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Articles / 2005

R2D2 in the O.R.
Da Vinci robot makes surgery easier for doctors and patients

Ventura County Star
By Brett Johnson

A few weeks removed from having 14 inches of her colon taken out, Marci Grace says she feels "like a miracle" and "a very successful pioneer."

She owes this to a peculiar, cutting-edge procedure on May 5 at Community Memorial Hospital in Ventura. Her primary surgeon, Dr. Gösta Iwasiuk, wasn't even at the operating table, and his hands never entered her body, yet he displayed a deft touch that he likens to that of a "super expert." Helping him was what he termed a "praying mantis" apparatus that probed her body. She starts with octopus. With its 21st-century technology and bevy of attached gizmos, it sported, she said, a special effects look "straight out of 'Star Wars.'"

She recounts the disbelief that registers in others' faces when she tells them what was done to her. Or as Grace sums it up, "How many people do you know have been operated on by a robot?"

Wave of the future
R2D2 in the O.R.? Well, sort of. The so-called da Vinci robot doesn't move or squeak and isn't quite R2-lovable, but it does plenty to impress. It can cut, sew, grasp and help minimize blood flows deep in the body during surgery.

The computer-enhanced system magnifies operating fields, gives doctors greater ability to see things and move instruments in tight spaces, and, as in Grace's case, shortens patients' hospital stays and gets them back to work sooner. Called the latest advancement in what's known as minimally invasive surgery, the da Vinci robot and its ilk, says Community Memorial CEO Gary Wilde and others, are clearly the wave of the future.

"I believe we will see this type of equipment in virtually every hospital in the country within five to 10 years," Wilde said. ''Every hospital will have some form of robotic surgery."

Ventura-based urologist Dr. Cedric Emery, who was the first to use the da Vinci robot after Community Memorial acquired it last fall, agreed.

"Ten years from now—you wait—this will be the standard of care," said Emery, who has now done 14 operations with the robot and has another five on his schedule.

The da Vinci robot is only used in a fraction of surgeries—through early June, Community Memorial has used it in 30 operations—and is not without critics who wonder if it's as good as billed and perhaps only a gee-whiz passing fad.

Community Memorial says it is the only hospital between San Francisco and Los Angeles with a da Vinci robot.

But Emery and othel1l say a growing number of hospitals are getting them. The da Vinci's maker, Sunnyvale-based Intuitive Surgical Inc., said that almost 275 da Vinci systems are in use at hospitals and similar facilities throughout the United States, Japan, France, Canada, Australia, Belgium and other countries.

Its use jumped from 1,500 procedures in 2000 to about 20,000 last year, Business Week reported earlier this year. Intuitive recently received Food and Drug Administration approval to begin using the da Vinci technology on gynecological procedures, said Nora Julian, the company's corporate events manager.

And Intuitive isn't alone, Julian noted, citing a Santa Barbara company that is trying to develop a robotic "nurse" that can move around. There is, she added, much talk about using robotics in the battlefield to treat wounded, Though no one is eager for that possibility, it would bring the idea full circle; it was the Pentagon, she and others noted, that first explored the idea of using robotic technology for surgeries in the 1980s. Though that waned for a variety of reasons, the military is now warming to it again, Julian said.

Three components
Doctors marvel at the things the $1.2 million da Vinci robot can do. For instance, it has the ability, via sensors, to factor and compensate for tremors in the surgeon's hands.

"It's new and modern and pretty exciting," said Iwasiuk, a Ventura-based general surgeon. "The imagination is the only limiting factor in what we can do with this."

The da Vinci system has three components: the surgical cart, or robot, that has four arms that execute the surgeon's commands; a vision cart, which provides three-dimensional images of the operating field; and the surgeon's console.

The robot stands at one end of the operating table, arms extended toward the patient. Several tiny incisions, or ports of entry, are made in the abdomen. Using tube-enclosed trocars—"a pipeline, if you will," explained David Vie, a registered nurse who is a clinical specialist for Community Memorial's da Vinci program—the instruments are plunged into the abdomen through the ports. One of the arms is for the camera. The other robotic arms have tiny knives at their tips. They can also be fitted to hold clamps, sutures, graspers and dissectors; each arm mimics the dexterity of the human hand and wrist. A typical operation has three or four sites, or ports, where the trocars are inserted.

"The placement of the ports is critical," Vie noted.

The lead surgeon sits at the console—typically 10 to 20 feet away from the operating table in the room setup, Emery said. Peering into binocularlike lenses for views provided by the camera inside the patient, the surgeon sees the operating field, body organs and instrument arms in three dimensions, magnified 10 times.

Emery called that feature "a huge advancement," noting that other techniques are in two dimensions.

Just below the lens display, the surgeon's fingers grasp the master controls. Using thumb, finger and wrist movements at the console, the surgeon manipulates the robotic arms stationed above the patient at the operating table. The surgeon manipulates the camera using a foot pedal.

The arm instruments can rotate 360 degrees and offer greater precision. Iwasiuk says it allows him to sew stitches with a much finer touch, for example.

By using the da Vinci robot he said, "The rest of us are brought up to par with the super experts."

Benefits for doctors, patients
It's far from traditional surgery—abdomen open and organs exposed—Vie noted. Tinier incisions also mean less blood loss.

The older form of minimally invasive surgery, called laparoscopy, also uses surgical instruments inserted through small incisions.

Those instruments are guided by long handles in the surgeon's hands at the operating table. But Iwasiuk likened that to handling chopsticks. noting vigorous shoulder movements as well as having to glance up at monitors.

The technology in the da Vinci system, Emery said, could allow him to operate from even more remote locations, such as a different city. Last year, he said, a surgeon in New York operated on a patient in Paris using the da Vinci robot.

Emery called that a bit of a stunt; though possible, be doesn't think it will catch on.

He and others also were quick to point out that assistant surgeons, orderlies and techs are at the operating table with the patient, handling such tasks as suction, retraction and changing the robot's instruments arms as needed.

Emery called the da Vinci robot phenomenal and remarkable, adding, "The surgeons love it because it gives them better vision and better dexterity, The patients like it because they get to go home earlier."

So it was with Grace.

Grace, a 55-year-old Ventura-based independent producer and aspiring actress who also wants to do stand-up comedy termed her May 5 partial colectomy a "very, very serious operation." She had diverticulitis in her colon wall that caused swollen sacs and severe infections. She felt terrible.

Iwasiuk and others broached the idea of using the da Vinci robot and gave her a few weeks to think about it. She admitted she was apprehensive about having about having a machine do part of the procedure.

"In the back of your mind, you're thinking, 'I hope this robot works and doesn't malfunction in some way.' " she said.

When she got into the O.R. that day, she spied the thing and jokingly said from her gurney, "Hi robot." Iwasiuk said her procedure went very well.

Grace left the hospital on May 8—a nice Mother's day present, she noted—and was back at work in a week. Traditional surgery, she said, would have a two-week hospital stay and six weeks of recovery.

Four of her five scars are tiny, scarcely noticeable and "far less than if they had opened me up."

'That thing was fantastic'
The 13 Community Memorial doctors who use da Vinci received training at the University of Southern California or the University of California, Irvine.

The typical learning curve is about 10 to 12 cases before a surgeon becomes real comfortable with it, Vie said.

Last year, the Wall Street Journal reported on a Florida case in which a man died after an aborted robotic kidney removal; the family sued, claiming the two doctors involved lacked the experience to use the robot. The hospital disputed that but required surgeons wishing to use the robot to go through additional training.

Julian, the Intuitive executive, agreed about a learning curve, but said surgeons quickly become proficient in using the robot.

Patient satisfaction, she said, seems to he running high and "ultimately, those are the people we have to listen to."

Community Memorial likes what it sees so far.

Wilde said the hospital will allocate more money toward purchases of similar high·tech equipment.

"This is an example of us trying to provide the same level of sophistication that a patient would get in Los Angeles or San Francisco, so they don't have to leave home," he said.

Grace is glad she didn't have to and is ecstatic she is on her way to what she terms a "miraculous recovery."

"I feel better than ever," she said. "I feel brand new. I'm very pleased that I allowed it to be done robotically…That thing was fantastic."