The Robot In the Operating Room
It’s eight in the morning, the first scheduled surgery of the day in Operating Room 14 at Memorial Hermann Southwest Hospital. Dr. Michael Kleinman makes a small incision, approximately three centimeters long, at the level of the belly button on the abdomen of his patient, a 74-year-old woman. She’s about to have her gall bladder removed (cholecystectomy), the first of four such surgeries Dr. Kleinman has scheduled for the day.
Spreading the incision with his gloved hands, Dr. Kleinman inserts a silicone access port. The port contains four access sites, essentially holes through which Dr. Kleinman will pass a camera, two surgical instruments and a device that blows surgically clean air into the patient’s abdomen.
In a traditional open cholecystectomy, this is the point in the operation where the surgeon must increase the size of the incision, cutting into the abdominal muscles, in order to be able to visualize and manipulate the organs in the abdominal cavity. Instead, Dr. Kleinman walks from the operating table, past the patient’s left shoulder where he sits down on a stool behind a huge console. He slips his hands into a pair of controls that grasp his fingers. The hand controls operate the four arms of an operating room robot. He leans his forehead forward so that he looks directly into a pair of visual eye ports. Dr. Kleinman advances the camera forward via one of the robot arms and a real time 3-D image of the patient’s liver is seen as the instrument advances. Then he moves the camera forward to the cystic duct and cystic artery. He advances a forceps through another arm and begins dividing the serosa.
Welcome to the new world of single site robot-assisted surgery.
A staff surgeon at Memorial Hermann Southwest, Dr. Kleinman received the 2012 Gastrointestinal Care Excellence award. He’s performed about 30 robot-assisted surgeries at Southwest in the last six weeks using the da Vinci Surgical System. Robot assisted surgery is currently “quasi-mainstream” said Dr. Kleinman. Typically, he said, a surgeon should be conversant in a particular operation using other methods like open surgery and then laparoscopic surgery before proceed to robotic surgery.
Open surgery is the traditional kind of surgery in which a large incision is made into skin and tissues giving the surgeon direct access to internal structures. “This gives you a very large visual field so it’s easy to recognize the relationship between all the structures,” explained Dr. Kleinman. “You also have the advantage of being able to feel structures and tissues with your hands. For example, if you have a tumor in the colon, the surgeon can feel the texture of the tissues and know exactly where the tumor is. Also, in open surgery, the surgeon is not the only person at the table and this gives you additional perspective”.
Laparoscopic surgery involves a smaller incision and the insertion of instruments and a tiny camera to visualize the internal structures. “The procedure offers a better experience for the patient because of small incisions, much less pain and faster recovery,” said Dr. Kleinman. “For the surgeon, the trade off is you cannot touch an organ or structure with your hands. Tactile feedback is critical in all sorts of surgery. In addition, the surgeon’s field of view is much more limited in laparoscopic surgery and you are also limited by having a two-dimensional view. You’re trading many advantages to the patient for a more challenging operation for the surgeon”.
Robotic assisted surgery follows the same concept of better for the patient and more challenging for the surgeon said Dr. Kleinman. “In prostate surgery, which was one of the first surgeries where robotic assistance was widely adapted, the articulating arms (movable arms of the robot) have more dimensions of movements and move more like a hand and wrist than in laparoscopic surgery. In a tight environment like prostate surgery, with a pure laparoscopic technique, the instruments can’t be made to move in ways that facilitate good surgical technique.
“More significantly, the surgeon is concerned about the accuracy and security of connection between bladder and urethra and preservation of nerves which surround the prostate. In men, these nerves control erectile function. You do not want outcomes where your male patients dribble. You also want to maintain his ability to have an erection. Robotic surgery reduces incontinence and erectile dysfunction and that’s a proven clinical fact. The robot can preserve those nerves partly because of the articulation of the instruments and partly because the surgeon gets a 3-D view of the field through the stereoscopic cameras that serve as the robots eyes. The view can be magnified by a factor of ten, which allows increased accuracy and delicate repairs”.
The robot currently utilized by Dr. Kleinman at Memorial Hermann Southwest is the da Vinci Surgical System. It consists of three components: a surgeon’s console, a patient-side robotic cart with four arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system. Surgical instruments are mounted on the robotic arms, which are introduced into the body through cannulas. The da Vinci senses the surgeon’s hand movements and translates them electronically into scaled-down micro-movements to manipulate the tiny proprietary instruments. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console.
The U.S. Food and Drug Administration (FDA) has cleared the da Vinci Surgical System for a variety of procedures including surgery for prostate cancer, hysterectomy and mitral valve repair.
“Robots don’t work for every surgery,” Dr. Kleinman reminds us. “Each operation has different demands. You must have the right tool for the job. Robots still don’t give you tactile feedback. A surgeon must rely on his eyes and experience to know whether he is handling tissues appropriately. And each operation presents a surgeon with the challenge of where to cut because everyone is laid out differently inside. There’s much more variation than you think, especially where there is inflammation which obscures tissue”.
So when a surgeon first learns robotic assisted surgery, he or she first needs to learn how to operate the robot. Like an experienced pilot who flies 737’s and wants to transition to fly a 777, the surgeon first learns the system and then goes into a simulator. He or she learns how to move the instruments (three arms, only two which you can move at a time) and how to manipulate the camera to shift the point of view.
“That’s the mechanical part,” said Dr. Kleinman. “In my way of thinking, the instrumentation shouldn’t drive the operation. You’re not making up a new operation to have it done robotically. So when I do a basic gall bladder, for example, it’s the same procedure that I would do in open surgery only with different tools.
“You go through a training course where you start in cadaver lab. Then you move to operating under the supervision of an experienced robotic surgeon. In my third of fourth case under supervision, I became really impressed with the potentials for robotic surgery. The three-dimensional view and fine manipulation of instruments made the operation smoother and easier than if I had done it with straight lap technique”.
Meanwhile back in Operating Room 14, Dr. Kleinman is cutting, cauterizing and clipping the cystic artery, which supplies blood to the gall bladder. He then releases the gall bladder, cutting it slowly away from the liver where they touch. He brings the gall bladder up through one of the grasping forceps in a robot arm and gently deposits it on the operating room table. It is the size of a Roma tomato.
Dr. Kleinman orders the gall bladder sent to be examined in the hospital’s pathology lab. There have been no complications. The patient is being weaned from anesthesia. The incision is closed. The operation has taken about 30 minutes.