Robotic Surgery: Applications in Gynecologic

Oncology

Kathryn F. McGonigle M.D.Kathryn F. McGonigle M.D.Gynecologic OncologistGynecologic Oncologist

Do YOU Want a Robot Do YOU Want a Robot Doing Your Surgery?Doing Your Surgery?

The daVinciThe daVinci --S RobotS Robot

How things have Changed

Conventional Conventional laparotomylaparotomy

Robotic Surgery

Laparoscopic Surgery

Minimally Invasive Surgery

PROsPROs::•• Shorter LOSShorter LOS•• Faster recovery and Faster recovery and

better QOLbetter QOL•• Less scarringLess scarring•• Less PainLess Pain•• Lower wound infectionsLower wound infections•• Possibly:Possibly:

•• Less blood lossLess blood loss•• Fewer complicationsFewer complications

Which Incision Does Your Patient Prefer?

�Minimally invasive: ability to operate through smal l incisions

�Better visualization than open surgery

Open Vertical Incision Open Transverse Incisi on Laparoscopic orda Vinci® Incision

Minimally Invasive Surgery:Potential Patient Benefits

DaysDaysWeeksWeeksPain or Pain or discomfortdiscomfort

DaysDaysWeeksWeeksReturn to normal Return to normal activitiesactivities

11--3 weeks3 weeks44--6 weeks6 weeksRecoveryRecovery11--2 days2 days33--5 days5 daysHospital stayHospital stay

44--6 dime6 dime --sized sized incisions with incisions with

minimal scaringminimal scaring

Long incision Long incision with visible with visible

scaringscaring

Incision sizeIncision sizeLaparoscopic Laparoscopic OpenOpenBenefitBenefit

Why Robotic Surgery?..... Why Robotic Surgery?..... We have traditional laparoscopyWe have traditional laparoscopy ??

Minimally Invasive Surgery in Gynecologic/Gynecologic Oncology

�� Almost 30 years ago:Almost 30 years ago: Gynecologists were the first Gynecologists were the first surgeons to perform laparoscopic surgery years surgeons to perform laparoscopic surgery years agoago

�� Over last TEN YEARS:Over last TEN YEARS: Plateau in the growth of Plateau in the growth of laparoscopic procedures in gynecology laparoscopic procedures in gynecology

�� Today:Today: Fewer than 10% of hysterectomies Fewer than 10% of hysterectomies performed performed laparoscopicallylaparoscopically in USin US

�� 2008:2008: most gynecologists have not most gynecologists have not ““ embracedembraced ””minimally invasive surgeryminimally invasive surgery

Minimally Invasive Surgery in Gynecology

Why has growth of laparoscopy Why has growth of laparoscopy ““ stalledstalled ”” ??

�� 2 dimensional vision2 dimensional vision�� Straight instrumentsStraight instruments�� Counter intuitive hand movementsCounter intuitive hand movements�� Unsteady image controlled by assistantUnsteady image controlled by assistant�� Difficulty suturing and knot tyingDifficulty suturing and knot tying�� Long learning curveLong learning curve�� Surgeon fatigueSurgeon fatigue�� Long operating timesLong operating times�� Dependent on expert assistant surgeonDependent on expert assistant surgeon

Robotic Surgery Overcomes Many of the Drawbacks of Conventional Laparoscopy

Evolution of Robotic Surgery

� NASA and the military : Conceptualized telesurgery to provide surgical expertise to remote locations

� Telesurgery “drove” first development of robotic surgery platforms… limited by bandwidth limitations

� Telepresence surgery: today’s modern robotic surgery

Evolution of Robotic Surgery

� AESOP (Computer Motion, Goleta, CA): first robotic-assisted surgical technology: robot only controlled camera

� Zeus Robotic System : (Computer Motion, Goleta, CA): the first robotic system to provide instrument control� 2 dimensional image

� Intuitive Surgical (Sunnyvale, CA) purchased Computer Motion; Zeus Robotic System; abandoned in favor of da Vinci® Robotic Surgical System

MultiMulti --Specialty FDA Clearance Specialty FDA Clearance da Vinci® Robotic Surgical System

� 2001: Radical prostatectomy � 2002: Thoracoscopically assisted

cardiotomy procedures � 2002: Intracardiac procedures � 2004: Coronary revascularization � 2005: Gynecologic laparoscopic surgery

dada VinciVinci®® Surgical System U.S. Surgical System U.S.

19992000

2001

2004

Alaska

2003

2005

2002

Hawaii

200620072008-through Q1 close

Northwest Hospital

Children's Hospital

Swedish Hospital

UW

Virginia Mason

St. Joes

Tacoma General

X 2

Prov Everett

Evergreen

Overlake

X 2

X 3

Seattle / Tacoma

Robotic Programs

20012003200520072008+

Surgeon has…� 3 D image…improved

visualization� Better instrumentation,

surgical control & precision

� Fully wristed instruments� Better surgical dexterity

for complex aspects of procedure

� Easier & faster suturing� Better ergonomics

Double-click to view video

Robotic Surgery

Surgeon in control: less dependent on quality of su rgical assistant

Wrist and Finger Movement

�� Conventional Conventional laparoscopic laparoscopic instruments are rigid instruments are rigid with no wristswith no wrists

�� EndoWristEndoWrist ®® Instrument Instrument tips move like a human tips move like a human wrist wrist

da Vinci® System

EndoWrist®instruments

are small and fit through

keyhole incisions

Small Instruments Through Keyhole Incisions

Taking the “Mystery” out of Robotic Surgery:

anatomy of the robot

Anatomy of the Robotic Surgical System

��Side Surgical CartSide Surgical Cart : 3: 3--4 arms for 4 arms for controlling camera and surgical controlling camera and surgical instrumentsinstruments��Vision Cart: Vision Cart: Processes video Processes video signals signals ��Surgeon Console: Surgeon Console: Surgeon sits Surgeon sits remote from patient and controls remote from patient and controls robotic instrumentsrobotic instruments

A computer enhanced surgical system with three comp onents:A computer enhanced surgical system with three comp onents:

Side Surgical CartSide Surgical Cart

�� Surgical arms are Surgical arms are ““dockeddocked”” to to laparoscopic laparoscopic trocarstrocars placed in patientplaced in patient’’s s abdomen:abdomen:�� One arm for 12One arm for 12--mm 3 D camera mm 3 D camera

�� Two arms (standard Two arms (standard da Vinci® system) or system) or Three arms (Three arms (da Vinci S® system) for 8 mm system) for 8 mm instrument instrument trocarstrocars

�� Tops of Tops of da Vinci® trocarstrocars are fitted to are fitted to attach to robot armsattach to robot arms

Vision CartVision Cart

�� Independently processes video signals Independently processes video signals from each of two camerasfrom each of two cameras

�� Signals delivered to surgeon console and Signals delivered to surgeon console and monitors (at bedside)monitors (at bedside)

�� View at console is View at console is 3D + magnified3D + magnified(right and left eye have separate cameras)(right and left eye have separate cameras)

Surgeon ConsoleSurgeon Console

Surgeon Immersed in 3D image of surgical field

Surgeon ConsoleSurgeon Console

�� Surgeon controls robotic instruments via:Surgeon controls robotic instruments via:�� two surgical joy sticks (called two surgical joy sticks (called ““mastersmasters””) ) �� FootFoot--controlled clutches to control:controlled clutches to control:

•• Camera movementCamera movement•• positioning of masterspositioning of masters•• activiationactiviation of energy sources (of energy sources (cauterycautery))

�� SurgeonSurgeon’’s movements are:s movements are:�� translated in translated in REAL TIMEREAL TIME to the robotic to the robotic

instrumentsinstruments�� Scaled and processed to reduce tremorScaled and processed to reduce tremor

Robotic Surgery “Set up”

Robotic Surgery Team

�� Scrub TechScrub Tech�� Circulating RNCirculating RN�� AnesthesiologistAnesthesiologist�� Assistant (s)Assistant (s)�� and the Surgeonand the Surgeon�� and othersand others …………

The quality of the team makes a huge difference!

Place Laparoscopic Ports

Docking the Robot

� Robot is “docked” to patient trocars� Robotic instruments placed through trocars

into abdomen

Laparoscopic Hysterectomy Laparoscopic Hysterectomy vsvs dada Vinci HysterectomyVinci Hysterectomy

RoboticLaparoscopic

Completion of Case�� Surgeon goes Surgeon goes ““offoff--consoleconsole””

�� Robot is Robot is ““undockedundocked””

�� Laparoscopic ports are closedLaparoscopic ports are closed

��Allows more complex cases to be performed Allows more complex cases to be performed in a minimally invasive fashionin a minimally invasive fashion

��Obese patients Obese patients ��Shorter learning curve than laparoscopyShorter learning curve than laparoscopy��Conventional laparoscopy may fall short in Conventional laparoscopy may fall short in

adequately removing and treating gynecologic adequately removing and treating gynecologic cancerscancers

Robotic Surgery in Gynecologic Oncology

Gynecologic Cancers: 2008

Type Incidence Mortality

Uterus 40100 7470

Ovary 21650 15520

Cervix 11070 3870

Vulva 3460 870

Treatment of Most GYN Cancers Treatment of Most GYN Cancers Involves Hysterectomy and BSOInvolves Hysterectomy and BSO

Current Robotic Current Robotic Gynecologic ApplicationsGynecologic Applications

�� Endometrial Cancer Endometrial Cancer �� Early Stage Cervical CancerEarly Stage Cervical Cancer�� EndometriosisEndometriosis�� FibroidsFibroids�� Vaginal Vault Vaginal Vault ProlapseProlapse�� Genetic Susceptibility to CancerGenetic Susceptibility to Cancer�� Pelvic MassesPelvic Masses�� Obese PatientsObese Patients

Endometrial CancerEndometrial Cancer

�The most common indication for Robotic Surgery in Gynecologic Oncolgoy�Hysterectomy, BSO +/- LND

The Obesity FactorThe Obesity Factor

�� Endometrial Cancer : Endometrial Cancer : Obesity is the biggest risk factorObesity is the biggest risk factor�� There is an obesity epidemicThere is an obesity epidemic�� Incidence of uterine cancer is Incidence of uterine cancer is

INCREASINGINCREASING

Surgery in Obese PatientsSurgery in Obese Patients�� Is NOT JUST a Is NOT JUST a LITTLE HARDERLITTLE HARDER !!�� Longer surgical proceduresLonger surgical procedures�� Often have other coOften have other co --morbiditiesmorbidities

�� DiabetesDiabetes�� Hypertension/Cardiac DiseaseHypertension/Cardiac Disease�� Sleep ApneaSleep Apnea�� Joint problems/decreased mobilityJoint problems/decreased mobility

�� Increased risk of complicationsIncreased risk of complications�� Wound infectionsWound infections�� BleedingBleeding�� Deep Venous Thrombosis/Pulmonary EmbolismDeep Venous Thrombosis/Pulmonary Embolism�� IncisionalIncisional HerniaHernia�� Anesthetic complicationsAnesthetic complications

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2007

(*BMI ≥≥≥≥30, or about 30 lbs. overweight for 5’4” person)

2007

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Body Mass Index: examplesBody Mass Index: examples

�� BMI 30: 5BMI 30: 5’’88”” 200 lb200 lb

�� BMI 40:BMI 40: 55’’22”” 220 lb220 lb

�� BMI 50: 5BMI 50: 5’’44”” 295 lb295 lb

�� BMI 60: 5BMI 60: 5’’55”” 363 lb363 lb

Robotic Surgery in Robotic Surgery in Obese PatientsObese Patients

�� Classic approach to Classic approach to hysterectomy for uterine hysterectomy for uterine cancer in obese patient is cancer in obese patient is LARGE VERTICAL INCISIONLARGE VERTICAL INCISION

�� Obesity is NOT a Obesity is NOT a contraindication contraindication to Robotic Surgeryto Robotic Surgery

�� We believe it is the We believe it is the PREFERREDPREFERRED surgical surgical approachapproach

OBESITY is a MAJOR problem in US•Like the economy and global warning need to “fix” the underlying problem

We need to take care of today’ s patients today!!

WomenWomen ’’s Cancer Care of Seattle: s Cancer Care of Seattle: Robotic Surgery ExperienceRobotic Surgery Experience

�� June 2007June 2007 --October 2008: n=?? Robotic October 2008: n=?? Robotic Hysterectomies cases (2 surgeons)Hysterectomies cases (2 surgeons)�� 3 patients converted to 3 patients converted to laparotomylaparotomy : : ((carcinomatosiscarcinomatosis n=1, large uterus and adhesions n=1, large uterus and adhesions

n=1, n=1, minilapminilap for bleeding for bleeding omentumomentum n=1)n=1)

�� Obese patients: Obese patients: �� BMI> 30: n= 48 pts (?%)BMI> 30: n= 48 pts (?%)

•• BMI 30BMI 30--39: n=26 39: n=26 •• BMI 40BMI 40--49: n=16 49: n=16 •• BMI > 50: n=5 BMI > 50: n=5 •• BMI = 60: n=1BMI = 60: n=1

Robotic Surgery: DisadvantagesRobotic Surgery: Disadvantages

�� Training and learning curve: not as Training and learning curve: not as difficult as traditional laparoscopydifficult as traditional laparoscopy

�� Long Operative times: improves over timeLong Operative times: improves over time�� Cost $ of Robot and disposablesCost $ of Robot and disposables�� No increase in reimbursementNo increase in reimbursement�� NOT applicable to multiNOT applicable to multi --quadrant surgeryquadrant surgery

Better Patient Satisfaction

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How to Become a Robotic SurgeonHow to Become a Robotic Surgeon

�� Basic Laparoscopic skills Basic Laparoscopic skills �� Case observationsCase observations�� OnOn--line line da Vinci® ““ coursecourse ””�� 22--hours hands on training with hours hands on training with da Vinci®

representative� One-day “pig lab” training with da Vinci®� Perform 3 “proctored” cases

Robotic Surgical Privileges at Robotic Surgical Privileges at Northwest HospitalNorthwest Hospital

�� Primary robotic surgeon:Primary robotic surgeon:�� Intuitive SurgicalIntuitive Surgical Certificate of Robotic Basic Certificate of Robotic Basic

Training Training �� Documentation of performing 20 robotic surgical Documentation of performing 20 robotic surgical

casescases�� 3 Proctored case 3 Proctored case

�� Assistant robotic surgeon:Assistant robotic surgeon:�� Basic Laparoscopic skills Case observationsBasic Laparoscopic skills Case observations�� OnOn--line line da Vinci® ““ coursecourse ””�� 22--hours hands on training with hours hands on training with da Vinci®

representative

Woman’s Cancer Care of Seattle at Northwest Hospital

www.wccos.com

�� Board Certified Gynecologic Oncologists: Board Certified Gynecologic Oncologists: Dr. Kathryn McGonigleDr. Kathryn McGonigleDr. Howard Dr. Howard MuntzMuntz

�� Both surgeons listed on Both surgeons listed on daVinciSurgery.comdaVinciSurgery.com as as experienced robotic experienced robotic gyngyn surgeon surgeon

�� State of the art treatment for gynecologic cancersState of the art treatment for gynecologic cancers�� Genetic counseling/testing for women at risk for Genetic counseling/testing for women at risk for

ovarian cancerovarian cancer�� Research protocols Research protocols

Woman’s Cancer Care of Seattle Pelvic and Robotic

Surgery Fellowship

�� One year Fellowship at NWHOne year Fellowship at NWH�� Training:Training:

�� Robotic Pelvic SurgeryRobotic Pelvic Surgery�� Advanced Laparoscopic Pelvic SurgeryAdvanced Laparoscopic Pelvic Surgery�� Challenging Pelvic SurgeryChallenging Pelvic Surgery�� UrogynecologyUrogynecology and Pelvic Reconstructive Surgeryand Pelvic Reconstructive Surgery

�� Gynecologic Oncologists:Gynecologic Oncologists:�� Kathryn McGonigleKathryn McGonigle�� Howard Howard MuntzMuntz

�� GynecologistsGynecologists�� ChauChau --Su Su OuOu

�� Urologists and Urologists and ColoColo --rectal surgeonsrectal surgeons

The FACES of:

Kathryn McGonigle MDHoward Muntz MD

Emily Vason PAC

C

Carrie Wieneke-Broghammer MD (Fellow 2008)

Sonia Rebeles MD (Fellow 2008-2009)

The FutureThe Future

�� MultiMulti--Quadrant SurgeryQuadrant Surgery

�� Improved instrumentationImproved instrumentation

�� Expanded indications for other surgical Expanded indications for other surgical specialtiesspecialties�� ENT SurgeryENT Surgery

�� General Surgery (Nissan General Surgery (Nissan PlicationPlication))

�� TransoralTransoral Surgery (NO abdominal Surgery (NO abdominal incision)incision)

TORS (Transoral robotic surgery) for ENT

Single cannulation (transgastric) Surgery

Robotic Surgery…is here to stayeven Leonardo could do it!

Thank you!