Vanderbilt’s first robotic surgical procedure was performed in mid May by Dr. Joseph A. Smith Jr., William L. Bray Professor and Chair of Urologic Surgery. Smith used VUMC’s new $1 million-plus Da Vinci Surgical System, built by Intuitive Surgical, to perform a radical prostatectomy.
Introducing a new degree of freedom and control for the surgeon, and eliminating the awkwardness of endoscopic technique, robotic systems help to extend the important benefits of minimally invasive surgery to new groups of patients.
"Robotic surgery will be critical for Vanderbilt’s future as a training center for minimally invasive surgery," said Dr. R. Daniel Beauchamp, J.C. Foshee Distinguished Professor of Surgery, Chairman, Section of Surgical Sciences. "We’re not interested in just having the robot in its current state. We want to push the boundaries of where this technology will have a role."
To help drive the development of new robot applications, Beauchamp said Vanderbilt surgeons will work with experts in the School of Engineering to create new instrumentation and to integrate radiological images alongside the robot’s view into the operating field. Beauchamp hopes within four years to have established a center having as many as five of the expensive robots.
Endoscopic surgery, a less-invasive alternative to traditional open surgery, uses small incisions, or ports, for the insertion of an optical device (endoscope) and surgical instruments. Viewing the operating field through a video monitor, the endoscopic surgeon manipulates instruments with the use of mechanical extensions. Compared to traditional open surgery, endoscopic technique reduces blood loss and postoperative pain and allows quicker recovery from surgery. But it’s an awkward way to work, involving large arm movements and requiring the surgeon to transpose his movements as he manipulates instruments in a visual field where up is down and left is right.
"To me, what the robot really does is shorten the learning curve for endoscopic surgery," said Dr. Noel B. Tulipan, professor of Neurosurgery, who is working to adapt the Da Vinci system for use in fetal surgery for spina bifida and other neural tube defects.
The Da Vinci robot uses three arms, one for the endoscope and two for surgical instruments, each entering the patient through its own port. "It’s very intuitive," said Smith, who hadn’t worked much with endoscopic technique before training on the robotic system. Hand movements mimic those of open surgery, allowing Smith to transfer to the robotic approach the skills and experience he has gained in performing more than 2,000 open radical prostatectomies.
Sitting across the room from the patient and using his feet to manipulate the endoscope, Smith looks through a hooded display at a three-dimensional view of the operating field, magnified 15 times. "You see nerves and other features much better than in open surgery," he said.
Wrapped in Velcro strips, Smith’s middle fingers and thumbs are wired so that their movements are relayed to the surgical instruments, minus the normal tremor that hands produce. Using different control settings, Smith can scale the robot motion up or down, so that a hand movement of 5 cm, for example, could move the instruments one-half or 3 or 8 cm (for prostatectomy he chooses to work close to actual scale). Dissection of nerves is more precise and suturing is easier, and Smith can rotate instruments as he never could hope to using only his wrists. As the case progresses the instruments are periodically exchanged – scalpel, cautery, needle holder, etc. A key member of the operating team, Dr. Duke Herrell, assistant professor of Urologic Surgery, assists at the operating table, using additional ports to retract and to pass suture.
"You can learn to use the robot in half an hour," Tulipan said. And with the magnified 3-D view, "It feels as if you’re in the operating field."
In addition to applications in urologic and neurologic surgery, Beauchamp expects the robot to be used in general surgery, cardiac, thoracic, vascular, ob-gyn, and surgical oncology procedures.
Media contact: Paul Govern, (615) 322-4747 paul.govern@vanderbilt.edu
