Robotic Surgery: Surgery of the Future?

1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future Robotic Surgery:Surgery of the Future? David S. Wang, MD Assistant Professor of Urology Boston University School of Medicine May 19, 2006 1:20-2:00pm

2. What is the status of robotic surgery at your hospital? QUESTION: • Not available • Available • Purchase pending • Exploring options 0/0

3. If you were asked the best approach for a radical retropubic prostatectomy, what would you recommend? QUESTION: • Open procedure • Laparoscopic procedure • Robotic procedure 0/0

4. ROBOTIC SURGERY Overview • Introduction to Robotics • Cardiac Applications • Urologic – Robotic prostatectomy • How to build a successful robotics program

5. Goals of Robotics • Expand minimally invasive surgery to new surgical procedures and specialties • Improve the surgeon’s clinical capabilities • Improve patient outcomes

6. Limitations of Traditional Laparoscopic Surgery • 2-D vision, hands and instruments misaligned, hand tremor • Long instruments, hands & wrists outside patient • Fixed instrument tips inside patient • Steep learning curve • Suturing difficulty

7. da Vinci™ Surgical System

8. da Vinci™ Surgical System • Surgical Cart • Surgeon Console • InSite™ Vision System

10. da Vinci™ Surgical System • Surgeon Console • Hand to eye alignment • Natural movements • Ergonomic surgeon position • Camera control by Surgeon

11. da Vinci™ Surgical System • Superior 3-D image • Stereoscopic design with two 3-chip cameras • Better resolution than standard laparoscopy tower 3-D Vision System Open surgery orientation

12. da Vinci™ Surgical System • Surgical Cart • 3 Instrument Arms with multiple joints provide access to entire anatomy • Single unit design • Set-up time 5 to 15 minutes

13. da Vinci™ Surgical System • Eliminates tremor • Enables ambidexterity • Provides motion scaling from 2:1 to 5:1 • Accelerates learning curve

14. da Vinci™ Surgical System EndoWristTM Instruments • Modeled after the human wrist • 6 Degrees of freedom • Natural control without buttons or knobs • Surgical hand movements are transposed to the instrument tips

15. Robotic Endowrist Instruments

17. da Vinci™ Procedures Completed • Radical Prostatectomy • Pyeloplasty • Ureter Reimplant • Donor Nephrectomy • Nephrectomy • Ureterolithotomy • Adrenalectomy • Cystocele Repair • Excision of Renal Cyst • Lymphadenectomy • Varicocelectomy Urology General Cardiac Valve Surgery CABG Nissen Fundoplication Bariatric Surgery Cholecystectomy Hernia Repair Lysis of Adhesions Arteriovenous Fistula Toupet Esophagogastectomy Adrenalectomy Gastric Bypass Colon Resection Pyloroplasty Heller Myotomy Gastroplasty Appendectomy Intra-rectal Surgery Sigmoidectomy Bowel Resection Lumbar Sympathectomy Ventral Hernia Splenectomy Hemicolectomy Gynecology Hysterectomy Radical Hysterectomy Tubal Reanastomosis Myomectomy Lysis of Adhesions Pelvic Floor Reconstruction

18. CARDIAC APPLICATIONS

19. Mitral Valve Repair Introduction • Shorter hospital stay • Less pain and scarring • Less risk of infection • Less blood loss and fewer transfusions • Faster recovery • Quicker return to normal activities

20. Mitral Valve Repair Nifong et. Al, 2005 • 1st Robotic mitral valve in 2000 • US Multicenter trial • 112 patients at 10 centers • Robotic mitral valve repair • Small right mini-thoracotomy • 0 deaths, strokes, device-related complications • Re-operation rate of 5.4%

21. Mitral Valve Repair Chitwood et al 2005 • 100 davinci robotic mitral repairs • 1% mortality • Complication rate low • ? Evolve into standard of care?

22. Mitral Valve Repair

23. Contact Information

24. Mitral Valve Repair

25. Mitral Valve Repair

26. CABG Introduction • Beating Heart • LIMA • LAD

27. ROBOTIC RADICAL PROSTATECTOMY

28. Prostate Cancer Introduction • Most common solid cancer among males • Second most frequent cause of cancer deaths in males • 225,000 new cases per year • 31,500 men died in 2002

29. Prostate Cancer Surgical Treatment Options • Open Radical Prostatectomy • Potential for large blood loss • 25% transfusion rate • 3 to 4 day hospitalization • Difficult visualization of the pelvis • Laparoscopic Radical Prostatectomy • Robotic Prostatectomy

30. SURGERY Anatomy

31. Robotic Assisted Prostatectomy • Benefits of laparoscopic surgery • Improved visualization of anatomy • Ease of knot tying • Excellent anastomosis • Reduced blood loss • ? Improved continence and sexual function

32. Robotic Radical Prostatectomy Who is a candidate? • Localized prostate cancer • Generally good health • No prior pelvic surgery • >10-year life expectancy

33. Robotic Radical Prostatectomy • Confirm diagnosis of prostate cancer (slides reviewed at BMC) • Prostate surgery should be performed at least 6 weeks after biopsy • Medical clearance from primary care physician • Bowel preparation day before surgery Pre-operative Preparation

34. Robotic Radical Prostatectomy Expected Hospital Course • Admitted day of surgery • General anesthesia • Operation generally lasts ~3 hours • Clear liquid diet after surgery • Regular diet day after surgery • Most patients discharged on the day after surgery

35. Robotic Radical Prostatectomy • Home with catheter in bladder • Catheter removed in 10 days • Resume usual activity ~2 weeks • Back to normal 4-6 weeks • Continence >90% Postoperative Course

36. Robotic Radical Prostatectomy Potential Risks of the Procedure • Conversion to open procedure • Injury to surrounding organs • Rectal injury • Incontinence • Erectile Dysfunction

37. Patient Positioning

38. PORTPLACEMENT ROBOT

39. Laparoscopic Robotic Prostatectomy

40. Laparoscopic Robotic Prostatectomy

41. Laparoscopic Robotic Prostatectomy Menon et al. J Urol 2003 • Henry Ford Hospital in Detroit • >350 patients • OR time 160 minutes • EBL 153 cc • 6% positive margin rate • 6 months • 82% age < 60 potent • 96% continent

42. Laparoscopic Robotic Prostatectomy Boston Medical Center • 2 urologic surgeons • One surgeon – extensive laparoscopic experience • One surgeon – extensive open experience • Dedicated OR team • Site visits and training sessions • Due diligence • DaVinci acquired January 2005

43. Laparoscopic Robotic Prostatectomy Boston Medical Center – First 50 cases • First robotic radical prostatectomy in Mass. • Operative time first case – 8 hours • Time to 5 hour proficiency – ~10 cases • Current surgical time – 2.5 to 3.5 hours • Critical review of videotapes – improving upon technique • No conversions to open procedure • 1 case aborted – unrelated to robotics

44. Laparoscopic Robotic Prostatectomy Boston Medical Center – First 35 cases • Blood loss 100 to 200 cc – 1 pt transfused • Complication rate 6% • Majority of patients discharged POD#1 or POD#2 • Positive margin rate – 14% • Early continence >80% • Late continence – too soon to tell • Erectile function – too soon to tell

45. Conclusions Robotic Prostatectomy • Successful establishment of robotics program in Urology at BMC • Learning curve reduced using team approach • Less blood loss • Faster patient recovery • Low complication rate • + margin rate comparable to open surgery • ? Surgery of the future

46. BUILDING A SUCCESSFUL ROBOTICS PROGRAM

47. Building Robotics Program Planning Committee • Prior to purchasing robot • Members • Surgeons (Urology, Cardiac, Gyn, GSurg) • Anesthesiologists • OR Staff • Nurses • Finance Officer • Strategic Planning • Marketing • Biomed/Engineering

48. Building Robotics Program Who will use the robot? • Limit number of surgeons in the beginning • Need to have dedicated physicians who have done due diligence • Limit number of staff who work with robotics

49. Building Robotics Program Site Visits • Intuitive Surgical – visit your hospital to ensure that facility is adequate to accommodate robotic unit • Visit other sites – Robot TEAM to visit robotic site to understand and see robot in action

50. Building Robotics Program After Robot Purchased • Dry lab sessions • Surgeons – comfortable • Staff – comfortable • Familiarity with equipment • Appropriate instruments