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Articles / 2009

da Vinci Robotic Surgery at CMH Slices Recovery Time & Trauma

Your Health Connection
April 2009

How would you feel if, faced with major surgery, your doctor gave you the option of returning home the day after surgery rather than three to five days, with significantly less pain, discomfort and loss of blood, reduced trauma to your body, smaller sutures and scarring, and the promise of a quicker recovery time and return to your normal activities?

THE EXCITING NEWS is Community Memorial Hospital (CMH) in Ventura has made this possible for surgery patients. CMH has a reputation for being “the first on the block” to provide patients with the newest in medical technologies, according to Paul D. Silverman, MD, a urologist who, in addition to four other CMH surgeons and urologists, has employed the newest da Vinci robotic surgery to perform major operations during the past four years. The other CMH doctors with da Vinci proficiency are General Surgeons Constanze S. Rayhrer and Gosta W. Iwasiuk, and Urologists Cedric Emery and Marc Beagler.

Silverman says CMH’s distinction for adopting technology exceptionally early dates back several decades, including the purchase of the first CAT scanner, possibly before UCLA and USC, several firsts in nuclear medicine, and now they are the first hospital between Los Angeles and San Francisco to employ da Vinci surgery (long before UCLA). Largely due to the expense of the equipment as well as the time and commitment it takes to develop proficiency, CMH is the currently the only hospital in Ventura County to offer this advantageous surgical technology. The equipment, a robotic system, carries a $1.2 million price tag and another quarter million for annual maintenance and support. CMH’s first da Vinci surgery took place in November, 2004, one month after the equipment was purchased and installed.

The liberating advantages of da Vinci extend to CMH patients even more than its medical staff. In addition to those already mentioned, da Vinci surgery provides other benefits to those about to face major operations, including fewer blood transfusions, less risk of infection and improved clinical outcomes in many cases.

Although the physicians enjoy the challenge and excitement of being at the forefront of medical technology, they receive no extra financial compensation for working with da Vinci. In fact, they must work harder and longer to train on the equipment. Their reward comes in the form of surgical patients who are much happier with their surgical outcomes. The hospital also benefits by being able to treat more patients in less time, with more successful outcomes. It’s truly a win-win situation. Silverman confirms that adoption is consumer-driven and patient-driven.

How da Vinci Works
Dr. Rayhrer, MD, General Surgeon, explains that da Vinci really is an extension of laparoscopy, used since the early ’90s to perform surgery using a lighted laparoscope inserted through much smaller incisions than those used in traditional surgery. The laparoscope (a camera), which is inserted through one of the incisions, transmits a twodimensional picture of the organs on a video monitor, and surgeons perform the operation by inserting surgical instruments into additional small incisions.

“With laparoscopy,” says Rayhrer, “we lost our depth perception, but we got used to it after awhile. It made suturing complicated. The other thing we ‘lost’ was our wrists. Because laparoscopic instruments are straight, you can open and close them, but you can’t bend them. It’s like tying your shoes without using your wrists.”

One way the da Vinci robot has improved upon laparoscopy is by giving three dimensional images back to the surgeons. It allows them to see the roundness of things like the colon, enabling them to trace it better visually. They can also see blood vessels much earlier than with laparoscopy, making operations safer. Silverman explains that da Vinci provides magnification up to 10 to 15 times the actual size.

Rayhrer says in addition, “the robot’s instruments are really well-engineered. They have wrists in them; we can do all the motions with them so easily.” It makes operating very intuitive, she comments, “just like name of company that makes it — Intuitive Surgical.”

Dr. Emery, a CMH urologist who performs radical prostatectomies using da Vinci, agrees, “I can see better, sew better, preserve nerves better, and all with less blood loss.”

Da Vinci, which is totally computerized, consists of three components: an ergonomic surgeon’s console, a patientside cart with four interactive robotic arms, and a high definition 3-D vision system. Silverman explains, “The surgeon sits 10 to 15 feet away from the operating table in an armchair and views the operation through a view port.” He or she uses hands and feet to move the master controllers to operate the robot’s arms, creating the precisely-controlled micro-movements of the instruments. An assistant surgeon is positioned at the bedside. The robot is placed between the patient’s legs and, Silverman says, “da Vinci’s four arms drape over the patient and are connected to the ports.” One robot arm controls the camera and the other three control the 5-millimeter (0.2 inch) instruments which are inserted into the patient via a hollow tube inserted through each incision which is less than 1 centimeter or 0.4 inches.

The computer provides motion scaling, enabling surgeons to tailor the ratio of their hand movements to the corresponding movement at the tip of the instrument. Every movement is controlled by the surgeon, and millions of safety checks are performed by the processor during the procedure for enhanced surgical precision and control.

Operations Performed Using da Vinci
The FDA has cleared the da Vinci Surgical System for both adult and pediatric use in minimally-invasive urologic surgical procedures, general and gynecologic laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures (those performed using an endoscope to visually examine the chest cavity) and thoracoscopically- assisted cardiotomy (involving surgical incision of the heart). Da Vinci may also be used with an auxiliary incision to perform cardiac revascularization (providing a new, augmented, or restored blood supply to the heart).

A few of the more recognizable operations currently being performed by da Vinci surgeons worldwide are radical prostatectomies, hysterectomy, gastric bypass, bowel resection, thyroid surgery, kidney operations, cardiac bypass and heart valve repairs.

In the past year, CMH surgeons have performed 65 cases using the da Vinci Surgical System: 35 prostatectomies (surgical removal or resection of the prostate gland), 18 colectomies (excision of a portion or all of the colon), nine Nissens (when the sphincter in the lower esophagus functions improperly, the stomach is wrapped around the lower end of the esophagus to treat the reflux of gastric contents), two laparoscopic cholecystectomies (gallbladder removal) and one hernia operation.

Silverman does quite a few prostatectomies using da Vinci and explains that patients are able to return home one or two days after the operation as opposed to three to five days using traditional surgery. Da Vinci patients have minimal post operative pain and they are able to drive in one week as opposed to six weeks for regular surgery. Potency rates are 50 to 70 percent, sometimes even 80 percent following surgery. Incontinence is experienced only about 10 percent of the time.

Dr. Emery, Urologist, performs radical prostatectomies using da Vinci as well as some urethral surgeries, often together with Dr. Iwasiuk. Emery says, “Patients love it. The surgery takes two hours. I love it because I can see better to operate. Blood loss is minimal, if any, and I can see the nerves better, which is very critical to this operation. The surgery is extremely difficult and delicate and we need clear margins [making sure adequate tissue has been removed] in order to cure the cancer.” He explains that da Vinci surgery came into its prime doing prostate surgery. The system is ideal because the camera can stay fixed during the entire case. He believes da Vinci improves the potency rate following these operations and has seen patients regain potency within one month following surgery. The operation can take two hours, which is very quick, and the patients feel very comfortable.

Emery provides an informed testimonial for da Vinci. He says, “If I had to have my prostate removed, there’s no doubt I would have it done with the da Vinci.” Given five options for different procedures, this is the surgery he would choose.

Dr. Iwasiuk, MD, a general surgeon at CMH, has performed many successful operations using da Vinci including colon sections for cancer, Nissens, the Heller myotomy where the muscles of the lower esophageal sphincter are cut to enable food and liquids to pass to the stomach, stomach surgeries, splenectomies (surgical removal of the spleen), and colostomy closures. He explains, “One of the core measures when we do colon cancer is the number of lymph nodes that can be removed. With da Vinci, that number is better — it’s higher because we can be so much more precise due to the magnification of the operation site.” He also explains that exploratory surgeries are not performed with da Vinci. “With today’s sophisticated CAT and MRI scans,” he says, “most of the time we know what we are going to find ahead of time.”

Dr. Rayhrer explains, “We use da Vinci on almost all colon cancers; our default now is to use it. Most colon operations involve cancers or problems with diverticular disease [involving an abnormal pouch or sac opening from the colon]. But we use it for a broad range of procedures … basically almost every laparoscopy. The results are better and faster than with traditional surgery.”

Rayhrer says, “Through colon cancer we learned with experience that the less frequently patients are exposed to an immunologic event, the better they do. With da Vinci, the immune system is not impacted as much. It makes a real difference.” With traditional colon cancer, it usually takes five to six days for patients to return home and they can’t eat much more than Jello for three days. With da Vinci surgery, they go home the second day following surgery — walking. Rayhrer has also used da Vinci to correct acid reflux, remove stomach cancer, for gall bladder and spleen removal, and to remove tumors on adrenal glands.

Any situation which would exclude using minimallyinvasive instruments and surgical procedures would also rule out using the da Vinci robot. These might include factors such as bleeding disorders, a history of prior surgery, pregnancy and serious cardio-pulmonary conditions.

How da Vinci was Developed
Da Vinci is aptly named after Leonardo da Vinci who, among many other accomplishments, invented the first robot. He is also known for developing painting techniques using precise anatomical accuracy and three-dimensional details to bring his masterpieces to life.

Dr. Iwasiuk says that the da Vinci robot was first developed and promoted by the Pentagon for military use in the 1980s. He explains, “It’s been known for a long time the sooner you get to the injured patient in the field the more likely he is to survive.” Da Vinci would enable the soldier to be in an ambulance, having been rescued from the field but not moved too far. “The surgeon in the back lines could take care of the problem remotely.”

After 20 years of development by the former Stanford Research Institute, the military didn’t quite achieve its goal. Although they are still pursuing this goal through a different avenue, the original surgical system was too bulky for field use and operating the system was dependent on too many people for use in battle. “But,” says Iwasiuk, “the technology was sold to Computer Motion in Santa Barbara that had developed a series of surgical robots including AESOP and Zeus.” AESOP was a voice-controlled robotic arm and Zeus was the first robotic surgical system that performed the world’s first transatlantic surgery. Computer Motion merged with Intuitive Surgical in 2003, which is continuing to develop da Vinci today.

The Future of da Vinci Surgery
Intuitive Surgical's goal is to broadly extend the benefits of minimally-invasive surgery. They are exploring telesurgery to facilitate surgeon-to-surgeon proctoring and coaching. This will enable surgeons to become proficient in da Vinci surgery by studying with leading specialists, smoothing out the learning curve and reducing disruption to their schedules. Intuitive Surgical will also develop additional products and technologies to expand the use of da Vinci.

Iwasiuk explains, “We are looking forward to da Vinci getting even more precise to allow work on smaller areas. This will enable us to do more complex procedures with kidneys, ureters and bladders … every type of operation will become more precise.” He recently performed a more complex operation to separate a patient’s colon and bladder that had been abnormally connected with a fistula. More operations of this nature will be possible in the future.

In addition, says Iwasiuk, “A technology called NOTES [normal orifice trans endoscopic surgery] is currently in development. The idea is for us to be able to perform operations without using visible incisions — to enter instead through incisions made in the colon, vagina, or another orifice located near the site of operation.” NOTES is currently being tested with animals and in some countries it is being performed on human patients.

For now, the da Vinci Surgical System is a technology breakthrough that has revolutionized the way surgeons operate, improving significantly on laparoscopic surgery and helping to relieve some of the patients’ fear of surgery with its promise of less pain, fewer scars, and faster recovery. CMH is performing some operations locally that are unique to the capabilities they’ve developed during the past four years. Perhaps Rayhrer sums it up for the patients best, “People go to work faster — they feel better. The most amazing part of the robotics is watching the patients get better faster. That’s the part I won’t get used to!”

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