By Michelle Dorey Forestell, Local Journalism Initiative Reporter, Kingstonist.com
October 8, 2024
A robot has given Kingston Health Sciences Centre (KHSC) advantages only dreamed of a mere five years ago. And the KHSC team would love to give it a pal.
KHSC’s A. Britton Smith Q.C. Robotics Program was officially launched in November 2018 after a generous donation by Arthur Britton “Brit” Smith allowed the purchase of a surgical robot system. In that first year, just over 20 robotic-assisted surgeries occurred for certain prostate, rectal, and general surgeries, with a plan to expand offerings for patients for whom this was the best surgical approach.
Now, colorectal surgeon Dr. Sunil Patel says they have done “about 150” similar surgeries over the past 12 months and, “I think we’re seeing our trajectory go to probably about 180 next year, which is up from we started with a goal of performing 70 to 80 cancer surgeries a year.”
Essentially, the team have done double the number of surgeries they’d hoped to achieve as their original goal. Additionally, KHSC became the Canadian leader in robotic surgery for rectal cancer in 2021.
“We have one of the most comprehensive and largest colorectal programs in the country, ” enthuses Michelle Mackay, Program Operational Director of Perioperative Services. She explains that they have just passed the one-year anniversary of doing cutting-edge thoracic robot-assisted surgeries.
“We also do urology, gynecological, and now thoracics. We’re also one of the most comprehensive programs in the country because of doing those four different services,” she says.
As MacKay leads the way to the surgical bay to introduce the surgeons who work with the robot, she explains that the program is looking at expansion. With a second robot, she says, “Not only could we do more of the same services, but we could look at other services, all based on quality outcomes and value-based care.”
She points out that, each year, using the robotic system saves KHSC nearly $400,000 in decreased (often by more than half) Intensive Care Unit admissions, decreased 90-day hospital readmission rates, decreased emergency department return visits, and even decreases in the length of time people need to stay in the hospital after surgery.
This is further emphasized by a team of enthusiastic surgeons who are proud of their achievements and eager to introduce their robot.
Colorectal surgeons Patel and Dr. Hugh MacDonald have been working with the robot since it arrived at KHSC, and Dr. Ameer Farooq joined the team more recently.
Dr. Patel explains the advantages of robotically assisted surgery.
“The obvious one is for the patient. Historically, the surgery was done ‘open’; it’d be a big incision. Then, some of it could be done laparoscopically, but not all of it because of the depth of the surgery in the pelvis. Some of it had to be done using a combination of laparoscopic and open,” he says.
“We quickly learned the robot was a whole next level of innovation.”
MacDonald adds that, compared to open and laparoscopic surgery, “From the patient’s perspective, they’re going home very early, like, one or two days for some of them. The majority were at home by day four. And historically, about the seven to ten days was the norm (for hospital stays following non-robotically assisted surgeries).”
MacDonald lists the advantages of surgeries employing the innovative technology: “Quick recovery of gut function. Quick recovery of mobility. Quick recovery of being able to tolerate your diet and then transition back to their volume of…”
Patel interrupts, joking, “And probably a quick recovery to pickleball is what they really seem to want to get back to. Most of our patients are in their 60s and 70s, and they seem to really like pickleball.”
Thoracic surgeon Dr. Andrew Giles jumps in, “[Patel] did a cancer operation on a patient. She was discharged day two after surgery and showed up in my clinic on day six, looking totally normal. I was shocked… She was already like eager to get back to pickleball, though. And I booked her for chemo immunotherapy right then and there for her advanced lung cancer and then operated on her a month later. So she went through two robotic operations in the span of 100 days.”
Dr. Patel says, “It’s definitely an advantage to our patients. It’s obvious; they look so different. They return to their lives very, very quickly. The scars are in areas that they don’t mind.”
But the advantage for the surgeons is pretty awesome, too, he says.
“For us, it saves us our necks and our backs. When we’re doing our surgeries ourselves, like we kind of hunch over like this,” Patel says, demonstrating an awkward, hunched-over stance.
“I was getting tennis elbow. I know a lot of our colleagues have back and neck problems just from the kind of chronic mispositioning of your body. Whereas this is, it’s a game changer.”
Giles adds that there are some considerable advantages to his surgeries.
“It has shown a significant decrease in the number of times you have to make that big open incision. So, in the literature, it’s about 10 per cent for [open] operation. It’s about two per cent for robots. So that means of 100 patients: six people are being spared good thoracotomy,” he says, (thoracotomy) referring to a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax.
“But more importantly, I think it’s enabling us to do things that we weren’t previously able to do through other techniques. So, you kind of look at two ends of the spectrum. One is earlier lung cancers, which we’re discovering more and more now,” says Giles, adding that this will only increase in the future, as the team is going to be screening for lung cancer.
Giles explains that he is looking for and removing very small lesions, noting “you don’t want to have to take half or a third of the lung for these things. You also don’t want to offer them a poor cancer operation where [some cancer gets left behind].”
“There’s a more complex procedure called a lobectomy/segmentectomy, which basically looks at the subdivisions of the lung, but this is a highly technical operation, particularly in the lower part [of the lung]; something that I was never taught how to do during my training,” he says.
Giles marvels that only two years ago, he was training at the Mayo Clinic in the US, and even there, “It was considered not to be possible through conventional techniques, but we’re now doing [robotic lobectomy/segmentectomy] routinely in Kingston.”
Farooq agrees, explaining that he is also incredibly proud to be able to offer the most cutting-edge training available. He points out that KHSC has one of the few programs in the country that offers robust robotic training to both residents and fellows. Other hospitals look to KHSC for an example of how to work in robotic surgery training.
“Basically, even within the last few years, we have radically changed a lot of ways that we do operations,” he says.
And the learning isn’t just saved for medical professionals; on the media tour offered by KHSC, this reporter gets to pull up to the console. Nishant Patel from Intuitive Surgical, the company that produces the Da Vinci surgical robot like the Da Vinci Xi at KHSC, is on hand and set up a special mock surgery that even these typists’ hands can tackle.
The robot looks like it belongs in Tony Stark’s basement, looming above the surgical table with four spider-like arms. The room has two consoles, each with a viewfinder, an ergonomic seat, finger controls, and foot pedals for controlling the camera’s movement, along with the robot arms. Dr. Patel demonstrates the finger controls, then, he offers me his seat.
Sitting at the console, the robot responds to human eyes. Dr. Patel says that’s what “wakes it up,” so to speak. Even without glasses, peering down through the lenses is fascinating because everything looks like it is in 3D and crystal clear. Nishant has set up a three-dimensional set of colourful tissues ready for manipulation by the metal instruments at the end of two of the robot’s arms.
Manipulating the robotic arms in real time with index fingers and thumbs in the controls brings the instruments to life at a slight touch. It is a thrill and, as Patel says, there is “absolutely no lag,” even though the robot is about 10 feet away.
McDonald must be seated at the other console because his voice suddenly guides his new “student” through her first surgery.
“So you’re my trainee; I can come in and mark like this,” he says as an ‘X’ appears over one area, “so you don’t cut over here. And if I don’t know what you’re doing, I can clutch the camera so you can’t move it.”
He can adjust the camera’s focus to where he wants it. He can also take over and stop his students’ hands from moving the robotic forceps. The robot tools even correct for any tremor in the surgeon’s hand, he says later, “But don’t worry,” he laughs, “none of us have a tremor.”
The tools look as close and easy to use as a knife and fork working on a tender steak dinner. Poking here and there, then pinching a piece of blue “flesh,” a bit too hard, looks like an error.
“Oops! I broke it,” this reporter exclaims.
There are audible inhalations around the room, and McDonald says reassuringly, “No… no, you didn’t. Everything is fine.” Lesson learned: Don’t joke about breaking something when operating a multi-million-dollar piece of technology.
Picking up a piece of string and attempting to tie it proves futile; it’s not as easy as Anthony Edwards made it look on ER.
It’s only later, looking at the “body” the robot is working inside, a smallish watermelon-sized dome, that I realize just how small the “practice surgery site” was. Amazingly, most of the instruments are about eight millimetres, and the “pieces of string” were around 0.3 millimetres wide.
As fascinating as the robot is, there is something else striking about the surgical bay: the comradery and enthusiasm are palpable.
Dr. Patel explains that they are all a great team and work well together, but even more so, the robot takes a great deal of the stress out of surgery for human surgeons.
“I’m no longer stressed… I think that the environment is much calmer in robotic cases; I know I’m a lot calmer because I can see precisely what I want to see. Everything’s kind of within my control. If the fellow is doing something, I can get more direct [and] specific with my feedback and take over, say ‘it’s not quite how I want it,’ or show them, and then let them do it. So, I just think it’s a much calmer environment,” says Patel.
“The surgical nurses have commented on that, at least in our room.”
How much more comfortable and precise the act of surgery with the robot is hits home when Giles shows a video of a laparoscopic surgery he had performed. It is tense watching the instruments tentatively poke and prod and sometimes tear away bits of tissue to expose blood vessels before he removes a polyp and then staples the vessel shut.
Next, he shows the same surgery with the robot. Instead of stapling the blood vessel, he manipulates his instrument and some thread between two blood vessels and ties one off as though threading a needle with the steadiest hand ever seen. The blood vessels, he notes, are about three millimetres wide.
The reality is that surgery, no matter what kind, always comes with possible risks and concerns. But KHSC has the option to perform life-giving procedures with the steadiest hand, performed by calm and happy surgeons. The idea that robotic surgery not only improves outcomes, but also saves the hospital money that can then be put back into innovative care, is profound.
The team hopes to add a new Da Vinci 5 to their operating rooms, “designed to enable better outcomes, more efficiency, actionable insights, and 10,000x the computing power of their current Da Vinci.” Hopefully, with the generosity of Kingstonians, it can come sooner rather than later, the team expresses.
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More information on KHSC — the local health-care organization that oversees a number of Kingston hospitals, including Kingston General Hospital, Hotel Dieu Hospital, and the