By Martha Conway
St. Joseph’s Health has always been an early adopter of technology, so it is no surprise they became the first facility in Central New York to acquire da Vinci robotic surgery technology and start a comprehensive program for patient care – not long after the FDA approved da Vinci for general surgery, such as cholecystectomy and Nissen fundoplication to treat foregut problems. Surgeons performed 43 robotic surgeries the first (partial) year, nearly quadrupling that number the following year. St. Joseph’s Health has performed 13,284 robotic surgeries to date. As a result, they have attracted the surgical expertise of a range of specialists who use the technology to improve the health of patients, and their robotic surgery program is second to none in the U.S. In addition to the above, St. Joseph’s surgeons are using da Vinci for revascularization (coronary artery bypass), heart valve repair, hiatal hernia repair and other gastric reflux procedures, as well as groin or belly hernias, gynecological procedures, urology (including prostate) procedures and colon procedures. They are the leaders in robotic general surgery cases in Central New York.
The breadth and depth of surgeon expertise mean patients experience less scarring, shorter hospital stays, faster recoveries, less pain and few infections with da Vinci.
“To continue recruiting high quality surgeons – including our newest surgeon coming in September, we need to have robotic access availability,” said Chief Medical Officer Dr. Philip Falcone.
“Virtually everyone in a surgical residency and fellowship training receives robotic instruction and expects this to be available in the hospitals where they work. Robotics are now the norm, and access to this technology is an expectation for most surgeons.”
The Heart of the Robotic Surgery Program at St. Joseph’s Health
“St. Joseph’s started investing in robotic surgical technology at least 15 years ago,” said Dr. Zhandong Zhou, a cardiac surgeon who performs bypass and valve procedures using da Vinci. “Surgeons can do single bypass surgery, but not many people need single vessel revascularization, so we started doing robotic bypass to the left anterior descending artery, then PCI [percutaneous coronary intervention] to non-LAD territories, which we called ‘hybrid’ revascularization.”
“St. Joseph’s is dedicated to robotic surgery.” “We put resources into it, employ excellent robotic surgeons and lead the market in terms of technology… ”
Dr. Belfield
Defects in the LAD cause widow-maker (often fatal) heart attacks; PCI opens narrowed or blocked sections of the artery, restoring blood flow to the heart.
“One of the major benefits is that patients recover very well, and – after a couple of weeks – they can do pretty much everything,” he said. “The results from this procedure have been wellreceived, but most people need multivessel bypass. Not everybody can have hybrid revascularization bypasses, so we started the multi vessel bypass. Initially, it was stressful, difficult and took a long time. We recently revised the technique to get them done more quickly and achieve identical results to standard surgery. We just presented our results at the STS Coronary Conference and got very positive feedback.”
“There are only a handful of people doing this in the country, and that makes us stand out,” Dr. Zhou said. “We are showing the world we are one of the few hospitals with the technology and expertise to perform robotic revascularization as good as standard surgery and with quicker recovery. Now patients come in and ask for robotic bypass, but the robots are in high demand because there are a lot of specialties using them, so we just don’t have enough spots.”
Dr. Zhou focuses on coronary bypass surgery because so many patients need it. “About half of open heart surgery patients need coronary bypass, and about half need valve surgery,” he said. “Mitral valve repair can be done robotically, but with limited scheduling slots and minimally invasive surgery being very successful – also done through a very small incision – we can do those either robotically or standard using special instruments, and we can do as good a job as with the robot. For the coronary bypass surgery part, we can do more along the lines of bypass, if we have the [scheduling] spots. Down the road, one of the areas to explore is total robotics – make the incision even smaller.”
Dr. Zhou said while the priority right now is catching up on patients needing bypass, there are other things they can do. “If we can get bypass surgery caught up and I find more time, I can do more,” he said. “We do about 1,000 surgeries a year; 400 to 500 of them are coronary bypass surgeries. We have about 100 mitral valve surgeries, some of which can be done robotically, but I can use special instruments and do as good a job. We do about 400 to 500 coronary bypass surgeries; last year, we did about 20 to 30 percent of them robotically. ”
By avoiding sternotomy and using a rib spreader to access the heart, there is less trauma to the body, minimal scarring, very low infection rates, shorter hospital stays and quicker recovery times. Patients should still expect some discomfort for a few days because of the need for a chest tube.
“After that comes out, things are dramatically better,” he said, adding that cryotherapy is available. “I don’t think patients know the range of options available at St. Joseph’s Health. I’m operating all the time, so I don’t have time to spread the message, but anyone who needs these procedures can call my office. I am happy to talk to them.”
Not everyone is a candidate.
“Some patients are too obese, and that makes it hard,” he said, “and some patients have very small arteries.”
Dr. Balasubramaniam Siva Kumar, a general surgeon who has performed well more than 2,000 robotic surgeries to date, agreed.
“It’s a definite advantage in many surgeries, but it’s not the answer for all surgeries,” Dr. Kumar said. “It’s still not ideal for very large growths and tumors, because it’s riskier to maneuver around larger structures. The size of the patient is a consideration, too. It’s difficult to use robotic surgery in pediatrics because of the positioning required for smaller patients. There is a need to miniaturize the equipment to use robotic surgery in smaller people and on larger masses and growths, as well as extensive cancers.”
“Over the years, we’ve been able to maintain the highest standards through a committee approach to program oversight. The range of services is wide and very high-quality.”
Dr. Kumar
Infection rates are almost non-existent because they don’t do sternotomies, Zhou said.
“Chest wall incisions rarely become infected,” he said.
“Occasionally, a large breasted woman gets an infection because the incision typically is under the breast, and moisture can collect there; but cosmetically for women, it’s very good. With large breasted women, we can make the incision above the breast to avoid chances of infection.”
Exemplifying the Range of Possibilities
Dr. Kumar started performing robotic surgery about 17 years ago when Chief of Urology, Dr. William Roberts, asked him to collaborate with the urology team to do laparoscopic urologic procedures.
“He asked me to lead an expansion into general surgery,” Dr. Kumar said. “I learned everything I could, and we were among the very first to adopt robotics for general surgery.”
Foregut and hiatal hernia surgeries top the list of robotic procedures Dr. Kumar performs today. He’s also done colon surgery, hernia repair and pancreatic surgeries.
“Robotic technology adds dimension to surgery,” he said. “We can gain a much wider range of access to more radius and with more precision, expanding the ability to do more precise surgeries.”
Dr. Kumar said there also are hybrid procedures that allow access to areas of the body that are difficult to reach and previously required large openings to access. “You can use robotics to reach the areas, then do hands-on surgical procedures via very small openings,” he said. “I do quite a range of robotic surgeries and don’t plan to add any new ones; however, the technology continues to evolve, and St. Joseph’s Health is working on developing further services in this field.”
Like Dr. Zhou, Dr. Kumar said robotic surgery minimizes trauma to tissue. He said surgeons used to do exploratory surgery with a wide-open field to see inside the body. Now the same results are achieved without that trauma. He said there are benefits to surgeons, also.
“Surgeons can work in a comfortable, seated position and achieve better reach with robotic instruments,” Dr. Kumar said. “They can perform much more intricate procedures for much longer periods of time, and they experience much less fatigue doing laparoscopic surgeries than they did during traditional procedures that required great manipulation.”
St. Joseph’s Health Tailors Care to Each Patient
Dr. Beata Belfield is a minimally invasivetrained general surgeon whose fellowship was in robotic surgery; she was recruited by St. Joseph’s Health for precisely that reason.
“Robotic surgery was an absolute prerequisite for any hospital in which I chose to work,” she said, adding that the program is cutting-edge, and the staff are very happy to help create a great patient experience. “I specialize in gallbladder removal, hernia repair and anti-reflux procedures; I’m very happy with my niche, but I would like to do more acute surgeries – procedures we would otherwise do through a big open incision – emergency procedures I’d prefer to do robotically, if possible.”
Dr. Melinda Stevens, a general surgeon, said she’s been doing robotic surgery since about 2015, starting out with small hernias under the mentorship of Dr. Kumar.
“The smaller the incision, the less risk of infection,” Dr. Stevens said. “As for intra-abdominal complications, they are slightly less with the robot because of the 3D visualization and the ability to handle the tissue with instruments that move exactly like our hands. It’s so much better than standard laparoscopic cameras, which are very good, but it’s better with 3D visualization.”
Dr. Belfield said robotic surgery is a good option for appropriate patients. “Certain procedures are not conducive to being done minimally invasive, so robotic surgery is another tool in our tool kit,” she said. “There are certain hernia procedures I do mostly robotically, then at the very end do something open, such as scar revision or removal of excess skin. But most surgeries are either open or robotic.”
“I’ve since developed further skills with larger, more complicated hernias, colon surgery, emergency surgeries – including appendix – and also use the robot more now for doing gallbladders because of the superior visualization and tissue handling,” Dr. Stevens said. “Every year, I’m growing the list of things I do with robotics vs. what I used to do just laparoscopically.”
Dr. Stevens said she wants to add large, complicated hernias that normally are done with a component separation in open fashion.
“I’d like to do it robotically, which is a longer procedure, but in the end, it’s less post op pain for patients, so it’s worthwhile doing it that way,” she said, adding that certain surgeries are not ideal to be performed robotically.
“Patients who’ve had numerous surgeries and who have a lot of scar tissue may not do well with robotic surgery,” she said. “It is best to talk to your surgeon about whether you’re an ideal candidate, because it’s hard to know what your surgeon will think, even if you’ve had surgery before. Meeting with the surgeon helps patients understand their disease process and whether it is a good option for robotic surgery. We tailor our approach to individual patients.”
Dr. Stevens agreed. “It’s difficult to gain access to the abdomen,” she said. “You really need to be able to fully see everything in order to get in safely to avoid injury to the bowel, in particular. Sometimes we have to convert to open in those patients. Some patients are extremely petite – very thin. For a tiny umbilical or groin hernia, the openfashion incisions for those wouldn’t be much bigger than with the robot, so sometimes it doesn’t make sense to use the robot for those. It’s really patientby- patient. I sit down with my patients and explain the ins and outs of standard laparoscopic vs. open vs. robotic, and we decide together.”
Drs. Kumar and Belfield emphasized that the robot is one of the tools the surgeon uses – it does not move independently of the surgeon.
Dr. Belfield said she believes robotic instrumentation will get smaller and less expensive as other companies enter the field, driving competitors to make more efficient, smaller, and less expensive technology.
“Years ago, robotic technology was focused on cardiac surgery, but so many specialties use it, there isn’t focus on particular specialties,” Dr. Zhou said. “In a few years when the patent expires, a lot of companies will likely try to come up with new and better technologies.” Dr. Stevens believes some of the instrumentation will result in smaller incisions; she also thinks the number of procedures surgeons are able to do with the robot will continue to increase as more physicians become proficient with the technology, which will allow them to increase the versatility of its use with time and experience.
Dr. Kumar added he thinks technological developments are going to focus on miniaturization for pediatric patients and imaging improvements that will allow 3D images to be overlaid on the patient’s anatomy to better target more precisely something like a tumor.
“Applications will widen,” he said. “Resulting enhancements could mean da Vinci isn’t just a surgical tool anymore, but possibly a treatment delivery method for something like precision radiation completed with surgery. The next 20 years we will see things very different from what we are seeing today.”
Why St. Joseph’s Health?
“St. Joseph’s is dedicated to robotic surgery,” Dr. Belfield said. “We put resources into it, employ excellent robotic surgeons and lead the market in terms of technology. We were the first to have a robot in an outpatient surgical center and the first to have the newer generation of Xi surgical robot in the main hospital. St. Joseph’s is cutting-edge on surgical robotic technology and a high volume center that leads to shorter hospital stays and fewer complications for patients.”
“St. Joseph’s has the longest and broadest range of experience with robotics in Upstate New York,” Dr. Kumar said. “Over the years, we’ve been able to maintain the highest standards through a committee approach to program oversight. The range of services is wide and very high-quality.”
“Our longevity in the field and ability to attract the most talented surgeons are the reasons we get superior results,” Dr. Zhou said.
“St. Joseph’s has been at the forefront of robotic surgery and particularly in the field of general surgery, which really got started doing upper abdominal surgeries, like hiatal hernias,” Dr. Stevens said. “St. Joseph’s has been doing this longer and in significantly higher numbers than any other hospital in the area, and we have continued to increase its use across the breadth of general surgery. We have numerous surgeons with various levels of robotic surgical expertise and experience.
In general surgery, we work as a team, and there’s always someone there to take care of any problem.”
St. Joseph’s:
• leads robotic general surgery cases in Central New York (9,300-plus cases vs. the closest competitor with 7,000);
• has the busiest cardiac robotic program in CNY;
• was the first in CNY to have a da Vinci system at an outpatient facility and the first to have an Xi at a surgery center;
• has performed more than 1,700 robotic cases in 2022 and more than 1,100 so far in 2023;
• have five surgeons who have passed 1,000 robotic cases each; and
• they are the leaders in da Vinci foregut procedures in Central New York, performing 153 cases in 2022 and 102 so far in 2023.
“I think it’s important for people to understand this technology will be the standard of care in many facets of surgery, and it isn’t offered everywhere,” Dr. Stevens said. “Having a hospital filled with surgeons very experienced with the robot is an important option people should know about.”