Tulane University Hospital and Clinic uses robotic surgery for minimally invasive surgeries

Webster, Richard A
New Orleans CityBusiness
Monday, January 24 2005

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A 6-foot-tall, 1,200-pound machine hung over Brian, a New Orleans native, as he lay prone on a surgical bed bathed in green fluorescent lighting.

The arms of the machine, inserted deep inside Brian's abdomen, moved silently as they burned through fat tissue, slowly progressing toward his prostate.
In less than three hours, Brian's prostate would be cinched inside a small bag along with a deadly cancer. And that night, Brian would return home, pain-free, with only five small scars to remind him of the experience.

Doctors and patients alike hail the new surgical technique as a revolutionary breakthrough.

We're always innovating and going one step further to make it easier for the patients, said Dr. Raju Thomas, head of the Tulane Prostate Cancer Program.

The technology used to remove Brian's prostate, called a da Vinci Surgical System, was created in 2000 by Intuitive Surgical, based in Sunnyvale, Calif. It reduces trauma to the body, decreases hospital stays and increases recovery time.

In the two years since Tulane University Hospital and Clinic became the first in the Gulf Coast to test the new technology, robotic surgery has become the standard-bearer in minimally invasive surgery.

In October 2002, Tulane Hospital purchased a da Vinci Surgical System for $1.2 million, becoming the first hospital in Louisiana and the Gulf states to acquire the technology.

It's simple to use. In Brian's case, a surgeon stood next to the bed manipulating by hand two long rods sticking out of his stomach. In the far corner of the sterile room, another surgeon sat peering into a smaller machine while his hands moved metallic joysticks silently as his feet pressed a series of pedals.

The only blood visible was on the high-definition television screens located above the heads of the surgical team.

Today, more than 270 systems are used in the United States and 320 worldwide. In the third quarter of 2004, Intuitive reported $35.5 million in sales, a 52 percent increase from $23.4 million for the third quarter of 2003.

Millard Callicott, account manager with Intuitive, said the robot is most commonly used to remove prostates. Of 80,000 prostatectomies done in the United States last year, 12 percent were performed with robotic technology.

The system can also be used for heart operations and gastric bypass surgery, Callicott said.

Before, with coronary bypass surgeries, they'd have to crack the chest open, Callicott said. But with the dexterity of our system they can put instruments between the ribs and you can do closed chest heart surgery.

Before robotic surgery, performing a prostatectomy required 6- inch abdominal incisions. The large incisions increased the risk of infections, hernia, blood loss and nerve damage affecting sexual functions and incontinence mechanisms. Such surgery often required heavy doses of narcotics to dull the pain, which slowed metabolism and retarded the healing process.

The average hospital stay for a patient undergoing such a procedure was three days or more. Recovery time could last up to eight weeks.

All of that has been completely eliminated with the new technology, Thomas said. The post-operative results have been excellent so far as quality-of-life issues are concerned.

The da Vinci Surgical System cuts the hospital stay down to one day or less and recovery time to two weeks. Thomas credits the minimally invasive nature of the new technique.

Huey Delaneuville of Norco had his prostate removed less than two weeks ago at Tulane Hospital using robotic surgery and said there have been no complications.

I never even had to take any pain medication, Delaneuville said. The doctor gave me some but I never took it. It's amazing how easy it all was.

In the surgical room at Tulane Hospital, doctors cut five quarter- inch to half-inch incisions into Brian's abdomen. Doctors inserted long metal rods into the incisions equipped with tools such as forceps, needles or suction devices. A camera at the end of the fifth rod allowed surgeons to see where they were operating.

The doctors affixed three of the rods, including the camera, to the robotic arms of the da Vinci system, which is wheeled between the legs of the patient.

The procedure required three people - a lead surgeon, bedside surgeon and scrub nurse.

Thomas acted as lead surgeon and sat down in front of a console 5 feet away from the patient. Using joysticks, Thomas controlled the robotic arms attached to two of the rods inside of the patient's abdomen.

The robotic arms simulate exactly what my hands are doing, he said while looking into the viewfinder. It follows exactly what I do in all degrees, giving me full rotation. I can go into areas normal instruments can't, like under the pelvic bone. A regular instrument can just open and close - these can be fully articulated.

Thomas manipulated the camera with foot pedals. The image was displayed on several large color screen televisions, magnified to 10 times its normal size. Inside, the viewfinder's two fused lenses provided a three-dimensional image, the first time surgeons have been able to peer inside the body with full depth perception, Thomas said.

As Thomas burned through fatty tissue and scar tissue using an electrified cautery hook, the bedside surgeon, Dr. George Jabren, controlled two rods by hand, clearing a path for Thomas by providing irrigation and suction.

When sutures were needed, a needle and surgical thread were passed through one of the small incisions. When the prostate could be removed, a bag was inserted into the patient. Thomas placed the prostate into the bag, cinched it and removed it through an incision.

At no time were Brian's internal organs exposed, save for the movie-like image on the television screens.

The high initial cost of the robot is offset by its indirect cost- savings, Thomas said.

Everybody is concerned about escalating health care costs but in no analysis does anybody take into account the overall benefit to patient and what in turn happens to society, Thomas said. We save money on the reduced hospital stay and by getting the person back to work in two weeks as opposed to eight weeks. Nobody puts that into any cost evaluation.

For health care economists, they need to look at technology like this that enhances the precision of surgery.