Extracting a Friendly Tumor Using da Vinci Xi

Dr. Roger Smith, Chief Technology Officer of the Nicholson Center at AdventHealth, demonstrated an unusual tumor extraction using da Vinci Xi, a robotic surgery system. Halldale Group’s Industry Reporter Amanda Towner was there.

Fellow health care providers and members of the community gathered together in the operating room curiously watching as Dr. Smith performed a tumor extraction on a friendly and familiar subject. The room was quiet, with eyes transfixed on the operation before them.

After just a few minutes, Dr. Smith exclaimed, “I think Irecognize that tumor. That tumor seems to have feet and hands.”

The crowd waited in anticipation for the tumor to berevealed from beneath the incision.

“Oh! It’s a gummybear,” said Dr. Smith.

The room filled with laughter as he extracted the gummy bear“tumor” from the raspberry-filled Krispy Kreme donut “patient.”

Dr. Roger Smith, Chief Technology Officer of the Nicholson Center at AdventHealth, demonstrated a robotic surgery operation on the da Vinci Xi, removing a gummy bear “tumor” from within a jelly-filled donut “patient.” Image credit: AdventHealth.

As part of the demonstration, the donut was placed inside a stomach trainer that simulated an insufflated abdomen. Dr. Smith placed incisions on the donut and pulled the tissue apart to explain how the system works.

General abdominal procedures that can be performed with the da Vinci include  bariatric surgery, gallbladder surgery, inguinal hernia repair, ventral hernia repair, acid reflux disease surgery (nissen fundoplication), stomach surgery (gastrectomy), pancreas surgery (pancreatectomy and pancreaticoduodenectomy/Whipple procedure), small bowel surgery, and spleen surgery (splenectomy). Patients will most likely experience surgeries with this system if a prostate is removed or hysterectomy is performed. While robotic surgery is incredibly common, most people in the community do not understand what it means when given the option to have it. The demonstration was part of an initiative to show how safe and effective robotic surgery can be – with less gruesome subject matter.

The crowd was welcome to not only watch, but also to try out the da Vinci Xi out for themselves. Dr. Smith took volunteers to the surgeon console, where he adjusted the seat and explained basic maneuvers like clicking the foot pedal on the right to pick up a third instrument. He invited participants to try different exercises with the gummy bear, like cutting off its head, switching it between instruments or stretching it out.

Dr. Smith placed incisions on the donut inside the insufflated stomach trainer and cut through the tissue to explain how the da Vinci Xi system works. Image credit: Author.

“Real tissue does not stick to your instruments like a donutdoes,” Dr. Smith said.

But rest assured these messy instruments won’t be operating on anyone, as these tools are used strictly for training.

This operating room (OR) is about 30 percent larger than normal. It features a regular OR bed to produce a training environment that is as realistic as possible.

The system is used once a month to train surgeons from all over the world who are learning to use the da Vinci Xi for the first time.

“They might be surgeons that do microscopic surgery or opensurgery, and they don’t know how the robot works. So they come to our coursesand we put them through different versions of a five-day course, a three-daycourse, whatever it is they are here to learn,” said Dr. Smith.

Surgeons learn how to set the machine up, how the instruments work, how the camera works and more until they are proficient. Even though hand dominance is not affected, with the ability to interchange instruments from right to left in the system, surgeons are trained so that both hands are equally adept.

The training begins with simple puzzles and exercises usinglaparoscopic instruments, like putting jacks in a bowl or moving rings on pegs,to build dexterity and help trainees become accustomed to switching theirinstruments.

Then trainees go through dry-lab training on the da Vinci Xi with the Fundamental Robotic Surgery (FRS) Psychomotor Skills Dome, a 3D object made of silicone that was built to mock the feel of actual tissue. It can be used in various exercises for instrument control, needle control, third arm control, knot tying, suturing, blunt and sharp dissection, and safe use of energy. Trainees, for example, can follow the patterns on the dome to cut out various shapes.

The FRS Psychomotor Skills Dome, a 3D object made of silicone and built to mock the feel of actual tissue, can be used for instrument control, needle control, third arm control, knot tying, suturing, blunt and sharp dissection, and safe use of energy. Image credit: Author.

They then progress from dry-lab training to wet-lab, working on tissue from turkey thighs and cadavers, and finally progress to simulated procedures. As surgeons come from different areas around the world to train, the number of required training hours varies and is determined from the hospital from which the surgeon originated.

Dr. Smith passed around one of the instrument arms, whichhad a tip the size of a fingernail, to put in perspective how small-scale therobotic surgeries are. While he told the crowd it costs about $2,500, he alsomentioned that it has to be thrown away after 10 uses, soliciting a gasp fromthe audience.

To guarantee the instrument is in good condition, it is only recommended for 10 uses. A microchip inside of the instrument records the number of surgeries it has undertaken and will not let it pair with the robot after 10 times. While these same instruments are used for training, they are set to larger numbers, ranging anywhere from 30-128 uses.

When surgeons have completed the course, they are assigned to work with practicing robotic surgeons in their home hospitals who mentor them for 10-30 operations. Mentors lead the surgeries, progressively handing more tasks to the mentored surgeons until they are proficient and a mentor is no longer needed.

Visitors got to experience some of what the trainees go through in the course. Puzzles were arranged in the next room, where we could test our dexterity skills with laparoscopic tools – just as a surgeon would on his or her first part of training.

Halldale Group Industry Reporter Amanda Towner practices her dexterity skills, moving a ring through a looping metal wire puzzle with laparoscopic instruments. Image credit: Author.

Visitors could pass plastic beads between straw platforms,thread string through metal obstacles, coerce a ring across a winding loop, orpass an object between instrument hands to attach it onto a different platform.

While the tasks were entertaining, some puzzles were moretedious than others and others were impossible, giving visitors a largerappreciation for robotic surgeons and a greater understanding of the trainingsurgeons go through to be proficient in the art of robotic surgery.