How Technology Is Reshaping the Surgical Field (podcast)

Over the past 10 years, robotic surgery has developed and is now used for basic general surgical procedures and very complicated cancer-types of surgeries.

Robotic cardiothoracic surgery is a very interesting application because the difference to the patient is extreme. In the olden days, this involved having to open a patient’s chest just to do a cardiac valve procedure. Now it can be done robotically.

Other robotic procedures can be done for the treatment of GI, lung, kidney and prostate conditions. It is used to treat gynecological conditions, including fibroid removal and pelvic floor prolapse. Pelvic floor prolapse tends to happen as women get older. Our organs start to fall through the vaginal vault. This can cause urinary incontinence and stool issues. The patient can be fixed by re-securing those organs up in the pelvic cavity and that could be done robotically.

Any tool that we used in open surgery we now have for robotic surgery, such as stapling devices and cautery devices.

There have been all sorts of instrument advances over the years. The biggest advance over the past few years has been the XI machine, which is a system that rotates on itself. It allows for great mobility within the patient cavity. We can operate in the upper abdomen and we can operate in the lower abdomen with the same movement of the equipment.

It’s 10X [ten times magnified]. The surgeon’s visibility is beyond what you can see with your own eyes and it’s three-dimensional, like your own vision.

Robotic surgery is a laparoscopic form of surgery. Basic laparoscopic surgery is very limiting. It’s like operating with instruments on a stick.

The surgeon is at the patient’s bedside operating through these tunnel-like ports — these keyhole openings — operating with instruments that you can rotate on your own wrist. But that’s all they can do basically. It’s very challenging to operate this way. You’re looking at a camera vision on a monitor at a distance and your movements are sort of opposite of the way you would go. Up is down and down is up. You have to have great hand-eye coordination for this type of keyhole laparoscopic surgery.

Laparoscopic surgery became very popular in the 1980s, but unfortunately could only be applied to super simple surgeries, such as gallbladder, the appendix, taking out an ovary and hysterectomy. That’s about all you could do with straightforward laparoscopic surgery. Any time we tried to expand that form of surgery onto more complicated surgeries, it was super challenging, and only a few places in the world could use this type of minimally invasive technology. It was cost prohibitive. It was a learning curve for the surgeons. It was just not feasible.

This robotic technology now give us the capability of doing far more complicated surgeries. We have three-dimensional vision and 360 degree wrist articulation at our control. The camera is now in the control of the surgeon and not an assistant following the surgeon along as is true in basic laparoscopic surgery. It’s absolutely phenomenal. Basically, it allows minimally invasive types of surgery to be applied to many more complicated surgeries that we couldn’t do before.

The benefit to the patient is innumerable. The hospital, of course, tries to equate benefit with the dollar sign. There are shorter hospital stays, the patient’s return to work is quicker, less pain and less use of narcotics. All are benefits we can easily relate to. But there are so many quality of life outcomes that we just can’t put a dollar sign on that are invaluable to the patient. Our cancer patients are able to get chemotherapies quicker. You can’t put a dollar sign on that.

There is less blood loss. Some of that depends on the organs that were taken out. But there is far less blood loss because it’s a meticulous surgery done under ten times magnification. In some cases, you can be left almost scarless.The incision port sites are button size.

The surgery is absolutely in the surgeon’s control. It requires our hand movements to control the instrumentation. The surgeon is at a distance from the patient’s bedside, controlling this instrumentation, looking through a technology that allows us to see the vision that the three-dimensional camera is seeing. It’s absolutely awesome.

The technology allows us to move the camera to different ports. It allows us to get to multiple areas in the body in the same surgery. Everything is cool about it. It makes our day so much more satisfying because it is a meticulous surgery. Just in my own experience, say with radical prostatectomies [removal of prostate] or a surgery performed for prostate cancer patients, the difference compared to an open prostate cancer surgery is night and day.

Robotic surgery shortens surgery in many instances. It really depends on the type of surgery we’re talking about. For a radical prostatectomy, in experienced hands, it changes timing by about half, which allows for increased efficiencies in the operating room. It helps us to do more patients on any given day.

I would say in general, for all types of surgeries, you could easily say it improves recovery by at least 50 percent.

There is a significant learning curve behind robotic surgery training. This is the challenge of universities in this country — to train our residents in the use of this type of technology. It’s somewhat challenging because they’re still learning anatomy and how to operate in general. I think that’s what makes Scripps very different. We have a mass of surgeons with incredible surgical expertise in their own areas that have now incorporated the robotic technology into their own practices. Our surgeons, with their experience and their surgical teams, have really been able to take full advantage of this type of technology. The technology is great, but you have to have the experience behind it and that’s what sets Scripps apart. In the city of San Diego, our surgical expertise is unsurpassed.

Our nursing teams are crucial in many settings — anywhere from the office, to pre-op, to intra-op, to post-op and on the floor. Because of our volume and our surgical expertise throughout the entire system, we have those nursing teams to help assist the patient through the whole experience. We can’t do our job without those teams being as good as they are.

We now have eight robotic systems in our hospitals together. We’re all sharing our experiences, and we’re one big team — one hospital helping another hospital and sharing ideas on efficiencies and such. It’s really neat this multi-hospital system that we have.

[There are 60 surgeons across the Scripps system who do robotic surgery at all Scripps hospitals].

For robotic surgery, the exclusions are few and far between. In prostate cancer surgery, we would never think about doing an open radical prostatectomy. The only patient that can’t have that type of surgery would be a patient with lung issues who wouldn’t be able to tolerate it. The abdomen has to be filled with a gas in order for us to have a working space. That creates a pressure. The patient’s lung and cardiac status have to be able to tolerate that kind of pressure.

There are some patients, very few, who have physiologic issues that would prohibit any kind of laparoscopic surgery. Otherwise, the opposite is true. We can do robotic surgery on patients who aren’t candidates for open surgery or laparoscopic surgery. That’s the difference. There are many more patients who are now surgical candidates who couldn’t get through the surgery before the advent of robotic technology. That’s what’s neat about it.

Robotic surgery is getting more and more minimally invasive. At some point, we will be doing most surgeries through a natural orifice, through the mouth, through the vaginal vault, through the GI tract.

From a cancer perspective, sometimes we need to be in the area of concern for cancer control reasons. In the field of cancer, we’ll probably always need to be in the cavity of interest. But it’s getting more and more minimally invasive, more and more technologically advanced where we don’t have to have cables. We can do this digitally. The original idea of having a surgeon offsite performing the surgery is where we’re headed.

We’re super happy that we can offer this technology in the San Diego area and that patients don’t have to go elsewhere for their surgical care. We can offer the best the world has to offer right here in this area.