University Health System’s Robotic Surgery Programs

By Donald Finley
Thursday, July 19, 2018
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Physician experts from UT Health San Antonio come together in one place to offer both routine and complex robotic surgeries in a wide range of surgical specialties.

No longer can robotic surgery be described as a fledgling technology. Some robotic procedures have more than two decades of accumulated data regarding outcomes. Surgeons who embrace robotic surgery cite the pinpoint precision that robotic surgery allows, the three-dimensional views of the surgical field and the greater flexibility of the instruments to work on hard-to-reach places in the body.

For patients, “the biggest appeal is that it’s minimally invasive,” says Georgia McCann, MD, Assistant Professor of Obstetrics and Gynecology at UT Health San Antonio, who chairs the Robotic Surgery Committee at University Hospital. “Minimally invasive procedures are associated with less blood loss, less perioperative complications, less risk of infection and faster recovery. It gets people back to work faster.”

And while robotic procedures can be technically challenging, they often are less physically demanding on the surgeon — reducing fatigue over long, complex procedures and even the slightest tremor that fatigue can bring. University Health System established its robotic surgery program in 2011 with the purchase of the da Vinci Si Surgical System. Volumes have grown by 30 to 40 percent each year since then, and in October, the Health System purchased a second device, the da Vinci Xi with dual consoles for training, new instrument arm architecture for better anatomical access, longer instrument shafts and a greater range of motion with smaller arms.


Kent Van Sickle, MD, Chief of the Division of General and Minimally Invasive Surgery at UT Health San Antonio

Ten surgical specialties have been using the devices, including general surgery, colorectal, gynecology, gynecology-oncology, urogynecology, surgical oncology, thoracic, transplant, urology and otolaryngology.

“Adoption of robotics largely came from the surgeons who, once they got in the console and started doing the surgery, just said to themselves, this is better. I can see better, I can dissect better, I control my own camera,” says Kent Van Sickle, MD, Chief of the Division of General and Minimally Invasive Surgery at UT Health San Antonio. “You have higher degrees of freedom and much more range of motion.”

At an academic center such as University Health System, surgeons not only train other surgeons on robotic procedures, they also are pushing the envelope — expanding the kinds of surgeries that might benefit from a robotics approach.

The fact that many surgical specialists work in close proximity is a benefit, Dr. McCann says.

“That’s one of the more unique things about our program. Because we have all of the surgeons in the same place — as opposed to other centers where not everybody operates at the same hospital — it’s not uncommon that three or four surgeons will combine efforts for one complicated case.”

TORS

Among the advanced robotic procedures offered at University Hospital is trans-oral robotic surgery, or TORS. The primary application is to excise malignant oropharyngeal tumors arising from the tonsils or base of tongue. These cancers have been on the rise in younger men due to the human papillomavirus, or HPV, that causes cervical cancer in women.

“The incidence of tonsil and base-of-tongue cancers is increasing in otherwise healthy patients who don’t have the usual risk factors like heavy smoking and drinking,” says Jay Ferrell, MD, Assistant Professor of Otolaryngology-Head and Neck Surgery at UT Health. “We’ve seen a big jump in the rates of these HPV-related cancers over the last several decades.”

In years past, reaching these cancers required a large incision on the face or neck and complex open procedures that often required splitting the jaw and cutting directly into the pharynx. That could lead to complications of speaking and swallowing, requiring a tracheostomy and feeding tube for months or even years. For the past 20 years or so, radiation and chemotherapy have been the treatment of choice.

“In contrast to traditional, smoking-related head and neck cancer, these HPV-related cancers respond very well to treatment, with high cure rates,” Dr. Ferrell says. “However, the drawback is that these patients (with HPV-related cancers) are younger and have much longer to live with the side effects of chemotherapy and radiation therapy, which can be potentially debilitating.”

Those side effects often include severe sore throat, skin changes and wounds, and, in extreme cases, damage to the muscles and nerves for speaking, swallowing and normal tongue movement.

Robotic surgery allows the surgeon to access — and visualize — these hard-to-reach tumors. And by removing them, that can mean reducing the amount of chemotherapy and radiation patients receive afterward.

“It’s not for everyone,” Dr. Ferrell says. “This is not for people who have very large tumors at the back of the throat or large lymph nodes and are going to need a lot of aggressive therapy. But in some of these younger, healthier patients who are caught pretty early with these cancers, it is a reasonable treatment option — and potentially can reduce the amount of radiation and chemotherapy they get.”

Stomach

Dr. Van Sickle and his colleagues use robotics for gastroesophageal reflux disease (GERD), hernia repair, gallbladder surgery and other common procedures. Much less common is a robotic combination therapy for gastroparesis — a disabling condition most often seen in diabetic patients in which the stomach doesn’t empty properly. Another less common procedure they perform is robotic roux-en-Y gastric bypass surgery.

“We’ve been able to combine two surgical therapies for gastroparesis in one procedure, and we’ve found it to be very effective in selected patients,” Dr. Van Sickle says. “One is the implantation of a medical device called a gastric stimulator. It basically interrupts the signal from your stomach to your brain that tells you you’re full and gives you that feeling of bloating and nausea.

“The other procedure is called pyloroplasty. It was widely used for peptic ulcer disease surgery in the 1960s and ’70s. You cut the stomach’s sphincter muscle and suture it back in such a way that it stays open. Between half and two-thirds of our patients see almost a complete resolution of their symptoms.”

As for roux-en-Y bypass, Dr. Van Sickle says the robot addresses the most common complication seen in these patients — leakage at the connection between the pouch created from the stomach and the small intestine.

That connection, if it leaks, is a devastating complication that can be life-threatening, requiring weeks in the hospital, Dr. Van Sickle says. Even high-volume centers can see a leak rate of about 2 percent.

“What has been found is that when you do the bypass robotically, it essentially doesn’t leak. The reason it doesn’t leak is that when you can sew that connection between the pouch and small bowel with the robot, you place every suture within 1/10th of a millimeter where you want it, cinch it down tight as air, and you can put multiple stitches in.”

Liver

The Texas Liver Tumor Center is an offshoot of University Transplant Center, a partnership between University Health System and UT Health San Antonio. Two of its liver surgeons, Danielle Fritze, MD, Assistant Clinical Professor of Surgery, and Tarunjeet S. Klair, MD, Assistant Professor of Surgery at UT Health San Antonio, have been doing liver resections robotically.

The robot is especially useful in patients whose cancer would be hard to excise laparoscopically because of its location.

“I think the key as I see it is the potential to expand the minimally invasive approaches to operations and patients who otherwise wouldn’t have been candidates for a minimally invasive approach, and to be able to do the operations with the same high-quality oncologic outcomes just through smaller incisions and shorter recovery,” Dr. Fritze says.


Kent Van Sickle, MD, Chief of the Division of General and Minimally Invasive Surgery at UT Health San Antonio

Obesity and diabetes are common denominators in many of the conditions the surgeons treat. Dr. McCann says the majority of robotic cases she performs are for endometrial cancer, which is associated with obesity.

“Most of the patients we operate on are obese and have multiple medical comorbidities that put them at high risk for postoperative complications,” Dr. McCann says. “The robot allows us to do these complicated surgeries on very sick people and gets them back on their feet faster.

“Traditionally we were doing traditional surgeries on these women with midline laparotomies,” says Dr. McCann, who added that readmission rates are significantly higher with that procedure. “That’s associated with higher costs, decreased quality of life and a lower chance of starting any adjuvant therapy they might need on time. Robotic surgery almost eliminates all those complications.”

University Health System recently obtained a new AirSeal system for performing minimally invasive surgeries, which uses lower pressure to insufflate the abdomen. That helps the patient breathe better during surgery and has been associated with lower postoperative pain. It is especially helpful with obese patients, Dr. McCann says.

The surgeons continue to expand the usefulness of robotic surgery. Dr. Van Sickle says his team has begun doing abdominal wall reconstruction robotically, peeling layers of the abdominal wall and putting in mesh using tiny incisions.

“I think the unique thing about our program is our ability to do complex cases — whether it’s complex pelvic surgery or complex upper abdominal surgery,” Dr. McCann says. “In the community practice, more of the complex patients will get referred to an academic center. That’s where we fall, in being able to do those complicated cases here minimally invasively.”


For more information about University Health System’s robotic surgery programs, contact Steve Soliz at 210-643-4441 or email steve.soliz@uhs-sa.com.