As my friends and readers know, in May of 2007 I performed a live right kidney and adrenal gland removal for intuitive surgical. This was telecast to the AUA conference in Anaheim. My hospital helped me edit the video which I did a voice-over for and made into a nice 7 minute piece. I was told it was going on our hospitals website.
I then received an email that it was put on you tube. I am not sure how I feel about this. Exposure is good, but is this the correct forum? I have personally put videos on google video before, but not you tube.
I think the piece is pretty neat and can be viewed below.
I welcome comments about using youtube or other media to promote work. I think surgeons can learn by watching this piece and will find it interesting, but I wonder how it will be perceived.
A surgical team led by Dr. Pier Cristoforo Giulianotti, chief of the division of minimally invasive, general and robotic surgery at the University of Illinois Medical Center at Chicago, has performed the first fully robotic Whipple procedure in the Midwest.
The operation, also called a pancreaticoduodenectomy, is the most common surgical treatment for cancerous or benign tumors of the head of the pancreas. The procedure involves removal of the gallbladder, bile duct, part of the stomach and duodenum, and the head of the pancreas.
"The Whipple operation is one of the most demanding surgical procedures of the abdomen," said Giulianotti, the Lloyd M. Nyhus Professor of Surgery at UIC. "It generally requires a very long abdominal incision to expose the pancreas and other organs, significant manipulation of the bowel, post-operative pain, and a greater chance of complications."
In 2003, Giulianotti performed the first robotic Whipple procedure in the world while practicing in Italy. Since then, he has performed more than 40 such operations.
I had the opportunity to meet Dr. Giulianotti, a very impressive person to speak to about robotic surgery. I look forward to reading about his upcoming accomplishments.
Laparoscopy has the potential for decreasing surgical morbidity, with smaller incisions, decreased blood loss, less postoperative pain with decreased intake of narcotics, shorter hospital stays, and faster recovery compared with open surgical procedures. While these benefits have been realized for urologic procedures such as nephrectomy, adrenalectomy, and pyeloplasty, technical obstacles have hindered its adoption in more advanced procedures such as prostatectomy.
This series demonstrates that robotic-assisted laparoscopic donor nephrectomy can be performed safely with low complication rates and outcomes similar to standard laparoscopic living donor nephrectomy.
I recently had an encounter with United Healthcare that initially resulted in a denial of a request to treat one of their patients with UPJ stenosis (partial obstruction of the drainage leading from the kidney to the bladder) with a robotic repair of the condition. The denial was initially based on the perception that such surgery was "experimental" and not a generally accepted form of treatment. After nearly two months of back and forth, I have approval to do the procedure and I believe I have convinced United Health to accept the procedure generally for all its subscribers. I have posted below several references to articles that I forwarded to the medical director in the course of our discussions. Most pyeloplasties are done in children and you can see that the articles reflect that, although my patient was an adult. Perhaps they will be of help to someone else in a similar situation.
There is an excellent website on robotic pediatric surgery. The surgery is performed using robotic technology by John Meehan, MD and assisted by Anthony Sandler, MD of the University of Iowa.
M.J. Fumo1, K.K. Badani
, S. Kaul , A. Shrivastava , S. Dusik-Fenton , F. Ogunfitidimi , S. Murali
, N. Ashani , K. Arumunga , R.H Littleton , J.O. Peabody , R.M. Sahabudin
, A.K. Hemal ,M. Menon
1Vattikuti Urology
Institute,
HenryFordHospital,
Detroit,
MI,
Institute of
Urology and
Nephrology, 2Hospital Kuala Lumpur
Introduction: The DaVinci robotic
system has the advantages of 3D imaging, magnification, and precise
movements with many degrees freedom; however, it is hampered by size
making optimal port placement essential to prevent loss of range of motion
from robotic arms colliding with each other or the patient's body. We seek
to clarify optimal port placement for transperitoneal renal surgery.
Conclusion:
Robotic
port placement for renal surgery can be optimized to eliminate loss of
range of motion. Placing the camera port laterally and robotic ports
antero-medially resulted in considerable flexibility of robotic movement.
I have performed several robotic adrenalectomies and about a dozen laparoscopic adrenalectomies. I have had excellent results with robotic and lap, and have not had any trouble with either the right of the left side.
I have several issues with this. I am fairly certain that the surgeons were experienced based on the results. Looking at retrospective data on this can lead to a false conclusion. The right side should be quicker since there is less tissue to mobilize, but often takes me the same time due to the extra care in isolating and controlling the right adrenal vein. I feel the right side are more difficult. I am still performing most of these laparoscopically because the endocrinologists that refer them only have privileges at a non-robotic hospital.
I especially like doing these robotically, as the robotic arms give you more flexibility with the enodwristed instruments.
On Monday, May 22nd, I performed a live telecast from Newark Beth Israel to the American Urologic Association Conference in Atlanta of a dvP. This was my first live telecast of a surgical procedure.
Our case was a success. The patient did very well and was discharged within 24 hours with minimal pain.
The robotic time was 80 minutes for the procedure.
I would like to thank my team at NBI and the administration for the support, as well as intuitive surgical and their engineers for helping to make the telecast go without a glitch.
I am hopeful to get a copy of the video/audio feed to stream on my website.
Some points about the procedure that were discussed:
This past week I performed a right robotic kidney removal for suspected kidney cancer. My patient also had gallbladder problems and needed to have her gallbladder removed. Dr. Kopelan performed a robotic cholecystectomy under the same setting with the same positioning.
This was the first time I used the DaVinci S to perform kidney surgery and it was a pleasure. Although the patient had a large liver which made the operation a little more difficult, the kidney removal took about an hour. We moved the robotic instruments around to do the gallbladder part and had an easy time setting up the robot in the new position.
Today, Dr. Marc Greenstein and I performed the first robotic diverticulectomy at our hospital, and likely among one of the first on the country.
This procedure was done for recurrent bladder infections, but can also be done for bladder cancer.
The operation went extremely well and much better than the typical open version of the operation. Our robotic time was under 1 hour and there was almost no blood loss, and should cut the patient's hospital stay from 4-5 days to overnight. The expected pain and bladder discomfort should be much less as well.
I will need to update my website and add some video when I get the chance, as well as submit a paper for publishing.
With the advantages of robotic surgery of less pain and less blood loss, I have always wondered what will be the end result of the operation in regards to patient recovery and operating room times.
Since the total operation time has routinely fallen to the 2 to 2 1/2 hour range I thought an outpatient prostatectomy was a safe alternative for a patient that didn't want to stay in the hospital overnight.
There are many forms of therapy for BPH (benign prostatic hyperplasia). Prostates that are very large respond poorly long term to minimally invasive therapies. Robotic simple prostatectomy is the newest therapy for large prostates.
BPH involves growth of the middle part of the prostate. The treatment involves removal of this part called the adenoma.
At the Pacific Rim Robotics Conference last month there was a session on robotic pyeloplasty. It was held on Saturday afternoon, the last day of the conference, and featured a lecture by Dr. Elspeth McDougall and a live broadcast of the operation from UC Irvine performed by Dr. Ralph Clayman. Dr. McDougall described the operation as they perform it at UCI and then showed their results in about a half dozen cases, including a bilateral pyeloplasty in a horseshoe kidney. The outcomes were at least as good as with open, laparoscopic or endoscopic pyeloplasty techniques. The steps that she described in her lecture were those that we would see Dr. Clayman follow in the live demo that was presented imediately after her talk. I was interested because I have done about a half dozen or more myself and my partner has done several as well.
I attended the PACRIM conference Sponsored by the Univ. of California, Irvine in early January. There were several interesting presentations and I plan to post a summary of different ones from time to time. The first in the series is regarding a presentation made by Dr. Randy Fagin from Austin, TX, on "Achieving a Time Efficient Procedure in the Private Practice Setting". There have been criticisms leveled at robotic prostatectomy stating that it isn't time efficient compared to open surgery. In our hospital my partner (280+ cases) and I (150+) are completing cases in 2.5 -3 hoursfrom the time the patient is wheeled into the room until he is wheeled out to recovery. That is already competitive with some other surgeons' times for open radicals. Dr. Fagin is doing even better than we are it would appear.
Note: Our patient has given permission to use his story and name in our article and we are preparing a press release to give more details of this incredible story.
At 94 most urologists would tell the patient they are too old for surgery, but with Dr. Lefkon's help I had performed this operation in a 90 year old woman and 94 year old man before and with Dr. Katz's help had performed the operation in a 92 year old woman and a 96 year old woman.
Arguably the most difficult operation in urologic surgery is removing the bladder in women for bladder cancer. Our team was the first in the tri-state (NJ, lower NY, CT) area to perform this procedure with the da Vinci robot.
Inguinal hernias often coexist in prostate cancer patients. They can
sometimes be found on physical exam or during staging CT scans. At the
time of transperitoneal robotic prostatectomy the inguinal areas are examined
with the robotic scope. If hernias exist, they can be fixed at the time of
prostatectomy..
I was recently faced with a case of a right sided UPJ stenosis with good renal preservation and two 5 mm stones in the upper pole. Having done at least a half dozen robotic pyeloplasties I felt that that would be the appropriate treatment for the UPJ but was not sure how to address the stones. I did not want to leave them in place and have to address them later. A separate percutaneous nephrostolithotomy seemed like overkill for the size of the stones. A PNL could be combined with an antegrade endopyelotomy, but the stones were in upper pole calyces and the combined procedure might require two separate entry points for adequate access (lower pole entry point to reach the upper-pole and a mid- or upper-pole entry point to reach the UPJ).
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