This story originally appeared in the Spring 2017 issue of Cincinnati Health & Life Magazine.
More than 12 years ago, J. Michael Smith, M.D., performed the first robotic assisted surgery at TriHealth. It was a coronary bypass procedure. “We were one of the first centers doing advanced cardiac surgery with the da Vinci®Surgical System,” says Dr. Smith, Chief of Cardiac Surgery at Good Samaritan Hospital. “I had patients say to me, ‘Let me get this straight: You’re doing this but the Cleveland Clinic isn’t?’”
Today, TriHealth is a national leader in robotic-assisted surgery, with seven da Vinci® Surgical Systems between Good Samaritan and Bethesda North hospitals. According to Intuitive Surgical, Inc.,TriHealth is in the top 1 percent nationally when it comes to volume of procedures performed.
In addition to heart procedures,TriHealth surgeons are using robotic technology to perform many complex procedures throughout the body, including the lungs, pancreas, esophagus, bladder,kidneys, colon and male/female reproductive organs and glands.
“We’re really fortunate to have a lot of experience with robotic-assisted surgery,”says Erik Dunki-Jacobs, M.D., a surgical oncologist at TriHealth. “It’s an advantage for our patients. Dr. Smith was an early adopter for robotics in cardiac surgery. As a result,TriHealth became a training center for surgeons,both nationally and internationally.”
Providing the Best Surgical Options
What any patient wants when faced with potential surgery is to have the most appropriate procedure that will provide the best outcome. TriHealth offers robotics as part of a comprehensive toolkit of surgical options, and surgeons with extensive experience who can tailor the approach to each individual patient.
Traditionally there are two approaches to surgery: open and minimally invasive. Open surgery, which involves an incision large enough to gain access to the operating field, allows surgeons to work inside the body with hand-held tools. Minimally invasive surgery, of which there are two types—laparoscopic and robotic-assisted—allows a surgeon to perform an operation through several, much smaller incisions.
During a laparoscopic procedure, a surgeon will insert a camera and hand-held instruments through those small incisions(usually an inch or less), and perform the surgery with 2D vision.
Robotic-assisted surgery is performed by a highly trained surgeon who uses a robotic system. Miniaturized medical instruments are inserted through very small incisions (about the size of a dime) and controlled by the surgeon via a console,located right next to the patient. Not only are the instruments wristed, allowing them to turn and maneuver with ease, but they also are able to bend far beyond the ability of the human hand. This gives the surgeon even more precise control than laparoscopic tools.
One of the robotic arms holds a 3D camera,which sends high-definition, magnified images to a monitor, giving the surgeon a much better view than would be possible either with the human eye in open surgery or with the 2D imaging of laparoscopy.In addition, the robotic system manages the level of force applied by the surgeon and removes any random movements.
“The visibility of the anatomy is unmatched,”says Thomas C. Maynard, M.D.,Director, TriHealth Division of Hepato-Pancreato-Biliary Surgery, and the first in the region to offer minimally invasive pancreatic surgery. “I’m able to dissect into tissue planes that I thought would be impossible. Not only is the visualization better than traditional 2D laparoscopy, but it’s far better than open surgery while wearing loupes [magnifying glasses]. I’d have to stand on my head to suture some of the tissue I’m able to suture with the robot.”
How Patients Benefit
These features help surgeons perform complicated procedures that require precise actions on very small targets.“Robotic-assisted surgery makes it possible to do some procedures in a minimally invasive way that otherwise would have to be done with open surgery,” says Dr. Dunki-Jacobs. “This is important because patients who have minimally invasive surgery have less blood loss,fewer wound complications, shorter hospital stays and less pain.”
“Because patients have less pain,” says Kathryn O’Keefe, M.D., a cardiothoracic surgeon at TriHealth Heart Institute, “they use narcotics less. Overall, they recover and return to normal function in less time.”
For some patients, this can mean more than simply getting back to work and normal activities faster—it can mean being able to continue with vital treatment sooner. For example, some patients who have pancreatic cancer have a surgery called the Whipple procedure, which involves removing the head of the pancreas,the duodenum (the first part of the small intestine), a portion of the common bile duct, the gallbladder and sometimes part of the stomach. The treatment plan for most patients who have this surgery includes starting chemotherapy once they have recovered.
“I predict that in time, we will see more patients who have a robotic Whipple procedure go on to get those treatments,”says Dr. Dunki-Jacobs, “and they’ll get them sooner because they have fewer complications from surgery and recover from it faster.”
Some patients may see another benefit from having their surgery done with the assistance of robotics. “For lung cancer patients, there’s some evidence that the number of lymph nodes surgeons are able to remove using robotics is higher than open surgery,” says Dr. O’Keefe.“As a result, we can stage patients, or discover the extent of their cancer, more accurately, and staging is the most important determiner of the best course of treatment.”
At TriHealth, about 50 percent of Whipple procedures are performed with the aid of robotics. “And that will continue to increase,” says Dr. Dunki-Jacobs.Likewise, the esophagectomy procedure,which is done to remove a cancer of the lower esophagus, or tube that connects the mouth and stomach, is another highly complex cancer surgery. At TriHealth, it is being performed robotically for nearly all patients. “No other area hospitals are doing either procedure robotically,” says Dr. Dunki-Jacobs.
Thoracotomy is a procedure in which a surgeon cuts between two ribs to expose the chest for lung operations.It requires a 5- to 10-inch incision that extends from the front of the chest to the back, running just below the armpit, and cuts through multiple muscle layers. It also requires separation of the ribs, and in some cases removal of all or part of a rib. Recovery from this type of surgical incision is one of the most difficult. When surgeons use robotic-assisted surgery to access the lungs, this painful procedure can be avoided. Instead, surgeons reach the lungs through a few small incisions on the side of the body.
At TriHealth, about half of patients having lung surgery don’t have to have athoracotomy because their surgery can be performed robotically. “Nationwide, the average is 10 percent,” says Dr. O’Keefe.“The higher volume of patients we have has made us better robotic surgeons.”
The precise movements and excellent view of the surgical field that the robotic system gives surgeons, coupled with fewer complications and easier recovery for patients,have made robotics an integral part of the TriHealth system of care. “There’s no question robotic-assisted surgery is going to be used increasingly,” says Dr. O’Keefe. “Surgeons and patients are noticing the benefits, and there’s a big push nationally to get more surgeons trained.”
Experienced surgeons are key to a successful robotic-surgery program. But they’re not the only key: “You’re very reliant on your team with robotics,” says Dr. O’Keefe. “We’re lucky at TriHealth to have dedicated and highly skilled surgical assistants and team members. They’re very experienced with robotics and committed to excellence.I’m thankful for every one of them.”
Compassionate patient-centered care is central to TriHealth’s mission. By offering a personalized, tailored approach to surgery, TriHealth’s highly trained surgeons—who are experienced in procedures from the routine to the highly complex—are following that mission,providing what’s best for each patient,each time.