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“The procedure is minimally traumatic“

Robot-assistance: “The procedure is minimally traumatic“


Photo: Prof. Axel Heidenreich

Professor Axel Heidenreich;
© RWTH Aachen

The da Vinci Surgical System revolutionizes the job in the operating room. For several months, surgeons at the RWTH Aachen University have worked with the da Vinci Surgical System. Here, the surgeon no longer stands alongside the patient, but instead works at a console from which he operates the surgical instruments inside the patient.

Professor Axel Heidenreich is the Director of the Department of Urology at the RWTH Aachen University Hospital and Executive Board Member at the EURO Prostate Center Aachen in Germany. He spoke to about the opportunities the use of the da Vinci Surgical System is offering physicians and patients. Recently you have started to work with a new, minimally invasive surgery procedure, the so-called da Vinci Surgical System. Why did you integrate this system into surgical practice?

Axel Heidenreich: At the moment we use the da Vinci Surgical System for radical prostatectomy, meaning the surgical removal of the prostate due to prostate cancer. There are three aspects where an implementation makes sense.

On the one hand, it is significantly less traumatic than previous surgical techniques. On the other hand it provides the opportunity to approach certain structures more specifically and more gently. The da Vinci Surgical System intraoperatively enables an up to ten-fold magnification of important vascular and neural structures that need to be preserved.

And the third aspect is that the postoperative early regenerative process of patients is faster than we are able to see with previous surgical techniques. In the long term course no significant differences ensue between both methods as it pertains to oncological, functional and regenerative processes. Which technology does this robot-assisted system use?

Heidenreich: It is a three-dimensional picture of the surgical situs. The da Vinci Surgical System consists of three key components: The first component is the so-called console from which the surgeon works. The second part consists of the robot which moves the robotic arms and the surgical instruments and the third feature is a matrix monitor where the surgeon and the assistants can see how the surgery is progressing.

The entire system operates with computer software that transmits a 3D picture seen at the surgical situs via a camera system with infrared interfaces onto the surgeon’s console. In addition, the surgeon at the console can move the surgical instruments inside the patient through his hand movements. How exactly does the surgeon work when using the da Vinci Surgical System?

Heidenreich: The surgeon no longer stands alongside the patient as we know it from traditional surgeries, but rather sits at a console and therefore away from the patient. However, this console is still located in the operating room. In theory though, the console could also be located in an office and the patient in the operating room could be operated on from there. Technically this would all be possible.

However, the communication between head surgeon and the assistant surgeons in the operating room is very important. So the surgeon using the da Vinci Surgical System no longer stands sterilized at the operating table, but sits more or less comfortably at this console and can perform surgery from there.

Photo: A surgeon sits at the console

During the operation, the surgeon is not standing next to the patient but rather sitting at a console; © Axel Heidenreich, RWTH University Hospital Aachen How should we envision the surgery?

Heidenreich: I sit at the console and have small hand grips available, which I move via Bowden control cables. With the computer software, movements I enter into the screen on which I can also see the 3D picture of the patient, are being transmitted and carried on exactly the same way in the patient’s body.

In just the same way as with a microscope, you look through an eyepiece lens, though in this system you have a large, three-dimensional screen in front on you. This three-dimensional picture shows the surgical instruments you use during the surgical procedure, the corresponding surgical situs and you can maneuver the surgical instruments and the camera in the patient situs via the console. With the help of the camera, the picture can be magnified or minimized if necessary.

During all this, the patient is approximately five meters away from the console in the operating room. During the surgery, an additional surgeon and a surgical nurse have to move specific surgical instruments to assist the head surgeon. To be able to follow how the surgeon is working, both assistants can track the surgery two-dimensionally on several monitors. What kind of experiences were you already able to gain?

Heidenreich: We have already used the da Vinci Surgical System for three months and have performed a large number of radical prostatectomies and renal surgeries. We exhibited that this procedure is minimally traumatic and that patients recover significantly faster than is the case in previously common surgical procedures. Were you able to detect any drawbacks?

Heidenreich: One large drawback is the cost of the system, since it costs about two million Euros. This is an acquisition that has to be amortized over time. In addition, the introduction of the da Vinci Surgical System into surgical procedures takes time in the beginning. The surgeries take longer than those skilled surgeons are familiar with using the traditional techniques. One drawback therefore is the fact that you need to become acquainted with a new form of surgical technique. For what type of surgeries is this procedure thus far being used?

Heidenreich: We primarily use it for radical prostatectomies as well as urethral and renal artery reconstructive surgery. In addition it is used for the organ saving procedure for tumor enucleation for renal tumors. Are there other options where the da Vinci Surgical System can be used?

Heidenreich: Basically you can use it for radical cystectomies, meaning surgical procedures where you have to remove the urinary bladder due to cancer growth and need to reconstruct a bladder replacement. There are many different experiences at the moment. That’s why we are not using it for now, since it is unclear whether the so-called oncological results are equally as great with the da Vinci Surgical System as they are with open surgery procedures. What’s more, surgery time for a cystectomy with the da Vinci Surgical System is at least twice as long as with an open surgery procedure. Why has this procedure become so important for these kinds of surgeries for you to introduce it?

Heidenreich: Primarily it pertains to the minimal surgical trauma. This is due to the gentle surgical technique as it pertains to worry-free procedures. In addition, minor blood loss and the lower risk of possible infections speak in favor of this system since you work in a closed system so to speak. Are there other medical areas that use this surgical method?

Heidenreich: In our hospital we have used this system for specific surgeries in oncological gynecology. We are also starting to use the da Vinci Surgical System for certain liver surgeries. Globally it is primarily being utilized for urological surgeries.

Photo: An assistant helps during the surgery

During the operation an additional surgeon and a surgical nurse assist by operation certain instruments to help the chief surgeon; © Axel Heidenreich, RWTH University Hospital Aachen options does the da Vinci Surgical System provide in the future from a technical perspective as well as in its international expansion?

Heidenreich: From a technical point of view there are a few interesting, new developments that we are trying to implement in collaboration with the RWTH Aachen University. For example, there is a possibility through specific radiological procedures, meaning magnetic resonance tomography, to highlight tumors in color that are located within the prostate gland or inside the kidney.

Via a specific computer operation, this MRT picture can be integrated on the monitor from where I perform the surgery, to where it would be superimposed over the prostate and you would be able to exactly see where the critical regions are and where the tumor in its specific size is located. In doing so, large tumors could be more precisely operated on.

One tries to develop sophisticated surgical instruments and technologies for larger systems, so that major and difficult surgeries can be performed more easily. In addition, one tries to use the da Vinci Surgical System within the scope of pediatric urology. How much is this technology already established internationally?

Heidenreich: Internationally this system is clearly more prevalent than it is in Germany. Here an estimated 25 systems are currently being used. In other countries, for instance in Belgium, a country that’s significantly less populated, there are approximately 40 da Vinci systems. It’s similar in the Netherlands. The U.S leads the way with over 400 systems. Why did it take longer for Germany to also introduce the da Vinci Surgical System?

Heidenreich: In the U.S.A. the system was much more deliberately advertised as a technical innovation, without the existence of any great experiences. Due to competition pressure, hospitals were thus forced to purchase this equipment. Germany acted somewhat more cautiously and scrutinized whether this system gains an advantage over traditional procedures. And now that this advantage is noticeable, are we following?

Heidenreich: Yes we are. We are for instance trying in collaboration with other university hospitals to acquire these systems and to join forces. The results that we now achieve with the robotic system are collected in a so-called prospective database. After a certain amount of time we want to precisely analyze whether the system really delivers many advantages and if so, what advantages those are and where there might be disadvantages. Until now this has not yet been thoroughly researched. But this is also among our objective targets.

The interview was conducted by Simone Nefiodow and translated by Elena O’Meara.


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