Karpov Oleg Eduardovich — Corresponding Member of the Russian Academy of Sciences, M.D., Ph.D., Professor, General Director of the National Pirogov Medical Surgical Center of the Ministry of Healthcare of the Russian Federation. Author and co-author of more than 270 scientific papers and 6 monographs. Honored Doctor of the Russian Federation.
— Dear Oleg Eduardovich, Pirogov Center is a multidisciplinary institution of the federal level, actively introducing innovative technologies into practice. When did robotic surgery appear in your center?
— This happened in late 2008 thanks to the active support of the Ministry of Healthcare of Russia and became the embodiment of the dream of the President of the Pirogov Center, our Teacher, Academician Yu. L. Shevchenko. He got acquainted with robotic surgery at US military surgeons in the early 90s of the last century and highly appreciated the prospects for its development.
In December 2008, the first operation was performed in our center using a robotic Da Vinci complex — prostatectomy, and at the same time a seminar with international participation “Robotic Surgery” was held on the basis of the center. These events became the starting point for the introduction of this technology in various areas of surgery.
— The first robotic complexes were developed for the space industry, weren’t they?
— Many advanced technologies are developed for military or space programs, and then successfully used for civil purposes, including in medicine. The first robotic surgical system was created to provide urgent surgical assistance to astronauts at the orbital station. This development interested the military, as it made it possible to remotely conduct operations, reduce the likelihood of complications, reduce the area of operational injury. Subsequently, a civilian version of the equipment appeared.
— Is there any work in Russia to create an alternative to the robot Da Vinci?
— Not without pride I will answer: yes. In April 2017, Russian scientists presented a robotic surgical system that not only competes with the American analogue, but in many respects surpasses it. This is a joint development of specialists from the Institute of Design and Technology Informatics of the Russian Academy of Sciences (IDTI RAS) and the Moscow State Medical and Stomatological University named after A.I. Evdokimov (MSMSU) of the Russian Ministry of Healthcare. The initiators of this idea are the head of the Department of Urology at the MSMSU, the Corresponding Member of the Russian Academy of Sciences, Professor D. Yu. Pushkar and the Professor of IDTI, S. A. Sheptunov. Work on the creation of a domestic robotic surgeon has been conducted since 2012.
According to the developers, the domestic robot-assistant has a higher accuracy of manipulation, provides an excellent 3D-visualization. Undoubted its advantage is portability (weight 4.5 kg), which allows you to mount the unit to a standard operating table. At the same time, its cost is much lower than the American equivalent.
— So, according to the main indicators, the domestic robot-surgeon surpasses the foreign one?
— That’s right. This is a fundamentally new concept. In addition, the robot is assembled exclusively from components of domestic production. According to the Minister of Healthcare Veronika Skvortsova, the robot assistant is ready for serial production.
— Where in Russia is it possible to get an education in the field of robotic assisted surgery?
— A specialist who wants to start training in a robotic surgical complex Da Vinci must have the basics of traditional and laparoscopic (thoracoscopic) surgery, have experience in performing operations in urology, gynecology, abdominal surgery and coloproctology, thoracic and cardiovascular surgery, etc.
It is very important to study where the experience of using such technology is accumulated and there are qualified specialists in the relevant field. In the age of digital technology and the Internet, as you understand, the necessary information is easy to find.
— Oleg Eduardovich, since it’s about digital technologies, how important is this direction for our healthcare?
— In my opinion, it is extremely important. After all, the breakthrough of innovative technologies in the late XX — early XXI centuries radically changed the face of the world. In our time it is impossible to imagine the effective work of a medical institution that provides specialized and high-tech assistance, without digital technologies, including advanced development technologies. In clinical practice, telemedicine and telecommunication technologies are highly in demand in the operation of high-tech medical equipment, such as robotic surgical and rehabilitation complexes, navigation systems. Methods of personalized medicine are increasingly being used, workplaces for specialist doctors, registrars, laboratories, diagnostic offices, pharmacies, accountants and managers are being automated. Electronic document circulation, including electronic medical cards of patients, is actively introduced.
The most promising will be the use of telemedicine to remotely conduct medical diagnostic, rehabilitation, scientific and educational activities and obtain the so-called “second opinion”. It is no accident that the development of digital medicine, the creation of “smart” hospitals, chambers, etc. The Ministry of Health of Russia considers one of the priority areas for the coming years.
— But back to the robotic surgical complex. What are the main advantages of robotic surgery, please?
— The experience accumulated in recent years by specialists of the Pirogov Center in urology, gynecology, abdominal surgery and coloproctology, oncology and thoracic surgery, confirms the opinion of domestic and foreign specialists about a number of advantages of robot surgery before traditional laparoscopic technique.
This is a greater amplitude of the movements of the instruments than in the human hand, with no tremor; excellent, if necessary, increased stereo image (3D), providing the effect of “penetration” into the patient’s body; Improved ergonomics — the principle of “organist” (the surgeon controls a robotic surgical complex with the help of hands and feet, sitting in a comfortable position); the highest accuracy when manipulating, or, as we say, precision, which is especially important for operations in confined spaces; less traumatic surgery and blood loss, a low number of complications, which certainly contributes to early activation and accelerated rehabilitation of patients.
— Oleg Eduardovich, in which areas of surgery is the Da Vinci complex used most often, what is the experience of the Pirogov Center in performing such operations?
— Most often, urologists, gynecologists, and abdominal surgeons turn to robot-assisted endovideosurgery. Less often this technology is used in chest and cardiovascular surgery, endocrinology. The ratio of the use of Da Vinci in various areas of surgery is approximately the same both in Russia and abroad. By the way, foreign experts consider chest and cardiovascular surgery as one of the priority directions in the development of robotic surgery in 2018.
In the Pirogov Center by the end of 2017, more than 1200 robot-assisted operations were carried out. Our urologists, gynecologists and abdominal surgeries are in the lead. Operations with the use of the robotosurgical complex are also performed by thoracic surgeons (especially with mediastinal tumors) and endocrinology surgeons.
— And how much do these operations cost?
— In 2009, on the initiative of the Pirogov Center, permission was granted to use the new medical technology “robot-assisted endovideosurgery”. This is the correct and official name for it. In the same year, the order of the Ministry of Health of Russia included in the list of types of high-tech medical care that are provided to Russian citizens free of charge under the so-called “quotas”.
— In your opinion, as the leader of one of the leading federal multidisciplinary centers, is patient-oriented surgery a fashion trend?
— This is a very relevant and significant, in my opinion, theme and not just a trend, but one of the important directions of the development of medicine in the coming years.
With increasing list of new diagnostic and therapeutic technologies, methods, medicines, and various protocols and standards, we can miss the patient himself — a specific patient with his individual characteristics and variety of manifestations of the underlying disease, not to mention the combination of diseases. Foreign colleagues have noted such negative phenomena for a long time. That is why personalized, or patient-oriented medicine is so important, including surgery. It should not be a disease, but a patient. I think it’s clear that treating an average patient is about the same as analyzing the average temperature for a hospital.
— How to achieve an individual approach to treatment?
— Obviously, taking into account the previously mentioned factors and the increasingly narrow specialization of doctors, achievement of patient-orientation medicine (this, by the way, is also one of the priority directions in healthcare, designated by the Ministry of Healthcare), is possible only if a multidisciplinary approach is followed. It will help determine the selection of diagnostic and treatment methods for a particular patient. The principle of a multidisciplinary approach with access to a patient-oriented protocol in our center has been practiced for about 10 years and has proven itself well. Our experience in the past year, we shared with colleagues in the pages of Russian magazines.
It is not necessary to hope that the innovative technology will become a panacea, it is necessary to include it in the existing list of methods, thereby widening the choice of the surgeon. So it was with the robotic complex — the specialists of our center studied its possibilities, the results of using it in the country and abroad and only after that included robotic assisted operations in the practice of the Pirogov Center, taking into account the developed indications to them.
Thus, in each specific case, the surgeon makes a choice between open surgery, laparoscopic or robot-assisted. In this, there are elements of personification of treatment.
— Thank you, Oleg Eduardovich, for a very interesting, informative conversation!
For the special issue “Robotic surgery in Russia: Present and Future”