Divinci robot – Thoracic Surgery

ALAT : The Grand Trifecta

Talking about the roles of traditional VATS, single port surgery and robots in modern thoracic surgery.

The Ethicon (Johnson & Johnson) sponsored session was by far, the best of the conference – and an excellent overview of modern technologies in thoracic surgery.

Dr. Diego Gonzalez Rivas

“Is uni-port surgery feasible for advanced cancers?” Short answer: Yes.

The first speaker, was Dr. Diego Gonzalez Rivas of Coruna, Spain. He is a world-renown thoracic surgeon and innovator of uni-port thoracoscopic surgery. He discussed the evolution of single port surgery as well as the most recent developments with this technique, including more advanced and technically challenging cases such as chest wall resections (2013), sleeve resections/ reconstructions (2013), pulmonary artery reconstructions (2013) and surgery on non-intubated, awake patients (2014).

Experience and Management of bleeding

The biggest challenges to surgeons learning this technique is management of bleeding. But as he explained in previous lectures, this can be overcome with a direct approach. (these lectures and YouTube videos, Dr. Gonzalez explains the best ways to manage intra-operative bleeding.) In the vast majority of cases – this did not require deviation or conversion from the uni-port technique.)

As surgeons gain proficiency with this technique which mirrors open surgery, the only contra-indications for surgical resection of cancerous tissue (by single port) are tumors of great size, and surgeon discomfort with the technique.

Dr. Mario Ghefter

My favorite lecture of the series was given by Dr. Mario Ghefter of Sao Paolo, Brazil. While his lecture was ostensibly about video-assisted thoracoscopy (VATS), it was more of a retrospective vision and discussion of the modern history of thoracic surgery as seen through the eyes of a 22 year veteran surgeon.

He talked about the beginnings of VATS surgery and the contributions from such legends as Cefolio and D’Amico, including the 2005 paper – and modern-day thoracic bible, “Troubleshooting video-assisted thoracoscopic lobectomy (Demmy, James, Swanson, McKenna and D’Amico).

Dr. Ghefter also talked about how improved imaging and diagnostic procedures such as PET-CT and EBUS have been able to provide additional diagnostic information pre-operatively that helps surgeons to plan their procedures and treatment strategies more effectively.

As a counterpoint to both Dr. Gonzalez and Dr. Buitrago, Dr. Ghefter acquitted himself admirably. He reminded audience members that even the newer technologies have some drawbacks – both as procedures and for the surgeons themselves.

He also successfully argued (in my opinion) that while the popularity of procedures such as multiple port VATS and even open thoracotomies have dropped drastically as thoracic surgeons embrace newer technologies, there will always be a place and time for these more traditional procedures.

Dr. Mario Ghefter is the Director of Thoracic Surgery at Hospital do Servidor Público Estadual – Sāo Paulo and on staff at the Hospital Alemão Oswaldo Cruz.

Dr. Ricardo Buitrago

Native Colombian (and my former professor), Dr. Ricardo Buitrago is acknowledged as one of the foremost experts in robotic thoracic surgery in Latin America.

During his presentation, he discussed the principles and basics of use of robotic techniques in thoracic surgery. He reviewed the existing literature surrounding the use of robotic surgery, and comparisons of outcomes between thoracic surgery and traditional lobectomy.

He reviewed several recent robotic surgery cases and the use of robotics as a training tool for residents and fellows.

While he mentioned some of previously discussed limitations of robotic surgery (namely cost of equipment) he cited recent studies demonstrating significant cost savings due to decreased length of stay and a reduced incidence of surgical complications.

He also discussed recent studies (by pioneering surgeons such as Dr. Dylewski) demonstrated short operating times of around 90 minutes.

Another home run: Dr. Gonzalez Rivas does it again!

the Babe Ruth of thoracic surgery continues his winning streak; and Dr. Benny Weksler heads south to the University of Tennessee. Kudos to both of these fine surgeons!

I am beginning to feel like a bit of a sports reporter when it comes to Dr. Gonzalez Rivas and innovations in thoracic surgery..

The Babe Ruth of modern thoracic surgery

It’s another home run for Dr. Gonzalez Rivas as he and his team perform a single port (uni-port) thoracoscopic lobectomy with under local anesthesia, as reported by a recent story, “Operan un tumor e pulmón con una sola incisión y anestesia local” by Raul Romar in La Voz de Galicia.

Dr. Gonzalez Rivas demonstrates uniportal VATS

The answer is International collaboration and sharing of ideas

Dr. Gonzalez Rivas is used to sharing his ideas. After all, he spends a considerable amount of time traveling the world doing just that; sharing information about and teaching surgeons how to perform the single port thoracoscopic technique. But that doesn’t mean that he does find time to learn from his peers during his travels.

The article above highlights the importance of this international collaboration as it details how Dr. Gonzalez Rivas began to consider applying a local anesthesia approach to the single port surgical technique after talking (and visiting) surgeons in Taiwan and China.

Once he found the perfect candidate, he was ready to implement local anesthesia into his single port approach.. The rest, as they say – is now headed for the Annals of Thoracic Surgery.

Click here for English translation (note translation is not exact).

In other news:

Welcome to Tennessee!

Dr. Benny Weksler, our own American (via Brazil) superstar surgeon recently made the move to the University of Tennessee. Dr. Weksler made the move in November of 2013 and is now settling in to his new position as Chief of Thoracic Surgery for the University of Tennessee (UT) Health Science Center and UT – Methodist.

Dr. Weksler, one of the United States most prominent thoracic surgeons, particularly in the area of esophageal surgery reports that he has big plans for the UT health system and the thoracic surgery department.

Big Plans for UT and the city of Memphis

These plans include a lung cancer screening program targeting vulnerable populations in Memphis including the uninsured/ underinsured, African-Americans (who are disproportionately affected) and smokers.

Related: Dr. Weksler talks about smoking cessation

Minimally invasive techniques for esophageal surgery

He has also started a new minimally invasive esophageal surgery program for esophageal cancer and reports “that there is almost an epidemics of squamous cell carcinoma of the esophagus” which is something tha was more rare in his previous practice in Pittsburgh, Pennsylvania.

Dr. Weksler and his colleagues are putting together a multi-disciplinary treatment plan to try to get these patients to a complete evaluation with a surgeon, an oncologist, and a radiation oncologist to provide patients with comprehensive, multi-faceted and coördinated care.

“The Surgeon Speaks” – Dr. Weksler talks about robotic surgery in this 2009 Jefferson University publication.

As a former Memphis resident, I want to say, “Welcome to the mid-south.. Hope you find time in your busy schedule to enjoy Beale Street, visit the Pink Palace and tour Graceland.. On behalf of all current Memphians, we are glad you are here.”

*This article was written by the author of this post.

Robotic surgery with Dr. Ricardo Buitrago, thoracic surgeon

Robotic (thoracic) surgery comes to Clinica de Marly in Bogota, Colombia

A year and a half ago, I interviewed and spent some time with Dr. Ricardo Buitrago at the National Cancer Institute, and Clinica de Marly while doing research for a book about thoracic surgeons. At that time, Dr. Buitrago stated he was interested in starting a robotic surgery program – and was planning to study robot-assisted thoracic surgery with Dr. Mark Dylewski.

buitrago 009 — Dr. Ricardo Buitrago in the operating room, April 2011

Fast forward 1 year – when I received a quick little email from Dr. Buitrago telling me about his first robotic surgery at the Clinica de Marly. At that point, I sent Dr. Buitrago an email asking if I could come to Colombia and see his robotic surgery program to learn more about it. We had several phone conversations about it and I also outlined a research proposal to gather data on thoracic surgery patients and outcomes at high altitude, to which he enthusiastically offered to assist with. Thus began my current endeavor, in Bogota, studying with Dr. Buitrago.

Now – after completing a proctoring period with Dr. Dylewski, Dr. Buitrago has more than a dozen independent robotic surgeries under his belt. He has successfully used the robot for lobectomies, mediastinal mass resections and several other surgeries.

As part of my studies with Dr. Buitrago – I’ve made a video for other people who may be interested in robotic surgery with the DaVinci robot and what it entails.

Hope you enjoy.

Talking with Dr. K. Adam Lee, MD about minimally invasive surgery

In Jupiter, Florida talking about robots, lung cancer screening and solitary pulmonary nodules with Dr. K. Adam Lee, thoracic surgeon

Jupiter, Florida

Dr. K. Adam Lee, MD and Dawn Bitgood, FNP

All my prepared questions fly out of my mind as I greet Dr. Lee and his team. It’s been several months since I first contacted Dr. Lee to ask about his new thoracic surgery program at Jupiter Medical Center in coastal Florida, but it has taken this long for me to find a way to Florida. After nine months here, Dr. Lee is well-settled into his new position as medical director of the thoracic surgery and lung center.

Detecting and treating lung cancer

We talk about the regional differences in thoracic surgery, with Dr. Lee confirming that the majority of his practice is surgical oncology; including diagnosed lung cancer and solitary pulmonary nodules. In fact, since coming to Jupiter, Dr. Lee has started a lung cancer screening program based on the newly released CT scan guidelines for the early detection of lung cancer, as well as a lung nodule clinic for the evaluation of lung nodules.

Minimally invasive surgery

With Dr. Lee, “minimally-invasive’ is the theme. “I want patients to ask, ‘do I have to have a thoracotomy?” he states. “I want patients to know that there are minimally invasive options,” he continues as he talks about the advantages of minimally invasive techniques such as robotic-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS). “Why should patients have all the pain [associated with large surgical incisions] if there is no reason not to do minimally invasive surgery?”

Dr. Lee should know; he’s been performing robotic surgery since 2003.

Lee Robot — Dr. Lee, performing surgery with the DaVinci robot

Teaching others

As part of his commitment to advancing technologies, he has recently paired with Ethicon Endo-surgery to be able to provide training in minimally invasive surgery to thoracic surgery colleagues all over the world. Twice a month, he travels to other facilities to demonstrate these techniques for other surgeons. The operating rooms at the hospital here have recently been outfitted for web-based broadcasting for the remainder of the time, so that surgeons, regardless of location are able to watch these demonstrations[1].

He reports that learning to perform robotic surgery is easier for surgeons to learn than video-assisted thoracoscopic surgery, explaining that while the instrumentation is different (using robotic arms to perform surgery), the tissue manipulation and techniques are closer to open surgery [compared to VATS], and thus more familiar to conventionally trained surgeons.

I didn’t get to see Dr. Lee in the operating room – but soon, everyone will be able to.

[1] Surgeons interested in learning more can contact either Ethicon Endo-surgery or Dr. Lee directly.

* I was surprised to find out that the lung cancer screening program (CT scan, radiology interpretation/ consultation and a consultation with a thoracic surgeon) is under 300.00 USD. In an age of exorbitant medical fees, this is an affordable option for early detection of lung cancer.

Dr. Thomas D’Amico: Duke Thoracic Surgery

A brief interview with Dr. Thomas D’Amico, Chief of Thoracic Surgery at Duke University Medical Center.

Dr. Thomas D’Amico is one of the first American thoracic surgeons I’ve had the privilege of interviewing for the website, after he was recommended to me by several other surgeons in Colombia. (Dr. D’Amico went to Medellin as an invited guest a few years ago and apparently made quite an impression.)

The irony in this scenario is unmistakable, since I worked for Duke (at another facility) for over three years – and knew of Dr. D’Amico, but had never met or spoken to him before.

Today, Dr. D’Amico took some time out of his busy schedule so we could talk about minimally invasive surgery, esophageal surgery programs and robots.

Dr. D’Amico is the Chief of Thoracic Surgery at Duke University Medical Center in Durham, North Carolina. Together with several other physicians that make up the thoracic surgery program; the surgeons at Duke perform 1600 – 1800 cases per year. This includes the entire spectrum of thoracic surgery procedures (thoracoscopic surgeries including lobectomies, wedge resections, mediastinal tumors, etc).

Last December, Duke started a minimally invasive esophageal surgery program, as well as a robotic thoracic surgery program. (Both of these concepts should be familiar to readers since we published articles on these very topics earlier this month, talking about the TIME trial in Europe, comparing outcomes between traditional and minimally invasive esophageal surgery, as well as previous post exploring the dearth of published literature on Robotic Thoracic Surgery. )

Since its inception six months ago, the program has done 80 -100 cases of minimally invasive esophageal surgery. Notably, Duke has an established esophageal cancer program – which performs about 70 – 80 esophagectomies a year. This doesn’t sound like a lot, but it actually distinguishes this program as a high volume center, which is important for reducing morbidity and mortality. Multiple studies have confirmed that esophageal surgery patients do better (less deaths, less complications) when they have surgery with thoracic surgeons at high volume centers.

The Robotics program, headed by Dr. Mark Onaitis is performing about 8 to 10 cases per month. The program is currently limited due to access to the Divinci robot. (Currently, thoracic surgery has use of the robot one day per week.) Dr. D’Amico reports that surgical case times have been increased on the robotic cases but states that much of this is robot maneuvering time as the robot is brought into position for surgery.

I’ve asked to observe a robotic case so I can bring you first hand observations (a la Bogotá Surgery style), as well as have a chance to look around the dedicated thoracic surgery unit at Duke hospital.

Pleural mesothelioma and related conditions are less well-defined within the Duke Thoracic surgery program. They only see about 20 or 25 cases per year, and don’t really have an established program for these patients. Dr. D’Amico reports they are not actively pursuing brachiotherapy or HITHOC (intrathoracic hyperthermic chemotherapy) options. The main focus of the program remains minimally invasive procedures, which is where Dr. D’Amico sees the future of thoracic surgery.

As for the surgeon himself, he is surprisingly closed lipped about his personal and professional life, and declined to answer any questions on the subject. He has a reputation around Duke as a shy, quiet and gentle man but my time with him was extremely limited, so I have no insights, or impressions to pass along to readers. Hopefully, I’ll get another chance to speak with him in the future, so I am able to give more details about these programs, and the surgeon behind it all.

Robotic Thoracic Surgery

today, we are looking at the research and case reports related to the use of the Divinci robot for robot-assisted thoracic surgery..

I’m not sure if this should be filed under the Future of Thoracic Surgery – or news, since it won’t be long before more surgeons are performing their surgeries using the DiVinci robot.

I’ve already met a surgeon here in Bogota who has been training to start performing his lung surgeries using this technology.

It’s still a pretty new application of this robot – though reports go back to 2000, but it’s been slow to catch on in this specialty. The Divinci, which has been used for several years; in urology, gynecology and cardiac surgery is an expensive, large, unweldly machine so it takes consider time, and expense to get the necessary training and skills to use it appropriately.
However, one of the surgeons I know in Fresno, at the Stanford Cardiothoracic Surgery Clinic, Dr. Randy Bolton, has been using it for his cardiac cases for years..

So, today, we are looking at the research and case reports related to the use of the Divinci robot for robot-assisted thoracic surgery..

Robotic surgery for mediastinal tumors – Japan: a review of six cases including tomography, diagrams of staff positioning, and a discussion of port placement, as well as some of the problems they encountered (a lack of speciaized instruments).

The University of Illinois experience: 32 cases from 2001 – 2009 ; this study highlights some of the problems implementing new technologies – there is a significant learning curve, and it slows you down.. (The average operating time was 209 minutes). There are some color photos, so caution to the squeamish.

There are three articles pending publication on the use of robotic surgery for thoracic cases – one by Melfi, Vita, Divini and Mussi (European J Cardiothoracic Surgery)
and another, discussing 2 cases of pneumonectomy by robot by Spaggiari and Galetta that sound pretty intriguing.

I’ll see if I can update the article when the articles are more widely available.