A SURGICAL MASTERPIECE
Robotic surgery, once the stuff of science fiction, moves into its renaissance at the USC University Hospital.
He carves with the confidence of one who has spent years hewing the hardest marble and shaping the softest clay. The sculptor’s masterwork: a sum of cuts and strokes so precise a Renaissance artist might deem them sublime.
He is da Vinci.
No, not Leonardo, the artist-scientist-genius—though the inventive Italian engineer would undoubtedly be impressed with his namesake. This da Vinci is a surgical robot, the cutting edge of today’s high-tech surgeries. His master: Vaughn Starnes, M.D., Hastings Professor and chair of cardiothoracic surgery at the Keck School of Medicine.
Starnes and his team of cardiothoracic surgeons recently completed their first robotic work of art: They performed Southern California’s inaugural heart operation, using the da Vinci Surgical System robot at USC University Hospital.
The team—comprised of Starnes and Daniel S. Schwartz, M.D., and Ross Bremner, M.D., Ph.D., assistant professors of cardiothoracic surgery—repaired the mitral valve of Lotte Henderson in April 2001. They have conducted several more cutting-edge, robot-assisted mitral valve repairs since.
"Robotic surgery is going to revolutionize cardiothoracic procedures," Starnes says. "This is truly the next advance in heart surgery."
The system allows surgeons to operate remotely by using controls, much like joysticks, at a computer console. The robot responds quickly and easily, perfectly mimicking the surgeon’s movements. Surgical instruments are mounted onto the robot’s arms, their fully rotating tips inserted into the patient through small holes on the side of the torso.
Traditional mitral valve surgery involves a long incision. Surgeons must split the sternum, or breast bone, to reach the heart. Patients typically must recover for eight weeks before they can return to work. But through the small punctures and tiny instruments involved in minimally invasive robotic surgery, patients experience shorter incisions and less scarring, less pain, less trauma and less blood loss, and a quicker recovery time. “Patients can literally be back at work in two to three weeks,” Starnes says.
The da Vinci Surgical System is a product of Intuitive Surgical, based in Mountain View, Calif. USC University Hospital is one of several sites in the United States in a U.S. Food and Drug Administration-approved trial to evaluate the use of the da Vinci Surgical System to repair the heart's mitral valve. The robotic technology is a spin-off of advances in defense, Starnes notes. Intuitive Surgical developed the da Vinci technology at the urging of the Pentagon, which sought a way for military surgeons to perform operations remotely, without being on the frontlines or at sea.
April 27
Already under anesthesia, Lotte Henderson cannot see the robot to her right, covered in plastic sheeting to keep it sterile, as its arms are lowered toward her chest.
It is 10 a.m., and more than a dozen doctors, nurses and technicians move around Henderson with a choreographed sense of purpose. The doctors make a four-inch-long incision in her side and three other small openings in the skin where the robot’s pencil-thin video camera and instruments are inserted. Other small incisions in the groin area allow doctors to put Henderson on a heart-lung bypass machine, cycling her blood from the femoral arteries so they may stop the heart from beating while they repair it.
Team members next measure the size of Henderson’s mitral valve.
The mitral valve, Starnes explains, is the passageway between the heart’s left atrium, or upper chamber, and its left ventricle, or lower chamber. When the heart pumps, two leaflets—sort of like flexible doors—flutter open to let blood pass one way, then slam shut so blood cannot flow back to the atrium. But when the valve malfunctions, blood can slosh backwards and back up into the lungs, causing the ventricle to pump more blood. Outward symptoms include shortness of breath and tiredness.
In Henderson’s case, the valve leaks badly. At fault: two torn chordae, little strings that pull on the valve’s leaflets and are attached to the heart through the papillary muscle. Starnes likens them to the strings of a parachute, where the parachute canvas is a valve leaflet and the person connected to the parachute strings is the papillary muscle.
With two broken strings, the valve flops or flails open, letting blood flow through when it should not. So Starnes and his team must attach new, replacement strings.
“Lights down,” commands Starnes. Darkness envelops the room, leaving only Henderson’s upper torso, below the robot’s waiting arms, bathed in light.
While Schwartz, Bremner and other team members are at Henderson’s left side—opposite from the robot—Starnes sits down at a console about eight feet away. He grasps two controls that loop around his thumbs and forefingers, and places his forehead against a viewer that allows him to see the surgical field, highly magnified on a video screen. His feet lean on pedals below, as the other surgeons finish preparing the necessary tools on the robot’s arms.
Suddenly, the robotic arms tilt and swivel smoothly, imitating the movements of Starnes’ fingers. A quarter inch-long alligator clamp at the end of a thin rod opens its tiny jaws in Henderson’s chest and grasps a rounded suturing needle in its teeth.
“Greetings from Earth,” murmurs an observing physician, astounded.
Outside the operating room, six or seven specialists, nurses and passersby, equally amazed, gather in the hallway to watch the procedure magnified on a video screen. They see tiny graspers move the needle in and out of muscle, stitching tissue with sutures the width of a human hair. Schwartz removes and replaces instruments on the robot’s arms.
Now finished replacing the chordae, Starnes sews a shoelace-like ring into place around the circumference of the valve, tightening it into place. Schwartz snips the needle off, removes it, and carefully cleans the area.
“All right, I think we’re ready to close,” Starnes declares, emerging from the console and approaching Henderson’s side. The surgeons wear high-tech headgear: a headband holding fiberoptic cables that feed into a headlamp, which shines glowing blue light onto the patient. She is soon taken off bypass, and the heart beats again.
It is 1 p.m.
“How does it look?” Starnes asks a radiologist, who watches blood flow through the mitral valve via ultrasound.
“Water-tight.”
Just the answer they want to hear.
Future firsts
USC cardiothoracic surgeons are confident that robotic technology is the next great leap forward in surgery.
“This is going to allow us, ultimately, to do open heart surgery without opening the chest in any way except the small openings we need for port access, to put in the various devices we need to insert into the heart,” Starnes says.
He envisions that the robot will not only be used in valve repair, but in heart bypass surgery. “We’ll be pushing that edge here at University Hospital over the next year,” Starnes expects.
Such complicated procedures are possible because of the exactness and predictability of the robot’s movements, as well as the features of the robot technology. These set it a step ahead of current minimally invasive surgeries, Starnes says.
In today’s conventional minimally invasive surgeries, just as in the robotic surgery, surgeons make small cuts in the skin to serve as ports into the body. They insert thin rods that have minute surgical tools on their tips through the ports, as well as a tiny video camera or endoscope, which allows them to watch on a video screen as they cut and suture tissue.
These endoscopic surgeries are highly advanced, reducing hospital stays, patient recovery time, pain and the risk of infection. They have become the standard for procedures such as gall bladder removal.
They differ from the robotic surgery, however, in that the surgeon directly operates the tools from beside the patient’s side, and the surgeon is limited in the range of motion allowed by the surgical tools.
The robotic system, though, has articulated rotating parts, allowing the surgeon to turn and swivel the tools when they are within the patient’s body—more accurately and steadily reflecting natural hand movements.
“In a sense, it is like being inside the chest, operating with nimble, tiny hands,” Bremner says, “because the instruments have ‘wrist-like’ movements.”
In the case of da Vinci’s first surgery at USC, Starnes says, “It was probably a better repair than I would’ve done through open heart surgery, because the visualization is such that you can see the intricacies of the mitral valve and its chordal structure.”
Adds Schwartz: "Mitral valve repairs, technically, are among those requiring the most skill from a surgeon. This is a procedure not many people across the country do, even without a robot."
Appropriately enough, Starnes draws a military flight analogy when discussing the technology. “If the development of open heart surgery was like the creation of the jet plane, and thoracoscopic surgery was like the stealth bomber,” he says, “then da Vinci is like flying to the moon and back every day.”
The robotic surgical system is already used in Europe for numerous procedures, including gynecologic, urologic, abdominal, chest and heart operations.
In the U.S., however, approvals have come more slowly. The FDA has approved the da Vinci system for use in laparoscopic surgical procedures including cholecystectomy (gall bladder surgery) and Nissen fundoplication (treatment for acid reflux or heartburn), as well as more recently for urologic surgeries, such as prostate removal, and for thoracoscopic procedures (done within the chest).
At USC University Hospital in July, Bremner became the first surgeon in the country to remove a benign tumor from deep within a patient’s chest—a thoracoscopic procedure to excise a posterior mediastinal mass—using da Vinci.
Surgeons believe one advantage of the robot in chest procedures is that patients may feel less pain after the surgery. In traditional thoracic procedures, doctors must use the ribs as a fulcrum for their surgical tools, which may injure some nerves along the ribs, resulting in post-operative pain. But the robot does not need to rest against the ribs, “and because of this, there is no torque or pressure on the ribs—with decreased risk of injury to the nerves,” Bremner says.
Bremner hopes to continue using the da Vinci Surgical System for chest surgeries such as lobectomies (removing a lobe of a lung) and esophagectomies (removing part of the esophagus).
However, the broad FDA approval does not include heart surgeries, which are currently only done robotically at selected sites in the U.S.—including USC—as part of clinical trials.
The first FDA-approved robotic mitral valve surgery trial using da Vinci was done at University Health Systems of East Carolina/Brody School of Medicine at East Carolina University in November, 2000. The surgical team was led by W. Randolph Chitwood Jr., M.D., who hosted Starnes during his lengthy training with the da Vinci robot at East Carolina University earlier this year.
Starnes, though, notes that perhaps the best initial training for the skills required by da Vinci might be video games.
“My son said, `Gee, that sounds like a lot of fun. I’d like to come down and try it out,’” Starnes says with a chuckle. “I said, `Well, why don’t you go through about 12 years of medical training—and then we’ll let you give it a try.’”
Lotte Henderson knew her surgery was not really as easy as playing video games. She knew Starnes has honed his surgical expertise into an art form, and trusted him to do the procedure—with or without the robot.?
For more information on the Department of Cardiothoracic Surgery or the da Vinci Surgical System, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).
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