The Robots Are Here
And they’re delivering unprecedented precision to surgery and less pain and shorter recovery times to patients
Surgical Extension: Dr. Shady M. Eldaif at Atlanta’s Northside Hospital
Scientists, economists and sci-fi buffs alike have long predicted the arrival of robots – a day when smart machines would come to take our jobs and replace human touch and individuality with impersonal, cold technology.
In hospital operating rooms throughout Georgia, the robots have arrived. But rather than taking jobs, they are creating the need for specially trained and highly skilled surgeons, says Dr. Shady M. Eldaif, a thoracic surgeon in Atlanta who uses robots in about 90 percent of his surgeries. “The robot is an extension of the surgeon,” he says.
Rather than bringing a cold, assembly line-type approach to medicine, robots are enabling surgeons to perform highly individualized and intricate surgical treatments. And they’re doing so with less pain and blood loss and shorter recovery times than was previously possible.
The Rise of Smart Machines
Although the first robotic surgery system for general surgery – the da Vinci Surgery System – was approved by the FDA in 2000, robotic surgery still tends to have an air of mystery about it, says Dr. Karen Stuart, a gynecologic surgeon at Columbus Regional Health who uses the da Vinci robot for many of her more complicated surgeries. “When I tell people they will have robotic surgery, I let them know R2D2 will not be in the operating room, but I will,” she says.
Columbus Regional, which got its da Vinci robot in 2012, is a relative newcomer to robotic surgery in a state that is a leader in the field both nationally and internationally. Georgia surgeons were among the first to perform robotic surgeries, and in some cases pioneered robotically assisted procedures that are changing the lives of countless people around the world. Some are training the next generation of surgeons for robotic procedures, which many predict will become more common and more advanced with time.
Robotic surgery is the most recent development in an ongoing quest to make surgery less invasive, says Dr. Eldaif, who is chair of the surgery department at Atlanta’s Northside Hospital. Northside ranks first in the Southeast and fourth in the world in the volume of robotic-assisted procedures performed.
Minimally invasive surgery techniques came into wide use in the 1980s. Rather than requiring large incisions, such techniques typically involve making a few keyhole incisions through which a lighted scope and surgical instruments are inserted. These procedures minimize pain, scarring, blood loss and recovery time, but they also have drawbacks, chiefly the use of tools that Augusta University urologist Dr. Martha Terris likens to “tying your shoelaces with chopsticks.”
The da Vinci system offers the benefits of increased magnification and jointed hands with the same range of motion and dexterity as the surgeon’s own hands. Now, many surgeries that once required open incisions can be done minimally invasively. For procedures already being done minimally invasively, in some cases, the assistance of the robot improves results.
Studies conducted at multiple medical centers, including Northeast Georgia Health System, for example, have shown outcomes of hernia repair using the da Vinci robot were superior to those using traditional minimally invasive techniques. And that’s just one of the ways robotic surgery is improving surgery – and lives.
Hearts Mended, Less Trauma
A healthy mitral valve is critical to controlling blood flow through the heart’s left atrium and ventricle. When the valve is damaged, repairing or replacing it has traditionally required a highly invasive and painful surgery with a large incision, lengthy hospital stay and even more lengthy recovery period. For many people, however, robotic-assisted surgery is making the procedure less traumatic and the recovery period significantly shorter.
Unlike traditional surgery, which involves opening the front of the chest and spreading the ribs to expose the heart, robotic mitral valve replacement is performed through small incisions between the ribs on the right side of the chest, without disturbing the ribs, says Dr. Douglas Murphy, chief of cardiothoracic surgery at Emory Saint Joseph’s Hospital in Atlanta. A high-powered camera inserted through one of the incisions enables the surgeon to get a 3-D view of the heart’s structures. Surgical instruments, which are attached to thin robotic arms and inserted through additional small incisions, enable the surgeon to operate with the precision that previously only an open surgery allowed.
Dr. Murphy performed Georgia’s first robotic mitral valve surgery at Saint Joseph’s in 2002. In December 2016, he attained a world record after completing his 2,000th robotically assisted mitral valve surgery. His team also developed a minimally invasive technique called LEAR (lateral endoscopic approach using robotics), which he has since taught to surgical teams around the world. The LEAR technique enables surgeons to perform open-heart surgery through five small holes in the right chest.
Dr. Murphy says that patients appreciate the less invasive aspect of the technique, and the recovery is usually less than three weeks.
“The driving force for the Emory robotic surgeons, however, has been the ability to perform state-of-the-art cardiac procedures with very low complication rates,” he says. “We see the valve better, we can repair it effectively, and we can do it with minimal trauma to the chest wall tissues. The ribs remain intact like building a ship inside a bottle.”
Helping the Smallest Patients
When a young child has surgery, even a small incision can be large for a little body. And the scar left behind grows with time, becoming cosmetically displeasing as the child grows older. Yet minimally invasive procedures have rarely been used in children because of the small space in which the surgeon has to work and the precision required for their tiny anatomies. The introduction of robotics, however, is increasing the potential for minimally invasive procedures in young patients, says Dr. Brad Morganstern, a pediatric urologist at Augusta University who uses the da Vinci robot to perform a procedure called pyeloplasty on children as young as one.
Pyeloplasty is done to remove a blockage at the ureteropelvic junction (UPJ), where the kidney meets the ureter. When the UPJ is blocked, urine can back up into the kidneys, a serious situation that can cause kidney damage. Removing the obstruction and suturing the kidney and ureter is a delicate procedure requiring great precision, says Dr. Morganstern. “When you have the smaller anatomy and you are trying to put anywhere from 10 to 20 stitches into this one small section, being able to precisely place that suture is paramount,” he says.
Robotic surgery not only reduces the trauma of surgery in the short term, but it minimizes scarring later. Requiring three incisions about the size of the tip of his pinky – one of which can be hidden in the patient’s navel – is a huge advantage for pediatric patients, says Dr. Morganstern.
For men undergoing removal of the prostate (prostatectomy), one of the most difficult aspects of the surgery is the loss of bladder control that almost inevitably follows. For many, a robotic prostate surgery pioneered by Dr. Rabii Madi at Augusta University is helping to solve that problem.
Retzius-sparing radical prostatectomy is a technique that approaches the prostate from below, rather than above, the bladder. The approach allows surgeons to spare the ligaments and other connective tissues that are important to continence.
“With [conventional] prostatectomy surgery, many people have trouble controlling urine, at least initially,” says Dr. Madi. “It can take up to one year.” With the new procedure, however, many men don’t have to experience incontinence at all, he says, and those who do recover their continence more quickly.
Longer Life for New Joints
When a person’s natural hip or knee is irreparably damaged due to arthritis or, less commonly, injury, replacing all or part of the joint with an artificial implant can relieve pain and restore function. But how well the new joint works – and for how long – depends largely on proper mechanical alignment of the implant, says Dr. Beau Sasser, an orthopaedic surgeon at Summit Sports Medicine and Orthopaedic Surgery in Brunswick and medical director of Southeast Georgia Health System Sports Medicine. Robotic assistance allows joint surgeons to get the best alignment.
“The analogy I discuss with my patients is that a joint replacement is like tires on a car,” says Dr. Sasser. “If the tire is balanced properly, you can get 50,000 miles out of the tire; however, if it is not balanced properly, then it will wear unevenly, thereby decreasing the lifespan of the tire. This is the same for joint replacements. If they are aligned properly, the lifespan can be upwards of 20-plus years.”
The MAKOplasty procedure, which was first available in Georgia at the Southeast Georgia Health System, works by using a CT scan of the patient’s hip or knee and creating a 3-D model of that joint.
“Then the new implant can be created with the proper alignment parameters specific for that patient,” says Dr. Sasser, who performed Southeast Georgia Health System’s first robotically assisted knee replacement in 2008 with Dr. Denny A. Carter. “During the surgery, the robot does not allow the surgery to be performed outside these alignment boundaries.”
With the robotic arm’s real-time surgical feedback, surgeons resurface the joint, leaving healthy bone and tissue untouched and remove only diseased bone through a small four- to six-inch incision, Dr. Sasser says. An implant is aligned and placed in the joint with reproducible precision, which can result in a more natural feeling knee/hip and movement.
When to Go Robotic
Robotic surgery is most commonly used in urology, gynecology and thoracic surgery. It is used for situations requiring great precision – removing malignant tumors from the abdomen or chest, removing kidneys or treating endometriosis, for example – or in deep, difficult-to-reach areas of the body.
Despite its many benefits, robotic-assisted surgery may not be used for every type of surgery. For one, in some cases it’s simply not necessary, says Dr. Andrew Green, who directs the robotic program at the Northeast Georgia Health System. “As I tell my students, think about a car – if you have a Ferrari, you can go to the grocery store and get a gallon of milk with it. But that is overkill.”
Similarly, some surgeries can be performed equally well without the robot – appendectomies, gall bladder removal or the removal of benign ovarian masses, for example.
In addition to the type of procedure, other factors in the choice to use a robot include:
• Availability of robots and trained surgeons. While most of Georgia’s larger hospitals offer robotic-assisted surgery, not all do. The da Vinci’s price tag of around $2.5 million makes it off limits or at least impractical for many small hospitals. And even when a robot is available, it takes a specially trained surgeon to use it.
“The robot is only a tool to be used by excellent, well-qualified as well as well-trained surgeons who know how to do these operations in a traditional fashion,” says Dr. Eldaif.
Training in robotic surgery is now offered in many surgical residency programs, but more complex procedures require an additional two-year fellowship, says Dr. Terris.
• Patient size. While small children are benefiting from some robotic procedures, especially large patients may benefit as well. More flesh means larger incisions for the patient and greater challenges for the surgeon, says Dr. Green, a gynecologic oncologist.
“In heavy people, the surgeon has to use their shoulder strength to hold the fat back,” he says. “The robot does that for you, and you can use your fine motor skills to do a lot more delicate operations in heavy people.”
• Medical and personal issues. Factors such as previous surgeries, lung function and other health concerns influence a surgeon’s decision to use robotic surgery. Patient preferences can also play a role, says Dr. Terris. For example, if someone for religious reasons is opposed to blood transfusions, the surgeon may likely choose robotic surgery, which results in less blood loss.
Although the first surgical robotics came to Georgia nearly two decades ago, doctors say robotic surgery is still in its infancy. They predict a day when the devices will become smaller, their use will become more common and the procedures they perform even more advanced.
For now, the benefits of robotic surgery for patients are immeasurable – mainly the ability to receive the optimal results of surgery and get back to their day-to-day activities sooner.
“By offering our patients the most advanced technology, supported by good data, we are able to enhance patient recovery, allowing them to return to their normal living activities and really maintain a great quality of life,” says Dr. Eldaif.
Whether the operation is to remove cancer or repair damage, he says, robotic-assisted surgery enables the surgeon to “offer patients the best operation that is long lasting.”