Published: Synapse 2013, Vol. 2

Most advances in surgery are evolutions, not revolutions. They occur as small changes and refinements in how operations are performed rather than dramatic transformations that leave the old way behind.

In the field of general surgery, the introduction of laparoscopy was a revolution. The first operations using this novel "keyhole" technique sparked an explosion of innovations that shaped the current era of minimally invasive abdominal surgery. Compared with traditional "open" operations, laparoscopic surgery offers patients the benefits of less pain and scarring and a shorter hospitalization and recovery period.

Surgeons continue to seek ways to further minimize the impact of surgery without compromising safety or effectiveness, but inherent limitations of conventional laparoscopy have thwarted major leaps forward. Robotic surgery technology is helping overcome the constraints of traditional laparoscopy while opening the door to new innovations.

Introducing...Single-Incision Robotic Surgery
The latest advancement in minimally invasive abdominal surgery is robotic-assisted surgery through a one-inch incision in the navel. In standard robotic surgery, three to five small (less than a half inch) incisions are made, where "ports" are inserted to accommodate a tiny camera and surgical instruments. In single-incision robotic surgery, the camera and instruments all enter the body through a single port ... in the bellybutton.

The specialized equipment for single-incision robotic surgery is called da Vinci Single-SiteTM and is designed for use with the da Vinci Si Surgical System. Single-Site currently is FDA-approved for gallbladder removal (cholecystectomy) and for hysterectomy. This new robotic technology is now available at The Chester County Hospital for gallbladder removal, with the promise of much more to come.

Expanding Treatment Options and Expertise in Robotic Surgery
From its inception, the Robotic Surgery Program at The Chester County Hospital has aimed high, with a mission to stay at the front of technology while building proficiency and expertise. Offering the latest advancements in robotic surgery is a logical step in the program's growth.

"Building a strong robotics program is a top priority for the Hospital," says Mary Kehner, RN, BSN, MS, CNOR, Surgical Services Director. "We are committed to a surgery program that keeps pace with advancing technology. Robotics is the next wave in minimally invasive surgery, and we have fully embraced it."

Kehner and colleague Jim Kozub, PA-C, Robotics Program Coordinator, emphasize the Hospital's equal commitment to patient safety and the skill of its robotic surgery teams. "Our credentialing and quality control process is robust," says Kozub. "It meets or exceeds all available best-practice recommendations."

Demnicki and FukuchiRobotics-credentialed urologic and gynecologic surgeons have been performing multiport robotic surgeries on the Hospital's da Vinci Si Surgical System since September 2011. At the time of publication, more than 600 surgeries have been performed. In early 2013, the robotics program expanded into general surgery. To prepare for the growth, two experienced general surgeons on staff at the Hospital -- Steven Fukuchi, MD, Chairman of the Department of Surgery, and Pamela Demnicki, MD -- were credentialed to perform standard robotic procedures. Drs. Fukuchi and Demnicki then trained in the use of Single-Site technology and began performing single-incision robotic gallbladder removals. Plans are in place for gynecologic surgeons and teams to train to perform single-incision robotics-assisted hysterectomies, which are anticipated in late 2013.

Benefits for Patients
Single-incision robotic surgery offers benefits to patients, and since cholecystectomy is a common operation, the new Single-Site option has the potential to impact many people. In 2012, 406 laparoscopic cholecystectomies were performed at The Chester County Hospital.

"For patients who need their gallbladder removed, the big news is that the entire operation can be done through a one-inch incision that is hidden in the folds of the bellybutton," says Dr. Fukuchi. "In most cases, it's hard to spot the scar afterward."

"With only one incision, there also is the potential for less pain, less blood loss, and an easier recovery," adds Dr. Demnicki. She says that the bellybutton is a great access point because it is an area where there is no muscle and few blood vessels and nerves.

Most gallbladder surgery is done on an elective basis, meaning that patients are not acutely ill or in the hospital when the decision is made to have surgery. According to Drs. Demnicki and Fukuchi, any patient who is a candidate for elective laparoscopic gallbladder removal is considered a candidate for a robotic procedure.

Since the two surgeons began doing robotic procedures earlier this year, they are increasingly doing gallbladder removals robotically -- most recently using the single-incision approach. The procedure usually takes about an hour to complete, no longer than a standard laparoscopic cholecystectomy, after which patients stay overnight in the Hospital for discharge the next day. A week later, patients are seen in the office for follow up. The surgeon checks the incision and makes sure there are no problems.

"Basically that's it -- one post-op office visit is usually all patients need," says Dr. Demnicki.

Return to normal activities varies, but a week after the operation most people can go back to work and resume light exercise.

"We have a lot of healthy people in Chester County who want to get back to the gym and their Zumba classes," says Dr. Demnicki. She usually advises eager exercisers to wait 4 to 6 weeks before doing any vigorous abdominal work.

"Going home with one little Band-Aid can sometimes fool patients. I have to remind them their body is still recovering from major surgery, and that they can go back to their Zumba classes soon -- just not yet."

Advantages for Surgeons
For surgeons who specialize in laparoscopic procedures and wish to offer the least invasive option, the technology and equipment designed for single-incision robotic surgery overcame many of the challenges of a standard laparoscopic approach.

"With conventional laparoscopic surgery, all movements are counterintuitive," says Dr. Demnicki. "So, to move an instrument left, I move my hand right. To move an instrument up, I move my hand down."

Single-incision procedures add a layer of complexity. One problem is that conventional instruments are rigid and straight, and when they are inserted at the navel, they cross each other inside the body.

"In non-robotic single-incision laparoscopic procedures, not only were the movements counterintuitive -- up is down, left is right -- but visually the instrument the surgeon sees on the left in the monitor is actually the instrument in the surgeon's right hand," explains Dr. Demnicki. "These challenges prevented single-incision laparoscopic procedures from being widely used in the past." The robot eliminates this problem and restores normal eye-hand control for the surgeon.

The single-incision robotic instruments also are designed to avoid colliding with one another outside the body -- another problem that occurs with standard laparoscopic instruments. From his experience using the new technology, Dr. Fukuchi believes the improved maneuverability of the robotic instruments combined with the magnified, high-definition 3D view of the surgical area will allow for greater precision and safety in performing intra-abdominal procedures.

"To be worthwhile, new technology needs to be better for the patient than what we're currently using," says Dr. Fukuchi. "With the robotic system, I can see details of the anatomy I've never seen before. The view and the control I have with the surgical instruments are far superior to what I can see and accomplish with standard laparoscopy."

Breakthrough Technology
Single-incision traditional laparoscopic surgery is not new. It can be done using conventional methods, but the technique is challenging and not widely practiced. Robotics technology solves many technical difficulties and opens up the possibility of offering less invasive treatment to more patients who are facing abdominal surgery.

"Single-incision robotic surgery may not be a giant leap forward in gallbladder surgery, but it represents a major evolutional step in the surgical treatment of disease of abdominal organs," says Kozub, who is a physician assistant with a long history in the field of laparoscopic surgery.

"I was around when the idea of using a laparoscope to take out a gallbladder was considered crazy," says Kozub. "But because surgeons began doing that simple operation, instruments and techniques evolved that now allow us to do virtually anything laparoscopically, including taking out sections of diseased colon, spleens, kidneys and everything else. We fully expect this to happen with single-incision robotic surgery, and we plan to be ready as the technology and procedures evolve."

By Debra Dreger
Photos by Rick Davis

Robotics Program Highlights

  • 14 robotics-credentialed surgeons
    • 7 Gynecologists
    • 5 Urologists
    • 2 General Surgeons
  • 621 total cases*
  • 34 single-site cholecystectomy cases**

*September 2011 through July 2013
**May through July 2013

Credentialing and Quality Control:
Pillars of a Strong Robotic Surgery Program

Credentialing refers to the process used to qualify surgeons to perform robotic surgery. Only experienced laparoscopic surgeons are considered for robotics credentialing at The Chester County Hospital. The process involves offsite visits to observe experienced robotic surgeons, simulator drills to hone skills, training in a specialized lab, and proctored cases.

The Hospital also requires surgeon and team training in all new robotic technology, such as Single-Site. As a further preparatory step, robotics teams do a dry run together before going live. To keep surprises to a minimum, the entire team meets in the operating room the day before a real case to review all the instruments and steps in a new procedure.

For quality control, extensive data is collected for each robotic surgery case and then reviewed at monthly meetings of the Hospital's Robotics Quality Committee. The committee tracks such data as the time to complete a case and any unusual events or complications.

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