Souls of a New Machine
Doctors Use Robot Technology to Transform Surgery and Improve Patients' Lives
Peter Curran had none of the characteristics of an individual who might be at risk for colorectal cancer. He had no family history, had been healthy all his life, was active, and was not overweight. Yet, when his physician discovered a large mass in his rectum two years ago, he began a year-long fight for his life — a fight that landed him in the care of Deborah Nagle, M.D., chief of colorectal surgery at Beth Israel Deaconess Medical Center and leader in the field of robot-assisted surgery.“The idea of getting a big incision through my stomach muscles freaked me out,” Curran recalls. “The idea of recovering from major surgery and then going straight into chemo blew my mind. I made a deliberate decision that I needed to be as strong as I could be post-surgery going into chemo.” Curran opted to have robot-assisted surgery to remove his tumor. The advanced minimally invasive technique, where a surgeon controls a robot to maneuver instruments inside the body, offers smaller incisions, less blood loss, and faster recovery times and therefore improved quality of life for patients compared to open surgery. It also provides surgeons with the ability to perform more precise and oftentimes more challenging procedures than traditional minimally invasive, or laparoscopic, techniques without resorting to open. “The chances of having some operations completed in a minimally invasive fashion are much higher with the robot, and the pain seems to be less,” says Nagle, who started the first robot-assisted colon and rectal surgery program in Massachusetts at BIDMC two years ago. “Return of gastrointestinal function is probably even a little quicker than with laparoscopic. Patients seem to really bounce back. It is impressive.”
Robot technology was introduced at BIDMC four years ago to perform radical prostatectomy for patients with prostate cancer. “The whole point behind robotics is that it allows surgeons to do very meticulous reconstructive surgical work in small spaces with precision that exceeds that of the human hand,” says Andrew A. Wagner, M.D., director of minimally invasive urologic surgery, who was key in starting the robotics program and now leads the most comprehensive robotic kidney, prostate, and bladder surgery program in Boston. “It allows us to do careful suturing, reconstruction, and dissection in small areas that are difficult to access normally. The visualization is superior to standard laparoscopic surgery, the blood loss is minimized, and the increased precision allows a more straightforward and very high-quality operation.”
Although BIDMC purchased its first robot technology system only four years ago, the medical center is rapidly ascending to the top ranks in the nation and is now considered a leader in this field which is transforming surgery and improving outcomes and quality of life for its patients. And it is not just about the technology, which is now widely available. In the last two years in particular, BIDMC has developed a multidisciplinary program that combines its expert clinical care, groundbreaking research, and pioneering educational opportunities with the advanced, patient-centered surgical procedures. “BIDMC has the opportunity to nurture innovative surgery that no other facilities have the vision to conceive,” says A. James Moser, M.D., an expert in advanced minimally invasive surgery who joined BIDMC this spring as the executive director of the new Institute for Hepatobiliary and Pancreatic Surgery. “What my colleagues and I are doing is changing the paradigm away from open surgery toward a patient-centered approach to quality of life. That commitment to innovation is why I came here.” This revolution in surgical thinking is ultimately personalizing treatment for both the surgeon and the patient.
During robot-assisted surgery, the surgeon sits at a console, as opposed to standing next to the patient, and controls the surgical instruments with the motion of his or her fingertips. The console provides a steady, high-definition, three-dimensional visual as a guide. Unlike laparoscopic procedures, where the surgical instruments can move only in a straight line, the robot allows surgeons complete range of motion in the surgical space, which mimics the movement of the wrist and fingers. This flexibility is the main reason why the robot lends itself well to procedures in tight spaces, such as deep in the pelvis for colorectal and prostate cancer, or for complicated techniques, such as lymph node dissection, kidney reconstruction, nerve sparing, and pancreatic surgery. Despite the benefits of the technique, it is not a solution for all surgical procedures. Surgeons must balance the cost of using the technology and limited access to the robot, and use it only for their most complicated and challenging operations where the patient will benefit.
BIDMC currently has two robotic surgical systems — a single-console model on the East Campus and a new, dual-console system, which provides better visuals, training capabilities, and advanced technology for complex procedures on the West Campus. With the purchase of the new robot this spring and the rapid expansion of the program — from urology and colorectal to gynecology, pancreatic, and eventually thoracic surgeries — BIDMC is poised for success. “It makes for a much more robust program because the team of nurses, technicians, and nurse managers, which is already very good, becomes even more expert, the more cases they do,” Wagner says. “The best robotic programs in the country are those that incorporate multiple surgeons, different specialties to use it, and refine their techniques daily. In that way, the team becomes world class.”
In June Moser and Mark P. Callery, M.D., chief of the Division of General Surgery, completed the first robot-assisted minimally invasive pancreatectomy in Boston. “Pancreas surgery is an outlier in all of surgery in terms of its complications. It is a major vascular dissection, so it’s an operation that is accepted to have a much higher complication rate as a result,” Moser says. Due to the extreme complexity of pancreatic diseases, most surgeons avoid traditional laparoscopic surgery and instead opt for open procedures.
However, with the precision and flexibility of robot technology, surgeons are adopting the new approach. Moser, who is working to transform the care of patients with pancreatic disease and put BIDMC on the map as the top spot for advanced minimally invasive surgery, has performed more than 250 robot-assisted pancreatic surgeries. While extremely challenging for the surgeon — it requires as many as 100 needle changes — the surgery provides patients with the same positive outcomes of a minimally invasive approach. “Quality of life has to be the center of everything we do,” says Moser, who will use the robot to better treat diseases of the pancreas, liver, and gallbladder and help train his co-workers in these challenging techniques.
This latest expansion of robot-assisted surgery at BIDMC builds upon its established programming. BIDMC is still the only spot in the state that offers robot-assisted rectal cancer surgery, Nagle says. While the technique is not yet widespread, it is a perfect fit. “The instruments you have for laparoscopic surgery become more limiting when you go into the bony pelvis which isn’t flexible and where you can’t move things around as much,” she adds. Wagner has also become one of the most experienced surgeons in robot-assisted partial nephrectomy, a procedure to remove a tumor from a part of the kidney. The robot simplifies the challenging suturing to reconstruct the organ and allows for more precision and speed to work quickly and effectively. It also ties into BIDMC’s clinical and research expertise in kidney cancer. “It’s a multi-pronged, multidisciplinary approach to kidney cancer that is relatively unusual,” he says. “We have the largest team of kidney cancer experts in New England.”
While prostatectomy has become the gold standard of surgical prostate cancer care in most academic medical centers and the market is much more saturated for robot-assisted gynecological surgery, BIDMC is progressive with its multidisciplinary approach in both fields and dedication to teaching its residents. “When we are able to offer these minimally invasive procedures, the patients are often very surprised about how quick their recovery is,” says gynecological oncology surgeon Chris McCann, D.O., who performs endometrial cancer and endometrial hyperplasia cases on the robot. “Especially in the obese population where the risk of wound infection and complication can be extremely high after open surgery, you minimize that with these procedures and that really helps recovery.”
BIDMC is further expanding its robotics program through training opportunities for new students and even current surgeons. The learning curve is incredibly high as surgeons start from scratch in simulation exercises to get a feel for the console and controls, lack of tactile feedback, and seated position away from the patient before performing intricate surgery. Using the new dual-console robot on the West Campus, the lead surgeon can hand over control of the instruments to the assistant during surgery, but can still direct and watch every step using the same three-dimensional visual. If the surgeon wants to instruct a different approach or does not like what the assistant is doing, he or she can immediately take over control of the robot, similar to an instructor taking over in a driver’s education car.
This focus on education also extends outside of the operating room. Last year, Wagner and partner Martin Sanda, M.D., director of the BIDMC Prostate Care Center, led the first robotic urology teaching course in New England in the Carl J. Shapiro Clinical Center. The course consisted of didactic lectures and hands-on training using robotic simulation and inanimate tissue models designed at BIDMC. Approximately 20 surgeons and urology trainees from around the region had access to four dual-console robotic systems during the two-day seminar. Next year, McCann and the Department of Obstetrics and Gynecology will hold a one-day, hands-on gynecology robotics symposium. “We are very progressive when it comes to robotics compared to some of the other institutions,” he says. “There are new technologies coming down the pike, including the dual console, that have improved our ability to train our residents. You can sense a little more excitement from them when doing the cases.”
While surgeons recognize the benefits for robot-assisted surgery, the published research is limited, something the BIDMC experts hope to change. Based on his research at the University of Pittsburgh Medical Center, Moser and his colleagues recently published single-institution outcomes data in the Annals of Surgery, which demonstrated that for a distal pancreatectomy, robot-assisted surgery leads to a reduced risk of conversion to an open procedure, less blood loss, and improved outcomes for patients. BIDMC has shown its leadership in outcomes research on a national scale. Recently Wagner and Sanda completed the first multicenter prospective study designed to compare traditional open prostatectomy to robotic prostatectomy. “This study is the first prospective multicenter evaluation specifically designed to compare clinical outcomes and cost effectiveness of these two approaches,” Wagner says. His team has also recently published the BIDMC robotic kidney surgery experience in the World Journal of Urology, the Journal of Endourology, and Urology.
Philanthropy plays a major role in the continued support of outcomes research and expansion of the robot-assisted surgery program to improve patient care at BIDMC. Surgeons agree on the need for an additional dual-console robot on the East Campus. The improved technology would not only fulfill the demand for operating time and allow for ease in more complicated operations on the East Campus, but also offer the ability to train additional surgeons and residents. “Over the next five to 10 years, most surgeons are going to be trained in robotics, and they are going to realize that this equipment and technology is here to stay and patients really do benefit,” Wagner says. And as the patients learn about the new technique, the demand for robot-assisted surgery is rising. “If patients can recover faster, take minimal narcotic, and have a much higher chance of having their operation completed in a minimally invasive fashion, they are going to ask for the robot,” Nagle says.
Peter Curran agrees. Two years later he is still cancer free. “To me it was a no-brainer,” he says of his decision. “I had confidence in Dr. Nagle, and I had confidence in the surgery. I think it was a good gut instinct.”