Medical Professional Publications

Robot-Assisted Laparoscopic Surgery Offers Less-Invasive Treatment

(From the September 2013 Issue of PediatricsOnline)

Robot-assisted minimally invasive surgery

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In January, Nationwide Children’s Hospital launched a Robot-Assisted Laparoscopic Surgery program, which utilizes advanced robotics technology to give surgeons greater precision, dexterity and visualization than possible with conventional laparoscopic tools. The da Vinci Surgery System features three arms surgeons control from a console in the operating suite. The arms bend and twist just like human hands and wrists—only steadier—and allow surgeons to place sutures, reconstruct tissues and perform other tasks that are far more difficult to complete in traditional laparoscopy. With the aid of 3-D technology built into the console, surgeons have a view of the surgical site that is far closer than human vision allows.

Daniel Herz, MD, joined Nationwide Children’s in January to lead the program. When Dr. Herz began performing robot-assisted surgery in 2004, he learned the craft on the first generation of robotic equipment. Today, the technology is more precise, the surgical tools are smaller and more flexible and the high-definition monitors offer far superior visualization than ever before. Since Dr. Herz’s arrival at Nationwide Children’s earlier this year, he and others on the robotics team have performed 64 procedures, a number he expects to grow as more surgeons are trained to use the system. We met with Dr. Herz to talk about the program and the future of robot-assisted surgery at Nationwide Children’s.

What are the benefits to robot-assisted surgery?
Compared to standard laparoscopic procedures, robot-assisted surgery shares the same benefits in minimizing the invasiveness of the operation, which leads to less time under anesthesia and a shorter recovery. But the robotic technology dramatically expands the surgeon’s natural abilities. The robotic arms and instruments allow for the same dexterity that before was possible only through open surgery, and the range of motion is far better than the human hand can do on its own. The equipment’s movement is precise and not at the mercy of the natural tremor of human hands. And the 3-D visualization and high-definition monitoring possible with this technology is superior to anything we’ve seen in the laparoscopic surgical field. Overall, the primary benefit of the robot is that it makes each surgeon a “top gun” and allows more surgeons to perform these procedures safely.

What kinds of questions do parents often have about performing robot-assisted surgery on their children?
I think many people hear the phrase “robotic surgery” and imagine a machine wielding a scalpel doing surgery on their son or daughter. I like to emphasize the robot-assisted part—the surgery is performed by the surgeon, not the robot. The robot is not autonomous; it doesn’t move unless we direct it to. I try to explain that the robot is just another tool we have at our disposal—granted, a very high-tech tool—but a tool nonetheless. In general, I find that parents are mostly concerned with the fact their child has to have surgery, and once I explain how the system works, they are comfortable with it.

What kind of procedures can be performed with robot-assisted surgery?
We use robot-assisted surgery to treat a variety of conditions. Among the most common is urinary reflux, in which urine from the bladder is able to flow back up into the kidney through the ureter. To correct the problem, we perform a ureteroneocystostomy, or ureteral reimplantation, which changes the position of where the ureter attaches to the bladder and prevents this back-up. Another procedure we perform often with the robot is pyeloplasty, a treatment for a congenital defect called ureteropelvic junction obstruction. About one in every 1,500 children has this condition, in which the urinary tract is blocked at the junction where the ureter meets the renal pelvis.

We have had great success using the robotic technology for partial or complete nephrectomy, which removes part or all of a damaged or diseased kidney. We are also able to treat complicated pyeloplasty failures with a procedure called ureterocalicostomy. Once only possible through an open surgery that involved a 10- to-20-centimeter incision, we now perform this operation through robot-assisted laparoscopy that requires three incisions, each only about 5 millimeters long. Bladder neck reconstruction or bladder neck sling, both used to treat incontinence caused by a variety of conditions, also are much easier robotically and are very rarely attempted by traditional laparoscopy any longer.

In addition, our General Surgery team has recently begun to utilize robotic technology, and has performed such procedures as cholecystectomy to remove a diseased gallbladder; ileocecectomy to treat appendicitis or Crohn’s disease; j-pouch procedures for ulcerative colitis or colon cancer patients; and bariatric surgeries such as gastric sleeve.

How are surgeons trained to use the robotic equipment?
We have developed a rigorous training program that involves completion of computer simulation modules, dry and wet lab training sessions, and a period of proctoring for the first 5-10 surgeries depending on individual surgeon progress. Before any new surgeon’s “first case” or before performing a new type of surgery, a dry-run is planned and performed. The surgeon, entire robotic surgery team, director of robot assisted surgery, and the robotic surgery and surgical team coordinators are present for all of these events. The purpose of this is to discuss logistics, equipment and specific safety concerns before the morning of the surgery. During this period, emphasis is placed on learning to use visual cues to compensate for the lack of tactile or haptic feedback that the surgeon has in open or pure laparoscopic surgery. Understanding the limitations, power and precision of robotic instruments is also emphasized at this stage.

We have partnered with our anesthesia colleagues to avoid inadvertent movement while the robot is docked and the robotic instruments are engaged within the patient. We have specific protocols to avoid injury from positioning and inadvertent collisions of the robotic arms with the patient’s limbs, face or head. Three additional surgeons at Nationwide Children’s have completed the robotic training program and are now performing surgeries using this technology. Another two surgeons are currently in training.

The use of this technology is not without controversy. What can you tell us about concerns regarding the da Vinci system and where things stand?
Earlier this year, the Food and Drug Administration (FDA) launched an investigation into the safety of the robots. Though the agency won’t release specific numbers, officials say there have been numerous complaints regarding the 11-year-old technology. The agency is looking into these complaints and in a statement outlined plans to discuss the matter with surgeons.

It’s important to note that the FDA itself has said that it is uncertain whether the rise in reported adverse events is not simply related to an increased awareness or willingness to report such events among doctor and hospitals.

Not to sound too much like a cliché, but those that do robotics are pioneering a new era—one that will see robotics replace not only most if not all laparoscopy, but much of open surgery as well. With this type of challenge there are going to be mishaps and missteps. We keep patient safety at the forefront here at Nationwide Children’s, and do not succumb to market pressures or company advertisement or aggressive marketing—that is the cornerstone of our program. It is my belief that, based on our unrelenting focus on safety of robot-assisted surgery and the rigorous training program surgeons must complete before performing robot-assisted surgery at Nationwide Children’s, our program will serve as an example for other children’s hospitals to follow.

Recent publications:

Ficko Z, Herrick BW, Herz DB, Pais VM Jr. Successful Transcloacal Ureteral Stent Removal. Urology. 2012 Dec, 80(6):1361-3.

Herz DB. Biomarkers for Inflammatory Renal Damage in Children with Febrile Urinary Tract Infection: a Potentially New Top-Down Approach. The Journal of Urology. 2011 Nov, 186(5):1760-1.

McQuiston L, Macneily A, Liu D, Mickelson J, Yerkes E, Chaviano A, Roth D, Stoltz RS, Herz DB, Maizels M. Computer Enhanced Visual Learning Method to Train Urology Residents in Pediatric Orchiopexy Provided a Consistent Learning Experience in a Multi-Institutional Trial. The Journal of Urology. 2010 Oct, 184(4S):1748-53.

Daniel Herz, MDDaniel B. Herz, MD, is a member of the Section of Pediatric Urology and director of Robot-Assisted Laparoscopic Surgery at Nationwide Children’s Hospital. He previously served as director of Pediatric Urology at Children’s Hospital at Dartmouth, and associate professor of surgery and pediatrics at Dartmouth Medical School. Certified by the American Board of Urology in both urology and pediatric urology, Dr. Herz received his medical degree from SUNY Health Science Center at Brooklyn (Downstate Medical Center) and completed his urological residency at University of Pittsburgh Medical Center. He completed a two-year clinical and research fellowship in pediatric urology at the Hospital for Sick Children, University of Toronto.

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