OFFPRINT FROM KIRURGEN NO. 2 2020

NO.2 2020

OFFPRINT FROM KIRURGEN NO. 2 2020 ROBOTIC-ASSISTED THORACIC SURGERY AT AKERSHUS UNIVERSITY HOSPITAL – Experience gained after one year of operation

RESEARCH & EDUCATION

ROBOTIC-ASSISTED THORACIC SURGERY AT AKERSHUS UNIVERSITY HOSPITAL – Experience gained after one year of operation The first robotic-assisted lobectomy for lung cancer in Norway was performed at Akershus University Hospital on 17 December 2018. In this paper, we present the experience we have gained from the establishment of this high-technology service in our division after one year of operation.

HENRIK AAMODT, FRODE REIER- NILSEN, FRODE A. OLSBØ AND RUNE EGGUM VASCULAR/THORACIC SURGICAL DIVISION, AKERSHUS UNIVERSITY HOSPITAL, LØRENSKOG CORRESPONDENCE: HENRIK AAMODT – HENRIK@AAMODTASAN.NO

INTRODUCTION

BACKGROUND

In the summer of 2018, Akershus University Hospital

The first variant of the robot was launched in 1983. The

(Ahus) installed a surgical robot – Da Vinci Xi (Intuitive

“Arthrobot” was a simple assistant used during arthroscopy.

Surgery) with two surgeon consoles and one simulator.

Through the 1980s and 1990s, a number of other robot-

This system had been in demand for some time, not least

ic systems were launched, assisting surgeons during hip

by our colleagues in the division of urology.

prosthesis surgery, brain biopsies and guiding the camera during laparoscopies.

With the support and enthusiasm of the Head of the Division and experienced Video-Assisted Thoracic Sur-

The Da Vinci robot technology is based on research con-

gery (VATS) surgeons, ready to step out of their comfort

ducted at the Stanford Research Institute, with support

zone and learn something new, we were to start our RATS

from the Defense Advanced Research Projects Agency

program. The division of urology had already started

(DARPA) and the National Aeronautics and Space Adminis-

working with robotic-assisted surgery. This project

tration (NASA). The initial plans were to utilise this technol-

could therefore be. this project could be implemented

ogy for telesurgery during wars and for astronauts in space.

with a robotics team that was already very professional

The very first robotic-assisted surgery using Da Vinci was

and dedicated, comprising qualified theatre nurses and

a coronary operation, performed in 1998. In 2001, the first

a team of anaesthesiologists.

RATS thymectomy was reported by Dr Yoshino in Japan. In 2002, Dr Milfi in Italy performed the first RATS lobectomy.

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RESEARCH & EDUCATION

PICTURE 1: Ahus 17 December 2018, Drs Reier-Nilsen, Durand, Eggum and Olsbø

THE DA VINCI XI SYSTEM The system is made up of three components: 1. The surgeon console, where the surgeon sits and operates 2. The vision cart (system computer, light and camera unit and control units for the energy instruments) 3. The patient cart with the four robotic arms

PICTURE 2: Intuitive Surgery – Da Vinci Xi robotic system (copyright)

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RESEARCH & EDUCATION

PICTURE 3: Drs Aamodt and Durand

THE PROCESS TO CERTIFICATION APPROVAL AS A CONSOLE SURGEON The training programme required to qualify as a certified console surgeon using the Da Vinci robot is comprehensive, mainly due to the complexity of the system in addition to new and unfamiliar dimensions for the surgery itself. With the robot, the surgeon does not have any tactile feedback from the instruments, while the operator has to control four robotic arms and the camera.

STUDY VISIT TO HÔPITAL PRIVÉ D´ANTONY IN PARIS The first stage of the process involved visiting a hospital where lung surgery was performed using a robot. At that time, none of the hospitals in Norway were performing robotic thoracic surgery, so we travelled to Paris to visit Dr Marion Durand at the Hôpital privé d’Antony, a high-volume centre for thoracic surgery. She performs two to three robotic-assisted operations every day. This proved to be a very inspiring visit, and we are delighted that Dr Durand agreed to be our proctor.

TRAINING AT IRCAD IN STRASBOURG AND ORSI IN GHENT Our training started with an online Da Vinci Xi course, with a detailed review of the different component parts, functions, utilisation and procedures of the robotic system. The course ended with an online exam. We then moved on to simulator training using our robot at Ahus. The minimum 4 I KIRURGEN 2-2020

requirement was 30-40 hours of training. After one year of operation, statistics published by Intuitive show that the Ahus robot is the most frequently used system in the Nordic countries, measured by the number of procedures.

In light of this, the bulk of our simulator training had to be scheduled in the evenings and at weekends.

The certification process comprises an introductory course followed by training using porcine models and cadavers.

Only two institutes in Europe provide this type of training: the Research Institute against Digestive Cancer (IRCAD centre) in Strasbourg, France and the OLV Robotic Surgery Institute (ORSI centre) in Ghent, Belgium. These are both extremely well-equipped centres providing training for future console surgeons, where Intuitive has dedicated training departments for robotic surgery, with courses held by the company’s own instructors. This part of the certification process comprises several modules that have to be passed.

The introductory course comprised lectures and theoretical reviews provided by experienced RATS surgeons. This was followed by system training, docking and simulator exercises, along with exercises using animal models and cadavers.

During all robotic training, a proctor is present as an assistant, using a separate console and providing continuous feedback on operative strategy, tissue handling, and

RESEARCH & EDUCATION

PICTURE 4: Port position recommended by Dr Durand

efficient and safe control of the robotic functions.

PICTURE 5: Port position

spatula in the right hand. The surgeon also controls a third arm with prograsp forceps, and a camera in a fourth port.

ADVANCED COURSE / STAPLING COURSE

The system is dynamic and allows all instruments, including

After some procedures performed independently, the training

the camera, to be switched between ports when necessary.

process continued with certification in the use of the robot

We have decided always to have two surgeons attending

stapler. This instrument is different from the staplers used

robotic surgery – one main surgeon at the console and one

with Uniportal VATS, as the anvil is the moving compo-

assistant at the operating table. We believe this is important

nent and not the cartridge. Surgeons need to get used to

in relation to the learning curve for both surgeons, and for

this process. Our team attended a course at the Université

safety reasons. To date, we have not had any need for emer-

René Descartes in Paris, along with our proctor, Dr Marion

gency conversion but, following the recommendation of Mr

Durand, and at the IRCAD in Strasbourg with Mr Tom

Tom Routledge, we have adapted his Emergency Check List

Routledge. This course comprised lobectomies on cadavers,

and we review this before every operation, in conjunction

where we observed the correct use of the robot stapler and

with the “Safe Surgery” checklist. This is an important pro-

were able to practise this in detail. This course was also

cedure for the entire team, as an emergency conversion

an opportunity to receive feedback from our proctor on

performed incorrectly can cause the robot to “freeze” and

general surgical techniques using a robot. Having accumu-

it will not be possible to remove it from the exposure field

lated some surgical experience as a console surgeon, this

for a thoracotomy.

was a valuable course in terms of further development of our surgical techniques.

Mr Tom Routledge and Dr Bernard Park visited Ahus in the autumn of 2019. Both are highly experienced RATS

RATS LOBECTOMY AT AHUS

surgeons. Mr Routledge is the thoracic surgery consultant

We have decided to follow the procedure used by Dr

at Guy’s & St Thomas’ Hospital in London, while Dr Park

Durand for robotic-assisted lung surgery (Figures 4 and 5).

works at the Memorial Sloan Kettering Cancer Center in

This involves the use of two 8 mm trocars, two 12 mm tro-

New York. Each participated in two procedures, and we

cars and an assistance port (AirSeal®) with CO2 insuffla-

gained a valuable introduction to various methods of

tion. The main instruments comprise a bipolar diather-

performing RATS surgery, with a view to robotic setup,

my grasper in the left hand and a monopolar diathermy

surgical technique and operative strategy.

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RESEARCH & EDUCATION

PICTURE 6: In the robotic theatre

WHY UTILISE RATS? After one year of operation, we have noted several benefits with robotic-assisted thoracic surgery. Primarily, the surgeons have unparalleled vision and perception. Our standard port setup provides us full access to the entire thoracic cavity, both visually and surgically. Other benefits are HD image quality and stereoscopic field of vision with 3D, along with a stable camera platform and up to x20 magnification. The console provides a comfortable and relaxed working posture for the surgeon, from which he/ she controls all four robotic arms, which also have tremor filtration. The instruments have EndoWrist functionality with a 7-degree angle and 360-degree rotation. The trocars for the four arms move stably around a fixed point in relation to the thoracic wall (fulcrum effect), which is thought to reduce post-operative problems caused by intercostal neuralgia. Lymph node dissection is notably more accurate than with VATS, and complete removal of the individuallymph node stations can be performed without problems.

This is reflected in the pathology results, where the number of lymph nodes is significantly higher for RATS than for VATS in our material.

During the first six months of the RATS programme, we performed one operation per day. As our experience of robotic surgery has increased, we are spending less time on each operation, and we now routinely schedule two operations on those days we have access to the robot.

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To date, most of the 50 procedures we have performed have been lobectomies. We have also performed thymectomies (histologically inconclusive mediastinal tumours and Masaoka-Kuga stage I thymomas), diaphragm duplications for diaphragmatic paralysis, metastasectomies and sublobar resections. For the latter, we have found the FireflyÂŽ function in the robot very helpful for accurate visualisation and segmentation. Firefly is a function in the robotic camera system, where indocyanine green is injected pre-operatively, and near-infrared light is emitted by the camera to fluoresce the dye in circulated tissue.

We believe that we will be able to offer mini-invasive surgery to a larger number of patients with our RATS technology. Looking back over the past year’s experience, it is obvious to us that a number of the patients who have undergone RATS surgery would have been converted to a thoracotomy if VATS had been our primary access.

So far, access to the robot has been the major limiting factor. Fortunately, Ahus recently approved the purchase of an additional robotic system. Once the new system is in place we will be able to double the number of operating slots on the robot and our goal is to transfer all our current VATS volume to RATS.