The Surgeon May Never Have to Touch His Patient

Hunched into a gray machine, David Ornstein uses foot pedals and joysticks to stimulate the image produced in two peep holes. Outside of his vision, a larger vertical gray machine moves its arms in accordance to Ornstein’s commands. What may seem like a video game is serious surgery, but Dr. Ornstein, the surgeon and an assistant professor of urology, may never have to touch the patient.
In the middle of the surgery room in UC Irvine’s Medical Center, an anonymous 81-year-old male patient lies face-up and unconscious. His stomach, stained yellow with povidine-iodine, resembles a sea urchin, birthing the probes of four arms, which lead to the larger vertical machine towering above him.
Dr. Ornstein said that many people, upon hearing about robotic surgery, fear that ‘the robot will take over. There’s no intelligence involved. The robot won’t work on its own. It is an extension of the surgeon’s arms and eyes,’ Dr. Ornstein said.
Robert Brown, 57 years old and the patient of the first surgery performed with the help of the new da Vinci surgical robot said, ‘After meeting Dr. Ornstein and doing my own research, I understood that the surgeon is in control of the robot and I had perfect confidence.’
Under the command of the surgeon, the da Vinci S HD Surgical System is able to create small incisions for six instruments and work under the otherwise intact skin of the patient’s abdomen. The largest incision would be about two inches. According to Browne, the procedure is sometimes called ‘band-aid surgery,’ indicating the minimal invasiveness of the process. Browne, diagnosed with prostate cancer, had his prostate removed (a radical prostatectomy) and when he awoke, he found five one-inch incisions and one two-inch incision on his abdomen.
The 81-year-old now on the table is the sixth patient of the new da Vinci and is diagnosed with bladder cancer. He is in the process of having his bladder removed. It would be a five- to six-hour process.
Robotic surgery has been available for about five years how. UCI Medical Center has three of the older models of the da Vinci, and received the newest model in the last week of March. The latest model has a fourth arm, which offers greater control and liberates an assistant to perform other tasks, and provides a clearer, more accurate and improved visual perception (with high-definition-projection) of the patient’s body. The benefits of robotic surgery include less bleeding, the need for less fluids and less healing time.
According to Dr. Ornstein, many surgeons have been through training, a two-day process, with someone from Intuitive Surgical (makers of the da Vinci). Training begins with practice on inanimate objects, and then on pigs and cadavers.
Dr. Ornstein buries his face in the da Vinci, which provides a three-dimensional image of the inside of the patient’s abdomen. Through a microphone, he commands two assistants in urology, sitting at either sides of the patient and holding two other instruments, to perform tasks such as suctioning blood. The same image that Dr. Ornstein sees is displayed for the two assistants two-dimensionally on two screens. There are six instruments in the patient’s abdomen now: the monopolar, which cuts, the bipolar, which coagulates and cuts, a grasping tool, another arm which bears a light and a camera and two others which are interchangeable and manually-controlled by the two assistants.
Along with the chief surgeon and the two assistants, there is also a scrub nurse and a circulating nurse.
‘Unless you have a dedicated team, it could take a long time and there could be a lot of problems,’ said David Finlay, an assistant and a resident of UCI Medical School.
For the next few hours, Dr. Ornstein remains in the same seat, position and manner while grabbing and cleaving tissue in a deliberate and cautious process to detach the bladder from the two ureters.
da Vinci Technicians stand by in case of technical difficulties. About an hour into the surgery, the screens begin to flash black and white. A technician was called in to fix the problem and ensure that the operation will proceed successfully.
According to Dr. Ornstein, there is no more risk in using a robot than performing an open-cut surgery. In fact, the robot reduces risks because the improved visualization of the machine allows the surgeon to be more precise.
Though the da Vinci provides for safer surgery and less recovery time, the process can be more meticulous and may take longer for certain types of surgeries. For the 81-year-old, it would be five to six hours with the help of the robot, and four to five without. For Browne’s surgery, the removal of the prostate, it would be two to three hours either way.
Toward the end of the surgery, the 81-year-old’s bladder is pulled through the two-inch cut and then the two ureters the bladder was once connected to are stapled.
Now without a bladder, the 81-year-old will have to wear a bag that will drain his urine for the remainder of his life. For most patients, normally younger, ‘[the surgeons] would make a new bladder out of the intestine so that the patient doesn’t have to wear a bag,’ said Dr. Ornstein.
The patient will take five to six days to heal, a shorter recovery period as opposed to seven to eight days with the open-cut surgery.
The prostatectomy, however, requires even less time to heal. The usual recovery period of two to three days is shaved to less than 24 hours. Browne woke up four hours after the completion of his surgery and walked every few hours. He was released from the hospital in less than 24 hours. As early as nine days after the removal of his prostate, he was driving, meeting friends and planning social events.
‘Surgeons are beginning to understand how they can use [robots] for certain types of surgeries,’ Browne said. ‘[Robotic surgery will] reduce health care costs in the long run, and recovery time … [but] they’ll always need the surgeon. You still need the human line to make decisions. … Robot is really the way to go. I’m a believer.’
The first surgery by the older model of the da Vinci S HD Surgical System was performed at the UCI Medical Center in June 2003 and was the first on the West Coast.
The da Vinci, which costs $1.5 million, is usually used to perform neurological surgeries.
‘It opens up a lot of new opportunities to patients with cancer or diseases in a manner that will cause fewer side effects and allow them to heal faster. We can fix the organ without causing so much damage,’ Dr. Ornstein said.
Dr. Ornstein has worked as a surgeon for seven years, four of which have been at the UCI Medical Center. He has performed about 250 surgeries on the prostate and 25 on the bladder.
For more information on Intuitive Surgical’s da Vinci S HD Surgical System, visit http://www.intuitivesurgical.com.