Last week, Kent Hospital announced their new Robotic Cholecystectomy Program, a minimally invasive surgery to remove gallbladders using the da Vinci SI robotic system.
Currently, Kent is the only hospital in Rhode Island offering robotic gallbladder removal, although there are two other da Vinci robots in Rhode Island hospitals used for other procedures.
By using a robot for gallbladder removals, surgeons are allowed to operate through either one single incision near the bellybutton or a few small incisions similar to the currently used laparoscopic surgery. This results in less scarring and a faster recovery.
During the procedure, the patient is on the operating table while the surgeon sits at a nearby computer console to control the robotic arms performing the surgery. Cameras on the arms transmit a 10-times magnified, three-dimensional, high definition live picture of what is in the patient’s body. If necessary, near-infrared technology called Firefly can be used to illuminate the area the surgeon is operating on (in this case the gallbladder and surrounding ducts). Unlike traditional laparoscopic tools, which are straight, unbendable rods used for surgery, the instruments on the end of these robotic arms are able to bend and twist similar to the human wrist.
Through all of these advances, the surgeon is able to perform this procedure with enhanced vision, precision and control.
While the surgeon is at the console, the rest of the surgical team is at the operating table monitoring flat screen TVs that broadcast a two-dimensional version of what the surgeon sees on his screen.
Dr. Joseph Brady is a general surgeon who has been leading the robotic surgery movement at the hospital. He began the training process for the procedure a year ago after being visited by a representative from the da Vinci company.
“Initially, I was very skeptical about it,” said Brady.
When he met with the representative, Brady was asked what would make performing a gallbladder removal easier for a surgeon. Brady answered better visuals. When he saw videos of the high-definition, 3D visuals provided using the robot, he was intrigued.
“The safety of that operation comes down to being able to see better,” said Brady.
Brady said that in laparoscopic surgery, there is a lack of depth perception; he compared it to looking at something with only one eye. But there are two eyes in the camera on the end of the robotic arm providing the proper depth perception as well as light. The wrist-like mobility of the instruments at the end of the arm is also an added benefit.
“I think it really does provide more for a surgeon and a patient in terms of safety,” said Brady, explaining that the area cut during a gallbladder removal is close to other ducts connected to the liver; the robot’s magnification, light and visual-improvements assist the doctor in performing a successful procedure.
As far as safety of robotic procedures, a study published in the “Journal for Healthcare Quality” by researchers from Johns Hopkins Medicine stated the risks and complications were underreported, causing a misleading picture of safety. According to a September 2013 release from Johns Hopkins, about 1 million robotic procedures had been performed in the United States since 2000, with 245 complications including 71 deaths reported to the U.S. Food and Drug Administration. The study reviewed those adverse events reported to the FDA between Jan. 1, 2000 and August 1, 2012 and cross-referenced those with legal judgments and stories in the news media.
The researched found eight cases where the complication was not reported appropriately to the FDA; according to the study, five cases were never reported while two were only reported after a media story.
Of the 71 deaths reported, 22 stemmed from gynecological procedures, 15 from urological procedures and 12 from cardiothoracic procedures, with the most common cause of death being excessive bleeding. Most non-death complications occurred during robotic hysterectomies.
Brady said the risks associated with a robotic gallbladder removal are the same as those associated with a laparoscopic removal, which is the most common procedure.
“I’d have a hard time pointing out increased danger related to the robot,” said Brady.
The only difference Brady sees is the patient cannot be moved while under anesthesia because of the position of the robot; during a traditional procedure, the clinical team could reposition the body if needed.
“The operation is still done the same way, it’s just a different tool,” said Brady.
Kent Hospital CEO Sandy Coletta explained that this is just another step Kent has taken to provide the most state-of-the-art treatment they can to the community.
“What we’ve really been focused on is ensuring the care provided here [at Kent] is as good or better than care provided elsewhere,” said Coletta.
Robotic surgery provides surgeons with better vision and precision, but it also provides patients with cosmetic advantages and quicker recovery. Patients going in for gallbladder removal range in age from teenagers to older adults; because single-spot robotic surgery requires only one incision near the belly button, a scar is less visible. According to Brady, the incision required for single-spot is about 2.5 centimeters; general robotic surgery requires about four incisions, but they are all smaller than 2.5 cm.
“The ability not to have a scar is important in the younger population,” said Coletta. She added the most uncomfortable part of surgery is the incision, so smaller incisions from robotic surgery lead to a faster recovery.
Coletta and Kent Information Officer James Beardsworth admit there is no data to show a robotic surgery is clinically better than laparopscopic; the patient outcome is the same with the exception of a less-visible scar.
“The patient outcome might be the same thing, but it’s better for the surgeon in the way he does his work,” said Coletta.
Brady has performed between 15 and 17 robotic gallbladder removals. Even though he has performed the laparoscopic surgery nearly 2,000 times, he believes patients are always interested in the newest technology and procedures.
“Every person I’ve mentioned it to, I haven’t had a single person say, ‘I want it the other way,’” said Brady. “People trust that you aren’t going to do anything to hurt them.”
Brady always makes sure to tell his patients that he has only done this procedure x-amount of times, especially the patient he performed his first procedure on. When he decided to learn the technology, Brady underwent excessive training, beginning with a “test drive” to try out the equipment, practicing to pick up items and operate the equipment. The rest of his training consisted of nearly 16 hours of simulation training; online course, two animal labs (one traditional robotic and one single-site) and, finally, his first four procedures were monitored.
When asked how many robotic gallbladder removals are expected, Beardsworth said it is hard to know.
“There’s a large, untapped population we can draw on, but to put a number on it would be difficult,” he explained.
Coletta said a gallbladder removal has become a fairly common procedure, and the cosmetic advantages of a robotic removal would likely attract people to Kent.
Coletta said that because of Kent’s involvement in the Care New England Network of hospitals, the hospital was able to receive this robot from Women & Infants’ Hospital. They purchased a new da Vinci robot, providing Kent with their former machine; Kent only had to purchase upgrades.
Because both hospitals have this technology, patients have a choice of hospitals. Surgeons from Women & Infants’ can perform their robotic gynecological procedures at Kent, while surgeons from Kent can travel to Women & Infants’ to perform their urological procedures.
Coletta said the main focus for Kent has been providing robotic gallbladder removal, but there are surgeons at the hospital trained to perform kidney or prostate work using the technology; the robot is not surgery-specific. In fact, down the line, as surgeons chose to get trained, Coletta predicts many standard general surgical procedures could be performed robotically.
Further, Coletta predicts that all gallbladder removals will be performed robotically in the future.
“We saw this happen with prostates. It was a relatively small trickle at first,” said Coletta, explaining that now all prostate removals are done robotically.
Brady said that surgery is always moving towards being less invasive and believes this is the future.
“It’s gonna stay,” said Brady. “In my opinion, five years from now, every general surgeon will have experience with the robot.”
The Johns Hopkins study also showcased the growth of robotic surgeries; between 2007 and 2011 the number of robotic procedures increased 400 percent in the United States and 300 percent worldwide. Also, by the end of 2011, there were 1,400 surgical robots in US hospitals, up for 400 in 2007.