Robotic help

Ten years ago, during his surgical fellowship, Dr. Ravi Nagubandi got a glimpse of his future when he observed an early version of robot-assisted surgery.

Now he regularly performs operations using Oroville Hospital’s da Vinci SI Surgical System. Two other physicians also use the multimillion-dollar equipment, which came to the medical center in January, and others are lining up to get trained in the sophisticated, minimally invasive means of surgery.

Nagubandi has primarily used the da Vinci for gallbladder surgeries, but two weeks ago he branched out into colon surgery. Meanwhile, obstetrician/gynecologists Pamela Simons and Peter Bippart have used the da Vinci to perform hysterectomies.

That’s just a sliver of the technology’s potential. Robert Wentz, CEO of Oroville Hospital, said a cardiothoracic surgeon from Stanford University has applied for heart-surgery privileges. Intuitive Surgical, the da Vinci’s manufacturer, says the surgical system also is used on the bladder, kidneys, lungs, abdomen, prostate, head and neck.

“It’s a very versatile piece of equipment,” Wentz said, “and we will continue to expand its use as our physicians get more trained.”

It consists of two consoles, where the surgeon (or surgeons, in a multi-doctor operation) can see the surgical site and operate the surgical implements; a four-arm tower that moves the tools; and a large-screen viewing center for other members of the surgical team.

The technology expands upon laparoscopy, a minimally invasive technique in which a small tube with a camera and/or tool gets inserted through an incision to check for abnormal growths or perform a procedure.

Much like laparoscopic surgery, the surgeon makes a small incision through which he or she inserts the instruments. Unlike laparoscopic surgery, with the da Vinci, the surgeon views the operation three-dimensionally and has greater range of motion with the tools.

“The incisions are small anyway,” Nagubandi said, comparing laparoscopy to robot-assisted surgery. “But the visualization [with the da Vinci] increased depth perception, because the camera that is used has two heads on it, so the image synthesized for me is a three-dimensional image rather than the two-dimensional image in a traditional laparoscopic surgery, and you can zoom in very close.

“When it comes to the instruments, the instruments in traditional laparoscopic surgery tend to have a jaw-like motion, whereas the robotic surgery instruments have a mini-wrist—not only does [the instrument] do the open/close technique, but it also moves like a human wrist with a greater degree of freedom, so it increases our dexterity quite a bit.”

The software in the system also makes it easier to perform single-site surgery: placing multiple tools through one incision, rather than needing multiple incisions to accommodate the multiple tools. The fewer and smaller the incisions, the less risk for infection and an easier (shorter and less painful) recovery period.

Like Nagubandi, Wentz had his eye on robot-assisted surgery for years. What he was waiting for, he said, was “a surgical champion—a surgeon who was very interested in doing it. We found that in Dr. Nagubandi.”

Nagubandi became a true believer last year after attending a conference on minimally invasive surgery. He learned about the latest da Vinci system, and he pitched the idea of getting one.

“I was impressed by the latest advancements,” Nagubandi explained. “The latest robot has four arms instead of three. Added to that, the software in the technology is upgraded from the previous versions. Now there is a simulator available, so the surgeons can practice on the simulator before the actual operation.

“Plus this is the latest technology where further advancements can be downloaded onto the system and you can upgrade the system further. I liken it to getting a new app—if they come up with a new development in the software, you can simply download it, so this latest machine, we don’t have to throw it away in two or three or four years when new developments come.”

Nagubandi estimates he underwent 30 hours of training specifically on the da Vinci, not including additional practice runs on the simulator. It’s a continuing process, one that others soon will commence.

After the da Vinci arrived, Nagubandi and the surgical team determined how best to set up the equipment in one of Oroville Hospital’s five operating rooms. (When not in use, the da Vinci components can be moved off to the side to allow for a traditional surgical setup.) They conducted a dry run, then performed their first robot-assisted gallbladder surgery.

The response from patients has been positive, both Wentz and Nagubandi said.

“There is a universal enthusiasm about it,” said Nagubandi. “There are some people who know of somebody in their family or outside it who went to Sacramento to have this kind of surgery done, and they’re excited we have it here.

“I spend a good amount of time for them to understand what the robot does, and I also say that it’s the surgeon who’s in control, not the robot.”

That is a key distinction. As with laparoscopy, the da Vinci robot is a tool. Wentz said it has been used for more than 1 million operations, and Nagubandi sees it as a tried and true technology.

“Some people may have apprehensions about the robot,” Nagubandi said, “but the robot has been there for more than 10 years and increased in its technical capabilities, and I think it’s stood the test of time.

“Obviously it’s the surgeon who’s important. It doesn’t matter whether the robot is there or not—it’s the quality of surgeon that’s most important. Ultimately, for the surgeon, what’s important is, ‘What’s the right thing to do for the patient?’”