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Dr. Brian Blackwood, top, and physician’s assistant Beth Hewes perform a robotic knee replacement surgery on Boulder resident Bruce Borowsky’s left knee in February at the Boulder Community Health Foothills Campus. The robotic tool wrapped in plastic in the center of the frame is an example of the state-of-the-art medical technology for a wide range of surgical procedures that has gone solidly mainstream. (Cliff Grassmick/Staff Photographer)
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You’ll let robots prepare your burgers, check you in to your hotel, build your cars, mix your drinks and even fight your wars.

So how about to operate on your spine?

The idea might not sit well at first blush with some, but robotic-assisted surgery, far from being an artifact of some dystopian near-future science fiction, has gone solidly mainstream and increasingly represents the state-of-the-art medical technology for a wide range of surgical procedures ranging from full joint replacements to spinal fusion.

The Boulder County area now offers a variety of procedures involving robotic technology, both at area hospitals, and also free-standing ambulatory surgical practices that send patients home the same day from procedures such as hip replacements, which once would have required lengthy hospital stays.

Boulder resident Bruce Borowsky, 59, has suffered knee issues for some time, having had both knees surgically repaired for miniscus tears over the years. But still, his left knee had for some time still been in a bad way.

“I’m very active. I travel all over the world constantly, and I’ve been able to power through the pain, and I’m able to forget about it pretty well for the most part. But sometimes. it catches up to me, after a day spent hiking or filming or whatever,” said Borowsky, a producer at Pixel Mill Studios, and co-founder of Boulder Digital Arts.

He saw joint replacement surgeon Dr. Brian Blackwood speak at the Boulder Jewish Community Center two years ago, and subsequently made an appointment.

“He told Jenny (his wife, Jenny Doyle) and I that he could do the surgery right then, that I was well-qualified,” Borowsky said. “But he also said in his experience it’s generally best to wait as long as you can. Because generally, you only want to do this once.”

That day finally came on Feb. 19, at Boulder Community Health. Borowsky said he did not overeducate himself on what the procedure would entail.

“The less I know, the better,” Borowsky said two days prior to the procedure. “Jenny understands it. She’s a health care professional. But for me, I guess the best way to describe it is my reaction to one of the nurses at the doctor’s office, who said, ‘It’s sort of like a carpentry workshop, in there.’ The less I know, the better.”

Doyle said, when the procedure was done that day, “”I’ve seen oil changes that took longer.” Her husband went home from BCH by noon the next day.

‘Mild trepidation’ is gone

Just over three weeks earlier, Blackwood, a surgeon at Boulder Centre for Orthopedics and Spine, performed Colorado’s first Mako robotic-assisted joint replacement in an ambulatory surgery setting in Colorado.

He did so at the Boulder Surgery Center, which is partnered with BCH, and according to Stryker, its manufacturer, is currently the only surgery center offering the Mako robotic-assisted joint replacements in Colorado.

“Since I came here seven years ago, we’ve more than doubled the joint volume at the hospital with the robotics, and then we have shortened the length of stay by 60 or 70%,” said Blackwood. He received his fellowship training at the Coon Joint Replacement Institute north of San Francisco, came to Boulder in 2016, and is now a veteran of more than 2,000 joint replacement procedures.

BCH was the second hospital in the state to offer Mako robotic-assisted total hip replacement and partial knee replacement, and the first to offer Mako total knee replacement, having completed more than 2,050 joint replacements since 2013, according to marketing manager Celanie Pinnell.

Dr C. Brian Blackwood, center, talks about the Mako robotic-arm-assisted orthopedic surgery robot on the left with David and Sara Harper, of Superior. Boulder Community Health showed off to primary care physicians its array of new robotic surgical technology, including Mako, used for knee and hip replacements at the Boulder Jewish Community Center in February. (Cliff Grassmick / Staff Photographer)

“Robotic-arm assistance allows me to perform the surgery with less-invasive techniques,” Blackwood said. “It also aids in both perfect implant placement and soft-tissue balancing, leading to increased patient satisfaction, better function and improved longevity of the results.”

At a recent exhibit of robotic technologies held by BCH at the Boulder Jewish Community Center dubbed “Robopalooza,” Blackwood demonstrated aspects of the medical craft for visitors who included potential donors to the Boulder Community Health Foundation.

“We were one of the first places in the country, and the world, to really do the total knee replacement application” robotically, Blackwood said. “Before, it was partial knees, from to 2006 to 2011. And in 2011 they added total hip and in 2016 they added the total knee.”

The era of people shying away from robotic intrusion into the body, he said, is well past.

“For initial patients, there was a little bit of mild trepidation. That rapidly went away,” Blackwood said. “People assume every single surgery I do now is done with the robot, and people actually search it out and want to have that technology involved in their case and procedure.”

Explaining how the robot can see where the saw is during surgery, he said AccuStop technology that is part of the system will not allow him to activate a bone saw when the blade is not properly located.

“You can still screw up if you try hard enough, but it helps prevent it,” Blackwood said. “We can see where we’re actually going to make the cuts on the bone and follow that in real time, and stay out of the soft tissue.”

The benefits from robotic-assisted surgery, he said, are numerous.

“There are studies showing there is less soft tissue damage and more accurate cuts with using the robotic arm system than using the manual traditional techniques,” Blackwood said. “In addition, there are studies showing there is less use of opioids after the surgery, shorter hospital stays, faster recovery and less use of physical therapy.”

An executive order Thursday by Colorado Gov. Jared Polis has suspended all “nonessential” surgeries and medical procedures in Colorado in order to free up equipment, including ventilators and personal protection items for staff battling the coronavirus.

‘Essentially, carpentry’

While Mako technology is well-established in local operating rooms, the newest addition to the menu of what’s available in robotic-assisted surgery is Mazor X Stealth spine surgery, typically deployed in spinal fusion procedures.

The Mazor X Stealth system combines proprietary software to plan the surgical procedures, a robotic arm to precisely guide the placement of implants during complicated spine surgery, and real-time navigation feedback to make sure the procedure goes as planned. BCH’s Foothills Hospital was the first Colorado hospital north of Denver to offer it, having acquired it Feb. 4.

Dr. Kara Beasley is a neurosurgeon at Boulder Neurological & Spine Associates, and was scheduled to perform her first spinal fusion with it earlier this month. As of mid-March, the BCH Foothills Hospital had completed seven, but anticipated that number to grow, as more people seek it out.

She was singing its praises, and offering demonstrations at the JCC event. The Mazor X Stealth system was only launched in the U.S. in January of last year.

“What the robot lets us do is be more accurate than we can be” without it, Beasley said. “I’m only a human. My partners are only human, so we make surgical judgments, and even just moving our hand a couple of degrees in a certain direction can change the entire trajectory of a screw as it’s going in. And that can cause problems.

“What the robot does is it prevents us from having that human error or that human deviation as we’re putting screws and rods in. So it makes us far more accurate.”

Beasley, who joked that what she does is “essentially carpentry” — the vocabulary of her trade includes screwdrivers, taps and drills — emphasized that decompression of the spine during surgery, the removal or bone or discs, is still done “with my own two hands.” In three to five years, she expects that to also be accomplished with the help of robotics.

“What this allows me to do is to be faster, safer, and a quicker placement of the screws. The surgeon is still running it. It’s not like I press a button and walk out of the room,” Beasley said.

She also touted the fact that the Mazor X Stealth system is manufactured by Medtronic, based in Louisville.

“So our surgeons, myself and my partners, have been able to have significant input with the engineers and the software designers to let them know that as practicing surgeons, these are the things we need, these are the things we want,” she said. “If we find something isn’t working, we can just go directly to them because they are 15 minutes from us.”

Much as is the case with robotic-assisted joint replacement, the pluses for bringing robotics into a spinal procedure range from degenerative discs to scoliosis, its advocates say, include greater accuracy, fewer risks for complications and shorter hospital stays. Small incisions are not practical for full joint replacements, but minimal invasiveness is another plus arguing for its application to some spinal procedures.

As a neurosurgeon, Beasley also performs what is known as deep brain stimulation, which involves implanting a wire in the brain to send electrical impulses to areas of the brain responsible for body movement, to suppress the most noticeable symptoms of ailments such as Parkinson’s disease. She is not using a robot for that — yet.

“We’re not that far away,” she said, noting that Mazor’s Stealth Autoguide Platform, now on the market, will allow accurate brain biopsies, and its Renaissance system will facilitate placement of brain stimulation wires, called leads.

Cardiothoracic, general surgical, gynecological and urological procedures are all benefiting from robotic-assisted surgery courtesy of Intuitive’s Da Vinci Xi, which is the fourth iteration of a robotic program featuring boom-mounted arms, which offers broader anatomical access, 3DHD vision and wristed instruments controlled from a single console.

Dr. Kyle Marthaller, right, explains the Da Vinci Xi robotic-assisted machine at a Boulder Community Health-hosted event where the system showed off to primary care physicians its array of new robotic surgical technology.(Cliff Grassmick / Staff Photographer)

“It sort of takes traditional laproscopic surgery to the next level,” said Dr. Kyle Marthaller, a general surgeon at BCH. “It allows me to do very fine movements, movements that I would not be able to do traditionally laproscopically, in a minimally invasive environment.

“So traditionally a lot of these surgeries would be done open, meaning, a big incision. And this allows me to do fine motor movements, intricate surgeries using small holes. So instead of staying in the hospital five to seven days with a big hole in the belly, they can go home in two or three days from the same surgery and have the same outcomes.”

Marthaller’s youthful appearance prompted the question of his age — he’s 35 — so he is as freshly into his practice as some of the technology that he is using now, and will continue to to evolve rapidly as his career continues.

“I grew up playing Playstation, X-Box, those kinds of things,” he said. “So, I feel like, you know, this is somewhat a natural extension of that hand-eye coordination that you develop playing Halo, growing up.”

BCH’s Foothills Hospital is also the only medical facility in Colorado and the surrounding multistate region performing cardiac mitral valve surgery using the Da Vinci robotic-assisted system, Pinnell said.

The march of the robots through area operating rooms is hardly limited to Boulder.

At UCHealth Longs Peak Hospital in Longmont, the Da Vinci Xi robot has been in use since it opened in August 2017.

“It is the most-utilized service at Longs Peak for general, gynecological and urology surgical procedures,” said Kelly Tracer, spokeswoman for UCHealth Longs Peak Hospital in Longmont.

“Furthermore, we are currently evaluating becoming a Robotic Center of Excellence and evaluating the use of robots with additional surgical specialties that have demonstrated the ability to improve outcomes.

Kirsten Gurmendi, a spokeswoman for Centura Health‘s Avista Adventist Hospital in Louisville, said the facility acquired the area’s second Mazor X system for spinal procedures on March 2. It has been using the Da Vinci system for several years, and upgraded to the Da Vinci Xi in November 2018. Centura Health’s Longmont United Hospital is outfitted with Da Vinci Xi robotics.

‘Complete faith’

Borowsky, two weeks after his surgery, was still contending with some pain but was well along in his recovery.

“I’m walking without a cane or walker,” said Borowsky, who had driven his car for the first time post-surgery the day before. In fact, he said, “They had me walking up and down stairs the same day as my surgery.”

He had his first session of physical therapy nine days after the knee replacement, with two more on tap the week that followed.

An avid tennis player as well as a fan of other outdoor pursuits, Borowsky didn’t yet know his timeline for return to all the activities he loves.

“They’ve made no promises and I have very low expectations. I made sure I didn’t have anything planned, so I wouldn’t feel rushed. I’m just kind of going with the flow and I look forward to playing tennis again, as quickly as possible.

“I look forward to that day when I wake up and there’s no pain. But I have complete faith in the doctors, and the surgery.”

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