“The robot is really just a very sophisticated surgical tool,” says urologic surgeon Vincent P. Laudone, co-director of the robotic surgery program in Memorial Sloan Kettering’s Department of Surgery. “The bottom line is that it is the skill of the surgeon, working with the tool that he or she is most comfortable with, that gets the best result. And the main objective of any cancer operation — no matter how it is done — is to get all the cancer out and get it out safely.”
How It Works
Originally developed by the US military, the surgical robot was designed to allow complex surgery to be performed on a wounded soldier by a surgeon at a console in a hospital remote from the battlefield. Robot-assisted surgery is an extension of laparoscopic surgery, a minimal-access approach that allows surgeons to perform operations using scopes and instruments inserted through several small incisions. The robot adds enhanced vision and control and consists of several components, including an ergonomically designed console, four interactive robotic arms, and a three-dimensional, high-definition vision system.
At the console, a surgeon uses finger, eye, and foot controls to manipulate the arms of the robot. “There are several advantages from the surgeon’s point of view,” explains Dr. Laudone. “You can see better because the eyes of the robot — the camera — can go right down to the tissue and project a three-dimensional image, magnified tenfold.” In addition, the robot translates a surgeon’s hand, wrist, and finger movements into real-time movements of the surgical instruments inside the patient. “The robot takes my motions, copies them, and scales them down,” Dr. Laudone says. “If I make a one-inch movement, the robot scales it down to a quarter inch. The precision is extraordinary.”
Because the robot also allows surgeons to learn laparoscopic surgery much more quickly and proficiently, robot-assisted surgery has been rapidly accepted. Laparoscopic surgery demands skills very different from the hand motions used in traditional open surgery, and the training time needed to master the movements using the robot is much shorter.
For patients, the main attractions of laparoscopic surgery and robot-assisted surgery are smaller incisions with the potential for less postoperative pain, less blood loss, a shorter hospital stay, and quicker recovery. In principle, the operation may be more effective and the surgical side effects greatly reduced. In practice, however, the benefits and side effects differ with each type of operation. “The best studies confirm that the results of any type of surgery depend more on the skill and experience of the surgeon than on the technology used,” says Peter T. Scardino, Chair of Memorial Sloan Kettering’s Department of Surgery.
“Along with the advantages of robotic surgery come some disadvantages,” Dr. Scardino explains. “The robot lacks a sense of touch. The surgeon can see but not feel the tissue — a dilemma for cancer surgery, since cancer can typically be felt as a rock-hard nodule. Early in a surgeon’s experience, there is a greater risk of serious complications, and a tendency for inexperienced surgeons — or those without special expertise in cancer — to perform an operation that is not ideally matched to the extent of the disease. For example, in nationwide studies, surgeons performing laparoscopic and robotic operations for kidney cancer were more likely than traditional surgeons to remove the whole kidney rather than just removing the tumor and saving the rest of the kidney.” (Partial removal of a kidney reduces the risk of chronic kidney disease compared to total removal.)
Urologic surgeon Vincent Laudone (left) and gynecologic surgeon Mario Leitao are co-directors of the robotic surgery program in Memorial Sloan Kettering’s Department of Surgery.
“The goal when I use a robot is that I should be doing the same exact surgery I would have done in a traditional open operation,” says gynecologic oncologist Mario M. Leitao, Jr., co-director for robotic surgery. “The idea is always to do the correct surgery for the properly selected patient for the right reasons.”
“When the robot was first introduced as a surgical tool in 2000, it was not specifically targeted for use in cancer surgery,” Dr. Laudone elaborates. “Over the intervening years, however, the surgical treatment of cancer patients has become the major focus of robotic surgery and Memorial Sloan Kettering is ideally suited for utilizing the robot for these purposes, given the exclusive concentration of our surgeons on cancer. Backed by the principles of cancer treatment developed over decades at Memorial Sloan Kettering, we can use this technology to deliver the best care to our patients.”
Since the introduction of robotic surgery at Memorial Sloan Kettering approximately a decade ago, the volume of robot-assisted surgery has increased more than tenfold, going from approximately 140 cases in 2007 to more than 1,400 in 2012.
The number of robots has also increased. Memorial Sloan Kettering now has five of the latest-generation da Vinci® SI dual-console surgical systems, which are used for both training and collaborative surgeries. While an operating surgeon can use just one console, during a dual-console operation, a surgeon seated at the adjacent console is able to see the same high-definition images of the patient’s anatomy and collaboratively manipulate the surgical instruments.
When used for training, the dual-console system allows for control over the instruments to be exchanged quickly between the teaching or mentoring surgeon and the surgeon learning a procedure. “It’s a wonderful teaching tool,” says Dr. Scardino. “You’re seeing the same thing, you have the same point of view, and you’re handling the same instruments.”
Who Is Using It
Robot-assisted surgery is used for an increasing variety of cancer operations at Memorial Sloan Kettering. Dr. Laudone and his urological colleagues perform radical prostatectomies (removal of the prostate gland) robotically. However, both he and Dr. Scardino caution that even though the robotic operation seems relatively easy and safe to patients, that doesn’t mean that surgery is appropriate for all men with prostate cancer. “The adoption of this technology around the nation has led to overtreatment of prostate cancer for many patients with low-risk cancers that are not dangerous and that should not have been treated in the first place,” says Dr. Scardino.
Dr. Laudone and his colleagues have published studies that show comparable outcomes with robotic and open surgery for high-risk prostate cancer at Memorial Sloan Kettering. “The focus of prostate cancer surgery at Memorial Sloan Kettering is on men with cancer that is truly life threatening,” says Dr. Laudone. “It is important to know that our approach to prostate cancer is to do surgery only when necessary. For patients better served by a surveillance or ‘watchful waiting’ program, that’s what we’ll recommend.” In this approach, treatments such as surgery and radiation therapy are deferred because tests indicate that the tumor is currently not life threatening and is at low risk of progressing. Patients are monitored for any signs of progression or changes in a tumor’s characteristics, and treatment can be considered later on if the cancer becomes more serious.
Dr. Leitao and his colleagues on the Gynecology Service performed more than 600 robot-assisted operations in 2012. “We are in the top five of centers in the world in terms of robotic surgical volume in gynecology,” Dr. Leitao says. Endometrial cancer (cancer of the lining of the uterus) is the disease in which robotic surgery volume is highest, followed by cervical cancer. The treatment for endometrial cancer is hysterectomy — the removal of the uterus and cervix, the fallopian tubes, nearby pelvic lymph nodes, and often the lower part of the aorta — a procedure for which the robot is well suited. And in cervical cancer, which is often diagnosed in women in their childbearing years who wish to preserve their fertility, Dr. Leitao and his colleague, gynecologic oncologist Ginger J. Gardner, have begun performing a procedure called a radical trachelectomy using the robot. The operation removes the cervix and reattaches the vagina to the healthy uterus. “We had not done radical trachelectomies laparoscopically at Memorial Sloan Kettering, and very few have been reported in the world,” says Dr. Leitao, “so the robot is starting to transform this type of cervical cancer surgery tremendously.”
“We respect the complexity and potential risk of this new technology… patient safety is always our most important concern.”
—Peter Scardino, Chair, Department of Surgery
Surgeon Vivian E. Strong, who specializes in treating patients with stomach (gastric) cancer and adrenal tumors, has advanced training in minimal-access surgical techniques. She is studying the application of the robot to stomach cancer operations, primarily the removal of the stomach in an operation called a laparoscopic gastrectomy, which she introduced at Memorial Sloan Kettering. In 2009, Dr. Strong led a study that showed that laparoscopic gastrectomy had the same chance of curing gastric cancer but with fewer postoperative complications than traditional surgery. She has now extended her work to include robot-assisted laparoscopic gastrectomies. “We are the highest-volume gastric cancer center in the nation,” says Dr. Strong, “and we have a duty to investigate what we can do to make care better for our patients.” Dr. Strong comments that robot-assisted gastrectomies are most often indicated in patients with early-stage stomach cancers. Larger, more advanced tumors may not be as amenable to the technique. Among the postoperative complications that robotic surgery helps to avoid are hernias, which may occur after surgery for stomach cancer and can require a second operation to correct.
Julio Garcia-Aguilar, Chief of the Colorectal Service, who has extensive expertise in robotic surgery, takes up Dr. Strong’s theme. “Our surgeons do more than 500 colon and rectal cancer operations a year and so are in an ideal position to introduce this technology into colorectal surgery,” he says. On Dr. Garcia-Aguilar’s service, surgical oncologist Martin R. Weiser has taken the lead in robot-assisted operations, and the program is advancing quickly as more surgeons are adopting and studying the approach in appropriate patients.
“The robot is a very elegant tool,” observes thoracic surgeon Inderpal S. Sarkaria, who has advanced training in minimal-access surgery for thoracic diseases, including lung cancer, esophageal cancer, and cancers of the middle chest such as thymomas, which sit on top of the lining of the heart. “An operation for which robotic surgery has been very well adapted is thymectomy [the removal of the thymus],” Dr. Sarkaria says. “The minimally invasive approach has spared the need for a median sternotomy [splitting of the sternum, or breastbone] to access the middle chest, and allowed us to perform the same surgery through four small incisions. And use of the robot has added a significantly greater level of ease and finesse to this operation, giving more thoracic surgeons the ability to perform and offer the surgery, which has a clear benefit over open approaches in suitable patients. In appropriately selected patients, robotic surgery is now the preferred method of performing these procedures for me and my Memorial Sloan Kettering colleagues.”
The finger controls of the surgical robot.
One of the more complex procedures in thoracic surgery is an esophagectomy (the total or partial removal of the esophagus). Dr. Sarkaria is leading the Memorial Sloan Kettering program in robot-assisted esophagectomy in an effort to reduce the risk of complications from this lengthy operation. He affirms the paramount importance of maximizing patient safety with the introduction of any new technology. “For the robot-assisted esophagectomy, a protocol requiring the presence of two attending surgeons in the operating room for each procedure was instituted,” Dr. Sarkaria explains, “creating an environment with two experienced sets of eyes identifying, troubleshooting, and solving technical pitfalls and complications during development of this technically demanding operation.” He and his colleague, thoracic surgeon Nabil Pierre Rizk, have worked together for the past two and a half years to develop the surgery. “We have completed 48 robot-assisted operations to date, along with a dedicated team of anesthesiologists and nurses who now know the operation thoroughly,” says Dr. Sarkaria. “Through our formal process of prospective procedure critique and improvement, we are steadily evaluating and developing an approach to esophagectomy that should set the standard for how these operations are performed in the future while, above all else, making patient safety our first priority.”
“We respect the complexity and potential risk of this new technology,” Dr. Scardino emphasizes, “and are committed to using it responsibly.” The Department of Surgery has established policies for surgeons to perform cancer surgery with the laparoscope or robot. “We’ve said, ‘Here’s what you have to do to get credentials to use these new technologies.’ Whether a surgeon wants to learn robotic surgery or wants to apply the technology in a new way, there are clear protocols,” says Dr. Scardino. “Patient safety is always our most important concern.”
How It’s Getting Better
The latest-generation da Vinci® SI surgical platform incorporates several new features, and among the most significant is real-time intraoperative imaging. The two intraoperative imaging techniques currently in use at Memorial Sloan Kettering are ultrasound and fluorescence imaging.
A view of the uterus during a hysterectomy. The robotic surgical instruments allow natural dexterity, full range of motion, and unparalleled precision.
With ultrasound, a probe inserted into the patient permits the simultaneous viewing of a patient’s anatomy and the ultrasound image, compensating for the robotic surgeon’s inability to feel the tissues. “Normally, you can only see the surface of what you are operating on. The ultrasound lets you see what’s underneath,” Dr. Laudone explains. “Sometimes tumors are hidden within a structure, especially the kidneys and liver. Because you can’t see the inside of an organ you can’t always see the extent of a tumor. The addition of ultrasound allows you to do a better, more precise operation.” Eventually CT scanners will also be used during operations to help guide surgery and to monitor results in real time.
Fluorescence imaging, which Dr. Leitao likens to “glow-stick technology,” is another key refinement in which a fluorescent dye is injected into a patient and, when excited by a laser, lights up, giving surgeons a more precise view of anatomical landmarks than is possible with the naked eye. The application of one of the robot’s foot pedals allows a surgeon to toggle between the image of a patient’s anatomy and images of illuminated tissues, permitting improved visual assessment of blood vessels and lymph nodes.
“And one of our most exciting new initiatives — in collaboration with our colleagues in the Department of Radiology and the Sloan Kettering Institute’s Molecular Pharmacology and Chemistry Program — is the development of molecular probes that target cancer,” Dr. Scardino says. “You can link these probes to a light-emitting agent so you can see the cancer in the operating room and tell whether or not you have completely removed it. We call it the ‘Glowing Margins’ project. Surgeons will actually be able to see the edges, or margins, of the cancer and know precisely what to resect to have the best chance of cure. You’ll be able to do the same thing with lymph nodes — see the light glowing in the cancerous nodes and know they need to be removed. I think molecular imaging in the operating room will be a big breakthrough that will lend itself extremely well to robotics and laparoscopic surgery.”
“At the end of the day,” says Dr. Garcia-Aguilar, “it is the skill and experience of the surgeon using this tool that gives the best outcome. I have always told patients, ‘Have your surgery done by an experienced surgeon, a surgeon you trust — and then let him or her decide what is the best operation to do.’”