although you may find cheaper one. "
Source:
The Motley Fool
By Rick Munarriz
Chindex International Announces First Intuitive Surgical Sale in China
The Chinese University of Hong Kong's Jockey Club MISS Centre Becomes First User of Intuitive Surgical's da Vinci® Surgical System
"Chindex International, Inc. (Nasdaq: CHDX - News), a leading independent American provider of western healthcare products and services in the People's Republic of China, announced today that it has concluded its first sale in China of the da Vinci® Surgical System, manufactured by Intuitive Surgical® (Nasdaq: ISRG - News), the innovator and market leader in surgical robotics. The system was purchased by The Chinese University of Hong Kong (CUHK) and was installed at the Prince of Wales Hospital under the management of the CUHK Jockey Club Minimally Invasive Surgical Skills (MISS) Centre, one of the comprehensive multi-disciplinary surgical skills centers in the Asia Pacific region."
"Roberta Lipson, Chindex President and CEO, commented from Beijing, 'We are very excited about this first sale of a da Vinci® Surgical System in Hong Kong, in particular because the CUHK Jockey Club MISS Centre will be such a high profile player and innovator in minimally invasive surgical procedures. The addition of this system to the Centre's state-of-the-art facility will both advance the quality of healthcare in the region as well as provide an opportunity to increase exposure to this exciting technology to surgeons throughout China.'
Intuitive Surgical's Senior Vice President of Sales, Jerry McNamara, said: 'We believe that the China market is ready to move to the next level of minimally invasive surgery with Intuitive Surgical's da Vinci® Surgical System, and are pleased that our partner, Chindex, is off to a good start with this system placement at The Chinese University of Hong Kong.'
Professor Andrew Van Hasselt, Chairman of the Executive Board for The CUHK Jockey Club MISS Centre expressed his delight about being the first China installation of the da Vinci® Surgical System, 'The mission of the Centre is to overcome the acknowledged drawbacks of traditional training methods in surgery by developing advanced training systems offering MIS techniques facilitated by virtual reality, robotic surgery and multimedia applications for training and education. The da Vinci® Surgical System will become a centerpiece in our facility.'
Chindex is an American healthcare company supplying both medical equipment and healthcare services to the Chinese marketplace, including Hong Kong. It sells medical equipment produced by a number of major multinational companies including Siemens AG as its exclusive distribution partner for the sales and servicing of color doppler ultrasound systems. It also arranges financing packages for the supply of medical equipment to hospitals in China utilizing the export loan and loan guarantee programs of both the U.S. Export-Import Bank and the German KfW Development Bank. It provides healthcare services through the operations of its network of private primary care hospitals and affiliated ambulatory clinics in China. With twenty-four years of experience, over 1,000 employees, and operations in the United States, China and Hong Kong, the Company's strategy is to expand its cross-cultural reach by providing leading edge healthcare technologies, quality products and services to Greater China's professional communities. Further company information may be found at the Company's websites http://www.chindex.com and http://www.unitedfamilyhospitals.com.
About Intuitive Surgical:
Intuitive Surgical, Inc., headquartered in Sunnyvale, California, is the global technology leader in the rapidly emerging field of robotic-assisted, minimally invasive surgery (MIS). Intuitive Surgical® develops, manufactures and markets robotic technologies designed to improve clinical outcomes and help patients return more quickly to active and productive lives. The company's mission is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. More information is available at http://www.intuitivesurgical.com and http://www.davinciprostatectomy.com.
Some of the information in this press release may contain statements regarding future expectations, plans, prospects for performance of the Company that constitute forward-looking statements for purposes of the safe harbor provisions of The Private Securities Litigation Reform Act of 1995. The Company cannot guarantee future results, levels of activity, performance or achievements. The numbers discussed in this press release also involve risks and uncertainties. The following factors, among others, could cause actual results to differ materially from those described by such statements: our ability to manage our growth and maintain adequate controls, our ability to obtain additional financing, the loss of services of key personnel, general market conditions including inflation or foreign currency fluctuations, our dependence on relationships with suppliers, the timing of our revenues and fluctuations in financial performance, the availability to our customers of third-party financings, product liability claims and product recalls, competition, hiring and retaining qualified sales and service personnel, management of inventory, relations with foreign trade corporations, dependence on sub-distributors and dealers, completion and opening of healthcare facilities, attracting and retaining qualified physicians and other hospital personnel, regulatory compliance, the cost of malpractice, our dependence on our information systems, the economic policies of the Chinese government, the newness and undeveloped nature of the Chinese legal system, the regulation of the conversion of Chinese currency, future epidemics in China such as SARS or Avian Flu, the control over our operation by insiders, continuity of relationships and variability of financial margins with existing suppliers, our liquidity and availability of capital resources to meet cash requirements, including capital expenditures and bid and performance bonds, and those other factors contained in the section titled "Risk Factors" as set forth in the Company's Registration Statement on Form S-3 (File No. 333-114996) filed with the Securities and Exchange Commission, as well as other documents that may be filed by the Company from time to time with the Securities and Exchange Commission. The forward-looking statements and numbers contained herein represent the judgment of the Company, as of the date of this press release, and the Company disclaims any intent or obligation to update such forward- looking statements to reflect any change in the Company's expectations with regard thereto or any change in events, conditions, or circumstances on which such statements are based."
Sources:
=> Chindex International, Inc.
=> Yahoo Finance
"Chindex International, Inc. (Nasdaq: CHDX - News), a leading independent American provider of western healthcare products and services in the People's Republic of China, announced today that it has concluded its first sale in China of the da Vinci® Surgical System, manufactured by Intuitive Surgical® (Nasdaq: ISRG - News), the innovator and market leader in surgical robotics. The system was purchased by The Chinese University of Hong Kong (CUHK) and was installed at the Prince of Wales Hospital under the management of the CUHK Jockey Club Minimally Invasive Surgical Skills (MISS) Centre, one of the comprehensive multi-disciplinary surgical skills centers in the Asia Pacific region."
"Roberta Lipson, Chindex President and CEO, commented from Beijing, 'We are very excited about this first sale of a da Vinci® Surgical System in Hong Kong, in particular because the CUHK Jockey Club MISS Centre will be such a high profile player and innovator in minimally invasive surgical procedures. The addition of this system to the Centre's state-of-the-art facility will both advance the quality of healthcare in the region as well as provide an opportunity to increase exposure to this exciting technology to surgeons throughout China.'
Intuitive Surgical's Senior Vice President of Sales, Jerry McNamara, said: 'We believe that the China market is ready to move to the next level of minimally invasive surgery with Intuitive Surgical's da Vinci® Surgical System, and are pleased that our partner, Chindex, is off to a good start with this system placement at The Chinese University of Hong Kong.'
Professor Andrew Van Hasselt, Chairman of the Executive Board for The CUHK Jockey Club MISS Centre expressed his delight about being the first China installation of the da Vinci® Surgical System, 'The mission of the Centre is to overcome the acknowledged drawbacks of traditional training methods in surgery by developing advanced training systems offering MIS techniques facilitated by virtual reality, robotic surgery and multimedia applications for training and education. The da Vinci® Surgical System will become a centerpiece in our facility.'
About Chindex International, Inc.
Chindex is an American healthcare company supplying both medical equipment and healthcare services to the Chinese marketplace, including Hong Kong. It sells medical equipment produced by a number of major multinational companies including Siemens AG as its exclusive distribution partner for the sales and servicing of color doppler ultrasound systems. It also arranges financing packages for the supply of medical equipment to hospitals in China utilizing the export loan and loan guarantee programs of both the U.S. Export-Import Bank and the German KfW Development Bank. It provides healthcare services through the operations of its network of private primary care hospitals and affiliated ambulatory clinics in China. With twenty-four years of experience, over 1,000 employees, and operations in the United States, China and Hong Kong, the Company's strategy is to expand its cross-cultural reach by providing leading edge healthcare technologies, quality products and services to Greater China's professional communities. Further company information may be found at the Company's websites http://www.chindex.com and http://www.unitedfamilyhospitals.com.
About Intuitive Surgical:
Intuitive Surgical, Inc., headquartered in Sunnyvale, California, is the global technology leader in the rapidly emerging field of robotic-assisted, minimally invasive surgery (MIS). Intuitive Surgical® develops, manufactures and markets robotic technologies designed to improve clinical outcomes and help patients return more quickly to active and productive lives. The company's mission is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. More information is available at http://www.intuitivesurgical.com and http://www.davinciprostatectomy.com.
Some of the information in this press release may contain statements regarding future expectations, plans, prospects for performance of the Company that constitute forward-looking statements for purposes of the safe harbor provisions of The Private Securities Litigation Reform Act of 1995. The Company cannot guarantee future results, levels of activity, performance or achievements. The numbers discussed in this press release also involve risks and uncertainties. The following factors, among others, could cause actual results to differ materially from those described by such statements: our ability to manage our growth and maintain adequate controls, our ability to obtain additional financing, the loss of services of key personnel, general market conditions including inflation or foreign currency fluctuations, our dependence on relationships with suppliers, the timing of our revenues and fluctuations in financial performance, the availability to our customers of third-party financings, product liability claims and product recalls, competition, hiring and retaining qualified sales and service personnel, management of inventory, relations with foreign trade corporations, dependence on sub-distributors and dealers, completion and opening of healthcare facilities, attracting and retaining qualified physicians and other hospital personnel, regulatory compliance, the cost of malpractice, our dependence on our information systems, the economic policies of the Chinese government, the newness and undeveloped nature of the Chinese legal system, the regulation of the conversion of Chinese currency, future epidemics in China such as SARS or Avian Flu, the control over our operation by insiders, continuity of relationships and variability of financial margins with existing suppliers, our liquidity and availability of capital resources to meet cash requirements, including capital expenditures and bid and performance bonds, and those other factors contained in the section titled "Risk Factors" as set forth in the Company's Registration Statement on Form S-3 (File No. 333-114996) filed with the Securities and Exchange Commission, as well as other documents that may be filed by the Company from time to time with the Securities and Exchange Commission. The forward-looking statements and numbers contained herein represent the judgment of the Company, as of the date of this press release, and the Company disclaims any intent or obligation to update such forward- looking statements to reflect any change in the Company's expectations with regard thereto or any change in events, conditions, or circumstances on which such statements are based."
Sources:
=> Chindex International, Inc.
=> Yahoo Finance
Guidant avalée, mais à un prix moindre
Guidant (GDT) sera bien avalée par Johnson & Johnson (JNJ) mais à un prix inférieur de 15% à celui convenu par les deux entités en décembre dernier.
Les difficultés survenues cet été par le fabricant américain d'appareils médicaux, Guidant, qui a été contraint de rappeler certains de ses implants cardiaques, menaçaient le rachat proposé par J&J.
Guidant en avait appelé à la justice pour contraindre J&J à mener à bien son acquisition après que ce dernier eut menacé d'y renoncer. J&J faisait valoir que le rappel des implants cardiaques et des enquêtes en cours visant Guidant avaient réduit la valeur de celui-ci.
J&J paiera finalement quelque 19G$ US pour prendre le contrôle de Guidant, soit 15% de moins que les 25,4G$ US annoncés en décembre.
J&J offre donc 33,25$US et 0,493 de ses actions pour chaque titre de Guidant. Le montant de la transaction atteint 21,5G$ US.
L'action de Guidant est ainsi valorisée à 63,08$US selon le cours de clôture de lundi, soit une prime de 9% par rapport à son prix de clôture de 57,75$US sur le New York Stock Exchange. Le prix initialement convenu en décembre était de 75$US.
L'accord révisé a été approuvé par les conseils d'administration des deux sociétés et doit être encore soumis aux actionnaires de Guidant. La transaction devrait être conclue au 1er trimestre de 2006.
Guidant annonce le départ de son président et chef de la direction, qui était en poste depuis 11 ans. Le président actuel de Guidant, James Cornelius, assumera la fonction par interim".
Source :
Webfin.ARGENT
Les difficultés survenues cet été par le fabricant américain d'appareils médicaux, Guidant, qui a été contraint de rappeler certains de ses implants cardiaques, menaçaient le rachat proposé par J&J.
Guidant en avait appelé à la justice pour contraindre J&J à mener à bien son acquisition après que ce dernier eut menacé d'y renoncer. J&J faisait valoir que le rappel des implants cardiaques et des enquêtes en cours visant Guidant avaient réduit la valeur de celui-ci.
J&J paiera finalement quelque 19G$ US pour prendre le contrôle de Guidant, soit 15% de moins que les 25,4G$ US annoncés en décembre.
J&J offre donc 33,25$US et 0,493 de ses actions pour chaque titre de Guidant. Le montant de la transaction atteint 21,5G$ US.
L'action de Guidant est ainsi valorisée à 63,08$US selon le cours de clôture de lundi, soit une prime de 9% par rapport à son prix de clôture de 57,75$US sur le New York Stock Exchange. Le prix initialement convenu en décembre était de 75$US.
L'accord révisé a été approuvé par les conseils d'administration des deux sociétés et doit être encore soumis aux actionnaires de Guidant. La transaction devrait être conclue au 1er trimestre de 2006.
Guidant annonce le départ de son président et chef de la direction, qui était en poste depuis 11 ans. Le président actuel de Guidant, James Cornelius, assumera la fonction par interim".
Source :
Webfin.ARGENT
USA: ENT/ORL Oncology Robotic Surgery
Dr. Gregory Weinstein is being interviewed by Christopher Dolinsky, MD, at the Abramson Cancer Center of the University of Pennsylvania, USA.
We are very lucky to have the opportunity to interview Dr. Gregory Weinstein, Professor and Vice Chair of the Department of Otorhinolaryngology, Director of the Division of Head and Neck Surgery, and Co-Director of The Center for Head and Neck Cancer at the Hospital of the University of Pennsylvania.
Today we are going to be talking about a fascinating new technology available to patients at Penn: the daVinci Robotic Surgical System.
"Dr. Dolinsky: Dr. Weinstein, thank you so much for joining us today. Let's start from the top – what exactly is the daVinci Robotic Surgical System, and how does it work?
Dr. Weinstein: The daVinci Robotic System has been used for a number of years, both in the United States and abroad. There are 305 of these robots nationwide as of this year. The way that the system works is that the surgeon sits at a console where he or she operates with joysticks, using his or her fingers. The surgeon looks through a scope that has a 3D picture of whatever is in the visual field. It is like looking right at the patient. It has a bedside cart that the console is wired to, and the cart has four arms, although we only use three of them. The middle arm has an endoscope on it that has two cameras that allow for stereoscopic vision. The two lateral arms are long fit arms that are either 10 mm wide, 8 mm wide, or 5 mm wide, and they are quite long. At the very end is the working end of the instrument. There are a variety of different instruments that can be used.
Essentially, the end of the instrument moves exactly like your hand does. It is as if your hands miniaturized and in whatever small cavity is being operating upon. The system has perfect movement with 6° of freedom, so it actually completely reflects the wrist.
Dr. Dolinsky: This is certainly a different approach to surgery than the traditional methods – has it been difficult to learn to use this system?
Dr. Weinstein: It has a very short learning curve. For instance, studies of this system have compared students [who have] almost no experience [with] throwing sutures in laparoscopic cases to standardized laparoscopic experts; the students were doing almost as well as the experts in a very short time because it is so intuitive. Thus the name of the manufacturer, Intuitive Surgical.
Dr. Dolinsky: Has it been used for any other surgical sites? If so, which, and how are the results?
Dr. Weinstein: It has been estimated that 10 per cent of radical prostatectomies were done robotically last year in the United States. So radical prostatectomy is a popular procedure for this system. It is also used for cardiac procedures, other urologic procedures, and now it has been approved for gynecology. Essentially, anywhere that laparoscopes can be used - this overcomes the deficiencies of laparoscopic surgeries.
Dr. Dolinsky: What types of deficiencies?
Dr. Weinstein: Deficiencies of laparoscopic surgery are that they tend to be one-handed, because you have a video scope and you have a handing scope. Even if you have two hands, you have a fulcrum effect because of the abdominal wall. If you want your instrument to move one way, you have to move your hand the opposite way. It is counterintuitive. It does not have the degrees of freedom of your wrist at the end of the instrument, because the working end is at the tip of a long instrument that is now in the body cavity. The value of the daVinci system is that you can use both hands, and the working end of the instrument moves the way your hand does.
Dr. Dolinsky: Is anyone else using the system in a similar fashion?
Dr. Weinstein: We were the first in the world to apply it to trans-oral work. We are the only center in the world with an IRB-approved study to look at this, and in fact the only center right now reporting on this. Drs. Hockstein and O'Malley, from our department, first started with mannequin and cadaver work and figured out how to use the scopes to get into the mouth, then we moved up to animal models. We now have an IRB-approved protocol where the primary endpoint is exposure. The question is, can you achieve the exposure to do the procedure? And if you can get the exposure to do the procedure, you do the procedure. That is the way the study works. We are also looking at secondary endpoints of safety and efficacy.
Dr. Dolinsky: How many cases have you done? And how have they gone?
Dr. Weinstein: We have done 19 cases to date. That includes supraglottic laryngectomies for supraglottic cancer, numerous tongue base cancer resections, and numerous tonsil cancer resections. It included two cases so far where the resection that we did would, in typical hands, have required a jaw split and a free flap reconstruction. In one of them, we didn't do any reconstruction, and we are just letting it heal by secondary intention. In the other, we actually avoided the jaw split, did the resection, and then brought the flap up through the neck. That saved the jaw split plating, significant swallowing and dental problems for the patient, time in the operating room, and cosmetic deformity.
Dr. Dolinsky: So you answered a bunch of the initial questions I had for you. Besides yourself, who else is doing this?
Dr. Weinstein: Dr. Bert O'Malley, the Chairman of the Department of Otorhinolaryngology: Head and Neck Surgery. We do most cases together, it is important to stress that. The whole project began as a resident's project and the fundamental work was done under the guidance of Bert O'Malley. One of our former residents, Neil Hockstein, did the first mannequin and cadaver work out at the company in California . Then, Bert and I have brought it to the clinical arena. Both Bert O'Malley and I are the principal investigators on the study.
Dr. Dolinsky: Have you encountered any complications with the system?
Dr. Weinstein: We haven't had any complications so far. And we don't think the complications of this surgery, using the robot, are going to be very common. At this point, it is looking as if it is going to be no greater risk than doing standard trans-oral surgery. It also allows us to get to places we couldn't get to before.
There is no standard trans-oral technique giving good access to the back of the tongue because of line-of-sight problems. Traditionally, when you are working on the mouth, you are using long instruments through the laryngoscopes (which are very tight tubes), and you are looking straight down through a microscope which is outside [of] the patient. With this system, we have 30° scopes that can look up and instruments that can then be positioned to cut around the tongue base. In the past, the limitation of trans-oral resection of tonsil cancer was that it couldn't involve the tongue base. We are doing radical removal of the tonsil plus the tongue base through the mouth, a surgery which heretofore required a jaw split to get access. Some cases need reconstruction and some cases don't need reconstruction at all.
The key thing in head and neck cancer is that if you can get negative surgical margins, you really impact favorably on the patient's outcome. All of our margins have been negative so far. We had a close margin in one patient, but we were able to go back and re-resect.
In addition, if you can perform surgery and follow it with chemoradiation or radiation afterwards without worsening the outcome in terms of function, then there is really no downside doing the surgery to improve local control. If the surgery is not going to impact on function (which it doesn't appear to do when we perform it trans-orally in these types of cases), then there is no reason not to do it.
Dr. Dolinsky: This sounds like a great choice for patients, but I was wondering if there are specific contraindications?
Dr. Weinstein: There are preoperative and intra-operative exclusion criteria. Pre-operative contraindications include: unexplained fever, untreated active infection, pregnancy, previous head and neck surgery that precludes trans-oral robotic procedure (in other words, if the prior kind of surgical procedure does not allow me to get into the mouth), and the presence of medical conditions contraindicating general anesthesia or trans-oral surgical approach. Intra-operatively, [an exclusion criterion is] the inability to adequately visualize the anatomy to perform the diagnostic or therapeutic surgical approach trans-orally.
Dr. Dolinsky: Do these surgeries take about the same amount of time as standard oral surgeries?
Dr. Weinstein: They are taking less time. That is a very good question. For instance, a patient I did recently (my last case was a tongue base/ tonsil cancer) had his procedure in about 2 hours or so - counting resection, frozen sections, everything. He will come back to have another procedure for the neck (neck dissection), which is a staging procedure. He is going to avoid a tracheostomy, and the neck dissection will take about three hours.
The traditional approach to a tongue-based tonsil cancer, if you can use primary surgery, is a 15-hour procedure, with a jaw split, tracheostomy, and 8-day hospitalization. It is going to be much less than that for him.
I have another example. The two supraglottic cancers we did - one of them had perfect exposure and it took us about 2 hours. In another case, the exposure was not as good and it took a little longer. But, it was a good procedure and it turned out fine. A traditional laser supraglottic laryngectomy (which is very popular right now trans-orally for T1, T2, and selected T3 cancers of the supraglottis) takes me about 3 to 3.5 hours to perform.
In general, my expectation is that the robotic surgeries will be either faster, or take the same amount of time, but with better visualization because of the optics. So it will have other advantages besides time. That is my general impression at this point. It is certainly not taking longer.
Dr. Dolinsky: So what would you say the major advantages are?
Dr. Weinstein: One of the major advantages we already discussed is the length of the procedure. Another is that we are also going to have improved vision and magnification with high-end optics. The ability to use two hands, without the fulcrum effect present in standard endoscopic approaches, is certainly an advantage, as is the ability to use a miniaturized electric cauterer in places that we couldn't get to before. The high magnification 3 dimensional camera and endoscope that is very near to the surgical site allows us to see, dissect, and control critical nerves and blood vessels that we typically cannot see well or deal with when working through a tubular laryngoscope using a hand help endoscope or even with loops or a microscope used at a distance from the actual site of surgery in the mouth. Those are going to be the main benefits to the surgeon.
The main benefits to the patient are going to be (in many cases): avoidance of tracheostomy, avoidance of a long procedure that requires complex reconstruction, and a minimally invasive approach that will decrease patient's rehabilitation time. Those are the kind of things we see down the pike for patients. I am giving you a gestalt because I have not analyzed this. But that is my prediction.
Dr. Dolinsky: What do you think about the future of robotic surgery?
Dr. Weinstein: I think that the future we are going to see is very exciting. First of all, I think that there are going to be new instruments that come along that allow us to do even more robotically. Robotic surgery is going to be one additional tool that is in our armamentarium for selected patients, but it is not going to replace everything. It will take a few years for us to figure out which are the ideal cases. But, it will be an important tool for selected cases to help us eradicate cancer and improve function.
Dr. Dolinsky: Any ballpark estimates on what percent of cases will be done this way in the future?
Dr. Weinstein: It is hard to say. It is hard [to predict] with new ideas and new technology. It is always complicated to see how these things are going to catch on, but our key focus is development first, and then teaching second.
Years ago, (in the late 1980's and early 1990's), I introduced an operation called the supracricoid laryngectomy to the United States from France. I am not sure if you are familiar with it, but it is now a standard operation. It took us about 10 years for it to be in the text books, written about widely, done nationally in numerous institutions, and considered part of the standard-of-care based on practice guidelines from various organizations. The way that happened, in my opinion, was not only by doing it and proving it could work, but by spending time teaching it. A major focus is to first perfect the technique, which is what we are doing now, and then the second major focus is going to be teaching it. Teaching it by publishing, by giving lectures and CME courses. If you don't teach it and get it out there, then it's like it doesn't exist. Those who want to learn will learn it and we will see if it catches on. It will only catch on if it is of value and is used efficiently and effectively.
Dr. Dolinsky: If you encounter specific limitations to the system, is there a way for you to suggest improvement to the company? Or do you think that, at least currently with what you have seen, everything seems to be working the way you would like it to?
Dr. Weinstein: We have everything we need right now for all that we are doing, but we are working on ways to improve the instruments and design new instruments that will be useful specifically for Transoral Robotic Surgery.
Dr. Dolinsky: If you were a patient, what do you think the best reason for enrolling in the study would be?
Dr. Weinstein: I think there are a number of reasons a patient may benefit. They may benefit by avoiding a tracheostomy. I think we are seeing faster rehab in functional recovery. When it comes to things like not having to have your jaw split, it is less surgery, less deformity, and less pain.
It is another surgical tool, it is just a highly, highly, sophisticated surgical tool. Although it is called a robotic system, remember, this is not an independent robot like you might see in the cinema. I am kind of digressing here to make a point. I told my uncle, who is 85, that we are doing this, and he replied that he didn't want a robot operating on him. The reality is that it is not a robot operating on you - it is the surgeon. Unless you are in there and your head is in the goggles and your hands are on the controls, the system will not work. It can't do the surgery for you. It is a tool. It is an extension of the surgeon. To me, the benefit is going to be allowing us to do very complex, sophisticated, successful surgical operations, without having to do very wide surgical approaches that we had to do in the past.
Dr. Dolinsky: Based on the way this works, would it be possible, with Internet connections, to operate on someone from across the country?
Dr. Weinstein: Yes. There have been a couple of experiments with that. There was one many years ago where they operated on a gall bladder across the Atlantic across telephone lines. Then there is a group in Canada using a prior iteration of this machine called the 'Zeus' (which you can find on the Internet). They reported 21 cases where the patients were 400 km away, with two surgeons working across ISDN lines.
There are complexities that need to be worked out in terms of latency, broadband width, and the integrity of the connection. We are actually extremely interested in this here at Penn. But the complexity of what you are describing, which is tele-surgery -- we are very close to having the technology to do that. It is all the other issues that go along with it that will be the impediment for its success -- issues like insurance, patient acceptance, and physician acceptance.
I do see tele-surgery in the future as [a solution] to a major crisis in American healthcare, which is the lack of specialists in rural America. If you had a person who is trained as an assistant who can take care of surgical complications and who knew the rudiments of the case, while the highly-specialized person is at a hub somewhere else, actually performing the surgery - you might be able to deliver healthcare to a section of society that presently doesn't [have access to it], and I think that is an exciting prospect for the future.
In fact, trans-oral robotic surgery would be the ideal area to start that type of surgery, because remember, for every other type of surgery, you have to make incisions to get in. But here, the orifice for getting into the patient is already there - the mouth. The risks and complications for this type of approach will be much lower. It makes some sense to start in that arena. But at this point, that is science fiction. And I would prefer to limit our discussion to science fact."
Source:
Onco Link
Johnson & Johnson conteste l'action en justice de Guidant
Johnson & Johnson a répété lundi qu'il n'était pas tenu de finaliser l'acquisition de Guidant, s'opposant ainsi à l'action en justice que vient de lui intenter le fabricant américain d'appareils cardiologiques.
Source :
Boursier.com
==> Lire aussi :
"Guidant descend encore d'un cran, Johnson & Johnson pourrait abandonner son offre" : cliquer ici.
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