State-of-the-art surgery with da Vinci machine
For Pulse
Sunday, October 19, 2008
Hunched over a huge, gray console that looks like a giant video game, Dr. Nikhil Shah presses his face against the viewfinder of a da Vinci robot, eyes glued to a 3-D image of the gooey insides of a man’s abdomen. His forefingers and thumbs twist twin joysticks that control tiny bird-beak snippers.
Through his magnified viewer, he uses the microtools that look huge to him to probe, push aside and cut thread-thin muscles, nerves and veins with precision in a prostate cancer patient lying on a gurney, 10 yards away.
File photo
‘Wow, that’s pretty awesome,’ says Dr. Nikhil Shah (left, staring into viewfinder) as he gets a high-definition look at a patient’s prostate during surgery with the da Vinci machine. Surgical assistant Karl Csepi is in the foreground.
File photo
Dr. Nikhil Shah not only uses the da Vinci robot, he teaches other doctors how to operate with the California-made machine. St. Joseph’s Hospital is one of 21 U.S. da Vinci training centers.
Photos courtesy of Intuitive Surgical Inc.
Robotic surgery using a video gamelike tool called the da Vinci machine is exploding around the world. Surgeons are using the precision the robot’s powerful camera gives them to perform operations that are intricate and delicate.
Georgia hospitals with da Vinci robots
- DeKalb Medical, Decatur
- Doctor's Hospital, Augusta
- Emory University Hospital, Atlanta
- Kennestone Hospital, Marietta
- Medical Center of Central Georgia
- Northside Hospital
- Northside Hospital-Cherokee
- Northside Hospital-Forsyth
- St. Joseph's-Candler, Atlanta
- Southern Regional Health System, Riverdale
- University Hospital, Augusta
Source: Intuitive Surgical
DA VINCI ROBOTS
710 in the United States
159 in Europe
77 in Asia, Latin America and the rest of the world
All the while in his stocking feet, he’s pumping foot pedals under the console like a piano maestro, joking that the robot “is a bit like being at Dave & Buster’s,” the entertainment centers known to metro Atlantans for food, drink and fancy video games.
The 90-minute operation is successful.
Patients spend only one night in the hospital, instead of three or four when surgery is done the old-fashioned way.
It’s one of the reasons robotic surgery using the $1.5 million da Vinci machine is exploding, especially for prostate surgery. It’s also being done increasingly for other intricate operations — ranging from kidney removal to hysterectomies and cardiac bypasses.
Shah said the robots usually allow surgeons to prevent the side effects men and their sexual partners dread most — impotence and incontinence.
His patients, like Dan Fernandez, call him “the rock star” of prostate surgery “because there are so many advantages of this technique.”
After his diagnosis, Fernandez, 50, of Smyrna, studied up on his disease, and late one night, Googled his way to St. Joseph Hospital’s Web pages, then sent an e-mail to the Atlanta hospital. To his surprise, he received a phone call from Shah within 15 minutes.
“He said, ‘I know it’s unusual to get a phone call from a doctor at night, but I saw your e-mail pop up, and I think I can help you,’ ” said Fernandez, an executive for Deloitte Consulting. “He said to bring my wife into the decision because if you become impotent, it’s a problem for your wife, too. It’s a couple’s disease.”
He scheduled the surgery, was discharged the next day, suffered little pain and has only a half-dozen tiny scars. And best of all, he said, “I never experienced incontinence, nor loss of sex drive or ability.”
Not all men are as lucky, but most operated on by surgeons using the da Vinci robot return to normal within a matter of months, Shah said.
Array of treatments
The robotic procedure is only one choice in what Dr. Brantley Thrasher, spokesman for the American Urological Association, calls a “bewildering” array of prostate treatments. The AUA has no clear guidelines, and its literature makes decisions tough. Each method has strong advocates.
Prostate cancer, the second most prevalent form of the disease in men after lung cancer, is treated with total gland removal, with or without the surgical robot. Other methods include external beam radiation, inserted radioactive seeds, hormone therapy and cryotherapy, or freezing of the organ.
Studies haven’t yet pinpointed “the best method,” said Thrasher, who uses the robot at the University of Kansas.
As of July 31, six St. Joseph’s doctors had used its four da Vinci robots for 359 operations, including 148 cardiac procedures and 181 prostatectomies, most by Shah.
Last year, the total for all da Vinci surgeries reached 456 at St. Joseph’s, compared with 748 at Northside Hospital, where 363 prostatectomies were done. At St. Joseph’s, 196 were performed, but Shah said that number will double this year.
WellStar Health System’s robot is used mostly for hysterectomies and other gynecological procedures. DeKalb Medical started using a da Vinci machine in October, and Emory has one of the robots.
Worldwide, 55,000 da Vinci prostatectomies were done last year, and it’s expected to hit 75,000 in 2008, said James Alecxih of Intuitive Surgical of Sunnyvalle, Calif., which makes the robots.
In 2007, 13,000 robotic hysterectomies were done worldwide; that’s expected to hit 32,500 this year.
Shah, who has performed more than 1,000 robotic procedures, was recruited in 2006 from the Henry Ford Center in Detroit, where he trained. The center is near the top in robotic prostate surgeries.
He said St. Joseph’s is catching up fast.
The robots offer many advantages, as Shah discussed during a recent operation.
Their tiny 3-D high-definition cameras magnify the insides of the abdomen, making tiny veins look like small cords. It makes it easier to spare critical nerves, resulting in “significantly better” erectile function than other procedures, he said.
Six dime-size incisions are required, into which the blindingly bright camera and small tools are gingerly probed and manipulated.
While maintaining a steady banter of jokes and instructions to the other eight people in a St. Joseph’s Hospital operating room, Shah, 39, carefully snipped, clipped and guided the tools toward the man’s cancerous prostate. Four huge plastic-wrapped spidery arms hovered over the patient.
In traditional laparoscopic surgery, small holes are made in the abdomen for tools and a camera, which shows only a two-dimensional image. In such nonrobotic operations, “you are depending on your tactile senses. It’s like operating with chopsticks.”
Working in concert
In the operating room, monitors are strategically placed so everyone can keep an eye on what’s going on, including Shah’s surgical assistant, Karl Csepi, 43.
Nearby, a monitor beeps as zigzag lines measure the patient’s vital signs.
“Wow, that’s pretty awesome,” Shah said after exposing the prostate.
Other surgeons, like Dr. Stephanie Yap of DeKalb Medical, are equally enthusiastic.
“The bottom line is patients will have a much faster, less painful recovery, and get back to their lives more quickly,” she said.
Dr. Gerald Feuer, a gynecological oncologist who operates at WellStar and Northside, said robot surgeries save money for patients in terms of less lost work time.
“It’s absolutely incredible how quickly they get back to normal,” he said. “I think this is going to be in the future of every gynecologist.”
Shah sees doctors, too, because St. Joseph’s is one of 21 da Vinci training centers in the United States.
Insurance covers most operations, which can cost more than $8,000.
During the recent procedure, Shah gently offered instructions to Csepi, whose eyes remained fixed on a nearby TV screen.
“It’s kind of like driving home after work, huh, Karl?” Shah prompted. Csepi nodded with a smile.
THE BENEFITS
Robotic surgery is a fast-growing specialty because it offers benefits over conventional techniques:
• Less time in the hospital, one day compared with three or four.
• Less blood loss, less need for blood transfusion.
• Faster recuperation. Most people are up and around the next day.
• Less scarring. It requires tiny holes, dime-shaped, rather than long, stitched-up incisions.
• Better outcomes. Research shows the pinpoint precision robots provide reduces the incidence of impotency and incontinence in prostate gland removal.
• Less post-operative pain.
• Allows for more precision.
• Reduced risk of infection.
Sources: Northside Hospital, St. Joseph’s Hospital
THE INQUIRIES
Questions to ask your doctor before undergoing robotic surgery:
1. What are the advantages of robotic surgery?
2. How much experience does the surgeon have in robotic surgery?
3. What is the risk of this surgery?
4. Does my insurance cover this?
5. Ask about previous results, his/her success rate, and whether he/she follows up on patient outcomes.
Sources: DeKalb Medical, St. Joseph’s Hospital
— This article is a reprint from The Atlanta Journal-Constitution.
