Minimally Invasive Surgery using a Robot

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Minimally Invasive Surgery using a Robot




Guest:  Dr. Andre Hebra - Surgery

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m interviewing Dr. Andre Hebra who is Professor of Pediatrics and Surgery here at the Medical University of South Carolina and Director of Pediatric Surgery as well.  Dr. Hebra, you’re one of the pioneers in the use of minimally invasive surgery for children and, in particular, in the use of the robot.  I understand we’re getting a robot here, at MUSC.  When do you anticipate that?


Dr. Andre Hebra:  We hope to have the robot by January or February of 2008.


Dr. Linda Austin:  Now, why is that important?


Dr. Andre Hebra:  Well, two factors.  Number one, of course, for selfish reasons, we like to have the robot available for minimally invasive pediatric surgery.  But, number two, the most important reason in a medical center like MUSC in which you have so many different surgical specialists that do very advanced minimal access surgery, the robot is an essential tool for surgeons that are involved in that field.  So, it would be applicable to many different fields, such as gynecology, urology, general surgery, and so forth.


Dr. Linda Austin:  I was fortunate enough to take my mother for a robotic procedure and I have to say that when I first heard of the robot, I kind of imagined R2-D2 or

C-3PO and was interested in seeing how it really works.  Can you paint a verbal picture of how the robot works and how it helps a surgeon to do a better job?


Dr. Andre Hebra:  That’s a great question because most people, and especially the children, when we talk about robotic surgery, that’s exactly what they envision, some R2-D2 that will come and put the surgeon to the side and take over and do the operation.  Fortunately, that’s not what happens. 


The robot, believe it or not, is a tool that is larger than R2-D2, at least three or four times the size of that.  It has two components to it.  One is comprised of the mechanical arms that are controlled by a pretty fancy computer system.  The modern robotic version has a total of four arms, so it allows the surgeon, who, obviously, has two arms, to, all of a sudden, have four arms.  You have total control of four arms.  And the surgeon will sit at a separate console, so that’s the second part of the robot, the surgical console.  The console can be in the same room.  It could be in the room next door, or it could be 1000 miles away.  I could do surgery here in South Carolina on somebody who has the robotic arms in California. 


The system communicates by high speed connections and has a very complex computerized system.  But, again, the part that would be attached to the patient is essentially a fairly large robotic system with four arms.  It’s about the size of a large refrigerator. 


Dr. Linda Austin:  And, as I recall seeing it, the four arms, then, look almost like, sort of, gigantic chopsticks that go through tiny incisions.  Can you describe, physically, what they look like?


Dr. Andre Hebra:  That’s correct.  The arms will then connect to instruments.  The instruments themselves have different sizes.  They range from 5-10 mm in size.  So, that’s pretty small.  That’s less than an inch in diameter for the instruments, and those are the instruments that will go inside the patient’s body.  They go inside the patient’s body through small chokers.  Chokers are like small cannulas that we place, for instance, if you’re doing an abdominal operation, you put those chokers in the abdomen.  It also allows you to place a camera so you can see, through the robotic system, the inside of the body, and you work through the robotic arms with very small instruments that go inside the body. 


So, although the robot itself is a massive piece of equipment, when you come down to the part that is performing the surgery, together with a surgeon, there are miniature instruments that give the surgeon, what we call, wristed motion, meaning, it allows a surgeon to mimic the movement of the human hand which, in normal laparoscopic surgery without the robot, is very difficult to do because you’re working in a two-dimensional plane.  You know, you can move side to side or up and down and open and close.  With a robotic system, now you have the movement of your free hand.  You can turn it around, flip it, flex it, and change the amount of force you apply.  It’s pretty fascinating to see how much the robot gives you in terms of degrees of freedom.


Dr. Linda Austin:  The surgeon who is actually controlling this, how, exactly, is he/she doing that?


Dr. Andre Hebra:  Once you’re sitting at the console, you look through a digital screen that is binocular.  So, the surgeon who is looking inside the console actually has a 3D view.  So, when you’re looking through that console, you can see inside the patient’s body is as if you were standing inside the patient’s chest or abdomen.  You can see everything as you would with your normal eyes in three dimensions, which is a tremendous plus.  With conventional laparoscopy, you see everything in a two-dimensional plane.  With robotic surgery, now, all of a sudden, you have three dimensions which is a great plus to facilitate performing complex tasks.  So, the robot, really, is a tool of minimally invasive surgery that is utilized for more complex operations that would be very difficult to do with, what we call, conventional laparoscopic or arthroscopic surgery.  


Dr. Linda Austin:  When a surgeon is learning this technique, what are some of the hardest things about it to learn?


Dr. Andre Hebra:  Well, number one is transitioning from the image that you become accustomed to, which is two-dimensional, looking at a TV screen, to a three-dimensional world.  Although we look at three dimensions all the time, as surgeons, you get accustomed to working in the two-dimensional world.  You have to transition back to your normal three-dimensional world within the patient’s body cavity. 


Number two is learning the movements of the wristed instruments.  The way you control the robotic arms and the robotic movements is by putting the tip of your fingers in small controllers and then, by moving your fingers, you generate the movement in this robotic arm that is far away from you.  So, you, like I said, you might be in a different room.  You may not even be in the same room where the patient is.  So, that takes a little bit of learning.


The third component is the way you communicate with your assistant.  Typically, your assistant is across the table from you in the operating room and you’re working together.  Now, here, you’ll be working together with your assistant but, again, he or she will be at the table and, maybe, in a different room, or several miles away from you.  So, you have to talk through microphones and listen through speakers and that’s a little bit odd when you start doing that, but you get you accustomed pretty fast.


Dr. Linda Austin:  Now, I’ve heard you and, certainly, others talk about doing robotic procedures thousands of miles away.  In fact, is that going on, in the world, now?


Dr. Andre Hebra:  It is in more of an experimental model.  The military had a great interest in developing that further so they could help soldiers that are out in the field, in Iraq, and injured.  But, it’s really only done for experimental purposes at this time.  It’s not done routinely.


Dr. Linda Austin:  What are some of the surgical procedures that you’ll be using the robot for here at MUSC?


Dr. Andre Hebra:  A good example, in pediatric surgery, is, for instance, the management of children that have anorectal malformations, such as Hirschsprung's disease or high imperforate anus.  These infants, they’re little babies, are born with a congenital anomaly in which they have difficulty having bowel movements, or they don’t even have an anal canal. 


With the robotic technique, you can operate on a baby that’s only a few weeks old.  You can put those small chokers in the baby’s tummy and then put the tiny 5 mm, or 8 mm, instruments inside and perform, for instance, a resection of part of the large intestine and rectum and reconstruct the anal canal using robotic technique.  Again, that can be done using conventional laparoscopy or open surgery.  But, by using the robotic technology, it allows you to accomplish, what we consider, a fairly complex task in a very easy manner.  And, in theory, it will improve your long-term outcomes because, technically speaking, the surgeon becomes better, you know, the way you can control your instruments, suture, and manipulate the tissues.  Your visualization inside, for instance, the baby’s pelvis, which is very tiny, is greatly magnified and is all in 3D.  So, you can see pelvic nerves that you could never see before.  You can see tissue planes that you could never see before.  So, it really gives you an edge on being able to perform, what we consider, a better operation. 


Dr. Linda Austin:  Do you envision that, one day, this will be done to operate on fetuses in utero, during pregnancy, or is that already done?


Dr. Andre Hebra:  The robotic technique has not been employed yet for that purpose.  There have been laparoscopic and minimally invasive surgeries performed in fetuses, but not, specifically, using the robot.  It might be possible if we can develop more miniature instruments.  One of the big limitations has been making those instruments small enough to allow for working in very small patients or very delicate tissues. 


One of the great applications, for example, is that you can now perform fairly radical resections of the prostate with preservation of pelvic nerves and much better outcomes for adult patients than ever before, to the point that radical prostatectomy using robotic surgery is now becoming, quickly, the gold standard.


In a very similar fashion, like 20 years ago, when laparoscopic surgery and laparoscopic cholecystectomy was introduced, within one to two years, laparoscopic cholecystectomy, removal of the gall bladder, became the gold standard because it was clearly a better way of doing it.  With prostatectomy, what we see now is that the operation using the robotic technology is so much better than any other technique that has been developed that pretty soon, in another year or two, it will become one of the new gold standards.


Dr. Linda Austin:  Dr. Hebra, thanks so much for talking with us today.


Dr. Andre Hebra:  Thank you.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.


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