Robotic SURgeRy - Baptist Health South Florida

B est P ractices fr o m t h e e x perts
at t h e C enter f o r R o b o tic S ur g er y
Robotic Surgery
WINTER 2012
Seeing the Light on Robotic Surgery
T
he most common question I get every
day is why robotics? To me, the
answer is very simple.
First, I am able to do more by using wristed
instruments in a comfortable environment that
I control. That leads to improved patient
outcomes—the subject of this issue of the
Robotic Surgery Advantage. If you can do the
same surgery with less blood loss, reduced
hospital stay times, comparable operating
room times and equal or better outcomes, why
not robotics?
When we first started doing laparoscopic
surgery 20 years ago, I thought that everybody
would be doing it in five to 10 years, but the
data today still show the vast majority of cases
are still being done through laparotomy or, even
worse, mini-laparotomy, with no visibility at all.
Therefore, when we first took on robotics I had
no grand delusions that this would be adopted
by all, and I was right.
Understandably, surgeons are more
Ricardo Estape, M.D.
Medical Director
South Miami Hospital’s
Center for Robotic Surgery
comfortable with what they were trained to do,
but why not embrace technology? Every other
profession in the world is taking advantage of
technological advances—why shouldn’t
surgeons use technology to their advantage,
especially since the data show improved
outcomes for all procedures? Change takes
time, but a skilled surgeon can easily become a
skilled robotic surgeon.
The goal of Robotic Surgery Advantage is
to show you that we can all make changes that
not only help ourselves but help our patients. In
this edition, Rolando Molina, M.D., discusses a
very novel approach to accessing
parapharyngeal tumors that has not been
previously reported. Robotics in ENT is a very
Percent Reduction in Length of Stay by Specialty
Using Robotic vs. Non-robotic Surgery
Percentage of Reduction
60%
30%
28%
27%
20%
10%
0%
GYN
GYN Oncology
Thoracic
See the LIght for Yourself
To arrange a case observation or simulator
training, call 786-662-8877.
PAGE 2:
Breakthrough Neck Tumor Removal
Achieved with ROBOTIC SURGERY
38%
36%
Ricardo Estape, M.D.
Medical Director
South Miami Hospital’s Center for Robotic Surgery
this issue
56%
50%
40%
new science, and our physicians are helping to
advance this field. Also in this edition, one of
the country’s most prominent robotic thoracic
surgeons, Mark Dylewski, M.D., discusses his
experience with robotic lobectomy for lung
cancer. Dr. Dylewski teaches his techniques—
ones he has pioneered here at South Miami
Hospital’s Center for Robotic Surgery—
throughout the United States and the world. Advances in surgical technology have
arrived and are making surgery more effective
and efficient. My question is, why would you
continue using a rotary-dial phone, when
smartphones are now mainstream?
Urology
General
PAGE 3:
INCREASING LENGTH OF SURVIVAL WITH
ROBOTIC-ASSISTED THORACIC SURGERY
BACK cover:
TEAM APPROACH CUTS
OPERATING ROOM TURNOVER TIMES
surgical innovations
BREAKTHROUGH: Neck Tumor
Removed Through the Mouth
R
emoving benign tumors from the
parapharyngeal space, the area
lateral to the upper pharynx,
typically involves an incision in the neck.
Surgeons must make their way carefully
through nerves, blood vessels, glands and
bones in an effort to locate and excise
the tumor.
Now, two otolaryngologists at South
Miami Hospital’s Center for Robotic
Surgery—Agustin Arrieta, M.D., and
Rolando Molina, M.D.—have successfully
removed such a tumor through the mouth
instead. The trans-oral robotic resection
of a benign parapharyngeal tumor
demonstrates how the Center’s experts are
pushing the boundaries of robotic surgery,
improving outcomes for an increasing
number of patients.
because surgeons could only see what was
visible through the small space of the
mouth. “The robot’s multi-image cameras
give us a tremendous amount of
visualization, which makes identifying the
tumor and other structures much easier,”
Dr. Arrieta says.
Plus, the angled scope and wristed
instruments of the robot allow surgeons to
easily see and maneuver around
obstructions. “Now we can take out a
tumor with the confidence we’ve got it all
and that we will not injure those very
important key anatomical landmarks,”
Dr. Molina says.
New Frontiers
In a recent case, a 40-year-old male
experienced little discomfort, was
discharged from the hospital after one
night, and has an excellent long-term
prognosis. Though parapharyngeal tumors
are uncommon, Dr. Arrieta and Dr. Molina
say they would perform the procedure
again in a patient with a benign tumor in a
suitable location.
Surgeons at South Miami Hospital’s
Center for Robotic Surgery also use the
trans-oral approach for tumors of the
oropharynx, including those on the base of
the tongue, tonsils and pharynx. And with
this success, robotic surgery may soon be
an option for other head and neck tumors
that typically require more invasive
procedures, including those in the
nasopharynx and maxillary sinus.
“The future is bright and the sky’s
the limit as we take the robot into other
areas where we have yet to venture,”
Dr. Molina says.
Fewer Complications
Approaching parapharyngeal tumors
through the neck in the conventional
manner involves scarring and the risk for
significant morbidity. Surgeons sometimes
must cut the mandible or remove the
salivary glands, which can be disfiguring
and impair swallowing and speech.
The trans-oral approach requires only
one small incision in the mouth and allows
patients to regain full function quickly. “We
also reduce the risk of damaging important
anatomical structures in the neck, such as
cranial nerves, veins and the carotid artery,”
Dr. Arrieta says.
Robotic Innovations
Before the advent of the robot, the transoral approach was much more difficult,
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R o b o t i c S ur g e r y A d v a n t a g e
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Preparing the robot for a surgical procedure.
Robotic-Assisted Thoracic Surgery
Reduces Length of Stay,
Increases Survival
T
horacic surgeon Mark Dylewski,
M.D., of South Miami Hospital’s
Center for Robotic Surgery, is
pioneering robotic-assisted thoracic
surgery that has shown significant
improvements in efficacy, reduced
complications, and overall cost savings for
hospitals using this surgical modality
instead of traditional open surgery.
To date, Dr. Dylewski has analyzed the
perioperative outcomes of 289 patients
(150 females and 139 males) who
underwent lobectomy, bilobectomy,
segmentectomy or pneumonectomy for
non-small cell lung carcinoma (stages 1a,
1b, 2a, 2b, 3a, 3b and 4) between Jan.
2007 and July 2011. This represents the
largest registry of patients who have
undergone robotic surgery for minimally
invasive pulmonary resection.
Drawing on the initial data from the
registry, Dr. Dylewski recently published a
paper in the Spring 2011 edition of
Seminars in Thoracic and Cardiovascular
Surgery entitled “Pulmonary Resection
Using a Total Endoscopic Robotic VideoAssisted Approach,” which documented
the specific benefits, and he is continuing
to build his registry and calculate outcomes.
In Dr. Dylewski’s paper, he notes that
“the robotic dissection of critical structures
is precise, and the added threedimensional, high-definition imaging
makes the procedure inherently more
accurate than with conventional
instruments performed through a utility
incision.” This accuracy, Dr. Dylewski says,
contributes to fewer complications,
improved operating room efficiency and
Direct Cost/Case for Lobectomy
VATS vs. Robotic
$20,000
$18,000
$16,000
$14,000
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
$0
$18,114
$15,363
$10,764
$7,590
Salaries
Robotic
$6,243
$5,790
Cases Numbers
VATS: 31
Robotic:67
$1,561 $1,531
Supplies
ultimately, cost savings for the hospital.
For patients, a robotic approach means
a better chance of survival and fewer
complications. Dr. Dylewski’s data shows
that a zero mortality rate and low inhospital pneumonia rate (3 percent) were
key benefits. Also, improvements over
conventional surgery were seen in rates of
atrial fibrillation (3.1 percent vs. 9.8
percent) and air leaks (4.8 percent vs. 6.7
percent) during the first 30 days after
surgery. Median operative blood loss was
70 ml—and only 4 percent of patients
required conversion to a thoracotomy. A
robotic approach also reduced the length of
stay to three days from four days with a
traditional video-assisted thoracic surgery
(VATS) lobectomy and most patients did
not require time in the ICU.
For the surgical team, the median
operating time is 90 minutes, with a range
of 30 to 280 minutes, and
total operating room time is
175 minutes, according to
Dr. Dylewski’s data.
VATS
Others
Total costs
Dr. Dylewski reports that the safety and
efficacy of robotic thoracic surgery
contributes to significant cost reductions
for the hospital. According to South Miami
Hospital’s registry data, the overall savings
was $2,751 per case for complete port
robotic-assisted lobectomy compared to
VATS. The cost for equipment and supplies
was slightly higher.
Improved outcomes, lower rates
of complications and decreased
length of stay support roboticassisted thoracic surgery as a viable
and preferred method of thoracic
surgery, according to the data Dr.
Dylewski has collected over a fouryear period. As robotic technology
and techniques evolve, Dr. Dylewski
expects robotic-assisted thoracic
surgery to become the standard of
care for lung cancer management.
Call The center for robotic surgery
at 786-662-8877.
CE N TE R FO R R OBOTIC S U R GE R Y : 7 8 6 - 6 6 2 - 8 8 7 7 | S o u t h M i a m i R o b o t i c s . c o m
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South Miami Hospital, Inc.
Center for Robotic Surgery
6200 SW 73 Street
Miami, FL 33143
Non-Profit Org.
U.S. Postage
PAID
South Miami
Hospital Inc
Come to the
Second Annual
Miami Robotics
Symposium
This February in Miami, world-renowned
experts in minimally invasive robotic
surgery will present their approaches to
surgical cases in a multidisciplinary
symposium. If you’d like to learn more,
call the Baptist Health CME
Department, at 786-596-2398 or
email [email protected]
When: February 16–18, 2012
Where: Fontainebleau Hotel
4441 Collins Avenue
Miami Beach, Fla.
800-548-8886
fontainebleau.com
Hosted by: Symposium Director
Ricardo Estape, M.D.
You CAN register at
MiamiRobotics.BaptistHealth.net.
Robotic Surgery
EDITORIAL BOARD
Ricardo Estape, M.D.
Medical Director, Gynecologic Oncology
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25
20
Agustin Arrieta, M.D.
55
Otolaryngology
50
Mark Dylewski, M.D.
Thoracic Surgery 45
40M.D.
Anthony Gonzalez,
General and Bariatric
35Surgery
Rafael Perez, M.D.30
10482M
Team Approach Cuts
Operating Rooms Turnover Times
Improvement in Turnover Times 2009-2011
2009
Gynecology
Otolaryngology
Carmen Rodriguez, R.N.
Assistant Vice President,
Peri-Operative Services
Raul Aued
Robotic Surgical Technician
Robotic Surgery Advantage is published by
South Miami Hospital’s Center for Robotic
Surgery to provide general health information.
It is not intended to provide personal medical
information, which should be obtained
directly from a physician. © 2012.
2010
2011
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25
Darren Bruck, M.D.
20
Urology
Rolando Molina, M.D.
South Miami Hospital was enthusiastic about the idea
and encouraged the team to find more efficiencies.
The team has now initiated an efficiency model
that allows multiple tasks to be executed by staff
simultaneously. “We also look ahead at a surgeon’s case
load and if he has several surgeries scheduled, we
assign an additional nurse and/or tech to the room, so
he can go right into the next room,” says Jolicoeur.
“We have also
designed robotic trays
(pictured at right)
that can be used by
most all specialties,”
says Robles. She adds,
“The hospital was very
generous to provide the
staff with enough
equipment for our team
to make the time
savings happen.”
Reducing turnover times even further will be the
goal of the team and hospital administrators.
Robotic surgery offers numerous benefits over
conventional surgeries, but it requires a highly skilled
team to make sure that all of the advantages are
fully realized.
At South Miami Hospital, Operating Room Nurse
Manager Helene Jolicoeur, R.N., and her team have been
able to reduce turnover times (patient out of room to
patient in room) for robotic cases by an average of
10 minutes per case since 2009 (see chart below).
A little do-it-yourself ingenuity was the key to the
improvement in efficiency. Jolicoeur’s team originally
had to unwrap all surgical supplies and drapes that
covered the robot separately as they prepared for each
case. “In robotic surgery, there are numerous disposable
items that need to be opened in preparation for the
case,” says Jolicoeur. “It was extremely time consuming
and really slowed us down.”
Her team, including Carol Robles, R.N., robotic
coordinator, and Raul Aued, robotic surgical technician,
came up with the idea of creating their own custom
robotic surgery pack that contained most of the items
specific to robotic surgeries. The management team at
50
Minutes
between
surgery in
robotics
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