Robotic arms help put more surgical options on the table

Technology's guiding hand

Diana Del Mauro | For The New Mexican

11/20/2009 - 11/21/09

Lilly Mondragon needed a hysterectomy, but when her gynecologist tried a laparoscopic approach, it turned out the fibroid tumor and the uterus were too large for that method to work.

In the past, Dr. Debbie Vigil would have been left with one option: to make a large abdominal incision. It isn't pretty, but in many cases, less-invasive techniques present serious limitations or risks.

This time, though, she had a better solution. After 25 years of experience at the operating table, Vigil is glad to have found new powers in the da Vinci Surgical System, which offers robotic arms to assist her. As a result, patients like Mondragon of La Mesilla don't have to be "opened up," and they are likely to have a faster recovery time, less pain and lower risk of infection.

To the patient, the end result looks much like a laparoscopic procedure — a series of micro-incisions rather than a long slice across the gut. But behind the scenes, the da Vinci surgical experience is a world apart from laparoscopy.

"You're operating with instrumentation and technology that is not very different from having your actual arms and hands in the patient's abdominal cavity," Vigil said. "The pelvis is a very narrow place with ureters, bladder, bowel — all sorts of structures that you can easily injure. So, the precision and the ability to get into these areas — to articulate as well as visualize — is critically important."

In October, Vigil performed the first hysterectomies with the new equipment at Christus St. Vincent Regional Medical Center. Mondragon, 50, said she spent two nights in the hospital and by the time she left, she was walking comfortably. Even so, she won't return to her desk job as a payroll administrator for six weeks, because she feels pain when she sits too long and her legs feel weak if she's on her feet too much.

"As far as the hysterectomy itself, it was great," Mondragon said. "I don't have this big old cut across my abdomen. I would absolutely recommend it."

Vigil expects that the typical da Vinci hysterectomy will take 90 minutes, from setting up the equipment (which is a big production) to wheeling the patient out of the operating room. But because there's a learning curve, Mondragon's surgery took three times longer than usual, Vigil said.

"The worst part for me was that I was out for so long at a 90-degree angle," Mondragon said.

Patients are strapped to the operating table and tipped head-down, a position that helps keep the bowel and intestinal tract out of the way. For a week after the procedure, Mondragon's shoulders and waist were sore. And, because she had been knocked out for so many hours, she was groggier than she expected.

Training surgeons

Christus St. Vincent Regional Medical Center brought the $2 million da Vinci Surgical System to Northern New Mexico for private-practice surgeons as well as the hospital's own surgeons to use — an open policy that's unusual in other regions of the state.

So far, two Santa Fe surgeons have been trained to use it: Dr. Cynthia Lewis, a hospital employee who specializes in urogynecology, and Vigil, a private-practice surgeon. Dr. Timothy Wetherill, a general surgeon employed by the hospital, is about to start the training process.

In 2008, both University Hospital and New Mexico Veterans Affairs Health Care System in Albuquerque acquired the da Vinci Surgical System, but access there is limited. Two surgeons use the robot-assisted surgical equipment at the VA hospital. At University Hospital, only surgeons who are faculty members have permission to use it.

University Hospital spokesman Sam Giammo said the da Vinci technique is being used most commonly for hysterectomies and the removal of the prostate gland in men.

Intuitive Surgical Inc., which has sold 916 da Vinci systems in the United States and another 326 to other countries, touts the robot-assisted technology as a breakthrough method that offers the "capabilities of traditional open surgery while enabling (doctors) to operate through tiny incisions." At no point does the da Vinci Surgical System make autonomous decisions, so it doesn't fit the strict definition of robotic surgery.

Applications range from gynecological procedures and general surgery, to urology, thoracoscopy (a procedure to view the lung) and cardiotomy (an incision in the heart).

Women facing surgery should discuss the pros and cons of each option. A vaginal hysterectomy, which does not require an incision on the abdominal wall, is least invasive.

The da Vinci Surgical System is overkill for simple procedures, such as tubal sterilization or the removal of an ovarian cyst. Conventional laparoscopy does the job faster, cheaper and with equal outcomes, Vigil said.

How it works

"You think video games are awesome, you ain't seen nothing," Vigil said when she told her 10-year-old daughter about the da Vinci Surgical System.

First, the surgeon creates four to six ports, by making 8 to 12 mm cuts in the abdominal wall, and docks the robotic arms onto the ports. Next, the surgeon installs a camera in the patient's body and determines whether the procedure is going to be easy or difficult.

As she sits at a console with her head in the viewing camera, the surgeon has at her disposal three robotic arms, a miniature camera that she can move around inside the body, and roaming eyes that explore narrow structures of the body in three-dimensions. Rather than programming the robot to make surgical maneuvers, the surgeon orchestrates the robot's every move.

Robotic arms clutch the surgical instruments inside the patient's body. A computer transmits the surgeon's movements to the robots, and the robots carry out the surgeon's orders right away. "It's an exact duplication; there's no delay," Vigil said. "It's happening at exactly the same time."

In traditional laparoscopy, the surgeon's range of motion is limited because the instruments cannot be rotated (it's like using chopsticks), and the surgeon has to perform the movements in reverse. (The surgeon pushes the instrument to the right to get to the patient's left side.)

The da Vinci approach is more liberating and more intuitive. Through two flaps, the surgeon pinches and loosens her fingers, moving her wrist in the same fashion as she would in open surgery. She can rotate the surgical instruments, and there is no mirror-image effect to deal with. Using the foot pedals, the surgeon activates cutting, burning and clamping.

Another port is designated for the surgeon's assistant. It is not hooked up to the robot. At the surgeon's request, the assistant can insert a suture and a needle, or some other instrument, into the patient's body and the surgeon will grasp it with a robot arm.

To prepare for her first robot-assisted surgery, Vigil observed other gynecologists using the device for hysterectomies, took da Vinci's online training course, and operated on anesthetized swine at the live pig lab in Sunnyvale, Calif., where Intuitive Surgical Inc. is headquartered.

Lewis was expected to operate with the da Vinci robot for the first time Thursday, and by the end of December she expects to be ready to do da Vinci surgeries solo about twice a week.

Lewis did not embrace da Vinci technology quickly. She talked to skeptical colleagues and examined a lot of research before concluding that the method offered clear advantages to her patients. In September, she attended an American Urogynecologic Society conference that was flooded with papers and videos on robotic surgery, and soon after she decided there was enough historical information about the technique to believe in it.

She intends to follow her patients a year after surgery to see how they fare.

For more information about da Vinci Surgical System, go to www.intuitivesurgical.com.