EXCITEMENT was an emotion Fr. Ramon Roy Falcunitin least expected as he was wheeled into the operating room in September last year. But that was exactly what he felt, confides this priest from Oriental Mindoro, before general anesthesia took over.
“I realized that I was more excited,” he says now, recalling how amazement at the contraption that would be instrumental in his healing had dispelled any fear or anxiety that had initially coursed through him.
At the center of the operating room, waiting for its first patient, was the “robot” that would “perform” the gastric fundoplication, the procedure needed to address Falcutin’s problem of hiatal hernia and gastro esophageal reflux disease (GERD).
“At first, I was a bit nervous – I guess that’s natural. And then, when I saw the robot – alam mo yun, para kang bata na natutuwa, lalo’t higit robot [you know the feeling, I was like a child, so thrilled by a robot],” he chuckles, lapsing into Tagalog. “It was brand-new – may plastic pa!”
The priest was the first patient scheduled for robotics surgery, a new technology in surgical procedure at the St. Luke’s Medical Center Global City only days after the hospital acquired the latest model of the da Vinci Si Surgical System instrument.
What is it really about men and robots?
“This is really ‘toys for the big boys,’” agrees Fr. Falcunitin’s surgeon, Dr. Narciso Navarro, who well understands the priest’s awe. The doctor heads the Robotics Team of the Minimally Invasive Surgery (MIS) Department of St. Luke’s, and his eyes sparkle playfully when he is referred to as the “robot master.”
But that, only after he has launched into a serious and exhaustive explanation of robotics surgery, as he does each time this option is offered to patients best qualified for this procedure.
The first myth to be shattered, Navarro says, is that it is a robot that will do the surgery. Citing the definition of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), what is referred to as the “robot” is actually “a computer-assisted electromechanical device” that is put in the path between the surgeon and the patient.
“The idea that it is the machine that will perform the procedure is not correct. It is the interphase between the surgeon and patient that is computerized; that’s when the robot comes in. The entire procedure is still under the control of the surgeon,” he clarifies.
Robotics surgery is actually robot-assisted surgery, which replaces the traditional process that has a surgeon or surgical team actually going into a patient’s body with surgical instruments. With this new technology, the surgeon uses a computer console to manipulate instruments attached to the arms of a robot.
The robot has four “arms,” whose ends measure about 5 millimeters (almost 1/20th of an inch) each. These arms are the only instruments that enter the patient’s body. One holds a camera, and the three others handle crucial functions such as cutting, clamping and suturing.
These robot “arms” in effect become extensions of the hands of the surgeon, who mans the controls from a console. During the entire procedure, the surgeon is seated at the console, with his head comfortably positioned to peer into a monitor that presents the entire “scene” captured by the camera.
“You know those movies where there’s a fighter pilot and he doesn’t actually see the enemy yet? But then you hear the sound that tells you he’s locked into the target. Then he fires the missile,” he illustrates. “That’s kind of what it’s like. My thumb and index finger fit into two Velcro straps and through the vision control – which is three-dimensional – what I see is the instrument inside. If I want to touch something, I just reach out and touch it. If I want to suture something, I have an instrument to hold a needle, and with my thumb and index finger, I sew. As I move my fingers, the robot arms move, just as I am moving them in real time. That’s sort of what it’s like – [being] in a video game arcade,” he quips.
Through these finger movements that control the robot arms, the surgeon is able to clamp down or hold out tissues, cut and suture them, stop bleeding and manipulate structures inside the patient’s body. He can even re-position the camera or move it to specific areas for close-up or different angle views.
When one considers that each of these robot arms replaces the actual hand of a surgeon reaching into the patient’s body to perform a specific task, it becomes easy to understand the advantage of robotic surgery to the patient. Instead of being cut open prior to, and then sewn up after, an operation as happens during traditional open surgery, the patient only has to endure about four or five 5 mm holes.
“The advantages are tremendous,” Dr. Navarro says. “It is minimally invasive. It causes less pain, less blood loss and less trauma to the body. And consequently, shorter recovery time.”
In Fr. Falcunitin’s case, the operation started at around 8 a.m. and ended at just past noon. When he awoke from the anesthesia at around 5 p.m., he looked down at his belly area to find five bandaid sized plasters.
What surgery wound would the priest otherwise have had, under the traditional open surgery method? “An inverted L-shaped cut, from the navel up to the chest and sideways,” explains his surgeon.
Robotics surgery is cutting-edge technology, Navarro continues, even way ahead of laparoscopy, which is already an advancement over open surgery. Laparoscopy makes use of a thin lighted tube put through an incision in the body to look at internal organs and surgically deal with certain problems such as cysts, adhesions, fibroids and infections.
“But the robotics system is still way, way ahead. It means a more accurate, precise and really exact way of doing surgery,” says Dr. Navarro.
How precise exactly is indicated by the fact that while a surgeon’s hand—even at the most controlled and ideal situation—vibrates at 100 microns per second (a natural tremor that is non-discernible by the human eye), the robot vibrates at the maximum of 10 microns.
“The Da Vinci system has a tremor control so that even if the surgeon actually has a tremor, the instrument has a way of sensing it and adjusts itself so that there will hardly be any vibration,” the doctor explains. Also, if the system detects that the surgeon at the console has a problem, it will shut off automatically. “The main control is the head of the surgeon at the console. Once he withdraws from the console, the system freezes, until the surgeon gets his head back in or somebody else takes over at the console.”
The system is wired to protect the human patient all the way, Dr. Navarro assures. In presentations on robotics surgery, he likes to quote the “three laws of robotics” from the 1942 short story “Runaround” by Isaac Asimov and John W. Campbell:
1. A robot may not injure a human being or, through inaction, allow a human being to come to harm.
2. A robot must obey any orders given to it by human beings, except where such orders would conflict with the First Law.
3. A robot must protect its own existence as long as such protection does not conflict with the First or Second Law.
But more important than his faith in the “computerized interphase” or the robot that comes between surgeon and patient, Fr. Falcunitin counters, is the patient’s trust in his doctor.
“Dr. Navarro explained my condition and the options available to me,” he recounts. “I came to him with chest pains, terrible heartburn, acid reflux.” The diagnosis was gastro esophageal reflux disease (GERD), meaning his sphincter, the body part connecting esophagus and stomach was relaxed so the contents of the stomach were regurgitated back into his esophagus. He also learned that he had Grade A GERD that, if it advanced to Grade D, could lead to cancer.
“When Dr. Navarro introduced the option of robotics surgery, I was a bit apprehensive because it is a new technology,” the priest admits. But the apprehension was nothing compared to the fear of a condition that would lead to cancer and render him incapable of continuing his work and ministry. At the time, he was already experiencing the negative effects of his illness in the constant pain, feelings of weariness and impatience because of his discomfort.
“I was more fearful of illness than of the robot,” Fr. Falcunitin candidly admits. “And besides, it was never really the robot that operated on me.”
Since St. Luke’s acquired the Da Vinci Si Surgical System robot, more than 20 robotics surgery procedures have already been performed in the hospital.
The primary advantages of robotics surgery are mostly ranged on the patient’s side. The procedure is minimally invasive and therefore less traumatic, with less blood loss. Incisions are very small, thus patient recovery is faster with less risk of infections. All around, the surgical wounds are less painful and healing time is faster.
For doctors, the foremost advantage of a robot-assisted procedure is that the presence of a camera enables the surgeon to get a picture of the surgical field in high definition, three-dimension stereovision which can even be magnified up to 20 times. Compared to standing over or alongside a patient during traditional surgery or laparoscopy, the doctor gets into a position that is comfortable and less tiring during robotics surgery.
The “downside,” as Dr. Navarro calls it, is that surgeons – even the best among them who have had “hundreds of surgeries” of experience – need extensive training for the technology. And constant and continuous retraining in preparation for each procedure – at least that is the way they do it in his department at St. Luke’s Medical Center, he says.
Of course, that “downside” eventually translates to an advantage for the robotics surgery patients who, like Fr. Falcunitin, continue to be amazed and excited at the thought of finding healing, not “under the knife,” but “in the arms” of a robot.
Do You Need a Robot for That Surgery?
The best applications for robotics surgery:
* Head and neck surgery – especially in inaccessible areas, for better aesthetic results and less morbidity
* Cardiac surgery – can achieve what open heart surgery can do; mitral valve replacement
* Lung surgery
* Thoracic surgery – lung resection (lobectomy), esophageal surgery, thymectomy, mediastinal tumors resection
* Gastric surgery – gastrectomy D2 dissection, gastric bypass, hiatal hernia repair, gastric fundoplication, Heller’s myotomy
* Colon surgery – right and left colectomy, low anterior resection
* Abdomino perineal resection
* Other general surgery procedures: cholecystectomy, liver cyst marsupialization, intra-abdominal masses
* Pediatric surgery