RATS – Thoracic Surgery

the 4th VATS International

The fourth VATS International Symposium is this October 20th – 21st, 2017. As readers know, this course has been highly recommended in the past by Thoracics.org.

The preliminary program has been released, and it looks like audience favorite and straight shooter, Eric Lim will be opening the conference.

Italian thoracic surgeon, and the inventor of the first uniportal VATS procedure, Dr. Gaetano Rocco, along with the prominent American surgeon, Dr. Robert Cerfolio will also be presenting. There will be several presentations comparing uniportal VATS with robotic assisted surgical techniques (RATS). But this is more than an academic discussion – in addition to notable speakers, the conference includes live cases, practical tips and hands-on training.

Representatives from Storz will be speaking to thoracic surgeons on caring, repairing and maintaining thoracoscopic equipment. There are still spaces available for attendees, including the state-of-the-art wet lab. This wet lab offers surgeons the opportunity to try new techniques using 3-D models, while proctored by leaders in the field.

To register for this event – visit VATS International 2017

Thoracics.org will be there, reporting on this event – as well as conducting live interviews with CTSnet.org for overseas real-time broadcast.

This June: NYU School of Medicine & Robotic Thoracic Surgery

Details about the upcoming Robotic thoracic surgery course at NYU this June.

New York University School of Medicine has an upcoming CME course on Robotic Thoracic Surgery this June (10th & 11th). The day and a half course will be held at NYU Langone Medical Center in New York City.

The conference covers robotic surgery basics as well as lectures on robotic esophagectomies and mediastinal surgery. Robotic master surgeon, Dr. Robert Cerfolio will be giving two presentations.

conference6 — Dr. Robert Cerfolio with a Latin American thoracic surgeon at a conference in Orlando, Florida 2015

Dr. Inderpal Sarkaria from the renown University of Pittsburgh Esophageal & Lung Surgery Institute will be giving a presentation on esophagectomies by the robotic approach. Dr. Sarkaria is the newest thoracic surgeon at the UPMC program run by Dr. James Luketich.

While it is a short conference, it’s a chance for interested thoracic surgery professionals to learn more about establishing a robotic surgery program. It is also part of a larger robotic surgery conference, the Second Annual NYU Langore Multi-Specialty Robotic Surgery Course.

All robotic surgery enthusiasts, fellows and interested surgeons – can register for the course here. Allied health professionals are encouraged to attend.

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.

New Masters: Dr. Mark Dylewski, Robotic Surgery

Talking with Dr. Mark Dylewski, one of the new masters of thoracic surgery in the area of robotic surgery

Most of us never had the opportunity to meet or talk to some of the ‘masters’ of thoracic surgery like Dr. Hermes Grillo (1923 -2006), the ‘Father of Tracheal Surgery’ but as we have discussed before, thoracic surgery is not static. New technologies and new techniques are emerging all the time, and with these developments – new masters of thoracic surgery.

Dr. Mark Dylewski, may look too young to be the father of anything, but he is certain to be remembered in thoracic surgery history as one its new masters, and as one of the ‘fathers of robotic-assisted thoracic surgery’. While he is not the only surgeon doing robotic surgery, he is certainly one of the most prolific robotic / thoracic surgeons and has trained a large number of his peers.

cirujanos — Dr. Garrett Walsh and Dr. Mark Dylewski, thoracic surgeons

Talking to Dr. Dylewski about robotic surgery

At the recent conference, Advances in Lung Cancer and Mesothelioma, we had the opportunity to sit and talk with Dr. Dylewski about the state of robotics in thoracic surgery. Dr. Dylewski is one of the foremost experts on the topic and teaches robotic surgery techniques at the South Miami Hospital Center for Robotic Surgery. Since he started performing robotic surgery in 2006, he estimates that he has taught over 200 thoracic surgeons how to perform surgery utilizing the DaVinci robot.

In comparison to other minimally invasive techniques (specifically VATS), Dr. Dylewski believes that robotic surgery has greater potential for use in thoracic surgery, due to its easy adoptability. He reports that unlike VATS, robotic surgery techniques utilize traditional surgical skills so that surgeons are usually proficient at robotic surgery after performing 30 – 40 cases. There are no counter-intuitive movements or altered visibility/surgical perspectives which are two of the things inherent in video-assisted thoracoscopy. He attributes both of these issues with the failure of more wide-spread adoption of VATS despite the availability of this technology for over twenty years. According to Dr. Dylewski, less than 30% of all thoracic procedures in North America are currently done using VATS.

Simply put, even some of the best thoracic surgeons may have trouble adapting to VATS techniques and as many as 20% will never fully adjust to video-assisted surgical techniques.

However, in his experience, robotic-assisted thoracic surgery such as complete portal robotic lobectomy ( aka CRPL-3 or CRPL-4, depending on the number of arms used) has a greater potential for widespread use. He explains that despite the initial hefty price tag, the robotic technology easily justifies its equipment costs, in terms of subsequent savings and benefits from decreasing the length of stay, less patient discomfort and greater patient satisfaction. He reports that these benefits have led to the adoption of robotic surgery as the standard of care in other specialties such as gynaecology despite the relative newness of this technology.

Dr. Dykewski also presented data regarding surgical outcomes from 355 cases, which includes a wide variety of thoracic procedures such as lobectomies, esophagectomies and mediastinal surgeries. Surgical outcomes were comparable to VATS procedures with a markedly shorter length of stay.

Dr. Mark Dylewski, MD

Thoracic Surgeon

Director of General Thoracic & Robotic Surgery

Baptist Health of South Florida

Miami, Florida

OR live with Dr. Dylewski

Spanish news story about Dr. Dylewski on YouTube

Selected publications

Dylewski MR, Ohaeto AC, Pereira JF. (2011). Pulmonary resection using a total endoscopic robotic video-assisted approach. Semin Thorac Cardiovasc Surg. 2011 Spring;23(1):36-42.

Ninan M, Dylewski MR. (2010). Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg. 2010 Aug;38(2):231-2. Epub 2010 Mar

Additional References and Resources

Meyer M, Gharagozloo F, Tempesta B, Margolis M, Strother E, Christenson D. (2012). The learning curve of robotic lobectomy. Int J MId Robot. 2012 Sep 18. doi: 10.1002/rcs.1455. The authors of this publication report that it takes 18 – 20 complete portal robotic lobectomies to obtain competency.

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.

Talking with William Serpa about the da Vinci robot

a sit down interview with William Serpa of Intuitive Surgical to discuss RATS (robot-assisted thoracic surgery) with the da Vinci robot.

As we look towards the future of thoracic surgery, at emerging technologies and procedures – one technology stands apart from the rest: robot-assisted surgery. Love it or hate it – all thoracic surgeons have heard of it. So you can imagine my excitement this week when I had the opportunity to sit down and talk to one of the representatives of Intuitive Surgical, the makers of the best-known robotic surgery device, the da Vinci robot.

William ‘Al’ Serpa sat down with me to discuss robotic technology and the growing use of robotic technology in thoracic surgery. While the da Vinci robot is used fairly frequently in urological and gynecological surgery, it is just now making inroads into other specialties. The robot, which costs in excess of one million dollars, is more than a financial investment; it is an investment into the future of modern surgery – and Intuitive Surgical understands this. The company maintains a long term mentoring relationship with surgeons trained on the da Vinci, and they take the training process seriously.

Interested surgeons of facilities with da Vinci equipment participate in multiple in-services, high-level on-site observations, and on-line training modules prior to beginning actual training on the robot in a 1 to 2 day skills lab. After completing this initial training, surgeons are mentored through several cases, increasing in complexity as they become more familiar with the robot.

Mr. Serpa reports that most surgeons demonstrate surgical proficiency with the da Vinci system after completing about twenty cases. This is also the minimal volume of annual cases required to be listed on the da Vinci website as a specialty provider.

Mr. Serpa and I discussed the perceptions that many physicians have of the difficulty of the learning curve for robotic surgery. We discussed multiple published reports that robotic surgery lengthens case times, and the realities behind robotic surgery. “Actually, after surgeons become familiar with using the robot, it doesn’t take more than a moment to re-position it.” That’s sounds similar to what several previous surgeons [using the robot] have reported – so I guess the only way to find it is to see for myself.

Hopefully, my next post about the da Vinci robot will come to you from the OR.

Additional References

Giulianotti PC, Buchs NC, Caravaglios G, Bianco FM. Robot-assisted lung resection: outcomes and technical details. Interact Cardiovasc Thorac Surg. 2010 Oct;11(4):388-92.

Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg. 2010 Aug;38(2):231-2.

Kajiwara N, Kakihana M, Usuda J, Uchida O, Ohira T, Kawate N, Ikeda N. Training in robotic surgery using the da Vinci® surgical system for left pneumonectomy and lymph node dissection in an animal model. Ann Thorac Cardiovasc Surg. 2011 Oct 25;17(5):446-53.

Palep JH. Robotic assisted minimally invasive surgery. J Minim Access Surg. 2009 Jan;5(1):1-7. Indian article – gives nice overview of robotic surgery.

Bodner J, Augustin F, Wykypiel H, Fish J, Muehlmann G, Wetscher G, Schmid T. The da Vinci robotic system for general surgical applications: a critical interim appraisal. Swiss Med Wkly. 2005 Nov 19;135(45-46):674-8.

Obasi PC, Hebra A, Varela JC. Excision of esophageal duplication cysts with robotic-assisted thoracoscopic surgery. JSLS. 2011 Apr-Jun;15(2):244-7.

Schmid T, Augustin F, Kainz G, Pratschke J, Bodner J. Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy. Ann Thorac Surg. 2011 Jun;91(6):1961-5.

Melfi FM, Viti A, Davini F, Mussi A. Robot-assisted resection of pulmonary sequestrations. Eur J Cardiothorac Surg. 2011 Oct;40(4):1025-6.

Spaggiari L, Galetta D. Pneumonectomy for lung cancer: a further step in minimally invasive surgery. Ann Thorac Surg. 2011 Mar;91(3):e45-7. Case reports of two pneumonectomies with the daVinci robot.

Kajiwara N, Kakihana M, Kawate N, Ikeda N. Appropriate set-up of the da Vinci Surgical System in relation to the location of anterior and middle mediastinal tumors. Interact Cardiovasc Thorac Surg. 2011 Feb;12(2):112-6. [this article has been cited in previous articles on the da Vinci robot.

Augustin F, Bodner J, Wykypiel H, Schwinghammer C, Schmid T. Initial experience with robotic lung lobectomy: report of two different approaches. Surg Endosc. 2011 Jan;25(1):108-13.

Al-Mufarrej F, Margolis M, Tempesta B, Strother E, Najam F, Gharagozloo F. From Jacobeaus to the da Vinci: thoracoscopic applications of the robot. Surg Laparosc Endosc Percutan Tech. 2010 Feb;20(1):1-9. Review.

Campos JH. An update on robotic thoracic surgery and anesthesia. Curr Opin Anaesthesiol. 2010 Feb;23(1):1-6. Review.

In-press:

Kajiwara N, Taira M, Yoshida K, Hagiwara M, Kakihana M, Usuda J, Uchida O, Ohira T, Kawate N, Ikeda N. Early experience using the da Vinci Surgical System for the treatment of mediastinal tumors. Gen Thorac Cardiovasc Surg. 2011 Oct;59(10):693-8. doi: 10.1007/s11748-010-0790-9.

History of Robotic Surgery – link to website

More about robotic surgery and the da Vinci surgical system

History of Intuitive Surgical and the da Vinci robot

Jupiter Medical Center: Q & A with Dr. K. Adam Lee

More robotic surgery as we talk with Dr. K. Adam Lee, the new director of thoracic surgery at Jupiter Medical Center in Jupiter, Florida.

Dr. K. Adam Lee, a thoracic surgeon with extensive experience in robotic surgery was recently selected as the Medical Director of the new thoracic surgery center at Jupiter Medical Center in Jupiter, Florida. (Jupiter, Florida is a oceanside community close to West Palm Beach, located between Orlando and Miami.)

Prior to coming to Jupiter, Dr. Lee was most recently at the Kennedy Health System in New Jersey.

Dr. Lee is well-known for his expertise in thoracic robotic surgery and has trained surgeons in using the DaVinci robot, in live demonstrations, conferences and educational sessions. Currently, Dr. Lee is working with three other thoracic surgeons.

After reading about Dr. Lee, I contacted him (by email) to ask about his plans for the future.

Q & A with Dr. K. Adam Lee

CdeT: There is quite a bit of interest in robotic surgery right now. Would you please tell us more about some of the robotic surgery procedures you are performing, and why these procedures are becoming popular?

Dr. Lee: [In our program, we are currently performing several different robotic procedures including]:

Robotic lobectomy for lung cancer. Lobectomy, or the surgical removal of a cancerous lobe in the lung, is the standard treatment of early-stage non small-cell lung cancer. Until recently, this procedure required a large incision that could cause the patient significant pain and a long recovery period

Segmentectomy- especially for pulmonary compromised patients, Wedge resections

Robotic thymectomy for myasthenia gravis/ Thymomas. The removal of the thymus gland is often a recommended treatment for patients who have myasthenia gravis, which is a neuromuscular disorder that can cause muscle weakness. Traditional surgery involves a large, length-wise incision along the breastbone, similar to that used for open-heart surgery.

Mediastinal biopsies and resections

Robotic resection of mediastinal masses. The mediastinum is the portion of the chest cavity between the lungs. When tumors or other masses grow in the mediastinum—such as thymoma or lymphoma—surgeons can remove the masses robotically through small incisions instead of the large incisions required with traditional open surgery.

Anterior:
Lymph nodes ie-lymphoma, metastatic lesions

Posterior:
Neurogenic tumors i.e Schwannomas.

Esophagus

Esophagectomy

Esophogeal myotomy for achalasia. Achalasia is a disorder that affects the ability of the esophagus to move food toward the stomach. Left untreated, achalasia can result in the widening of the esophagus to the point at which it begins to function as a reservoir instead of a conduit. That can lead to infection, obstruction and even the development of esophageal cancer.
Surgeons can correct this condition using a procedure called myotomy, in which the esophageal muscle is cut and repositioned.

Robotic laparoscopic Belsey fundoplasty for gastroesophageal reflux disease (GERD). The most common disease in humans, GERD affects nearly 20 percent of Americans. Nearly everyone experiences GERD from time to time, but it can lead to injury of the esophagus and upper digestive track, as well as esophageal cancer, if it is experienced on an ongoing basis. Belsey fundoplasty is a minimally invasive surgical technique that can correct problems with the esophagus that lead to GERD.

Thoracic Sympathectomy: Palmar Hyperhidrosis [this is a condition for excessive sweating of the palms.]

CdeT:. Will you be performing esophagectomies?

Dr. Lee: We will be adding minimal invasive esophageal surgery via Video Assisted and Robotic assisted thoracoscopic
procedures.

CdeT: Do you currently perform any single port surgeries?

Dr. Lee: We will review which cases would benefit from the single port exposure. Most probable are the mediastinal biopsy and resection cases.

CdeT: How many years have you been operating/ performing robotic surgery?

Dr. Lee: I have been performing robotic thoracic surgery since 2003.

CdeT: What is your average annual case volume and what
percentage of procedures are you performing using the robot?

Dr. Lee: We perform greater than 90% of all our thoracic surery cases utilizing the minimal invasive approach (VATS& RATS). We plan all of our pulmonary lobectomies for early stage Non Small Cell Lung cancers to be performed utilizing the four arm robotic lobectomy, a total endoscopic approach.

CdeT: Do you have a mesothelioma or any other specialty
clinics are part of your program?

Dr. Lee: Yes, we cover the entire spectrum of the thoracic disease process as well as participating in research trials. One of our sub specialty clinics is the emphasis on minimal invasive thoracic surgery.

CdeT: Where do you think the future of thoracic surgery is
heading?

Dr. Lee: I see the future continuing to progress in minimal invasive surgery. Currently a little over 20% across the country utilize MIS. This number will increase over the next 5 years and beyond as the result of MIS continues to show as good and better results as compared to the standard thoracotomy approach. Secondly, early detection methods will improve so as to find the cancers at earlier stages and hopefully shift the survival curves.

CdeT: What do you plan for the future of your program?

Dr. Lee: To be a comprehensive program with emphasis on early detection and minimal invasive surgery, utilizing trials and protocols for the most difficult of cases.

Dr. K. Adam Lee, MD

Thoracic Surgeon/ Medical Director of Thoracic Surgery & Lung Center

Jupiter Medical Center

1240 S. Old Dixie Highway

Jupiter, Florida 33458

http://www.jupitermed.com/lung

tele: 561 – 263 – 3604

Update: Dr. Lee’s most recent face to face interview.