Traverse City Record-Eagle

January 19, 2013

Robotic surgery gaining ground at Munson


TRAVERSE CITY — Mondays are Dr. William Nowak's surgery day, but for much of the time, you won't find him standing over his patient.

Nowak first makes three to four tiny incisions, about a half-inch long, and then inserts sleeves for four slender robotic arms. He then steps away from the patient to a console about 8 feet away. Burying his head in the machine, he uses joysticks to control the robotic arms, which are outfitted with surgical tools and a camera.

Munson Medical Center bought the da Vinci surgical robotic system in 2009 for $1.7 million. Initially, only three Munson surgeons used the da Vinci. Now that number is up to 15, with as many as 10 surgeries performed using it each week, said Carol McManus, Munson Medical Center's clinical coordinator.

"We have new ones coming on all the time," McManus said. "This is the wave of the future."

Clinical studies show robot-assisted surgery is pricier than traditional surgery, ranging from about $1,700 more for prostate surgery to $2,600 for a hysterectomy. The medical field is still debating whether surgical outcomes justify the higher expense, even as the popularity of robotic-assisted surgery skyrockets nationally. Studies do conclude, however, that surgeons new to robot-assisted surgery are more likely to make mistakes and take longer.

McManus believes that patient outcomes outweigh the higher costs.

"When you see a robotic da Vinci hysterectomy versus an open abdominal or even a laparoscopy assisted, it is less bleeding, less pain, quicker recovery, less risk of infection," she said. "The lack of blood loss is huge. You lose 50 cc's of blood; four times that amount is not uncommon in regular abdominal surgery. Once a surgeon becomes proficient, the operation is as fast, if not faster, than traditional surgery."

Patients with traditional abdominal surgery are usually hospitalized for one to two days, she said.

"With the da Vinci, you're home the next day," McManus said. "We've had patients out shopping within days, but it's not recommended."

Misty Wendel, 37, of Fife Lake, was one of them. She had a robot-assisted hysterectomy about a year ago, stayed one night at the hospital and went to her daughter's basketball game the next night.

"I felt amazing," she said.

Nowak was one of the earliest surgeons to use it and is one of its biggest proponents. A big advantage: it offers a three-dimensional view with magnification of up to 10 times.

"I've been in practice for 30 years and I've done hysterectomies six or seven different ways," Nowak said. "In my opinion, the robotic approach offers an unprecedented view of the anatomy."

He said less expensive laparoscopy surgery is limited to simpler surgeries and offers a two-dimensional view. The da Vinci can do more complex surgeries because the robot's bendable wrists allow for tight turns and intricate maneuvers, he said.

That said, Nowak acknowledged his learning curve was steep.

"I had performance anxiety. Of course, the (early surgeries) are proctored," he said. "Now I've done it hundreds of times. But the learning curve — it's a humbling experience and you have to work through it. You have to get confident. Once you become adept at it, it just takes off, and it's hard to go back."

Nowak said that a surgeon's experience and surgical record are key considerations when deciding on a surgery, robotic or otherwise.

"This isn't for everybody," he said. "Because you don't do it doesn't mean you're a bad doctor. It's just another tool that's revolutionized classic surgery."

The earliest robotic system, developed in the 1990s, sparked the interest of the Defense Advanced Research Projects Agency, which envisioned surgeons operating remotely on wounded soldiers, said Angela Wonson, spokeswoman for Intuitive Surgical, which makes the da Vinci. The battlefield application never came to fruition, but inventors realized its tremendous potential for hospitals, she said.

"There's a lot of technology in medicine that comes through the space or defense program, and this is a good example of one of those," Wonson said.

Urologist Dan Flewelling is one of the first crop of doctors to learn robotic surgery while in residency training. The da Vinci makes sense for urology because the camera can go deeper into the pelvis where it's hard to see, he said.

During his residency, he trained on games to improve his fine motor skills so that using the robot became second nature. Flewelling said he grew up playing video games, which made the transition to robotic-assisted surgery easier.

"You take a ring and move it across these different areas," he said. "I was doing that at the hospital and getting lost in them because they were so much fun. I'd forget I was putting in hours of extra training."

Now at Bay Area Urology, Flewelling said he can do procedures using the robot or the old-fashioned way. But he prefers the da Vinci because he can work in spaces too tiny for his hands.

"It's also best for patients," he said. "They lose less blood and they're back to full strength two weeks earlier."