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Physicians Update


Physicians Update

Fall 2009

Robotic Technology Applied to More Types of Surgeries


Robotic SurgeryIt was not long ago that robotic surgery was used only for limited procedures, such as laparoscopic prostatectomy, but today it is routinely available for a wide variety of surgical areas — urology, cardiothoracic, noncardiac thoracic, gynecology and general surgery among them. “This is technology that is here to stay,” says Erik Dutson, M.D., co-director of UCLA’s Center for Advanced Surgical and Interventional Technology (CASIT), which has been involved in developing new robotic surgical approaches as well as training surgeons in the techniques.

Similar to laparoscopy, robotic surgery is a minimally invasive technique that utilizes probes and a tiny camera placed through a needle-sized hole to visualize clear images inside the patient’s body and to carry out the surgery. The difference is that instead of directly grasping the probes, the surgeon sits at a console with a three-dimensional view inside the patient and manipulates robotic arms that grasp the probes. The robotic arms act like human wrists but with greater flexibility and precision; a system that filters out hand tremor allows better range of motion and amplifies the video image in 3-D to facilitate more exact movements.

The robotic system is particularly useful for operations that require the surgeon to work in a small space within the body, or when he or she must perform suturing that requires fine motor control, says UCLA urologist Peter Schulam, M.D., Ph.D., CASIT co-director. Prostatectomy, in which urologists work deep within the small pelvic area to remove a cancerous prostate gland and then do a reconstructive procedure, was thus well-suited to lead the way in robotic surgery.

Dr. Schulam and UCLA urologist Robert Reiter, M.D., M.B.A., have performed robotic prostatectomies at UCLA for approximately six years, with clear advantages of less blood loss, less pain and faster recovery. Two years ago, Drs. Reiter and Schulam began applying the technology to laparoscopic cystectomy to remove all or part of the bladder. The advantages are similar. “There is significantly less blood loss because of the enhanced visualization,” Dr. Schulam says, “and since the abdomen is open for a shorter period of time, patients are able to recover more rapidly.”

Dr. Robert ReiterDr. Reiter believes it’s likely that, soon, the entire operation — not only the cystectomy, but also the bladder reconstruction — will be done robotically. “Advances in our ability to perform robotic surgery and neobladder construction are leading to faster recovery, better outcomes and improved quality of life for bladder cancer patients,” he says. UCLA urologists are also starting to use the robot for partial nephrectomies for kidney cancer, as well as for some female urology problems.

UCLA’s newest surgical robot, the da Vinci S, gives surgeons an unprecedented visualization system with high-definition images and improved range of motion and interface that enables them to expand the complexity of their procedures, says Richard J. Shemin, M.D., chief of the UCLA Division of Cardiothoracic Surgery.

In cardiac surgery, the most extensive use of the robotic equipment has been for mitral valve replacement and repair. The technology is also being used by Dr. Shemin’s team in conjunction with mitral valve surgery to control cardiac arrhythmias, including atrial fibrillation, using the MAZE procedure — in which scars are strategically placed in the left atrial muscle to prevent the arrhythmias from occurring. Other applications in cardiac surgery are in certain coronary artery bypass procedures, as well as for less common cases such as intercardiac tumors and repairing certain holes in the heart.

“The robot is a very good approach for relatively confined parts of the human anatomy that are deep in the body,” Dr. Shemin says. For the mitral valve procedure, for example, the incision is under the right breast, and it is about 10-12 inches from the level of the skin incision to the valve. A camera is placed between the ribs and sits right outside the heart. “If you are performing this in a conventional manner, through that incision, you’re looking a long distance through a very narrow tunnel to see where you are operating. With the robotic visualization system, you don’t have a sense of that distance,” Dr. Shemin says.

In gynecology, robotics is being employed for a variety of surgeries, explains UCLA gynecologist Jeannine Rahimian, M.D. She notes that hysterectomies for both benign and malignant indications are benefiting from the technology. In the case of malignancies, the robot assists in lymph node sampling to enable a minimally invasive surgery that allows patients to go home the following day and be on their feet a couple of days after that.

“Normally there would be a much longer recovery period,” Dr. Rahimian says. “This significantly reduces blood loss, postoperative pain and recovery time compared to open surgery.” For patients who need fibroids removed while leaving the uterus intact, robotic myomectomy has also gained favor, as long as the fibroid is not too large. Robotics is also increasingly used in the removal of ovarian cysts and for uro-gynecology procedures, such as bladder lifts and colpopexy for patients with vaginal prolapse.

In all of the current surgeries in which robotic technology is employed, as well as the additional ones that are bound to be added to the list in the coming years, the robot is an enabling device, Dr. Dutson explains. “It allows us to push the boundaries of what we can do,” he says. “It makes difficult procedures a lot easier, which allows more surgeons to adopt the minimally invasive approach — an approach that ultimately benefits the patient.”

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