More surgeries at Modesto hospitals being done via remote control

Alfredo Gallardo of Modesto had his gallbladder removed Thursday at Memorial Medical Center in a surgery that will leave no visible scar.

The operation using a robotic surgical system was a first for the Northern San Joaquin Valley, where robots are a growing presence in operating rooms.

In July, Memorial became the second Modesto hospital to introduce a da Vinci surgical system. Its version is more advanced, allowing Dr. Refugio Gonzalez to perform the region's first no-scar surgery after making a tiny incision in Gallardo's belly button.

After flexible instruments including a 3-D camera were inserted through a port in the navel, Gonzalez worked with the robot to find the inflamed gallbladder. He cut it free and pulled the 4-inch organ through the navel port.

The patient went home Thursday afternoon with a few stitches in his belly button.

Gallardo, 83, said his doctor advised that he should be able to play trumpet again with the Mariachi La-Union band after resting for a week.

"It's a little bit of swelling around the belly button and it's sore," he said. When the doctor recently suggested he have robotic surgery, "I told him I was not scared. I told him, 'Go ahead and do what you have to do.' "

Gallbladder surgery once involved making an 8-inch incision on the right side of the belly. But surgery isn't so barbaric these days.

Fewer complications

Robotic systems are the newest wave, enabling doctors to perform surgeries with smaller incisions and giving them tools to see and work with complex tissues in the body. Proponents say robotic-assisted surgeries result in less blood loss, shorter hospital stays and fewer complications for patients.

Intuitive Surgical, the company that makes the da Vinci robot, said about 4,000 of the single-incision surgeries have been done since the system was launched in January. The newer version of da Vinci makes it possible to remove a gallbladder through the navel because of the flexibility of the rods that hold the forceps and scissors.

A common laparoscopic procedure for gallbladders leaves the patient with four small scars on the abdomen.

More than 700 robotic- assisted surgeries have been performed at Doctors Medical Center, which purchased a da Vinci surgical system in 2007 and has more than 10 doctors using the system. Memorial paid $2 million for a newer version of da Vinci that supports single-incision operations and has more advanced imaging.

Gonzalez said Thursday's hourlong surgery with Gallardo "went well. There was minimal to no blood loss. It took less time than expected."

At Memorial, seven surgeons use da Vinci for prostate surgery, hysterectomies, colon and general surgeries. And more are going through the training.

Dr. Kathleen Eve said she first thought surgical robots were a gimmick and waste of money, but she was won over when she started training with the system this year.

"For a fact, the surgeon can see much better inside the patient and use the robots' hands like hands are supposed to work," she said.

During her career, Eve has done laparoscopic procedures in which long instruments and scopes are inserted through small incisions in the patient, eliminating the need for large incisions. Laparoscopy also reduces blood loss and scarring for patients, but some doctors compare it to operating with chopsticks.

Greater range of motion

Advocates say robotic systems give surgeons a sharper view of the patient's anatomy and provide instruments with a greater range of motion to grab, cut and suture tissue.

Gonzalez used the robot to remove about half of the colon of Phaidra Medeiros of Gustine in late August; the surgery required a 2-inch incision. The mother of two said conventional surgery would have left scars on her abdomen.

"My surgery was five hours, a pretty major surgery, but you would never know it by looking at my stomach," she said. She added the post-operative pain in her abdomen has gone away.

The robots don't perform the surgery. Rather, the surgeon sits at a console about eight feet from the operating table. Hovering over the patient is a four-armed robot holding an endoscopic camera and flexible rods with surgical tools at the tips.

Once the camera and rods are inserted through ports in the patient's abdomen, the surgeon looks into the high-resolution viewer and handles the master controls — similar to playing with an Xbox. The system interprets the surgeon's hand movements, translating them into movements of the grabbers and scissors inside the patient.

Under the surgeon's command, the robot does the cutting and suturing with more precision. The jointed instruments, able to rotate 560 degrees, are far more flexible than the human wrist, making it easier for the surgeon to work in tight spots.

Doctors said robotics eliminate some of the physical demands of more conventional surgery. Eve said the long-shafted instruments used in laparoscopic surgery are not flexible, so the surgical team sometimes goes into contortions getting the camera in place or making difficult cuts.

"It's like a big game of Twister all over the patient's bedside," she said.

Gonzalez said it is advantageous to use the robot for "retraction" — or holding tissue aside while he operates deep in the pelvis. Holding retractors during a three-hour operation is physically exhausting, he said.

Getting a clearer view

One of the benefits for patients is the imaging system that highlights the targeted area when fluorescent dye is injected, said JoAnn Adkins, interim surgical services manager for Memorial.

It gives the surgeon a clearer view of nerves and blood vessels to avoid during the operation. Adkins said there are lower rates of incontinence and erectile dysfunction among prostate cancer patients who had robotic surgery. Before helping to develop Memorial's program, she worked with the robotic surgery teams at Henry Ford Health System in Detroit and Centennial Medical Center in Nashville.

Adkins said doctors first were trained in robotic surgery on a simulator at Memorial and then practiced the skills on pigs. Surgeons are required to complete 10 operations under the supervision of a proctor before they move on.

The FDA gave approval for the da Vinci system in 2000, and there now are 2,132 surgical robots in hospitals worldwide for performing cardiac, thoracic, gynecologic, pediatric and general surgeries. Despite their growing use, robotic-assisted procedures represent a small percentage of surgeries at Doctors in Modesto, which is looking to purchase the newer version of da Vinci, a spokeswoman said.

"I think it is going to be the wave of the future," Gonzalez said. "There is a lot of technology that will allow us to do surgery that is safer for patients."

Bee staff writer Ken Carlson can be reached at kcarlson@modbee.com or (209) 578-2321.