As the surgical instruments probe and snip their way through the spider web of tissue, urology surgeon, Maj. Tara Ortiz, is huddled on a stool, remotely controlling the operative action via joysticks and high-definition visuals.
Behind her is her patient, who is on the operating table to remove a kidney tumor. A few years ago, Dr. Ortiz's surgical hands would have been probing and dissecting the diseased body organ. Today, thanks to technology, that human action is delegated to the robotic arms hovering above her patient.
Say 'hello' to da Vinci, Carl R. Darnall Army Medical Center's robotic-assisted surgical system where humans direct the motion, but the robot performs the action.
"Robotic surgery is fascinating," said Ortiz, orchestrating the operative action with surgical precision. "It really is such an amazing advance for us as surgeons because it helps us see anatomy in greater detail and gives us access to places in the body that were previously very challenging to reach."
Better outcomes, quicker recovery
First approved for use in 2000 as a replacement for laparoscopic procedures, robotic systems like da Vinci have made the technical aspects of minimally invasive surgery easier, as well as less demanding both physically and mentally. Those key attributes have extended robotic-assisted procedures to numerous parts of the anatomy and range from hysterectomies and gall bladder removal to coronary artery bypasses.
"Think about asking someone to walk continuously with their arms straight out, trying to manipulate everything in the world like that," Ortiz said of the robot's ability to move 360 degrees. "The range of motion is far greater in a robotic-assisted surgery than an open-cavity one because the robot's arms can bend, turn and twist, unlike human wrists."
That flexibility is key in complex surgeries like removing the prostrate.
"Before the robot, a laparoscopic prostatectomy was rarely offered because it was tough on both the patient and the surgeon," said Dr. Hsiang Chi (Cathy) McLaughlin, a former military urologist who is now serving CRDAMC in a civilian role. "The patient would be tilted almost upside down for eight hours or more. It also was challenging because it was difficult to get into the pelvis with the long instruments that were needed to do that surgery."
The da Vinci technology also leads to better outcomes, according to Ortiz, a former medic turned surgeon, who marvels at the surgical advances of modern medicine.
"There is less bleeding, less body trauma and shorter hospital stays," the chief of urology said, comparing robotic-assisted surgery to open-cavity operations.
The da Vinci system's components include the surgeon's console, a high-definition vision system, the patient side cart and the robotic arms.
The patient first is positioned on a special operating table. Ortiz and her assistant, Dr. McLaughlin, will then work in unison preparing the patient for surgery by inserting four, pencil-thin metal rods into the patient's body cavity. At the tip of the internal rods are surgical tools for dissecting and suturing such as a scalpels, forceps and spreaders that robotic-certified surgeons like Ortiz remotely control. The detachable rods are then inserted into the robot's arms, which simulate the surgeon's wrist actions.
"Unlike open-cavity procedures where incisions could be several inches long, scarring is minimal with the da Vinci system," Ortiz said, adding that the quarter-inch incisions are just enough to insert the surgical instruments.
High-definition visuals, intuitive controls
Microscopic cameras mounted on the tip of the rods provide the surgeon with real-time, high-definition images of the patient's anatomy. The surgical console's 3D stereoscopic viewfinder displays the images, as well as the actions of the instruments under the surgeon's command.
"The images allow us to get closer to the surgical site than we would ever be able to do in open-cavity surgery, as well as gives us more flexibility and control," said Ortiz, who first observed a robotic surgery procedure during her residency at Duke University Medical Center. "It was amazing to see those 3D images for the first time. The magnification is just so much better than what the human eye can see."
At waist level is an intuitive, computerized instrument panel adorned with buttons and joysticks that mimic Ortiz's hand and wrist motions. The movements are electronically transmitted to the robotic arms into real-time, micro-movements. Using touch pads and controls, Dr. Ortiz can magnify the images via the high-definition viewfinder, as well as monitor the actions of the instruments under her command.
The console's foot pedals also provide Ortiz with a third set of tools, allowing her to zoom in, snip and switch between instruments.
While Ortiz's eyes are in the viewfinder exploring the operative field, Dr. McLaughlin is standing patient side, suctioning and clipping any bleeding blood vessels. The equipment McLaughlin uses also is part of the robotic system, which requires her to be alert to not only the operative field, but also the quirky movements of the robotic arms to avoid being hit.
Dr. McLaughlin, who also was introduced to robotic surgery halfway through medical school, said the robot is an asset during suturing because of its range of motion.
"Anytime there's delicate, technical sewing, you have an advantage over hand-stitching with the robot because of its range of motion," McLaughlin said.
Reduces surgeon fatigue
One bonus robotic surgeries have over open-cavity operations is less surgeon fatigue.
"Robotic surgery allows you to sit in a natural and relaxed position while working in some tough areas to reach, since it also provides a good image of the anatomy. You don't have to stand with your neck tilted to the side with a heavy headlamp on for three hours while trying to see something that is two feet away from you down in the pelvis," Ortiz said, adding that another big plus in robotics is eliminating any natural hand tremors.
After months of training, Ortiz performed her first robotic case during her second year of residency at Duke.
"It was a robotic prostatectomy (removing a prostrate)," she said, admitting she was both nervous and excited. "You begin slowly with trepidation, kind of like riding a bike. Sure, there're times that you're unsure if you're doing the right thing or moving the tissue in the right way, but experience gives you that confidence."
One of Ortiz's favorite surgeries is a robotic pyeloplasty, which is removing a blockage where the kidney and ureter meet.
"It's such an enjoyable case because it drastically improves your patient's quality of life," said Ortiz, who decided to pursue a medical career while tending to surgical patients in a small combat hospital on the battlefields of Afghanistan. "I enjoyed having a direct and immediate impact on patients, and that's why I chose to be a surgeon."
Regardless of procedure, Ortiz continues to be amazed with the enabling marvels of modern medicine that continue to expand operating room possibilities. Being a surgeon on that journey both excites and nourishes the California native's inquisitive soul.
"The human body is so impressive," she said. "There're so many intricate parts that have to work together synergistically. It's really a wonder that we each get up every day and go about our lives without awareness of the organic machinery that drives us. It also is fascinating that every one of our cells has a unique DNA blueprint with specific instructions about how to make our bodies function."