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Close-up view of the da Vinci Si, the latest in surgical robots, acquired by McKee Medical Center in September 2009.

The unparalleled anatomical accuracy and three-dimensional details of da Vinci’s drawings served as inspiration when Intuitive Surgical, Inc. named their newly developed surgical robot in 2000. The newest da Vinci® Surgical System, recently installed at McKee Medical Center in Loveland, provides physicians with enhanced visual detail that simulates an open surgical environment while allowing the operation to be conducted through multiple small incisions with tiny instruments.

McKee’s robot, the da Vinci® Si, allows physicians to operate while seated at a console viewing the patient through an enhanced, high-definition 3-D image of the surgical field. The surgeon’s fingers grasp the master controls below the display with hands and wrists naturally positioned. The system translates the surgeon’s hand and wrist movements precisely, in real time, moving the robotic surgical instruments inside the patient.

“The range of motion, 3-D visualization and wristed instruments essentially allow the surgeon to operate as if his or her hands were in the abdominal or pelvic cavity,” says John Crane, M.D., FACOG of OB/GYN Associates in Loveland. “The technology is a huge improvement over traditional laparoscopy,” he says.

The shortcomings of conventional laparoscopy ultimately led to the development of robotic assisted surgery, which is a form of laparoscopy. With conventional laparoscopy, the surgeon operates while standing, using hand-held, long-shafted instruments, which have no wrists. The surgeon looks up and away from the instruments, to a nearby 2-D video monitor to see an image of the target anatomy. The surgeon must also rely on his/her patient-side assistant to position the camera correctly. In contrast, the da Vinci System’s ergonomic design allows the surgeon to operate from a comfortable, seated position at the console, with eyes and hands positioned in line with the instruments. To move the instruments or to reposition the camera, the surgeon simply moves his/her hands.

Dr. Crane uses the robotic system for hysterectomies and other gynecological surgeries. It is also FDA approved for thoracoscopic (chest) surgery and urologic procedures.

McKee Medical Center surgeons who currently use the da Vinci Si robot: Elizabeth Howell, M.D., John Crane, M.D., Michael Eddy, M.D., Benjamin Girdler, M.D., Michael Lee, DO, and Randy Everett, M.D.

Robotic Prostatectomy

Benjamin Girdler, M.D., physician with Urology Center of the Rockies, regularly employs the robotic system at McKee for radical prostatectomies (removal of the prostate and surrounding tissue due to cancer). “It definitely makes a difference for patients,” says Dr. Girdler. “There is always much less blood loss. It is common in prostatectomies for patients to lose a tenth to a twentieth of the blood compared to an open procedure. Eighty percent of our patients go home the next day.”

Speaking about the medical research on robotic procedures, Dr. Girdler says, “The vast majority of nonrandomized data I am aware of shows equal or superior outcomes with robotic prostatectomy compared to open surgery [through traditional larger incisions].” Those positive outcomes include long-term (more than one year post surgery) continence and erectile function.

Robotics for urology is not limited to radical prostatectomy, but used for all major urological surgery including cancer operations of the kidney, bladder, ureter, and adrenal gland and reconstructive surgery of the kidney and ureter, as well as for pelvic prolapse.

According to the da Vinci Website, “The da Vinci Prostatectomy procedure is currently the fastest-growing treatment for prostate cancer, which is the second leading cause of cancer-related death in men.”

Urologic colleague, Curtis Crylen, M.D., is a bit more measured in his praise of robotic radical prostatectomies (RP). “RPs are certainly the most common type of prostatectomy in our practice, though with regard to long-term potency and continence, the data – only measured since 2005 – is not yet robust,” he says. However, he agrees robotic surgery equals open RP when it comes to cancer control, and bests it for blood loss, recovery duration and return to work time.

Both physicians encourage patients to discuss the best course of action with their doctor, because every case is a little different and requires an expert to determine treatment.

Benefits & Shortcomings

James Wolach, M.D., PC, Dr. Crylen’s partner at North Colorado Urology, also uses a da Vinci system at North Colorado Medical Center in Greeley. He explains the differences between using the robot and the traditional open surgery that he learned 15 years ago when he was a resident.

“There is a loss of tactile sensation when using the robotic controls. Having been trained to use touch, switching to the robot is tricky at first. It takes a while to get the mindset to feel tissues with the robot,” says Dr. Wolach.

Gynecological surgeon Dr. John Crane agrees about the learning curve. “It’s like losing a tooth,” he explains. “You keep putting your tongue in the hole, but after a few days you don’t notice the difference anymore. You adapt. It’s no limitation to me,” he says.

Intuitive Surgical, Inc. provides in-depth training for all surgeons who will work with their systems at their Sunnyvale, Calif. headquarters. As well, most large hospitals with residency training programs utilize a da Vinc® robotic system, as Drs. Girdler and Crylen did. Thus most new surgeons graduate with the knowledge.

Dr. Wolach is quick to note that the compensations for surgeons using the robotic system are dramatic. “The visualization is phenomenal. We can see the tiniest vessels and nerves [through the high definition 3-D vision]. That is a huge plus. And with all the patient benefits, it is worth it,” he says.

Intuitive Surgical’s Market Development Specialist, Nora Distefano, adds that the new da Vinci Si has dual-console capability to support training and collaboration during minimally invasive surgery. Distefano says by email: “The da Vinci Si System retains and builds on the core technology at the heart of the existing da Vinci Systems through:

• Advanced 3-D HD visualization with up to 10x magnification and an immersive view of the operative field
• EndoWrist® instrumentation with dexterity and range of motion far greater than even the human hand
• Intuitive® motion technology, which replicates the experience of open surgery by preserving natural eye-hand-instrument alignment and intuitive instrument control

“Together, these technological advancements provide da Vinci surgeons with unparalleled precision, dexterity and control that enable a minimally invasive approach to many complex surgical procedures,” says Distefano.

Asked if there is any reason to continue operating through open incisions, Dr. Crylen replies: “There are always going to be circumstances where open procedures are necessary, especially with certain cancers or for someone with lots of adhesions [scarring] from multiple surgeries.”

North Colorado Medical Center surgeons who currently use the da Vinci Si robot: Curtis Crylen, M.D., and Paul Hiratzka, M.D. Not pictured: James Wolach, M.D., and Michael Johnell, M.D.

Robotic Gynecology

Gynecological studies with da Vinci show similar patient benefits compared to robotic urology procedures like prostatectomies.

The journal Obstetrics and Gynecology reported in December 2008, “Although individual studies vary, robot-assisted gynecologic surgery is often associated with longer operating room time but generally similar clinical outcomes [like] decreased blood loss, and shorter hospital stay. Robot-assisted gynecologic surgery will likely continue to develop as more gynecologic surgeons are trained and more patients seek minimally invasive surgical options.”

Since da Vinci came on-line at McKee in September 2009, Dr. Crane has performed at least 23 robotic surgeries. Many of those surgeries are hysterectomies, myomectomies or radical hysterectomies. He is one of very few OB/GYNs in the region performing robotic surgeries.

Asked to recall a patient who has truly benefited from the new robot, he recounts the recent case of a 71-year-old woman on whom he operated. She presented with a pelvic mass (which is always, until proven otherwise, suspected as cancer). In previous years, Dr. Crane would have performed a full node biopsy, opening a 10-inch vertical incision the length of her belly. Her November operation took just five small (less than a dime’s diameter) incisions, two-and-a-half hours and only 50 cc of blood were lost. Her cancer was benign, though Dr. Crane did find a potato sized mass in her pelvic cavity. He removed it by securing it in a bag, then robotically crushing and vacuuming it out through one of the incisions. The patient was eating and walking around within two days and went home on the third.

Surgeons Crane, Girdler, Wolach and Crylen are at the forefront of minimally invasive surgery. Spurred on by superior patient benefits, they provide care that may eventually be the standard by which all are judged.

In addition to the surgeons interviewed in the editorial, several others at both McKee and NCMC regularly use the da Vinci robot to perform minimally invasive surgeries. McKee surgeons include: Elizabeth Howell, Michael Eddy, Michael Lee and Randy Everett. NCMC surgeons include: Paul Hiratzka and Michael Johnell. +