Michelle Davies | The Journal Gazette Cort Bulloch, a da Vinci clinical sales representative, positions the probes of a da Vinci XI robotic surgery instrument into a simulated abdomen in a surgical room at Dupont Hospital. The devices improve many routine surgeries.
Thursday, June 22, 2017 1:00 am
New surgery tool: Robot
Local specialists see instrument's myriad benefits
ROSA SALTER RODRIGUEZ | The Journal Gazette
At a glance
Robotic surgery using the da Vinci system
What it is: A technique that allows for minimally invasive surgeries using a robotic instrument with enhanced visualization of the body's interior and better maneuverability of tiny tools. The technique is an improvement over laparoscopic surgery in many cases and open surgical techniques.
Benefits: Less pain, blood loss and tissue damage, smaller scars and quicker recovery time for patients; less operating room time for surgeons once trained. As new models are developed, the cost of current equipment is dropping, broadening its use by smaller hospitals. In the future, the technique also may allow for some procedures to be done on an outpatient basis, cutting the cost of hospital stays.
The first thing to do when thinking about robotic surgery, said Dr. Scott Boyd, is to get Roombas out of your mind.
Doing surgery assisted by a robot isn't like those little round self-driving vacuum cleaners of TV infomercials.
“That's the first thing people think of when you say 'robot.' It's not like that at all,” Boyd said.
Lutheran Health's da Vinci robotic surgical instrument at Dupont Hospital, one of five at area hospitals in the network, looks more like an oversized periscope that grew tentacles.
“It's not a Roomba. That's what patients think – that it's a big thing that goes by itself. This is not an automaton,” said Boyd, a urogynecological surgeon. “It doesn't do anything I don't tell it to do.”
Boyd estimates he's done thousands of procedures, including hysterectomies, with da Vinci instruments in the last five years. And that's despite being dragged, as he put it, “kicking and screaming” into being trained.
“I was kind of old-school. I was not an early adopter by any stretch of the imagination,” he said. “I was not excited about spending four times as long on a procedure just to do it robotically.”
But Boyd was won over. He and 35 other doctors in the Lutheran Health Network now are credentialed to use the da Vinci systems, said Todd Klinedinst, leader of Dupont's surgery teams. The da Vinci instruments were developed and are marketed by California-based Intuitive Surgical Inc.
Starting with its first instrument six years ago, Lutheran has three da Vinci SIs and two of the company's newer model, the da Vinci XI. The instruments are at Dupont Hospital, St. Joseph Hospital and Lutheran's main hospital campus in Fort Wayne.
Parkview Health has three da Vinci instruments, an SI and two XIs. Both XIs are at Parkview Regional Medical Center, and the SI is at the Parkview-Randallia site.
Boyd said several features led to his conversion. Patients had less pain, less blood loss and less tissue damage. Scars consisted of only five small punctures. In some surgeries, such as the removal of a woman's uterus done with a traditional open incision, scars could be 6 to 8 inches long, Boyd said.
And, with practice, he could tackle more complex cases – and cut down to about an hour the time spent on the more routine surgeries that initially took four hours.
“It only took a couple of cases when I said, 'Gee, I wish I was doing this robotically' that I started saying, 'Let's do this (robotically) every time.' ”
Robotic surgery does not replace all the procedures that Boyd or other specialists and general surgeons do. The da Vinci instrument is used primarily as an advancement for procedures that might otherwise have been performed with an instrument known as a laparoscope.
Laparoscopes consist of a small camera on the end of a small tube, allowing the surgeon to visualize the interior of the body, and other tiny tools with which to cut and reposition body tissue. The da Vinci instruments employ a similar configuration.
Dr. Donald Reed, Lutheran's trauma center medical director, said the da Vinci instruments improve visualization by letting the surgeon see the area where he is operating in three dimensions.
“Laparoscopy – no matter what its proponents claim – you're still operating in two dimensions in a 3-D world,” he said. And, he said, in laparoscopic surgery, surgeons have to get used to using tools in an unusual way – more or less in reverse. To go left, the surgeon must go right, and down means up.
Da Vinci instruments' movements correspond with normal vision, but the view can be sharpened by moving the camera in and out. And, the tiny gripping instruments that are used to move and cut tissue and manipulate needles move fluidly and rotate with movements of the surgeon's wrist.
Surgeons sit at a console with a camera-like screen away from the patient's bedside during procedures that might otherwise require many hours on their feet.
The setup allays fatigue, said Klinedinst and Brett Weaver, a da Vinci clinical sales representative who works with Lutheran's staff.
Da Vinci instruments also can be equipped with a visualizing program called Firefly that allows the insertion of a harmless fluorescent dye that makes targeted body parts show up bright green on the console's screen.
Reed said that feature aids precision. In a gall bladder removal, he said, the dye would clearly indicate the common bile duct, which can lie under other tissue, and keep the surgeon from damaging it. About half of the 600 injuries that result from the 600,000 annual gall bladder removals are to the duct, he said.
The dye also can highlight lymph nodes for removal for biopsy in cancer surgeries, Boyd said.
Although not all surgeries can be done with a robotic technique, surgeons can use it to repair hernias, loosen adhesions from previous surgeries, and remove lung lobes, the prostate gland, a kidney or portions of diseased bowel.
Boyd recalled that it was the difference the da Vinci made in cancer cases that ultimately sold him.
“What we've noticed is (surgery)'s a kind of a blessing and a curse for cancer patients, because a hysterectomy was a big deal,” Boyd said. “They'd have this big scar and weeks (of recuperation).
“Now it's almost hard for them to accept that they have cancer; it's not a big ordeal. Sometimes I really have to convince them that yes, they do have cancer and they do have to take it seriously.
“But, yes, if it were my wife or my mother and she had to have a hysterectomy, I'd say absolutely. Do it robotically.”