Da Vinci - 100 surgeries

DA VINCI, THE ROBOT, REACHES 100 SURGERIES The British Hospital Robot has operated patients of many Institutions, most of them because of cancer.   “El País” witnessed a surgery performed in the British Hospital by Robot Da Vinci. A tumor was removed from a woman´s kidney without having to remove the complete organ, something that the medical staff would have had to do in a conventional surgery. In September Da Vinci reached 100 surgeries in patients of the British Hospital and private insurances, but also in mutualisms’ members and in Militar Hospital patients. Most surgeries were of prostate cancer, but there were also gynecological and thoracic surgeries. The surgical block´s door opens to get in there and what anyone can expect in a surgery can be seen. Six or seven people with masks and cloth caps are moving from side to side. When looking at the stretcher something turns out different. Robot Da Vinci was acquired by the British Hospital in 2011 and was subject of great controversy with the Ministry of Public Health which did not allow its use under the argument that it was only for private Institutions. After months of negotiations the team began to work. In September, the Hospital completed the first 100 surgeries to British Hospital and private insurance Institutions affiliates but also to members of mutualisms such as Casmu and patients of the Militar Hospital. After a Tumor. Who lays asleep and ready for the intervention is a woman in her sixties, she has cancer in one kidney and surgeons plan to remove the tumor without removing the entire kidney, something they would certainly have to do if they did not use the Robot. The heads of the team will be Roberto Puente, an urology Grade 5 professor at the School of Medicine, and Fernando Abarzúa, instructor of the Hospital of Harthford of Connecticut, United States, co-director of the Hospital Robotic Surgery Department with Gustavo Malfatto. Da Vinci won´t move an instrument until one of them sits on “controls”, a structure that works as a videogame. Who performs the surgery controls two devices similar to joysticks which move the Robot´s hands inside the patient and on a screen that projects images in front of his eyes, so the surgeon sees where to go and what to do. If he moves his head away from that sort of console the robot stops. Everything happens inside the person. On her abdomen there are four cylindrical supports of about 15 centimeters high (trocars) that are fixed and were placed thanks to four small incisions. Through there, enters air so there would be room to maneuver inside the patient without tearing any tissue. It is trough these supports that the Da Vinci instruments pass; long and thin rods with two forceps, a kind of scalpel and a camera that carries its own light. None of these four elements is larger than the tip of a pen. “I think this is the tumor”, says one of the surgeons, and on a screen where it is possible to see what he can see there is a lump that can be seen on the pink surface of the kidney. “I doubt that this is the tumor” says the other, and others without any comment listen silently while watching the screen. “It was not there in the scan where we saw it” he adds. The surgeon respects the opinion of his colleague and moves the robot arms to go to another area of the body involved. Minutes later, his colleague withdraws: “Yes, that is the tumor. The image is greatly amplified; undoubtedly this is the tumor”. Removal. It is 11:00 am the surgery began at 9 am and since then they have been going layer by layer of fat with Da Vinci forceps until reaching the indicated area. One forceps was holding a tissue and the other one was burning and melting a yellowish mass. Thereby, deeper and deeper while the third arm was taking away what it was being opened, (a pedal allows the surgeon to change from one to the other arm of the robot). The time has come. It is important to cover the kidney´s artery to avoid blood in the area while the cancer is removed. Otherwise, the bleeding would have been much more. But the cuts, the extraction and the complete suture cannot take more than 30 minutes, because more time without receiving blood could damage the organ function. Before doing so, they delimit with forceps the area trough which they will cut as well as drawing a circle around the tumor. The diameter of that circle will be also the one that they will cut downwards because the tumor is usually a sphere. A forceps presses the artery and they shout at a team member to start taking time. They start cutting. The operating theater is in completely silence. All eyes are on the screen and out of the body it can be seen the fixed arms of the robot slowly moving to the abdomen without the slightest sudden movement. “How are we doing?” Fifteen minutes they replied. There´s silence. The tumor is being removed. The surgeon in charge moves it with forceps in order to reach the deepest part, but his colleague warns: “Do not push it, just touch it sides”. Time continuous; they take it out completely. Martin Bertocchi, the assistant surgeon removes an arm of the robot and puts a rod with a needle and a thread. They enter again and begin to sew the kidney which would continue working. They leave the artery and observed. It does not bleed. The blood flows to the kidney and it does not leak from the wound. All went well. It does not operate alone. The surgery lasts one hour and a half more, time in which the tiny instruments of Da Vinci finish suturing and fastening the threads to the tissue. The last key point is to remove the tumor from inside the body. One arm introduces a nylon bag folded over itself. When it gets to the kidney area it opens like a parachute. The arm with forceps takes the tumor and drops it in the bag, which is immediately closed. Around the 1 pm they removed the arm from the Da Vinci, they fold them and move them backwards. They turn the light on and Bertacchi pulls the bag lanyards of one of the supports which are still fixed to the abdomen. The tumor came out of the body. Dr. Puente gives an exclamation and smiles. Task accomplished. What on the screen looked like a tennis ball is not bigger than the pit of a peach. They remove the supports and sew the cuts. In minutes the person will be already awake. The function of the patient´s kidneys will drop a 10%; if they would not have used the robot it would have dropped to 50% and it would have bleeding five more times. This type of surgery also reduces recovery time and complications. Tired, and half an hour before a new operation, the assistant surgeon raises the head and says: “The robot does not operate alone”. And he is right. “It allows us to reach all corners” Fernando Abarzúa, Paraguayan and trained in the United States, is a reference in the use of Robot Da Vinci. In an interview with El Pais he explained that the intervention witnessed is technically called partial nephrectomy of the kidney. ¨Nefros means kidney, “ectomy” is to extract an organ. In this case when a small portion of the kidney is removed is what it is known as “partial nephrectomy”, he mentioned, and he added that internationally it is recommended that an intervention like this should be done through robotic surgery instead of an open surgery (the conventional one). “The big advantage is mainly when there are tumors that are of difficult access. The robot plays a transcendental roll because by having four arms, basically allows to access to all the anatomical sites within the body”, with a good control of the tumor. The specialist also said the fact that they did not remove the kidney completely reduces the risk for the patient of possible new future diseases. “There is clinical and scientific evidence that preserving the kidney avoid co morbid conditions from the cardiac and renal point of view, meaning hypertension, heart and renal failure”. From the operating theater to the classroom of the School of Medicine The team that operates with Robot Da Vinci has its own characteristics. Both the instrumentalist and the assistant surgeon received training to work with a robot. In the same way the anesthetist should take extra precautions and work with highly sophisticated equipment which is appropriated to the characteristics of the intervention. As well as this, in the medical team usually could be found an electrical engineer who monitors that everything works properly; In Uruguay they also have the support from the manufacturing company, they said. All that the robot´s camera captures is recorded by a hard disk drive. Roberto Puente, Grade 5 of Urology, and Gustavo Malfatto, Co Director of the Robotic Surgery Department, emphasize the kindness of the team in what training is concerned, as they can carry the recorded images and exhibit them in class. Among the surgeries done with Da Vinci, most were urological (mainly of prostate cancer), but there were also gynecological, thoracic surgeries, and surgeries of congenital malformations. Working in a console also makes a surgery more comfortable for the surgeon if the intervention is long.