Advancing Robotic Surgery by Relying on Techniques, Technology and Team

The most important ingredient to a successful robotic surgery program is a collection of highly skilled surgeons. That’s the focus at Crouse Hospital.

In 2008, Crouse Hospital added a da Vinci robot-assisted surgical platform to its surgical portfolio and, in 2013, inaugurated its multidisciplinary Institute for Robotic Surgery. The hospital added a second da Vinci system earlier this year to open the possibility of minimally invasive robotic surgery to patients whose conditions may have previously required traditional open surgery.

The da Vinci system allows surgeons to introduce surgical instruments, attached to robotic arms, through incisions 1–2 cm in length, as opposed to the larger incisions associated with open surgery. The system’s high-definition, magnified 3-D visualization and increased instrument articulation can reduce blood loss, lessen postoperative pain, shorten hospital stays and expedite recovery times for patients.

David Albala, MD
David Albala, MD, Chief of Urology at Crouse

In only five years, Crouse’s multispecialty robotic surgery program has grown to become the largest in the region, with more than 600 procedures performed in 2013.

Before joining the Crouse team, David Albala, MD, Chief of Urology at Crouse, played an integral part in the minimally invasive and robot-assisted surgery program at Duke University Medical Center. He explains that the da Vinci surgical system is a game changer.

“When the robot-assisted platform came out, it leveled the playing field,” Dr. Albala says. “If you had laparoscopic skills, but weren’t necessarily great at suturing, you could use this platform, which makes suturing easier, and get a better result. This is what carried the robot to the forefront.”

“Crouse Hospital administration has developed a robotics program the right way, and that’s why I’m happy to be affiliated with them. The first thing they care about is patient safety. That’s the single most important factor.”
— David Albala, MD, Chief of Urology at Crouse Hospital

Skilled Hands Required

After performing approximately 1,400 robot-assisted prostatectomies, Dr. Albala’s proficiency with the technology has led to curative results comparable to open surgery and allowed him to reduce incontinence and impotence complication rates associated with urological surgeries. While the robotic platform offers a way for surgeons to provide these benefits, it takes practice and skill to achieve the platform’s full capabilities.

Witting Surgical Center
Mary Cunningham, MD, performing robotic surgery in Crouse’s Witting Surgical Center

“The technology is only as good as the surgeon,” Dr. Albala notes. “When patients come to my office, I tell them how many prostatectomies I’ve performed, as well as my average postsurgical patient potency and continence rates. I don’t tell them what the literature says or what other physicians are doing. I tell them what I’ve done.”

In addition to prostatectomy, Dr. Albala uses the da Vinci platform to perform a wide variety of urological procedures, including adrenalectomies, partial nephrectomies and piloplasties. For such procedures, the minimally invasive technology provides critical advantages, including reduced blood loss and less than a 1 percent chance of transfusion, according to Dr. Albala.

Where It Began

Crouse Hospital began its robotic surgery program in 2008 with surgeons Mary Cunningham, MD, and Douglas Bunn, MD, partners in GYN Oncology of CNY. Both surgeons are regional leaders and pioneers in gynecologic surgery. Board-certified gynecologic oncologist Dr. Cunningham explains that surgical treatment for endometrial cancer includes removing lymph nodes, which requires nimble maneuvering — something past treatment modalities did not accommodate.

John D. Nicholson, MD, and David Nesbitt, MD
John D. Nicholson, MD, and David Nesbitt, MD, of Colon Rectal Associates of Central New York

“When taking out lymph nodes, we’re operating around major blood vessels and nerves, which is much easier with 3-D visualization and better articulation,” Dr. Cunningham explains. “Before we began using the da Vinci, some surgeons used traditional laparoscopy, but it wasn’t as effective, and the percentage of patients who had to be converted to open surgery was higher than with the robot-assisted platform.”

Avoiding conversion allows patients to glean all the benefits from minimally invasive surgery, including markedly reduced recovery times.

“The vast majority of patients are back to normal activities about three weeks following the operation,” Dr. Cunningham says. “That’s about half the recovery time necessary after open procedures. For example, patients who undergo open surgery for endometrial cancer will be in the hospital for three to five days and typically take six to eight weeks to return to normal activities, as opposed to leaving the hospital the following morning and returning to normal activities three weeks after da Vinci surgery.”

Mary Cunningham, MD
Mary Cunningham, MD, a partner in GYN Oncology of CNY

Dr. Cunningham sees many morbidly obese and elderly patients, whose age or size would have complicated open surgery because of increased infection rates or inability to tolerate a major procedure.

The volume of patients Dr. Cunningham operates on has honed her skills and enabled her to offer the full spectrum of benefits to her patients. It has also given her the ability to discern when to use the modality.

“While not the method of choice for every patient or every procedure, robotic surgery can be useful in patients with a lot of scar tissue caused by endometriosis or prior surgery,” Dr. Cunningham says. “It allows the opportunity for the laparoscopic approach even in complex surgical cases.”

Navigating with Ease

Like gynecologic oncologists, colorectal surgeons find the da Vinci platform’s articulation particularly beneficial when operating in the cramped, lower pelvic anatomy, says John D. Nicholson, MD, FACS, FASCRS, attending colorectal surgeon at Crouse Hospital.

“The da Vinci makes it easy to go around corners and get to very narrow spaces,” he says. “The platform is extremely helpful in the rectum, for example. Colorectal surgeons operate in every quadrant of the abdomen, so many of our procedures require increased articulation.”

Standard laparoscopic instrumentation is rigid, rendering its maneuverability limited and sometimes difficult. The da Vinci platform’s patented EndoWrist instrumentation allows surgeons greater dexterity than traditional laparoscopy.

“The instruments articulate just like a wrist or a hand,” Dr. Nicholson says. “Whatever I can do with my hand I can do with the robotic platform, as opposed to manual laparoscopy, which uses primarily rigid instrumentation.”

da Vinci Si
The da Vinci Si HD Surgical System

The da Vinci system offers attachment options for a number of operative devices, including instruments used to seal or divide blood vessels. The addition of a surgical stapler has been especially useful for colorectal surgeons performing resections in the pelvis.

Dr. Nicholson notes that the da Vinci system doesn’t open the doors to new procedures but provides an advantage for surgeons operating on patients with rectal cancers, diverticulitis, irritable bowel syndrome, or any condition affecting the left side of the rectum — an area of the anatomy that made it difficult to maintain laparoscopic benefits.

“The robot is a tool to make laparoscopy better,” Dr. Nicholson explains. “We’re all doing procedures we could do in standard laparoscopy with a tool that improves the technical aspects. The difference is not that we’re doing procedures we couldn’t do before, but we can complete these difficult operations laparoscopically instead of having to convert to an open procedure, which forfeits the benefits of laparoscopy.”

In traditionally difficult laparoscopic procedures involving treacherously claustrophobic anatomy, the da Vinci system has allowed Crouse colorectal surgeons to reduce conversion rates to less than 2 percent, Dr. Nicholson reports.

The Team Difference

In the five years since Crouse started its robotics program, patient volumes have increased, and surgical use of the platform has expanded to multiple disciplines. None of this would be possible without the commitment of Crouse Hospital’s administration, which the surgeons say has been generous with the right resources for establishing and growing the program.

“If you’re going to have a successful robotic program, you have to have complete hospital system commitment, starting with a hospital administration willing to financially commit to recruiting a dedicated team,” Dr. Nicholson says. “It’s critically important to have the same team in the operating room, working all the procedures so there’s no chaos during surgery.”

The team, comprised of physicians’ assistants, surgical nurses, scrub techs, and a full complement of managerial leadership ensures that the most advanced tools are put in the most trusted hands.

For more information about Crouse Hospital’s Institute for Robotic Surgery, please visit crouse.org/robotics.

Source: MD News January/February 2014, Central New York Edition