Innovative robotic system at Memorial employs 3D video

Dr. Carson Wong performed his first robotically-assisted operation more than 10 years ago and never looked back.

“My whole career is based on innovation,” the Marietta Memorial Hospital urologist said. “I’ve grown up on the robot.”

Wong came to Marietta Memorial recently from Cleveland. He has seen four generations of da Vinci system robots, and in Marietta he has two of the latest to work with.

Wong said the improvements over the years have included better articulation of the instruments — making them work more like the human hand — and binocular, 3D video from the tiny cameras that move around inside the patient’s body.

The system is a somewhat imposing tower with four jointed arms protruding from its center, connected to a control module where the surgeon sits, his eyes fixed into a pair of lenses that resemble a binocular microscope. At hand height for the sitting doctor are two control tools with rings for the fingers to fit into.

Here’s how it works.

The patient is prepared in the same manner as for conventional open surgery or laproscopy — like a laproscopy, a hollow needle is inserted in the patient’s abdomen, and the cavity is inflated by pressurized carbon dioxide — but in the operating room things look very different. The arms attached to the tower are draped with sterile sleeves, disposable supplies of various kinds are unpacked, and the tools — a grasper, a needle driver, a cauterization tool, or whatever else is required, along with a tiny, high definition camera and light — are attached to the robotic arms. When the patient is wheeled in, draped from head to foot in a blue sterile gown, the surgeon goes not to the supine person on the table but to the control center, about 15 feet away.

A robotically-assisted surgery starts with a series of tiny — five to eight millimeter long — incisions. Metal sleeves called trochars are inserted through the openings and are used to guide the instruments into the area being treated.

On Thursday afternoon in an operating room at Marietta Memorial Hospital, oncologist and surgeon Dr. Rajendra Bhati was using the da Vinci to repair a hernia. The control module sits in a corner as Bhati leans into it, and his voice can occasionally be heard over an audio system by the technician and a physician’s assistant standing by the patient. The da Vinci looms in the center of the room, its four arms converging at a set of closely-spaced points on the patient’s abdomen.

Two monitors show what Bhati is doing, the interior tissue of the patient illuminated by the camera light, parts of it gently pulsing. The cauterization tool occasionally cuts something away as a second tool moves things around. Bhati ‘s hands make large movements — the system reduces the size of the hands’ motions to offer greater precision. When he needs a different instrument, the arm withdraws one of the tools from the patient’s body and a technician removes it and replaces it with whatever the surgeon needs.

Talking earlier in the day, Bhati offered one by one the advantages of robotically-assisted surgery: smaller incisions, less pain for the patient, lower volume of blood loss during surgery and a quicker and less stressful recovery.

The recovery portion is particularly important, he said. Hysterectomies using a da Vinci can now be outpatient procedures. By using the da Vinci in other procedures, hospital recovery times can be cut in half, he said.

The robotic system is also easier on the surgeon, Bhati said, even though it takes longer with some procedures. After the Thursday afternoon hernia operation, his next patient would require a Whipple procedure: a resection of the pancreas to treat pancreatic cancer. The procedure is lengthy and complex, he said, and doing it robotically takes five to six hours, whereas with open surgery it would take four hours, but the incision, he noted, is very large.

“It’s probably the most difficult procedure a surgeon can can do,” he said, explaining that on the standard index measuring difficulty, a gall bladder surgery is ranked at 12, open heart surgery at 50 and a Whipple at 80.

Marietta, he said, is the only Ohio hospital besides one in Cleveland that performs robotically-assisted Whipples.

“We’re 16th in the nation for the number of Whipples we do,” he said.

Dr. Warner Wang is a general surgeon who came to Marietta after practicing laproscopic surgery for five years in a small town in Kentucky. He had seen a da Vinci in action in Albany, N.Y., where he trained for surgery.

“I thought, ‘this is cool, this is the future,’ but I didn’t expect it to develop so fast,” he said.

A friend brought him to Marietta.

“I couldn’t believe you had not one but two robots, that technology is enviable,” he said.

Recovery times for major colon surgeries used to be a week, he said, and now they are half that. With shorter hospital stays, there are fewer hospital related complaints, he said. Wang said he uses the da Vinci on major colon resections, anti-reflux surgery, groin and abdominal hernias and complex hernia repairs.

“We’re equal with what we can do here to Cleveland and Columbus,” he said.

The system, he said, “is like having your hands right inside the patient.”

Carson Wong said he is seeing patients coming to Marietta from Cleveland and Columbus.

“Now, we’re seeing people coming south on I-77,” he said.

The system requires significant training. Wong said it’s difficult to get used to the lack of tactile feedback — the surgeon can see what the instruments are doing but can’t feel them.

“It’s an acquired skill,” he said.

The addition of a 3-D visual system a few years ago was a welcome advance, he said, and the magnification helps with precision work.

Sasha Myers, the RN who coordinates the robotic surgery program, said it’s used in about 700 procedures a year at the hospital.

Don Gillette, 73, had a double hernia repair using the da Vinci in October. He’s also had conventional and laproscopic surgery.

“With respect to recovery, the robotic surgery was fairly amazing. I had surgery on a Wednesday afternoon, I recuperated at home through the weekend, and I was back at work Monday morning,” he said. “I have a desk job, I don’t have to lift anything heavy, but still… straightforward and easy, no complications.”

At a glance

A quick history of robotically-assisted surgery:

¯ Arthrobot developed for use in arthroscopic surgeries at the University of British Columbia in Vancouver, B.C. in 1983.

¯ Probot used for prostate surgery and Robodoc use for hip replacement in 1985.

¯ Da Vinci system, originally part of a DARPA and NASA project that would have allowed doctors to do operations on battlefield wound victims or astronauts, developed by SRI and Intuitive Systems in the late 1990s.

¯ Memorial Health System bought its first da Vinci in 2013, later replacing it with an updated model and purchasing another updated model in 2015.

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