Recently, we sat down with IRMC Physician Group’s general surgeons to learn a little bit about the da Vinci Xi robot, Indiana Regional Medical Center’s newest innovative technology. Here is what we learned:
What is robotic surgery/the da Vinci Surgical System?
The da Vinci Surgical Robotic System is a highly specialized, extremely precise surgical instrument that allows the surgeon to operate with more precision than previously possible. Surgery has progressed from the traditional open surgery via large incisions, to a minimally invasive approach. Initially, this was done using small videoscopes through small incisions into the body. Several other small incisions are then made, and straight instruments are advanced into the body. These instruments are rigid and relatively inflexible. They open, close and spin and do not bend or flex at all. With the da Vinci Robotic system, the surgeon makes the same small, dime-sized incisions and places the instruments into the body. However, these instruments have a much higher degree of flexibility. They have the capability of 360 degrees of rotation. This was designed to reproduce the flexibility of the human wrist and hand. Now, you can reach around structures in the body, suture curved surfaces and do much more delicate dissection, etc. In addition, the videoscope that is utilized has two cameras lenses, one for each of the surgeons eyes. Thus, instead of flat panel view with the traditional videoscope, you now have binocular vision with 3D and full depth perception. In addition, the robotic videoscope allows for up to 10x magnification. Thus, the vision is superior to the human eye with the clearest, most detailed high definition available.
Who uses robotic surgery?
Many specialties utilize robotic surgery. At IRMC, it is the general surgeons who are currently trained in robotic surgery. However, it is used widely across the country for gynecologic surgeries, such as hysterectomies, urologic surgeries such as prostatectomies, thoracic surgery for lung and esophageal resections, and cardiac surgery for valve replacements.
What are the benefits of using robotic surgery over more traditional methods of open surgery?
The benefits of robotic surgery over open surgery are extensive. By utilizing small incisions, the trauma to the body is minimized. With open surgery, the body releases many inflammatory substances that lead to the prolonged fatigue, disrupted sleep patterns, etc. that patients experience with surgery. By limiting the incision size, these chemical mediators are released to a much lower level. Thus, the return to normal activity is a fraction of the time. After major bowel surgery, such as colon cancer or diverticulitis operations, the return of bowel function is dramatically faster. Instead of the typical 7- to 10-day or longer stay in the hospital with open bowel surgery, the average length of stay for robotic colon surgery is 2-3 days. Patients are started on oral intake typically the same day as the surgery. Of course, the most dramatic difference is the amount of post-operative pain. Instead of having discomfort for 2-3 months, most patients feel better in 2-3 weeks or sooner. The need for post op narcotics is much lower, with some of the robotic surgeries not requiring anything more than Tylenol or Ibuprofen for pain control. Naturally, with the severe opioid crisis in this country, this is a major advantage. We see advantages of robotics even over other minimally invasive abdominal surgery, known as laparoscopy. Since the surgeon can now do a more precise dissection, there is less trauma to the tissues internally, as well. The surgeon can also now suture easily with the robotic approach, which leads to the ability to perform more complex surgeries that could not be done without the robotic technology. Especially with pelvic surgery, such as rectal cancer, hysterectomies and prostate surgery, the ability to reach over the pelvic bones and suture is greatly enhanced. This is a limited space and with open surgery, the surgeon’s hands can fill up most of their vision. When a hysterectomy is done robotically, it is an outpatient procedure, with the patient being able to go home in less than 24 hours versus 3-5 days with the open technique. Again, the return to normal function is dramatically improved as well with the drastic reduction in post-operative pain. Finally, with smaller incisions comes a lower risk of wound complications such as infection, bleeding and separation.
Is the da Vinci Xi safe?
The da Vinci is very safe. The safety record with robotic surgery has been documented to be as good or better than open surgery. However, the da Vinci surgical robot is an instrument. Like all surgical instruments, it must be used by a skilled surgeon. As I tell my patients, any complications are from the surgeon, not the robot.
Who actually performs the surgery, the surgeon or the robot? Can you operate remotely?
The surgeon does all the surgery. The da Vinci robot is merely a highly specialized, very advanced surgical instrument. The surgeon makes all the incisions and places small tubes, known as a laparoscopic port, into the patient under videoscopic guidance. This is identical to the way it has been done for laparoscopic surgery since the early 1990’s. Then, the nurse in the OR positions the robot over the patient. The surgeon then attaches the robotic arms to the laparoscopic ports. The flexible instruments are then advanced into the body by the surgical team under direct videoscopic guidance. Again, this is identical to laparoscopic surgery, such as gallbladder surgery, that has been done for the past 25 years or more. Only when this is all done, the surgeon then sits down at the robotic control console and takes over the instruments. The surgeon controls the instruments at all times. The robot has no capability of independent motion.
How are surgeons trained in robotic surgery?
Surgeons go through extensive training to become certified in robotic surgery. First of all, they are already doing the same surgeries either open or laparoscopically. Thus, the training is focused on becoming familiar with the use of the robot to facilitate the surgery. When a surgeon expresses an interest in learning, they are initially trained on the surgical robotic simulator. This is similar to the training that fighter pilots receive before they can actually fly a plane. Surgeons spend hours doing simulated surgery with the robot. They also have to do web-based training and pass tests on their competence. They are required to go to a hospital where robotic surgery is already established and observe an experienced surgeon operate robotically. This surgeon also demonstrates the robotic technique. Surgeons are then required to travel to one of the industry’s training labs and be tested in their ability to use the da Vinci robot. After completing all the required training, the surgeon is then ready to proceed with their first robotic case. However, remember that they already have a vast experience in doing the surgery — now, they are just using a highly precise instrument that they have been trained on for several months. In addition, a national expert in robotic surgery is brought in to supervise and ensure that the surgeon is safe to proceed with the operation.
What types of procedures are being done using the da Vinci Xi robot at IRMC?
Currently, general surgeons Dr.’s Billimoria, Billon, Clark and Guddeti are the only ones utilizing the robot. Some of the procedures being done include colon and rectal surgery for both cancer and diverticulitis, hernia operations (both simple and complex hernias), Gallbladder surgery, and Hiatal Hernia operations. There are plans to develop both gynecologic and urologic expertise, as well.
Why choose IRMC for robotic surgery? Is this covered by insurance?
IRMC has invested in the future of surgery. Not only do they have the most advanced and up-to-date da Vinci Surgical Robot, they also have one of the most modern and advanced surgical suites in the state. The surgeons at IRMC have been doing robotic surgery for almost a year now. In addition, due to the state-of-the-art operating rooms, and the fact that IRMC has the most advanced da Vinci system available, Dr. Dan Clark, one of the previously mentioned nationally certified experts who travels the region and country certifying robotic surgeons, has relocated to IRMC to become the director of minimally invasive and robotic surgery. Dr. Clark has more than nine years of experience in robotic surgery and more than 25 years of experience in advanced, minimally invasive surgery. The robotic surgeons at IRMC also work together as a team. Thus, not only will Dr. Clark do the more difficult operations, but he also assists in surgery with the other robotic surgeons. Dr.’s Billimoria, Billon and Guddeti are also excellent surgeons.
Patients will see no difference in their insurance bills. For instance, the insurance pays the hospital and surgeon to do gallbladder, hernia or colon surgery. It does not matter how they do it, the insurance pays the same.
This article was originally published in Community Health magazine for the school districts of Armstrong and Indiana Counties.