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daVINCI PARTIAL NEPHRECTOMY HENRY FORD HOSPITAL - VATTIKUTI UROLOGY INSTITUTE DETROIT, MI December 6, 2007 00:00:10 ANNOUNCER: Welcome to Henry Ford Hospital in Detroit, Michigan. Over the next hour, you'll see a minimally invasive partial nephrectomy using the da Vinci S surgical system. In just moments, Dr. Craig G. Rogers, director of robotic renal surgery at Henry Ford Hospital and director of urologic oncology, Henry Ford West Bloomfield Hospital, will perform a state of the art minimally invasive approach to surgically remove tumors of the kidney while preserving as much healthy renal tissue as possible to maintain normal kidney function. Dr. James O. Peabody, staff surgeon of the Vattikuti Urology Institute, will moderate the event to explain critical portions of the surgery and answer email questions from viewers. OR-Live makes it easy for you to learn more. Just click on the "Request Information" button on your Web cast screen and open the door to informed medical care. Now let's join the doctors. 00:01:07 JAMES O. PEABODY, MD: Hi. I'd like to welcome everybody. I'm Dr. James Peabody, a senior staff urologist at the Henry Ford Hospital and Vattikuti Urology Institute. Today we're going to be having a live Web cast from Henry Ford Hospital in the VUI of a robotic-assisted laparoscopic partial nephrectomy using the da Vinci system. I'll be the moderator for the program for the next hour. Dr. Craig Rogers, who you just saw in the video, who's the director of our robotic renal surgery program, will be performing the surgery live from our operating room. I'd like to first go to a prerecorded message from Dr. Mani Menon, who is the director of the Vattikuti Urology Institute and a well-known pioneer in the use of robotic surgery for some additional introductory comments. 00:01:57 MANI MENON, MD: Welcome to VUI, the Vattikuti Urology Institute. I'm Mani Menon, director of VUI. We started doing robotic surgery in October of 2001. As of now, we've done close to 3,800 cases. About 3,600 have been radical prostatectomies, the VIP operation. But two years ago we started operating on kidneys, doing radical nephrectomies and partial nephrectomies. We started this program in collaboration with the Hospital of Kuala Lumpur in Kuala Lumpur, Malaysia, but have since continued doing this. And we've done, oh, I would say, about 100 to 150 renal cases. Today Craig Rogers, who is the director of our renal robotics program, is going to show you a robotic partial nephrectomy, a robotic radical partial nephrectomy. I hope you enjoy the operation and wish him, the patient, and us good luck. Thanks. 00:03:02 JAMES O. PEABODY, MD: Great. Before we go live to the operating room with Dr. Rogers, I'd like to introduce the patient to the audience. Our patient today is a 47-year-old male who presented with an incidentally found left renal mass. His past medical history is significant for hypertension. Obesity: his weight is about 102 kilograms, a little over 300 pounds or 21 stone for our friends in the UK). The patient has a serum creatinine of 1.3, which is just at the border for the normal range. I'm going to show you a series of x-rays here from his CAT scan. He has a 4.2 centimeter left renal mass. This first image is just above the level of the mass, and I'm going to move down through the images. You can see outlined with the yellow arrow the beginning of the mass. And as we move down, scrolling through the images, you can see the mass abuts the collecting system. It's a fairly large circumscribed tumor with an endophytic and exophytic component. A few more images here just to show the complete lesion. Now we'll go to the operating room live to meet Dr. Rogers and have him introduce the patient a little bit more and the rest of the team. Dr. Rogers? 00:04:33 CRAIG G. ROGERS, MD: Hello, and welcome to our live Web cast of a robotic partial nephrectomy. Today, as Dr. Peabody mentioned, we're doing a robotic partial nephrectomy for a patient with a fairly large tumor. This patient has about a 4.3 centimeter tumor. He's also a very large patient. So you may say, "Well, couldn't you sort of cherry pick the easiest case?" Well, we're beyond that. We think that robotic assistance has allowed us to push the limits and do tumors that are larger and patients that might not be considered the ideal surgical candidate. And this is a tumor that's going to require a lot of precision in cutting the tumor out and in reconstructing that kidney. As the CT images showed, it's deep into the kidney. And I feel that the technology today that we'll introduce is something that can benefit us. So Dr. Peabody, I think we'll kind of show the room setup a little bit, and you may have some slides of how our ports are arranged that we can go into. You can see the da Vinci robot is here over the patient, and we'll show some slides of that as well. And then I'll go ahead and start operating and you can kind of see what -- we've already gotten started because we have about an hour of footage and I want to let you see kind of the critical parts of the steps. So shall we go ahead and show them the inside of the screen now? So just to introduce you, go ahead and let go of what you have, everybody. So this is the kidney here in this covering of fat called Gerota's fascia. This is the spleen. And to get to the kidney, you have to mobilize the bowel out of the way. And the bowel has already been dropped down, which is down below us here. You can see the bowel that's been dropped out of the way. This is a standard step with any minimally invasive approach such as laparoscopy, so I figure everybody sort of knows how to do this part. Now, the -- one question that may be asked amongst some surgeons that do this laparoscopically is can you do this whole step robotically or do you have to start this procedure laparoscopically and then dock the robot later? We were able to do all of this robotically. So you can see the psoas muscle. We'll show, there's just a pad there that I used for hemostasis. The ureter is down below. The gonadal vein is down here as well. So we've identified both of those. So the reach of the robot, especially with the da Vinci S system, we can get all the way down and all the way up to the spleen without having to redock -- I mean, without having to use laparoscopy. So we're going to do a lens clean here. Jim, why don't you go ahead and show the port system. 00:07:39 JAMES O. PEABODY, MD: We have a slide here that shows the port placement. This is for a right kidney, so it's a little bit different with a left kidney. But the novel observation that we made through some of our work in Malaysia that Dr. Menon mentioned was that placing the camera port more laterally gives us a little bit more ability to move the robotic arms, the operating arms, up and down. So our port placement is shown here. That central port, the blue one, is for the camera. And we have sort of a baseball diamond-shaped port placement with the two main operating robotic ports would be first and third base with the camera port as second base. Home plate, the yellow dot, is a 12-millimeter port, which is the main working port for our assistant. We place a fourth robotic port, another 8-millimeter port, in this case the left lower quadrant. This image shows the left lower quadrant. And then generally if we need an additional assistance port, it'll be a 5-millimeter port that will be placed in the subxiphoid area. The patient we have today is quite obese, so the ports are all placed a bit more laterally than are shown in this picture, but this gives an idea of our port placement. 00:09:10 CRAIG G. ROGERS, MD: One thing, Jim. The lateral port technique, which we developed here, one thing that that offers us is with a lateral tumor, such as what we have today, it's an easier angle to resect the tumor. Now, it comes at a price. The hilum, or the dissection of the blood vessels of the kidney is a little harder to get to, but we feel that that will pay off in the end. So you know, as you can see, this is a close-up view of the kidney, and I'm going to be working down here. So let's go ahead and with assistance lift this kidney up and we'll kind of show them what we've exposed down below. All right. And go ahead and bring my arms in. Yep, go ahead and lift up like that and then give me my right and left arm. 00:10:16 JAMES O. PEABODY, MD: The da Vinci S system, because of the lower profile of the arms and greater reach, allows us to get up and down the whole length of the retroperitoneum, as Dr. Rogers mentioned. It also has some other features which we'll demonstrate in a little bit, the TilePro feature in particular, which allows us to have real-time view of the ultrasound images. 00:10:46 CRAIG G. ROGERS, MD: Okay. So now let's show everybody what we've done on the dissection here. We've got ureter there that you just saw peristalsing here. And as we work our way up, there's the gonadal vein up above us plugging into the renal vein, which is here. So the renal vein is being covered up by a little bit of soft tissue. Underneath the renal vein, you can see where the artery is pulsating here. So we still have some dissection to do. This is -- not only does this gentleman have some fat on the outside, but he has plenty of fat on the inside, which is going to take a little bit of work in dissecting this hilum here. Now, it looks like he -- yeah, you can see it right here. There's a lumbar vessel coming off of the renal vein. We're probably going to have to get that in order to get exposure of the renal artery. So one thing we can use here is a clip. Now, if I use the assistant to do this, it may be a tough angle, so go ahead and give me a robotic hemolock in the left hand, please. 00:12:10 JAMES O. PEABODY, MD: We have some questions from the Web site. One has to do with Medicare coverage of use of the da Vinci system and whether it's covered by Medicare. 00:12:22 CRAIG G. ROGERS, MD: These surgeries are covered, just like any partial nephrectomy, whether it was done open or laparoscopic. 00:12:32 JAMES O. PEABODY, MD: And another question we had as sort of a general one, talking about the advantages of the da Vinci technique over ordinary laparoscopy or conventional surgery. We have a slide I think we can put up that talks about some of the advantages. The advantages of laparoscopic approaches over open approaches tend to be shown in the first few bullet points: less blood loss, less pain postoperatively, generally a shorter hospital stay, quicker recovery, and a quicker return to normal activities. A number of these can be realized through the use of the laparoscopic procedure as well. However, the da Vinci system I think has some unique advantages as well, especially in terms of the reconstructive aspects of the procedure. Craig, are you able to comment about that? 00:13:36 CRAIG G. ROGERS, MD: Well, so some of the advantages -- you're talking about advantages of the robotic -- 00:13:40 JAMES O. PEABODY, MD: Of a robotic procedure over straight laparoscopic procedure. 00:13:46 CRAIG G. ROGERS, MD: Well, one is precision. Like for example, what I'm doing right now, this is a tricky lumbar vessel off the back side of a vein, and having a robotic instrument like this allows me to be able to steer this clip in where I want it. So one advantage is just having wristed instruments like this where I can precisely place not only clips but stitches as well. So when you're doing a reconstructive surgery such as a -- go ahead and give me the bipolar back -- such as a partial nephrectomy, there's a lot of precision involved in accurately cutting out the tumor and in reconstructing the kidney. So having instruments that give me articulation just like a human wrist is advantageous. Now, what it does is it takes the same proven benefits that have already been established with laparoscopy for a kidney surgery such as decreased length of stay, reduced pain medicine, back to work faster, et cetera. It's the same benefits, but it overcomes some of the technical challenges of doing it by conventional laparoscopy. Now, could this be done by laparoscopy? Sure it could. Can robotic assistance help? Sure it can. At least in our experience, we've felt that having instruments that give you a more natural movement and greater precision, greater magnification, can translate to better outcomes. So you can see in the instruments I'm using here I have a monopolar scissors in my right hand. So these are the scissors I'm eventually going to use to cut the tumor out. In my left hand I have a bipolar forceps, which I'm using to cauterize some of these tissues. The tissues right in this area are very vascular and can bleed, so you kind of have to cauterize your way as you get closer. So in this fat in here is going to be the renal artery, and we're going to kind of have to work our way to it. Another lumbar vessel there. 00:16:11 JAMES O. PEABODY, MD: We have another question about whether the da Vinci system can interface with other da Vinci robots at other locations. This gets to the question of sort of remote surgery or perhaps more likely and maybe more useful remote proctoring of cases to be able to monitor and help a surgeon who's perhaps learning to do the procedure. I think that's something that's in development. I believe there have been a few operations that have been assisted that way. But it's just really, as I understand it, a matter of getting adequate computational abilities, computer speed, bandwidth, to be able to interface. But that would something that would certainly be possible to do. 00:17:05 CRAIG G. ROGERS, MD: Well, I think we've actually -- we've had experience with that ourselves, I believe. You may be able to comment on that more. But this has been done and has been reported on. Now, I think there are issues with the surgeon being required to be in the room in the United States, so it probably isn't something that we would do here immediately as having like where you operate at home or something like that. I'm required to be in the room. All right, so go ahead and suck in here. Whoop, all right. All right, we're going to have to have a camera. We're going to have to clean the camera here. Let's do a lens change. We're going to clean the lens. 00:18:24 JAMES O. PEABODY, MD: Dr. Rogers, we have another question asking about in the unlikely event of needing to convert rapidly to an open operation, say for unexpected bleeding, how rapidly could the robot be undocked? 00:18:40 CRAIG G. ROGERS, MD: Well, that's something I hope that we won't demonstrate today, but it can be done. What you can do is the robotic instruments can be removed. The ports are attached to the robot, but the port and the arm can be pulled away as a unit, allowing quick undocking in less than a minute or two. So you can quickly get in if the need arises. All right, so what we're going to do is get a better look behind the vein here to get to the artery. There we go. So a little bit of lift here. Let me have you push that aside. That's great. See if we can get to the artery in here. So this is sort of the nitty gritty of the whole operation here. This is -- just to put it in perspective for those that don't do this kind of surgery, the main blood supply to the kidney is millimeters below me right now. And it's buried in all this fat you see and it has a lot of small blood vessels that go with it. So we have, as you've seen a few times, we've cleaned our lens because the kidney is so big, kind of flops in the way sometimes. We've got a vessel here. Why don't we put a clip on that, Raj, clip below me. 00:20:43 JAMES O. PEABODY, MD: Craig, do you think the wristed instruments help you in your dissection around the hilum? 00:20:47 CRAIG G. ROGERS, MD: Oh, definitely. 00:20:48 JAMES O. PEABODY, MD: Something you don't have with the straight laparoscopic approach. 00:20:50 CRAIG G. ROGERS, MD: And like here I can dissect -- I can get around this branch. I'm even considering whether to just cauterize this and take it. Hold on, Raj, let me -- since I've got a long enough stump, let's see what we get right here. Yes. Okay, put one clip below me. If you're having troubles getting in there, I'll just take it. Okay. So we release that. That gives us a better window here to where the artery is going to be. So really all we've got to do is get on both sides of it. So one side's going to be in there. Let's get this vessel out of the way. Keep that stretch. So stretch is very important here. Go ahead and lift up again. That's great. I'll zoom in so you guys can see this a little better. So these little branches all over, kind of a rat's nest of vessels, is what stands in our way. Now, once we're confident that we're on both sides of it, then what we can do is we're going to be prepared to put a clamp on the vessels that supply the kidney. This is a big tumor. So if you cut out the tumor, it's going to bleed. So we're going to do what's called warm ischemia, putting a clamp around the vessel to the kidney, around the artery to the kidney to block off the blood supply. And once you do that, you're under the clock. You only have a certain amount of time to work. The -- sort of the accepted dogma is roughly 30 minutes. Okay, so now we're starting to see the artery there. So I'm on one side of it. That's one side of the artery. And we know that the other side is right here. Okay, so we have hilar control. We can put a clamp there and we can block off the blood supply to the kidney. Now, the vein we can also put a clamp on here-- not now, we're okay. So the one clamp can go below, one clamp can go above. We're good. So let's go ahead and drop all this. Now it's time to find the tumor. All right, so all this was just to make sure our blood supply was controlled. Now what we're going to introduce here, or what we're going to show you, is the way we use our ultrasound here. We use a feature called TilePro that allows sort of a picture-on-picture, like when you watch two football games at the same time. Well, when I cut the tumor out, I have my image of what I'm seeing. I know the tumor is in this fat somewhere. I've got to find it. So the ultrasound probe here is going to come in, and I'm going to at the click of a button be able to see on the right -- now, probably your image is pretty small, but on mine it's really big. I see in the lower right corner the ultrasound image. And I can poke right here and you can see where I'm poking on the screen, but you can also see where I'm poking on the ultrasound image. So now I know that the tumor is below that. And then if you look in the lower left side of the screen, you see the CAT scan that shows the tumor. So I can get in any point in time a very precise view of where the tumor is. Now, we're going to have to roll this tumor a bit, so I'm going to go ahead and release some of these attachments laterally. All right, go ahead and put the probe on one more time. Let's find out exactly where we're going to go in. All right, so tumor is right there. All right. So go ahead and come out with the ultrasound probe now. We'll go back to our normal view. Unmag a little bit. And we'll this kidney. Because we're probably going to have to roll the kidney over in order to cut the tumor out. So getting a little bit more mobility on the kidney. 00:25:57 JAMES O. PEABODY, MD: We have a couple more Internet questions I'll just address. One is about the kind of tumor the patient has and another is about the size of the tumor. We measured it about 4.2 centimeters based on the CT images. In terms of the pathology, we don't know. We haven't done a biopsy on the tumor. It's a solid tumor, so it has a very high likelihood of being a malignant tumor, although there are some solid benign tumors that this could wind up being. So that answers those questions. Another questions about support from Intuitive Surgical on-hand during the operations. This comes from the UK. There oftentimes is support. We are a pretty experienced center, so we don't regularly have representatives from Intuitive Surgical on-hand. We're able to troubleshoot many of the robotic problems, but if we do have a problem, they're readily available. When we started our procedures, though, we had regular support from Intuitive, which I think is a useful thing as programs are developing. 00:27:03 CRAIG G. ROGERS, MD: All right. So this kidney's flipped over. Now let's open up. Put on the -- let's find the lower part of the tumor again. I'm going to have you pull the kidney back up just to kind of reconstitute its position. Now, this is where having the camera a little close can sometimes be a little more cumbersome. But once the tumor's exposed, I think it'll pay off. That's good. Yep, just keep holding it there. 00:27:42 JAMES O. PEABODY, MD: There's another Internet question about the upper limit of tumor size for doing a partial nephrectomy. Generally, that's about 4 centimeters. We can do tumors that are bigger than that when there's an appropriate indication for it, but if the tumors are much bigger than that, then oftentimes a radical nephrectomy is the appropriate procedure if there's a normal contralateral [unintelligible]. 00:28:15 CRAIG G. ROGERS, MD: You might be able to replace what I'm holding here with one hand, ultrasound with the other. We'll circumscribe it. So yeah, what you were saying, Jim, about the size of the tumor. So in general, a rough cutoff in the past has been about four centimeters, although there is good evidence to suggest that in select patients, the long- term cancer control is equivalent with patients done appropriately -- with the appropriate operation -- with tumors 4 to 7 centimeters in size. Therefore, if you can technically do the operation, then you can approach these bigger tumors. Come down right here. 00:28:59 JAMES O. PEABODY, MD: We have another question about the use of the da Vinci robot in surgeries other than prostate and kidney, asking can it be used for surgeries other than heart surgeries or other organs. And the answer to that is yes. The da Vinci system was originally designed primarily for use in cardiac surgery [where it isn't used] for mitral valve replacement and takedown of the inferior mammary artery and thymectomies, other sorts of thoracic procedures. It's been used in a wide range of general surgical procedures, really just about anything you can imagine: esophagectomies, Nissen fundoplications. At the more exotic end in Billroth-II procedures. It can also be used for more mundane things like cholecystectomies. 00:29:55 CRAIG G. ROGERS, MD: You go and hold where I am. Good. That's going to be the lower edge of it. It's going to be below us. So what we're doing here is opening the capsule of the kidney called Gerota's capsule. The tumor is going to be within that. So actually I'm going a little lateral here, but you can kind of see the bulge down here where the tumor is going to be. So what I'm -- 00:30:32 JAMES O. PEABODY, MD: And again, the tumor's located laterally in the kidney. We have -- 00:30:40 CRAIG G. ROGERS, MD: It is. Now, although it started lateral, you can see that the kidney is already kind of flipped over. So what used to be lateral is now going to be in front of us. 00:30:51 JAMES O. PEABODY, MD: And the tumor extends sort of inferiorly in the kidney. We have a couple questions from people who maybe didn't see the initial [CTM], so I'll show those again. This is an image from the mid pole of the left kidney showing the tumor. And we'll work our way down through a few images toward the lower part of the kidney. 00:31:16 CRAIG G. ROGERS, MD: There's tumor there. 00:31:18 JAMES O. PEABODY, MD: And you can see now as Craig's dissecting through the Gerota's fat that he's down to the point where he can see the bulge the tumor causes. Because it has an endophytic and exophytic component. 00:31:38 CRAIG G. ROGERS, MD: We'll leave a little bit of fat over that. We're going to have to clear some capsule away from this kidney because after you cut the tumor out, you have to sew it back together, and those stitches need to be accurately placed. So if we leave a little bit of this normal capsule for those stitches to come through. All right, go ahead and hold the fat up right there. Yep. Good. You can move the ultrasound probe back now. Go ahead and grab right there. 00:32:22 JAMES O. PEABODY, MD: There's a question about preoperative imaging and what we typically will use. Many of our patients come with a CT scan. We like to get the 3D scan with reconstruction, so sometimes that requires repeating a CT scan with a specific protocol for that. There's a question of renal vein or IVC involvement. Sometimes an MRI will be used, although occasionally a CT scan will give us adequate images to determine the extent of the tumor thrombus. With tumor thrombus, transesophygeal ultrasound can also be used. I don't believe there's been much experience, if any, in terms of tackling tumors with significant vena caval thrombi, though. 00:33:29 CRAIG G. ROGERS, MD: Robotically? No. I mean, theoretically, robotic assistance could allow you more control in a vena caval reconstruction after you excise the tumor thrombus either from the renal vein, or if it extends into the vena cava, as long as you can get control around that with a clamp. And you can see the bottom side of the tumor here. So you may notice that in this case, just to get better visualization of it, I'm going to go ahead and take some of the fat off the tumor. Now I'm going to send this separately as a pathological specimen. Hold on, take it down this way. So one thing when I was a fellow at the National Cancer Institute, we did a patient that had a renal vein thrombus poking all the way into the inferior vena cava. And what we were able to do doing that robotically is use the robotic clip applier to get underneath that thrombus, exclude it, milk it up towards the kidney, and then accurately fire that to then allow us to transect the renal vein and get control. Now, the reason we did it in the first place was we thought we were actually going to have to clamp the vena cava and reconstruct the vena cava. So theoretically, this could offer assistance even in cases like that. It would have to be very select cases, however. Go ahead and pull this down toward you, Raj. 00:35:11 JAMES O. PEABODY, MD: There's a question about the use of ultrasound, intraoperative ultrasound, for urologists who may not be familiar with its use and how feasible is it without guidance. I guess I would say that it probably would be smart to have guidance if you're unfamiliar with interpreting ultrasound images, at least initially. Arrange to have your radiologic colleagues there to help guide you with the interpretation of the images. Craig, do you have any thoughts about that? 00:35:38 CRAIG G. ROGERS, MD: I would agree. If this is unfamiliar territory to you, I would have somebody there to help you. I do feel that ultrasound plays a critical role here. We're going to get the ultrasound probe out one more time and define our margins of resection here. But when you have a deep tumor like this, one, you have to find the tumor in the first place. I mean, you see all this fat we had to go through to get to it. So the ultrasound can help guide you, one, just finding the tumor, and then once you've identified the tumor, where to cut. Because we still have to accurately define the borders of this tumor to get it out. And I think it's time for ultrasound. Now that we -- speaking of that. 00:36:24 JAMES O. PEABODY, MD: And the tumor is that -- the lesion is bulging just above where your grasper is. That's it. You're just at the junction there, you think, with your left instrument. 00:36:34 CRAIG G. ROGERS, MD: I think everything below me is normal. Let me just sweep this off just a little bit. I think tumor is above us. So go ahead and let's switch back. Let's mark this tumor out. Let me have you go like this, Raj, right on the crotch there. Yep. Okay, there you go. 00:36:57 JAMES O. PEABODY, MD: Down in the lower right hand corner you're seeing ultrasound images. 00:37:00 CRAIG G. ROGERS, MD: So go to tumor there. Right. So we see tumor. Now come back. That's normal. Go back on tumor. I'm going to poke here. Come back down a little bit. Okay, good. All right. So let's just start marking this junction here. 00:37:26 JAMES O. PEABODY, MD: About how far away from the tumor do you like to be when you're doing this? 00:37:31 CRAIG G. ROGERS, MD: Say that one more time. 00:37:33 JAMES O. PEABODY, MD: About how far away from the tumor, how much of a margin do you -- 00:37:38 CRAIG G. ROGERS, MD: Well, margins have changed over time, but in fact, I just came from the Society of Urologic Oncology meeting where we had a discussion about this. And now the thought is evolving to any margin that's negative is an adequate margin as long as you've got it all. And that's one thing where the robotic assistance can potentially help because if you are coming at a closer margin, you can see better with this in order to define that margin. All right, so I'm going to have to lift this up now, drop this fat down, and we're about ready to go here. Now, it's going to take a good, oh, 25 minutes or so to cut and reconstruct, so go ahead and grab that fat one more time. So I'm hoping that we'll have most of this out by the time we have to stop the live show here. Well, what do you know, they're going to extend my time. So pull down towards you. Now, that fat that's attached right now, we're going to be sending that off separately. We've got to remember that. And let's march our way around on this tumor. Pulling this out. You have to come around the top, so we're going to cut front to back. Let's get the best angle here. Let me have some suction right in there just to define this border a little better. Yep. That's great. 00:40:02 JAMES O. PEABODY, MD: We have a question about the recovery time and the usual hospital stay for patients like this, which in several series that have been published ranges from about a day and a half to four days in the hospital. 00:40:19 CRAIG G. ROGERS, MD: Yep. So the main benefit here is having a minimally invasive approach. Whether it's done laparoscopically, robotically, it's a minimally invasive approach avoiding the big incision. And it's really just a question of whether the robotic assistance can offer the same benefits of a minimally invasive approach to more people. And if you have select patients, such as these, with a challenging tumor that you might not otherwise try laparoscopically, you may spare some of these patients a big incision. All right, so we're going to go for it now, resecting along this plane. Let's go ahead and put this port in just a little bit more. Actually, you know what? It's good. So let's go ahead and get ready to clamp. So we're going to need a short, straight bulldog. Let's go ahead and lift the kidney up now, find where we were. We'll get on the hilum here. Hold on, careful. Let's find where we were. So there you see the clips where the hilum was. So go ahead and back off a little bit. Put your -- yep, not on the vein. Lift up. Excellent. Now can you suck in there if I lift up for you, Raj? Just to expose? Okay. Now let's come off the TilePro and let's mag down so everybody can see a little better. All right. That was our window here. Let's lift up just a little more. So that was it. All right, now if you can replace me just so I can redefine -- okay, so there's one edge. That's where your other clamp is going to go. Here's the other edge. 00:42:52 JAMES O. PEABODY, MD: And that's the renal artery there. 00:42:53 CRAIG G. ROGERS, MD: Yep. Okay, so go ahead and bring the bulldog clamp in. Suck one more time. Yep, this is our test clamp there that you're all the way around. Okay, so short, straight bulldog first followed by the long, straight bulldog on the vein. Go ahead and suck again. You've got that bulldog coming in. And the clock'll start ticking at this point once we get this on. Okay, suck one more time just to see your edge. All right, there's your upper edge. Go ahead and open and kind of hub it right in there. Yep. In, in, in all the way. And release. Okay, somebody watch the clock for us. Go ahead and get the long, straight bulldog for us now. On the vein. And just come right in here on your vein side, watching for that -- go above that wet clip so we don't hit that. Yep, go ahead and take your sucker off now and then go ahead and come on in. Big bite. There you go. Ah, hold on. Let me see if I'm happy with that. Go ahead and go -- yep. Is that as far as it's going to let you go? That's fine. Go ahead and take it. Okay? Come on off. Trying to catch on you? Hold on. Yep. Go ahead and slide off. You're fine. All right, so let's flip the kidney down now. Yep. Let go. 00:45:07 JAMES O. PEABODY, MD: So there are two assistants helping Dr. Rogers here. We have a question about that. One main assistant who's controlling the bulldog clips there, the ultrasound, and the suction. And you can see a grasper coming in there. And the assistants provide a supportive role, changing the instruments. Now Dr. Rogers is just beginning to excise the tumor here. So we'll focus on that for a little bit. 00:45:44 CRAIG G. ROGERS, MD: Now, this is still going to bleed. We expect that. There's going to be a lot of congestion within the kidney itself. I would love a prograsp in my left hand, if you'll give me one. 00:46:20 JAMES O. PEABODY, MD: Prograsp just gives you a little better grasp there than the bipolar? 00:46:24 CRAIG G. ROGERS, MD: Yeah, the sharp tips. Go ahead and give it to me if you've got it. The sharp tips help prevent entry into the tumor. Yep, go ahead and go for it. Quick exchange. And as you can see, we've got a big, bulky tumor here. It's going to take some work getting it out. So I need kind of a bulkier instrument. 00:46:52 JAMES O. PEABODY, MD: Craig, do you ever have a problem with the perirenal fat adhering to the capsule, and do you think the robotic approach helps you a little bit? 00:46:58 CRAIG G. ROGERS, MD: Oh, yeah. Sticky fat, it's miserable. So the articulation helps me kind of scoop that off. All right. Let's come down. Good. All right, just intermittently suck in there. Keep defining the -- that's good. Just hold that plane. Now, you don't want to work in a hole, so you've got to just keep moving around, working our way down from the top here. Yep. Come back down again. So you can see I'm outside. I've gone a little wide of the tumor there, so I'm going to correct. Come back here. Okay, let's come back down again. And then go ahead and lateralize that. So what I like here is the ability to be able to mag in. Yep. And you were talking about sticky fat. This is where you get it, right in here. So I'm going to need a grasper on this fat holding it back because it's going to keep getting in my way. Nice. All right. Yep. Occasionally we can -- so you can see collecting system entry right there. Yep. Go ahead and define our tumor again. Now, can you pull that foreground stuff out? There we go. Go ahead and lift that up. That's fine. Come around this way. Now, Pete, you've got those stitches all set to go. I'll be taking the -- all right, I'm going to need that fat lifted up, if possible. I'll go ahead and grab it, actually. You got it? Nice. 00:50:34 JAMES O. PEABODY, MD: The location of the tumor, you don't need to bring the ultrasound back in to reassess things? 00:50:39 CRAIG G. ROGERS, MD: Well, right now I'm okay with the margin that I'm getting, but if -- I mean, I'm okay with how it looks. If I was in doubt, yes, I would bring it back in. All right. I may end up even switching scissors to the long-tipped scissors if I'm still having trouble getting the cutting that I need, although it's coming. You've just got to kind of work it out. That's the nature of the beast with a big tumor like this. All right. Now, Raj, I'm going to have you push up a little bit. Or actually, you pushing down is great. Go ahead and keep doing what you're doing. This is where we had two planes here. I'm going to recapture this. So push that down. Bring this up. So that's slowly coming. And we'll mag down here. 00:52:25 JAMES O. PEABODY, MD: With the da Vinci S, you can zoom in through several different levels, which helps, without needing to move the camera forward. 00:52:33 CRAIG G. ROGERS, MD: [That's why we're out.] So still attached by some fat here. Hold on. Lift up still. All right. Lay that off to the side and let me have two needle drivers, some stitches. So that took nine minutes to cut the tumor out, but look at that huge crater there. So you know, this -- and there was a small entry into the collecting system I saw on the left side as we did that. What's that? Yeah, I'll take the 3-0 and an RB1 needle, please. 00:53:19 JAMES O. PEABODY, MD: Craig, can you talk briefly about cold cutting versus using cautery? We have a question on the Internet about -- 00:53:26 CRAIG G. ROGERS, MD: Well, I think you need to cut these out cold to retain your margins that the pathologists needs to tell you that you have a clean margin on this. So I believe in doing cold resection. 00:53:40 JAMES O. PEABODY, MD: A lot of your feedback seems to be the visual cue of how -- if you're seeing normal renal tissue as you're cutting through it. Is that? 00:53:45 CRAIG G. ROGERS, MD: Yeah, I don't know if you can appreciate on the screen what I'm seeing 3-D, but for me the visual cue is huge that allowed me to kind of keep these clean margins here. You can see that's a steep slope downward. Now, go ahead and give me the right hand with a stitch. Uh, okay, you need me to pull back so you're -- that's out. You're going to have to push that in a little more. Yep. All right. And are you able to give me another hand? Okay. If not, just give me a stitch with one hand. That'll work. Just go ahead and hand me the stitch first. 00:54:35 JAMES O. PEABODY, MD: So a question about whether two assistants are absolutely needed for this operation. 00:54:40 CRAIG G. ROGERS, MD: Oh, absolutely not. Yeah, you can do this with one. In fact, I didn't really showcase it today because we're already running out of time, but we use the fourth arm to replace some of the moves of an assistant. Because people say, "Well, if I do this lap, I can do it by myself, and now I'm more dependent upon an assistant." Okay, go ahead and suck in the bed for a second. And that's true that initially a skilled assistant is a necessity, but as we're utilizing the fourth arm more and more for things like elevation of the kidney -- I'm going to leave that there. Why don't you go ahead and give me the -- excellent. And actually, I'm going to rethrow this. Hold on, Raj. Okay, suck one more time. So we had one vessel right there that you can actually see. So place this. Now, this can be done either freehand tying or with lapro ties at the end. Lapro ties are absorbable clips. Oh, hey, what do you know, they gave me a lapro tie. All right, so you're going to get to see this one. So lapro tie goes on like this, and that means that they'll have to give me another lapro tie here. So now I can hold that up. Let's get a bigger bite on that. Yep, go ahead and lapro tie -- if you've got a lapro tie on one, we'll lapro tie the other one as well. 00:56:21 JAMES O. PEABODY, MD: You're closing the collecting system here, Craig, or a vessel, do you think? 00:56:24 CRAIG G. ROGERS, MD: A vessel. This is where sort of the oozing has been coming from. The collecting system, I think, is up to the left. Now, we -- we thought about putting a ureteral catheter up to inject methylene blue, but the visualization you see is good enough, I feel -- go ahead and suck one more time. 00:56:47 JAMES O. PEABODY, MD: Think you can tell when you're in the collecting system or not? 00:56:49 CRAIG G. ROGERS, MD: Yeah, I think I can tell. And go ahead and take that one. We got that last vessel right there with that last stitch. Go ahead and take it. And cut this. Yep. Nice. And I'll just reuse this stitch and free-tie the next one, and then we'll start our bolster stitches. So the one more I'm going to place is right there because that's where I saw some entry on the last one. All right, yep, go ahead and cut a little shorter. Yeah, right there. Nice. And I may just actually figure-of-eight this one as well. I think this is the benefit of not having to take this gigantic margin is that we spared him the gigantic entry into the collecting system. And so I think that it's just this one area here and we'll be able to close this. 00:57:48 JAMES O. PEABODY, MD: There's a question about whether we routinely use the ureteral catheter. I think in tumors where we think it's very unlikely we'll get into the collecting system, we probably wouldn't if we -- 00:57:56 CRAIG G. ROGERS, MD: Yeah, routinely no. And there's been debate on this whether you need to even close the collecting system. And part of that debate is hinged on some of the complications that you can see with conventional laparoscopy, where if you do this with a big needle, such as you need for conventional laparoscopy, you are more at-risk of an AV fistula, of an excluded [calix] of these complications that arise more from the needle size and the depth at which you throw it. But this is an RB-1 needle. This is a really precise needle. And I don't think we're going to have any of those issues. So I think when patients have a leak, that's a miserable complication. If you can just put a couple stitches in to avoid it, I'd say why not? Okay, go ahead and take this out. Let me have the bolster stitches now. 00:58:52 JAMES O. PEABODY, MD: If there was a leak, you would treat that by placing the stent. 00:58:57 CRAIG G. ROGERS, MD: I would. I believe in early stents, if someone does have a leak, to try to minimize the morbidity. All right, so let's have the -- I'm going to go ahead and use a 2-0 vicryl suture. Let's go ahead and close this. I'm going to close this end to this end. We'll put three of those in. And yep, great. All right. Go ahead and push that away from me a bit. I think we're good. Just trying to get some capsule here. These have lapro ties at the end of them, just like that last stitch I put. The lapro tie is an absorbable clip. Okay. Let's tuck this up for a rainy day. Let me have the next one. All right. 00:59:57 JAMES O. PEABODY, MD: So the plan will be to put three of these in one side and then put your bolster and FloSeal in? 01:00:02 CRAIG G. ROGERS, MD: That's right. You know, just getting some capsular bites here. Yeah, we'll put a hemostatic agent -- we use FloSeal. You know, it's -- they're all good. There are lots of good ones out there. But that's just our agent of choice. Okay, let me have the last one. Okay. So they're going to let us go over just a few minutes. So all you're going to see here is I'm going to put this bolster on this side. We're going to lay some FloSeal. We're going to put some Surgicel bolsters in the middle, come over the top with our stitches on the other side, and call it a day. So if they cut you out a few minutes early, you'll at least know -- 01:00:49 JAMES O. PEABODY, MD: What the next steps are. 01:00:50 CRAIG G. ROGERS, MD: What the next steps are. 01:00:57 JAMES O. PEABODY, MD: It sounds like we'll be able to stay through the rest of the procedure until we come off -- 01:01:04 CRAIG G. ROGERS, MD: You can see the capsule of the kidney crept back there, so you definitely want to get that or it tears through. Okay, go ahead and get -- actually, let me have the bolsters first. Give me two bolsters and then have the Surgicel ready. All right. Go ahead and drop those. 01:01:35 JAMES O. PEABODY, MD: You've pre-tied these. 01:01:36 CRAIG G. ROGERS, MD: Yep, these are just Surgicel tied into little, you know, cigarette shapes or whatever just to lay in there. Go ahead and inject the FloSeal along this and I'll take the last bolster after that. Then I'm going to have you kind of push this fat away while we put that other stitch on. Hold on. Let me move this aside for you. Okay, go ahead and inject. Yep, start up high, let it drip down. Yep. Little runny today. That's all right. Okay, one more bolster. Yep. Okay, so it's time to sew. 01:02:56 JAMES O. PEABODY, MD: This is an SH needle you're using? 01:02:58 CRAIG G. ROGERS, MD: Yes, it is. 01:02:59 JAMES O. PEABODY, MD: It's a little bit bigger than the RB-1 you used. 01:03:03 CRAIG G. ROGERS, MD: I just want to confirm this is the middle stitch. That's actually the upper one. Actually, all right. Yeah, it is bigger. Because you want a nice bite of capsule. Go ahead and lateralize that fat, please. Take that over that way and let me catch the capsule, which has crept back here. Can you push that over any more? Yep, let me take this. That's what I want. 01:03:36 JAMES O. PEABODY, MD: Get a little bit of the parenchyma and a good bite of the capsule? 01:03:38 CRAIG G. ROGERS, MD: Big bite of the capsule. All right. So we'll use that to secure -- so you can already see it's not a lot of parenchyma there, but as long as it's enough to hold, we're good. And we'll get all of them set up and then start cinching. You have the lapro ties ready, Pete? All right. Go ahead and pull that back again. Help me to find that capsule that's retracted on us. Take a little fat with it. What the heck. All right. And okay. Last one. Now, I'm going to -- once this last one's in, guys -- let's find it here -- we're going to have to do some compression of the kidney. We're going to bag this specimen. Okay, go ahead and lateralize the fat again. Yep. Here we actually have intact capsule. So I'll take that, try not to go through our other stitch, which I managed to do. All right, lapro tie is ready. Let's go ahead and secure -- yeah, go ahead and stay where you are. I'm going to need you to keep pushing that over. Not the stitch, though. Yeah, it'll tear through. Okay. So that one's cinched. This one -- this one's going to be a little trickier to cinch. All right, go ahead and put a lapro tie in the top one and get this out of your way. One second. Hold on. And I'm going to cinch -- let's make sure it's over the top, that it hasn't seesawed through, which it has. All right. All right, go ahead and take this one, cinch it down. Yep. All right. Get ready to cinch this one down. The top one we're going to have to just call it quits because it snapped off. You have another one? Okay, go ahead and cinch this one down. Yep, go ahead and take that. Okay, cut these off. Well, let me show it to you better. So yeah, cut this off. Yep. And cut this one. Yep. Let's take these out. Go ahead and remove those two. And we're going to take the clamp out. So remove those two, then I'll give you one more. Yep. Make sure you're free. Yep. They both coming out okay? And we'll take this one out. Now, we left a lap pad in there to help with our dissection, so I'm going to put the lap pad over the top here to help hold hemostasis. And then we'll take those clamps off and call it a day. So go ahead and take this one out. We'll put this last one in off-clamp after the clamp comes off. I think at that point they're going to cut out here. Can you -- do you -- if you got your needles, then go ahead and get this one. Otherwise, I'll tack it up and we'll just get -- yep, and take that one out. Yep, you got it? All right, so what we'll do is take the clamp off. We're a little smudged, and I apologize for that, but let's take the clamp off, and then we'll do a lens clean. Let's mag down again. Okay, yep. No, not while we're on clamp. Get the clamp off first. As long as you can see. Okay, time to get the clamp off. Go ahead and suck down there so we can find it. Somebody lift up for me. All right, go ahead and see if you can get down to the artery. Take the vein clamp off first. Yep, go ahead and take that one off. Yep. Okay. Now quickly now take the artery out. That's fine, just leave it there. Yep, take that one out. Now get the vein one out. You have to remove them from the body. Don't drop them. All right, that's fine. And I think we're going to call it there, Jim. 01:10:43 JAMES O. PEABODY, MD: All right, should we -- should we take a look back up at the operative site? 01:10:53 CRAIG G. ROGERS, MD: What I'm going to do before we really peek in there is put some pressure on that with a laparoscopic pad. Now, I think our ischemia time was 25 minutes, I was told. 01:11:04 JAMES O. PEABODY, MD: That's about what I had, yep. 01:011:08 CRAIG G. ROGERS, MD: All right, now go ahead and lift up. Let's find the lap pad. And let's do a lens clean, actually. 01:11:22 JAMES O. PEABODY, MD: Craig, have you had any problems on the vein, putting those bulldogs in? There was a question about whether a vein injury could happen as a result of that. Have you seen that ever or no? 01:11:33 CRAIG G. ROGERS, MD: I have not seen a vein injury from the bulldog clamp personally. This is an atraumatic clamp. It's wide, so it has a broader surface of its closing force. So I have not seen any issues from that at all. 01:11:50 JAMES O. PEABODY, MD: A couple other questions just while we're finishing up here. Diet, JP drain removal, foley removal. What's your sort of protocol for that? 01:11:59 CRAIG G. ROGERS, MD: So what we do -- let's go ahead and lay that on the tumor, lay that on the bed, and just hold pressure there. That's fine. So while we're holding pressure for about 5 minutes or so, I'll just talk with you. So what our normal protocol is is you start feeding them the day after surgery. You get them up walking around. If you advance the diet, if they feel -- most of them will have a drain in. In fact, we will put a drain in at the end of this case in case there's any leakage of urine. We take the drain out before they go home, which is roughly 1-1/2 to 2 days after surgery is our standard protocol. They'll go home on oral pain medicines. We usually say no heavy lifting or straining for several weeks after surgery. Once they're off the strong medicines, they can start driving and get back to their normal activities. But that's the normal routine after this. 01:12:57 JAMES O. PEABODY, MD: Another question about what was done, if anything, before the clamp went on in terms of maximizing or hoping to minimize the injury from warm ischemia: Mannitol, IV hydration, change in needle pressure. 01:13:12 CRAIG G. ROGERS, MD: We give Mannitol beforehand, which sorry I didn't announce that, but yeah, we give Mannitol ahead of time. Okay, so now while we're waiting here why don't we go ahead and bag the tumor. So let's go ahead and take care of the tumor here. That's what we're here for, right? 01:13:40 JAMES O. PEABODY, MD: Dr. Rogers, we have an email comment that I'll read. It's from a patient of yours. "As a recent recipient of a very successful result of the expertise of Dr. Rogers and Menon, I think this Web cast opportunity fascinating. My recuperation period was very short and the follow-up by the dedicated team was beyond expectation. Sincere thanks to the VUI team. 01:13:59 CRAIG G. ROGERS, MD: Oh, that was nice. 01:14:02 JAMES O. PEABODY, MD: We'll have to comp him on his next office visit, I think. 01:14:05 CRAIG G. ROGERS, MD: I'll have to find out who it was. I guess you can't say it overhead, but yeah, that was very nice. 01:14:13 JAMES O. PEABODY, MD: Do you have a particular recommendation for ultrasound equipment? Do you want to talk about that or do you think there are several -- 01:14:18 CRAIG G. ROGERS, MD: Oh, I'm glad you said that. I mean, any ultrasound is better than no ultrasound. We've been using a machine by ALOKA, which is the newest machine called the alpha 5 that allows us to do Doppler imaging as well. Now, I didn't show you, Ed, for lack of time. Go ahead and put that back on again. But this allows very high-resolution images and it allows also the ability to Doppler vessels. And so, for example, if a tumor's sitting right on a branch of the renal hilum -- don't move that around, just keep it where it is. If it's on a branch of the renal hilum, you can identify how deep to go. So for us, having a high-resolution ultrasound has been invaluable. All right. Actually, I think this is a good place to cut out. Now, I'm going to take another SH needle, please. And go ahead and put it on for now. Keep sucking. While we're waiting for that, I'm going to close Gerota's fascia. So all we're going to do now is I'm going to take a needle and close the Gerota's fascia here to the other side to provide a little -- obviously we'll take the lap pad out, but for right now let's leave it where it is. You know, it's providing good hemostasis. All those needles that I put through the kidney, they bleed, so pressure stops the bleeding. So we leave that on. We're off-clamp. It doesn't matter. All that oozing is going to stop. If it was arterial bleeding, there'd be bleeding all over the place, and it's not. So we know this is venous bleeding. This will eventually stop. And the more pressure we get, the better it will be. So we're going to put a needle in. We're going to suture this fat to that fat and just cover our defect, and it improves the hemostasis. So we put a few stitches in here. Go ahead and put a lapro tie on the end of that SH needle if you can and we'll put a drain off to the side here. That drain will go out -- our goal is that drain will be removed before the patient comes home. And the patient's going to have a -- the patient's going to have a catheter in overnight. That catheter will be removed in the morning. So that's kind of the general game plan here. Yep, I think we're good. I just want to thank everyone for coming to watch this today. 01:17:04 JAMES O. PEABODY, MD: Great. Thanks. Well, we're ready to wrap up here. This has been a wonderful demonstration by Dr. Rogers of this particular technique, and I think it's been a nice demonstration of the utility of the -- of the robot. A number of people who are doing laparoscopic nephrectomies and now laparoscopic partial nephrectomies that still could be a challenging case, especially for the tumors that are more intrarenal, that especially are the ones involving a collecting system. Techniques have evolved -- Dr. Rogers demonstrated some of those that could be used laparoscopically, but I think it's clear that the ability to do sutures is made easier by using the robot. And we've found that this has made our laparoscopic partial nephrectomies easier to do. I'd like to thank everybody who has been with us throughout the Web cast here, those of us who joined. I appreciate the interest from the number of people who sent email questions to us. We tried to get to as many of those as we could while still allowing you to see the surgery and listen to Dr. Rogers' thoughts as he was going. So again, we'll close here from Henry Ford Hospital and the Vattikutti Urology Institute. Thank you very much and have a good night. 01:18:36 ANNOUNCER: Thank you for watching the minimally invasive partial nephrectomy procedure using the da Vinci S surgical system performed at Henry Ford Hospital in Detroit, Michigan. OR-Live makes it easy for you to learn more. Just click on the "Request Information" button on your Web cast screen and open the door to informed medical care.
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