a

Live robotic hysterectomy surgery

guys we're all Michael and thanks for

joining us for this very special webcast

we are live at st. Luke's Hospital and

Cedar Rapids doing this live DaVinci bub

surgery I am KCRG tv9 Ashley Munson and

I would like to have you introduce

yourself now they're good I know dr.

John repin traffic pci urology and

minimally invasive director here at st.

luke's hospital and we're just getting

started here they're doing some prep

work in the other room we're right as

you can probably see behind us right in

the middle of an operating room here at

st. Luke's Hospital

we are taking your questions on this

morning about DaVinci surgery we're

going to get some background information

but we want to get that email address

out there so that in case you have a

question you can go ahead and send it on

in that email address is live at CR st.

Luke's comm live at CR st. Luke's comm

so if you have any questions about da

Vinci Surgery whether it be a

hysterectomy as we're going to see today

or any other kind of procedure go ahead

and pop us an email oh let's talk a

little bit now though about what goes

into preparing a patient for surgery

that process is underway right now so

tell us kind of you know when they come

to the hospital that morning what do

they expect well

they roll in into the pre surgical area

about an hour to an hour and a half

before surgery they're asked lots of

different questions about when they last

ate what allergies they have they have

changed out of their normal street

clothes into their hospital gown and

then we move them back to the operating

room after they've talked to the

anesthesiologist it was not the time to

surgeon we'll see them ahead of time as

well I just to go over things further

than a last minute fashion and make sure

everybody's also your age in terms what

we learned was that have

that's a okay yeah and once they moving

back to the operating room we gently get

them off to sleep and subsequently

proceed on with the prepping getting

things ready to go okay you know how

many people are in the operating room at

any given time obviously a surgeon to

operate the DaVinci itself but obviously

nesting well the anesthesiologist is

everybody at the beginning on the end of

the case and making sure things go as

well throughout and then in terms of the

operating room staff we always have at

least one person scrubbed in depending

on the type of case often what the

DaVinci cases will also have a second

surgeon scrubbed in at all times as well

and today that's doctor McCarran we

always have at least one circulator in

the room as well which means that's the

person who gets things that you need and

not scrubbed in sterile e to allow

access to things that you need for the

particular moment of the procedure such

as a suture of some type or a different

instrument how long does it take to

actually prepare the robot which we'll

see here in a couple of minutes but you

know to actually get it ready it's in

the operating room on standby pretty

much with all times but there's got to

be some prep work involved right you

need to drape the robot out with special

little plastic grapes and then make sure

it's all sterile a done and the mo our

staff here at st. Luke's has been very

good about doing that they show up a

half-hour to 45 minutes earlier than

they normally would to get things ready

and so it does take a little bit of time

especially when you first start with the

program but we've gotten it down down to

where really they are turnover time is

very minimal and they can have that

robot ready to go again in 15 minutes or

so okay we have taken a lot of questions

one of the questions I'm somebody wanted

to know was how expensive is the actual

machine because you know everybody knows

medicine is expensive the gadgets and

gizmos you guys work with they're really

pricey so tell us about the cost of the

DaVinci well one point six million

dollars is for the newest system right

now and that's the upfront startup cost

and then it's about a hundred thousand

dollars a year to maintain that we

currently obviously as technology

continues to improve and new things are

added to the robotic system you can

expect that price to probably go up a

little bit it's an expensive little

surgical instrument that's for sure

okay now you're a urologist um the

procedure we're seeing today is

obviously a gynecological procedure

right tell us a little bit about you

know is that is the general way you

would operate the same I mean in terms

of how many incisions you make how tell

us how that kind of goes for you well

depending on the procedure even from a

gynecologic or a urologic or general

surgery or whatever practice happens to

be using it the robot itself is

essentially the same there's a one

camera arm that's controlled by the

surgeon at all times and then three

three arms that independently move

instruments also controlled by the

surgeon based on foot pedals and hand

manipulations so that doesn't change

however what does change are the

instruments that you may use in any one

given time which these are

interchangeable the other thing that may

change is where the incisions are placed

depending on where you need to operate

on on if for example we're operating on

a kidney we'll have five to six small

incisions in the left upper quadrant or

the right upper quadrant if it's lower

lower down in the abdomen such as for a

prostate or for a hysterectomy then

obviously your incisions are gonna be

lower down more focused towards sort of

a pelvic area okay

let's talk a little bit more about you

mentioned a couple of the different

procedures you know kidneys prostate and

uterine surgeries what other kinds of

procedures can they be used for and are

they being used for here in Eastern Iowa

well the list continues to grow in terms

of actual surgeries that can be done

with the robotic system and

almost any surgery you can think of for

the most part could potentially be done

robotically it's not always practical to

do that both in terms of space because

the robot obviously is sort of a big

instrument just from a time aspect as

well sometimes it's not that handy some

of the things that are done now here at

st. Luke's we do robotic prostatectomy

x' partial nephrectomies so we take off

part of the kidney for kidney cancer

another thing we do here is we help the

drainage system of the kidney now that's

the plug for the urology inside of it

from a gynecologic perspective

hysterectomies we do sacral couple

suspensions which just basically means

checking the uterus of vagina back up

into the abdominal cavity for pelvic

organ prolapse anytime that's that type

of thing does that happen maybe with

childbirth and things like that or

certainly came naturally

can that happen to women again okay we

did have one question that I think it'd

be appropriate to actually bring in

right now from Shelby and she had a

question about could this be performed

for rotator cuff repair obviously that's

a very popular surgery to have but you

mentioned you know it may not

necessarily be the best method for every

surgery right you know I think that a

lot of it has to do with the space issue

in this in the space issue of the

rotator cuff there may not be enough

room just to get the instruments in they

need to speak be spaced far enough apart

that you have enough room to work and

ultimately I guess the orthopedic

colleagues would have to answer whether

you can do it with this robot or not I'm

sure you could do it at this time what

the instruments that we have is just not

practical I I wouldn't say it could

never be done that way I have a feeling

as the future continues with robotic

surgery and things become smaller and

smaller in terms of instrumentation

you know disguise the women know the

possibilities

yeah and I know I'm obviously we were

talking about some of the research

that's being done different procedures

being done across the country with this

as well that may be available eventually

here in Eastern Iowa as well what are

some of the avenues that they're

pursuing nationally well some of the

other big things that are done right now

cardiac surgery they ordered replacement

type surgeries so instead of a large

sternotomy you end up with a bunch of

small incisions across the chest which

obviously is big for recovery they're

doing that a number of institutions from

a general surgery standpoint they're

doing lots of different surgeries the

most common thing they're doing right

now is like a Heller myotomy which

basically means that when your diaphragm

is up too high they can kind of close

that back down for you so you don't have

maybe as much problem with our reflux

disease okay now I heard him mention the

word recovery and that's a lot of why

the davinci is so fantastic recovery

time for patients can be cut way down so

tell us a bit about the difference in

recovery time for like let's say a

traditional hysterectomy and the one

we're going to see here today well

traditionally for an abdominal

hysterectomy and dr. Rosenbloom could

probably speak to this a little bit

better here in the near future but often

six weeks would be your recovery time

because your incision would be anywhere

between a four and two six inch incision

down below the belly button it just

takes time for that off to heal now the

robotic system you end up with more

incisions but those incisions are much

smaller and so instead of patients being

in the hospital two to three days

they're home the next day instead of

being six to eight weeks back to their

regular activity it's often two weeks

and much less than that depending on

their level of activity and what they do

I know that we have patients who go back

to work often the week after surgery

depending on what they

and so from that standpoint is very nice

I think that certainly in the short term

the robotic surgery is much better for

recovery and hopefully in the long term

as well their surgical outcomes are

going to be a lot better and

subsequently allow long term sort of

lasting to what you wouldn't have done

in the first place yeah I think that's

what everybody probably if you have to

have surgery you want it to be quick and

as at least a little least amount of

pain as you could possibly have so I

definitely advantages of The DaVinci as

well let's talk more about what we're

gonna see in there you mentioned that

the surgeon controls it at a console you

tell us kind of about what they can do

with their feet in their hands well you

know I think one of the things that's

nice about this broadcast is when people

think about robotics and surgery they

think perhaps of c-3po from Star Wars or

you know like maybe the automaker robot

that's just sort of as assembly line

process and this this really isn't that

this robotic system is nothing nothing

really more than a very fancy expensive

surgical tool that is allowing us to do

some kind of special things here and and

what the console surgeon has before them

they sit sort of hunched over in a

little thing and when they they look

into the actual monitor what they see is

a three-dimensional picture of what's

going on which is very unique in terms

of minimally invasive surgery right

normally be traditional like laparoscopy

had to gallbladder out or or and if you

had your kidney out laparoscopically

that's a two-dimensional view that's

something that you can learn from a

spatial relationship but it's sort of

like trying to pound nails in with one

eye shut that doesn't sound very good

hang of it but you don't want to take a

full swing right away yeah definitely

just DaVinci system however is a three

dimensional system now what you'll see

today on on the monitor and at home as

well as here is a two-dimensional view

what we have to remember is that

actually dr. Rosalind will be having a

3-dimensional view Saussure like going

to Jos 3d with the red glasses on

arrangement he doesn't have to wear

those the whole shebang he gets it right

in front of his crew

okay well we just want to kind of update

you on where we are again we are taking

your questions for today's a live

hysterectomy and about a DaVinci surgery

in general so if you have any questions

just send us an email that email address

is live at CR st. Luke's com

live at CR st. Luke's comm and they are

in process right now actually just give

you kind of an idea of how things are

set up here we're in an operating room

directly adjacent to where the actual

surgery is happening you'll be able to

see the surgery and you have cameras in

there as well so we're kind of just

waiting there scrubbed in and they're

waiting for the patient to get in we

talked a little bit earlier about the

process of prepping a patient for

surgery but surgeons have to go through

a process as well so tell us kind of

what that's like

well obviously you have to get gown and

gloved and and before you can do that

contrary to what you see on ER perhaps

you actually have to put your mask on

they don't put that on in the operating

room for you okay well you have to scrub

and every different institution has

different types of rules in terms of how

long you're supposed to scrub and things

but on average it's between three and

four minutes and you get all dry it off

and once you're going to go out then

you're sterile a draped and pretty much

you really can't touch anything unless

it's on the operative field and that's

one of the things about the robotic

system is you have to be careful about

moving in the room it's a big system and

it's also stair lead rate so you can't

really run into it otherwise you have

many great things so that's just

obviously to keep bacteria from getting

right into the room to decrease your

chance for infection there's always a

risk of infection no matter how you

operate but the other side of that is

that with smaller incisions you think

that your risk of infection would be

less as well

yeah post-op you think okay very good

well we should take a couple of the

questions that we have right now we have

a woman who emailed us in her name is

Kristi and she's from out Vernon she

emailed us with a question she's

actually having a total hysterectomy in

December she wonders what she should be

doing in the next month to be best

prepared for the davinci operation so

maybe you can expand on that a little

bit

yeah I think I'll ask dr. Rosenbaum that

question here once we get started as

well but certainly anybody who with a

history of smoking and best you can do

is to try and decrease the amount of

tobacco you might be consuming right

before surgery if there's a weight issue

involved at all not that any of us have

that issue come the holiday season but

there's an issue and consideration can

be given to going on a little bit of a

diet obviously don't want to go on a

crash course crash course diet ahead of

time because that may actually hurt you

in the long run other than that just

trying to make sure you're in the best

physical shape that you can be in terms

of exercise and your activity level I

don't think that there's a whole lot

that she probably needs to do okay we

have another question how many surgeons

are trained to operate The DaVinci and

we can talk more about the process that

you have to go through because there's a

training involved as well so how many

are currently trained here currently

here in Cedar Rapids there's 11 surgeons

who are trained to use the robotic

system and that training process is

interestingly it sounds like it's very

short but it's fairly intensive it's a

usually a two to three day course where

you go to an institution where they're

doing a lot of robotic procedures and

the procedures that you learn at that

time aren't necessarily on how to do the

procedure but just how to use the

robotic system usually that involves

setting up and taking down a robotic

system multiple times to understand how

it works

additionally it often involves what we

call wet labs what labs just basically

means that you use the robot and

actually operate on animals with it and

understand sort of the relationship

between what your hand movements doing

what the robot does okay so just very

intensive training yeah it's an

accreditation process and then you and

then you watch and observe some cases as

well often times depending on the

institution proctors are required as

well meaning that you someone comes in

you knows how to do the procedure or has

done the procedure before not that the

person doesn't know how to do the

procedure who's doing the robot case but

it's just in terms of troubleshooting or

giving some tips perhaps in terms of

making it a smooth transition

robotic surgery let's talk about regular

surgery versus this robotic surgery are

there any cases where you would maybe

say we want to do the traditional

surgery as opposed to doing the da Vinci

or you know is the da Vinci superior in

other cases or depending on the patient

you know I think that's a really good

question the because certainly we get

that question asked a lot and yeah and a

lot of that has to do I think there's

lots of factors involved number one is

the patient's health depending on on

their lung status sometimes they're not

good candidates for minimally invasive

surgery the reason is we insulate or

blow up the abdomen of carbon dioxide

and sometimes a person's lungs can't

take that if they have bad lung disease

sometimes body habitus sometimes

patients are just too large we do in

this method a lot of it to I think is a

surgeon preference what you're feel

comfortable doing obviously you don't

want to do something where you feel like

you're kind of getting in over your head

in terms of things that you might be

able to do we mentioned earlier the cost

of the actual machine 1.6 million

dollars with the $100,000 that just

blows my mind hundred thousand dollars a

year to keep it up let's talk about the

actual cost of the surgery versus

traditional surgery do you think there's

a market difference the same you know

everybody's probably at home wondering

is my insurance going to cover this

those are all questions probably that

patients have about that well in terms

of insurance coverage very rarely do we

have a problem in terms of having it

reimbursed in terms of a robotic

procedure to the to speak to the actual

cost I have to admit that I don't really

know how much it cost versus an open

procedure that's my own personal

preference I don't want to know yeah I

wanted to really cover how I make my

decisions so in terms of how much X

versus Y costs unfortunately I don't

know the answer I can find out that okay

I'm sure a night out we do have a want

to pass along to you again the email

address since we're getting a lot of

good questions in already live at Sierra

st. Luke's comm and as we're streaming

this live we want to remind you in case

you can't catch the entire surgery we're

going to actually cover about an hour of

the surgery once we get started here

shortly but if you can't catch the

entire thing

be able to view it on st. Luke's er comm

as well as on KCRG comm so you should be

able to view the entire surgery and all

the questions that we're taking later

today as well so keep that in mind if

you can't stay with us the entire time

but do email us in those questions live

at CR st. Luke's comm now we do have a

question in here do you see many

patients who would rather have

traditional surgery because they could

be concerned about their robot you know

having a problem or something you know

that's that's not an uncommon question

either what happens if the robot decides

to quit working during the procedure in

our experience here actually we haven't

had that be a problem and and I think

that could probably be said nationwide

as well the robotic system itself goes

through so many checks and balances even

before the patient gets wheeled in the

room the likelihood that the robots

going to malfunction is much more likely

before surgery than during surgery and

even then it's very unlikely so I tell

my patients that in the unlikely event

that the robots kind of malfunction it's

probably gonna be before we start okay

and then you can always bring in a

regular surgeon to finish is that the

way it's well sometimes if we haven't

even started the procedure I'll say

let's just reschedule because they they

scheduled a robotic procedure for a

reason and we don't want to forget about

those reasons even though they're all

hyped up and ready for surgery on that

if the robot were to malfunction during

surgery it's not like it would run amuck

and pick up the patient throw them

against the wall like that if the robot

actually if there's a fault and those

faults to do is sometimes occasionally

occur those faults there's a fault

override and what happens is the whole

robotic system freezes up momentarily

until we determine what the fault is and

then usually you can take care of it at

the same time and sometimes it's just a

matter of their arms have run into each

other a little bit and it just sensed a

little bit too much tension it's

something hard to explain so you see the

robotic system on how that might

actually occur but it's it's not like

all of a sudden that would be invaded by

some sort of virus like a movie and and

just start

look like dr. Octavius or whatever yeah

spider maybe yeah yeah yeah so we won't

be seeing any of that here today thank

goodness that's not been a problem yeah

okay well that's good to know I'm sure a

lot of people concerned about that okay

well so we just wanna let you know

patient prep is underway the doctors are

kind of getting ready to go in the other

room but right here behind us you're

watching a live hysterectomy today here

on this uh we're live from st. Luke's

Hospital

but obviously on the web which is a cool

thing looks like we got some more

questions here okay so we just mentioned

does insurance cover the same as

conventional you said you hadn't had any

problems with that okay so how soon can

one get in for the surgery at st. Luke's

they know of a candidate that's

scheduled for a hysterectomy okay so how

we can go through that how how far out

would you say to a patient we need to

schedule for this kind of a surgery how

long from the time you say we need this

to the time it might actually happen a

lot of it depends on what the procedure

is certainly for a benign disease those

procedures may be scheduled out weeks to

even months in advance for a procedure

that's done for cancer obviously you try

and move that up depending on the cancer

I know that in case of prostate cancer

often we'll wait four to six weeks even

after a biopsy of the prostate to

perform a prostatectomy just to sort of

let the the inflammation of the prostate

and die down after surgery so to make

the surgery more more hopefully easily

done I can't speak to how far dr. rosen

boomer doctor McCarran or anyone else

here is booked out I know that they have

quite a few cases scheduled and so they

probably wouldn't be able to be done

next week okay keep that in mind so call

that cone out call me I'm sure open up

let's see here how much we have a

question here about ovaries we'll just

say that for dr. Rosenberg is it that's

not yours no no I know you went through

Medical School okay so that's an obvious

one will there be a way to watch the

procedure later since I cannot watch it

live yes you can watch it both on KCRG

calm and on say

Luxio calm that will be as well

throughout the day today

yeah the ovaries alone will save for

later okay

how long has st. Luke's been offering

The DaVinci that's a good question it

started here in late 2005 and has really

taken off since that time it was the

first robotic system as well as the

second robotic system where gifts of the

foundation here at st. Luke's okay to

st. Luke's Hospital and so we've been

offering him here since late 2005 the

FDA approved robotic surgery in 2001

both for prostatectomy and then a little

bit later on for hysterectomy so it

really hasn't been around that long from

a prostatectomy perspective just to sort

of give you an idea of how robotic

surgery in general has taken off in the

United States 65% of all prostates were

removed robotic ly nationwide last year

that's a pretty quick shift yeah

compared to 2001 when none were done so

it definitely is changing how we do

medicine a lot of different ways okay a

couple of our questions that we had

ahead of time this is a question I had

for him this morning but you know we all

watch those shows Grey's Anatomy ER

things like that doctors listening to

music while they operate

we were wondering you know okay what do

you like to listen to while you do

surgery yeah well every surgeon has

their own preference some surgeons don't

listen any music at all otherwise it

could pick a genre of music and you'll

probably find it in some operating room

at any given time lots of times with the

O our staff would tell you they're

differently but sometimes we let them

pick the music as well that being said

you know as often times the music make

it turn out depending on where we're at

in the case or what we might be doing if

you know there's some other issues going

on but certainly there is music going on

it's not usually elevator music either

you know it's country music or oh I sing

along as often as I can

much much to the chagrin of mostly

people in the operating room and the

worst part with the robotic system is

that there's a microphone on it so then

everybody gets to listen oh good yeah

everybody can be a part to your

beautiful singing voice right I don't

know if it'll really qualifies but at

least singing voice yeah ok what if my

doctor isn't trained on the DaVinci but

I want a robotic procedure done well

Sheila you'd have to take the Sheila

would have to take that up with her

provider you know it could be that

someone else in that practice does do

robotic surgery or the thing that we've

found here in Cedar Rapids at least a PC

ideology is that people are coming from

a distance to have their procedures done

Northern Iowa out-of-state even

depending on where they find it and one

of those things where I just encourage

them to try and find a place if that's

something that interests them don't be

afraid to get in the car and travel if

you need to but certainly here in st.

Luke's and here in Cedar Rapids we're

able provide those things ok we have a

question specifically for you from and

she wants to know why did you decide to

get trained on the da Vinci well I uh

after I was done with my residency

training I did a laparoscopic minimally

invasive fellowship and this is a

natural really adjunct to that in terms

of minimally invasive surgery this is

really the future of a lot of different

surgeries that we do now and if you

sometimes if you don't stay current the

things that you want to do now it's hard

to catch up later on minimally invasive

surgery has always been an interest for

me specifically and and seeing the

patient recovery has really been a

reward in that aspect so it just seemed

like a natural transition to what I

already did okay we mentioned earlier

the aspect of recovery time being so

much shorter what are some of the other

benefits to having this surgery as

compared to a traditional surgery there

are some really good studies out in lots

of different types of literature both

gynecologic and urologic in terms of

decreased pain after surgery now it's

hard to quantify that when you can't

take the same person person and do the

same procedure on them twice but but

definitely pain in terms of the pain

scale and things has been much less

after surgery obviously if your

incisions are smaller it's just

be that way your recovery is quicker in

terms of prostatectomy for example we

know that the cancer control rates which

is the most important thing is already

as good as open surgery if not better

and then other things in terms of side

effects after removing a prostate such

as possibly loss of urine and erection

issues those are also at better than

open surgery and so not only in the

short-term things better in terms of

being in the hospital but also the

long-term things in terms of your actual

outcome right 10 20 years down the road

even we have a question about let's see

here where did I put that we're getting

things handed to us by the way on took

the 100 or so Alyssa here we'll get rid

of this one okay so a reminder that you

can watch it live on KCRG comm and st.

Luke's er comm as well today and if you

have a question for us why don't you

email it to us at live at CR st. Luke's

comm that email address again

live at CR st. Luke's comm we want to

know a question that we had was how long

do these procedures take some for that

we're going to ask you

prostate or prostatectomy how long does

that take how long does the traditional

mr. esta the hysterectomy take you know

the procedures themselves are always

scheduled for a certain amount of time

and it's not one of those things however

when the whistle goes off the procedure

is done so sometimes they'll take more

sometimes it'll take less often times

when you're first starting to do the

procedures both from an institution as

well as from a surgical standpoint it

takes a little bit longer in terms of

understanding how things transition here

are prostatectomies are scheduled for

about three hours okay

certainly that's not all robotic time

that's going to sleep and waking up and

I know that they schedule their

hysterectomies for somewhere around two

hours I believe okay all the time the

patient goes under until they're in

recovery right okay right

and so the robotic time for that

obviously represents more than 50% but

certainly it's not just the whole thing

that's going on there's lots of stuff

that goes on behind the scenes what

you're seeing some up today yeah and

again we are being told that there is

some patient prep being done right

but we will get to the actual operation

shortly in the meantime I want to even

read you this as well this is actually

from somebody who had a hysterectomy

she's logged in right now to see what

was actually done to her since she

wasn't able to see The DaVinci surgery

when she was in the operating room she

says I had the robotic assistant

hysterectomy in October and I felt

normal on my eighth day post-op so

that's really quick less like a week in

a day I actually did a little painting

on my sixth day post-op I was a little

apprehensive prior to my surgery and of

course I'm glad I had the surgery I feel

much better now than prior to the

surgery more energy she said she who

knows so as we were talking about

earlier some of the advantages to having

that surgery done as well let's say you

want to kill that one over there I think

do we get a new one two or four dr.

Esper back on in there okay so we'll get

to that as well

maybe you want to tell us who actually

is gonna be in the operating room today

and we're gonna be hearing their voices

come in here in just a few minutes as

they're literally adjacent to us but

maybe tell us a little bit about who's

in there our anesthesiologist today is

dr. Mary caiman and our two

gynecologists working today dr.

Rosenbloom and dr. McCarran I know that

we also have some of our staff and

they're not actually sure who's in there

I think I saw Tina and I think I saw

Tammy I'm not sure who else isn't it I

think that Susan can't see through the

wall you're I will say that actually

there are four is that we are in today

our new ORS here at st. Luke's they've

undergone an operating room renovation

and specifically these rooms are

designed to help with the robotic system

they're quite large as you see often not

bring rooms in the past for about half

this size and so they are definitely

state-of-the-art stuff going on yeah

really cool stuff I've heard the

dementia get compared to a video game

before do you look at it that way I mean

obviously it's like worse yeah I better

die do you look at it that way though I

mean about a lot of hand-eye

coordination involved well certainly

there there is sort of the aspect of

sitting on a console and sort of having

to be much like a video game there

actually are some interesting studies

out there that show that kids are the

generation who grew up with video games

tend to be able to pick this surgery up

more quickly than

people who didn't grow up playing Atari

and things beyond if you remember Atari

- those people I'm a Super Nintendo

they're all super yeah yeah and now

we're deeper but it doesn't take

quarters by the way you don't have a

roll of quarters that you're competing

the machine doesn't work do you find

that there's been surgeons who have said

no I'm not interested in learning that I

want to stick to traditional

laparoscopic surgery you know I there's

always gonna be certain groups of

surgeons who stick with what they've

done all along and you know that's great

because you really need all aspects of

things to be able to be done but I think

that the majority of mainstream at least

in terms of I speak a lot about the

prostatectomy but a lot of the

prostatectomy type surgery is going that

way and so people who say you know I'm

really just going to keep doing it the

way that I have have sort of also

resigned themselves the fact that their

numbers will probably decrease over time

now when the when the surgeon actually

gets their hands in the robot and gets

you know going with the surgery can they

feel what's going on in the patient I

mean because the little robot arms are

actually inside the patient can they

feel what's the reaction like currently

the surgeon itself sitting at the

console you aren't able to have tactile

feedback meaning that you can't tell the

tension of a tissue per se however there

are a lot of visual cues that can kind

of tell you a little bit about that

knowing how the robotic system works so

that is about the only downside in terms

of the robotic surgery and actually some

interesting studies about that I had

some surgeons who began training on the

robotic system and that was their number

one complaint and then once they

actually started using the system within

a few weeks I said it didn't matter

anymore because I could see so much

better yeah due to the magnification of

the system do you do the

three-dimensional view in the system and

so interestingly however the Intuitive

Surgical company is working on a tactile

feedback system for the robotic system

that might give surgeons a better idea

of actual tension when they're tying a

knot or feeling a tissue trying to

decide it as that firm isn't soft so

stay tuned okay we do want to pass on

one thing apparently we are having a

frozen frozen picture you probably still

have audio and can hear us just fine but

you may lose your connection for a

little bit they are working to fix this

problem right now

obviously we're dealing with a lot of

liars and a lot of Technology here I've

been told that if you hit refresh on

your browser that that could fix the

problem and we hope to get to dr. Osman

here in just a couple seconds they are

doing some last-minute prep work in the

other room let's talk about the the

operating rooms that have been kind of

revamped what did they look like before

this well much smaller when I go back in

there trying to rewind here no the

operating rooms were much smaller

certainly they were typical operating

rooms in terms of up-to-date and sterile

and all those type of things I mean it's

not like we're operating operating in

the third world necessarily but the size

was much different in terms of the

lighting the lighting system in here is

much different than than it was before

and in our machines and things actually

have attached to the ceiling we can

actually hook up to the robotic system

is much different than before before we

had to wheel all those things in other

carts and so access to things that is

just much better ok what is what would

you say is the oldest patient and the

youngest patient you've ever performed a

DaVinci on the youngest the youngest

would be in their 20s that I personally

have and then the oldest we've taken a

prostate on a gentleman it was 77 so ok

you know certainly any age range and

this is applied for pediatric surgery as

well and in some institutions and so

they'll have newborn babies that have

this 1,400 pound machine hooked up to

him right and operated on it something

to see that delicate when a little baby

the size of a little football you know

and have this big robot hovering over

them what are some of the reasons that

you would need to do a hysterectomy or a

prostatectomy on a patient obviously

cancer would be one but are there other

reasons as well well is it and I can

speak probably most accurately for

prostate and we take a prostate out

usually

- cancer there are some benign

conditions of the prostate you could

potentially remove a portion of the

prostate robotic little mostly it's for

prostate cancer in terms of the

hysterectomy I'll let dr. rosewood talk

to us a little bit more about that cuz I

think he's gonna be online here shortly

all right do we have them in the other

room now can you hear us

there they are alright welcome we're in

the operating room and today in the room

I've got my partner dr. McCarran and he

also performed robotic surgery as do

several of my partners in the office so

I'm certainly not the only one doing

robotic surgery we have the wonderful

scrub team in the room as well

we've got Tammy we've got Tina we've got

Mary we've got Laura and we've got Amy

and our wonderful anesthesiologist is

dr. caiman this patient just for

information is in her 30s mid to late

30s and has chronic abnormal uterine

bleeding that's just not been responsive

to conservative care she's done having

children we've done a biopsy from inside

her uterus that showed some significant

abnormalities as well and after a

lengthy consultation regarding options

some of which were non-surgical some

which are surgical we decided to proceed

with hysterectomy she is very well

supported me is that although there are

different ways to do hysterectomies

including vaginal and otherwise she's

nicely supported and therefore going

from above is a very reasonable way to

do the surgery what we're going to start

with now is we're going to elevate her

abdominal wall we have to get what's

called a pneumoperitoneum that's where

we get some air into the tummy to

separate the vital structures from the

from the abdominal wall so we're lifting

up here as you can see

carefully placing the needle into the

tummy checking to make sure that

everything is in the right location now

we're going to hook up the gas gas on

this is inclusion

hi for please

now we're waiting to get approximately

three liters of carbon dioxides what we

use to insulate the abdomen and you'll

see that pretty quick or abdomen become

a bit rounded we're watching the

pressure on the machine is there our

power of controls here these screens in

the room that dr. McCarran will be

looking at are here and back behind me

there's one over here as well

doctor McCarran will later on come

around to this side to assist from this

side the actual robotic system is over

to the left here that we'll look at in a

bit with the console in the back there

we're now going to put some measurements

on your tummy or abdomen which allow us

to make the incisions in the correct

locations

a little bit

right there we go ten centimeters off to

the side of the umbilicus on each side

at about the level the humble like us

and then an isosceles triangle for you

mathematic and science students we go

about 10 centimeters up here just

underneath the rib cage for estimating

here now I'm gonna measure it see how

good I am today that's 10 and that's 10

that's pretty good yeah real form today

take the lighting or the marking we're

now going to place some quarter percent

marking which is a long-acting a local

anesthetic into the incision sites tends

to help with the pain relief for a good

12 hours or so afterwards some states

suggested that by injecting before this

incision instead of afterwards if there

might be better relief of that probably

either way is fine

did you a review a drainer stomach at

all

now we're going to make our first little

incision which is just below the

umbilicus

and we're going to place the needle into

the abdomen again to put our trocar

around

that will give us access for our camera

is there just one camera involved doctor

I'm sorry I need to turn my volume up

just a touch here there is someone

camera involved oh just one camera

involved at this point yeah let me find

my little control here a minute may or

may not find it me there we go now we're

going to place the camera in this is a

the three-dimensional camera we talked

about and we'll get our first view to

make sure we're in the abdomen which we

are what we're looking at now it's

intestines bowel the more formal term

for it just looking around make sure we

didn't bump into anything while we were

inserting the instrument so it doesn't

appear to be that's the case now we're

going to put our lateral instruments in

they are called eight millimeter trocar

so these little incision over here will

be about eight millimeters and dr.

McCarran we'll make the incision on that

side

these are the where the robot arms will

connect to two of the robot arms on

either side and into the camera as well

come in we're gonna de fog the camera

the cam is a little foggy so we're gonna

do fog it here should be a little

clearer all right

look down towards the Telus

we just turn there we go we're just

trying to heck with Australia if you

would though okay

now they're going into a certain

distance

that's about right and now we'll go over

to my side and do the same thing

we're doing by pushing on the belly wall

here to make sure we know the location

that there are no unusual blood

vasculature underneath it's always nice

to miss some of the blood vessels of the

abdominal wall if they did if we did hit

him it is something we can take care of

but it just makes the the case just a

little more challenging my younger years

challenges were fun in my latter years

here challenges aren't always so fine

doctor how many surgeries do you feel

comfortable doing in a day generally

we've been doing I've got three cases

scheduled for today we could probably do

four in a day but that gets to be a big

day probably bigger for my assistance

actually or if we do if we go back and

forth for example doctor McCarran does

one or two and I do one or two where we

alternate responsibilities that works

out pretty nice so four in a day would

be max we've been doing three we have a

wonderful team here at the very very

experienced and very good at turning the

rooms over between so if we needed to

deport they would be able to do it do

you find it less mentally exhausting to

work with the da Vinci and keeping your

you know what's about you through the

day I'm sorry my earpiece just kind of

calmed down a little bit can somebody

put it in my left ear please well maybe

dr. riff and trop can answer that too

certainly that the physician fatigue is

a real factor in terms of laparoscopic

versus

robotic system and so feeling like you

have arrested at the end of the case is

going to hopefully also provide a better

surgical outcome so yeah I think I think

that you certainly have less fatigue if

you do things this way what dr. McCarran

is looking at now we're looking at

actually on your upgrade once we put

this in right above there is the

patient's liver that's her liver up

there you can actually see the pulsation

through her diaphragm up top there which

is her heart and we're gonna slip this

in now this is our final port

the support that dr. McCarran will

assist me through right there underneath

the port is the stomach in that area

right there is the patient's stomach and

then there's a gut liver and underneath

would be there's the gallbladder just

sneaking underneath that little bulging

thing right there is the gallbladder so

if we heard they were doing a

cholecystectomy cheese removal the

gallbladder then that's where they would

be going we're not going there today and

I wouldn't be capable of doing it anyway

that would be the general surgeons okay

now we're gonna place the patient in

what's called steep Trendelenburg

dr. teaming with you this is a we placed

her in a high Trendelenburg with feet up

in the air that allows the bowel to fall

out of the pelvis so that we can see

much better and reduce the risk of

injury there's the uterus we're starting

to see now with and you can see the

bowel floating away the ovaries are the

white things on either side we'll look

at those closer and we get all hooked up

here and we'll get better focused in a

minute when we are hooked up to the

robot so now that's great like that dr.

Keemun if you have the gasps okay we're

going to dock the robot now

and I think we've got the afford so you

can see the plastic on the robotic

system itself that's actually sterile

drapes on each robotic arm back the

instrument there there's no sterile

drapes on it so obviously we have

someone manually putting the robot into

place today okay and all that is

prepared though ahead of the patient

being even wheeled in and the brush

everything and incur how much prep work

does it take to get you know that all

ready to go obviously we see the

surgical arms there how much would you

say is involved in getting it ready to

go

certainly there's more than just a

typical open case straight in sleeping

in things and I think that straight

spending on their experience of the o.r

staff at the tre pencil on how I tell

you that here they're they're pretty

quick about it you know I think that

well Janet emailing us earlier about her

robotic assisted hysterectomy and she

said she didn't remember going into the

room and seeing the robot one of the

reasons might be it actually has a metal

lock it down and there's sterile blue

drape on top of it sort of protecting

all the other sterile drapes at the time

and so even if she sought you me and I

recognized it as that

additionally they usually get a little

bit of a vacation for relaxation they're

probably pretty good feeling pretty good

when they actually get in there little

truth serum okay well we want to pass

this along as well we've been I guess

getting several emails about the costs

of this robotic surgery if you are

considering any type of surgery here at

st. Luke's Hospital you can call st.

Luke's has financial counselors they can

work with you to determine the cost some

where they are ahead of time also you

know looking at your insurance figuring

out what your insurance will cover if

you have that question or questions

about the cost I'm gonna give you a

phone number now if you have pens

they're at your computers the phone

number is three one nine three six nine

four seven two one one and again that is

for if you have any questions about the

financial aspects of this davinci

surgery you can go ahead and call three

six nine seven two one one here at st.

luke's hospital again you are watching a

live hysterectomy today done by the

DaVinci robot and

the husband was in the other room this

is dr. Wickham drop and then I'm

actually handsome from KCRG tv9 so we

just want to kind of pass along that I'm

there they're just about to sit down at

the robot right is that kind of where

things are yeah that's about where we're

at we're going to we've got the robot

doc now with the three arms and we're

going to put the camera back in now and

then we'll put our two instruments into

either the lateral ports that's what

you're seeing on the monitor right now

is that well that was dr. McCarran

they're putting in an integration okay

and he said the white on either side is

the ovaries are you what what's involved

in that hysterectomy no do you remove

just the uterus to you remove everything

well today today I think sometimes

there's a take the peek a please there's

a misnomer that a complete hysterectomy

is removing the ovaries when we talk

about complete hysterectomy we mean

taking the cervix and the uterus not

necessarily ovaries today we're not

taking the ovaries

she's pre menopausal and we would like

not to ever go through the menopause if

I take the ovaries out she'll go through

the menopause and have to deal with the

issues of menopause I leave the ovaries

in place she'll just not have to deal

with the pathology that sooner uterus

nor the period problems that she has it

does eliminate the risk of uterine

cancer and the risk of cervical cancer

leaving the ovaries there downside is

that there's about one in 100 chance in

a woman's lifetime that she can get

ovarian cancer but taking the ovaries

out at this age particularly is

generally something we tried to avoid

unless there's pathology the ovaries

such as endometriosis or tumors of the

ovary and she does not have that so now

you can see we just put the two arms in

that I'm going to go sit down and

control here now and dr. McCarran is

going to come over to my side that's

good I think everything looks good

so now that we've heard what's included

in the hysterectomy and this could go

for men and women you know getting a

prostatectomy as well are there hormonal

changes that are involved he mentioned

the ovaries are gonna stay in in this

case but you know if they come out as

does that change things for prostate if

that comes out does it change things the

prostate itself there's no particular

hormones that are secreted by the

prostate they're gonna affect anything

and I think what dr. Rose was alluding

to is when you take the ovaries out

that's when you have a precipitous drop

in a sturgeon which subsequently leads

on to menopause and the hot flashes it's

subsequently loss in bone mineral

density over time and somebody in their

20s and 30s you hate to have that start

already I'm not ready for that it's not

your day today is not my day

yeah that's why could it could in the

right it's a little foggy the hormonal

change its trends yeah the chicken could

cause the change if you take the ovaries

and it will cost a change unless you put

him on hormone replacement okay well as

we go back to the room one thing I was

interested in is he's pointing out all

the different things on the anatomy

everything is really close together I

guess you don't really realize it you

know looking at your your abdomen but

you're packed in there pretty tight ya

know for a prostate surgery do you have

to position the patient similar to what

he's done where you have to put the legs

up in order to get things to kind of

move around mm-hmm yeah very similar to

this position obviously there's no I

hope uterus sort of a giant ovary to

worry about here's the here's the

appendix showing you the appendix right

there I'm right there which we're not

going to do anything with today it's a

normal appendix I'm controlling the left

and the right hand now here these two

that's doctor McCarran coming in to help

out as we look down here we see some

vessels we're actually kind of looking

for the ureter it has some fairly

prominent vessels obviously coming out

the ureters going to be a little further

down

now how are you controlling the camera

is that with your feet no see how

there's foot pedals around controlling

the camera with both my arms on my foot

feet and the van the foot bells and my

hands are I'm controlling with excite

the ureters in its normal location right

up in right there I think that knowing

somebody want to get my earpiece again

it seems to be falling and back out

again

I think the mask is doing it well we're

seeing we're seeing about three

different I guess hands sort of come in

there there's something that's pushing

things out of the way obviously yeah

work what we're doing now is going to

sweep for vial back up higher that's why

you put in that steep Trendelenburg what

dr. mccarran's doing is pulling that

bottle up with his instrument and just

gets it out of our way

right and that's actually very nice like

that you got a very nice view of her

pelvis again her ovaries are there this

is the fallopian tube here that we're

gonna leave as well what's called the

external iliac artery over here and

these the ureters going to be running

right down

now how do you keep blood from being a

problem obviously are going to be making

some incisions yeah we prefer not to

make and even have any bleeding but

there's always a little bit of bleeding

the one nice thing about this surgery is

that the blood loss tends to be maybe

1/5 at times to one tenth of the blood

loss an open procedure we use a thermal

this dr. McCarran is going to help me

now grasping the uterus to kind of

manipulate it it looks like a nasty

instrument it is but it's since usually

coming out it's not going to be an issue

prior to the surgery we pay something in

the vagina that we'll see dr. McCarran

will lift up as well here and we'll see

a what we call a coal ring it's a blue

ring you already lift are you lifting up

there dr. McCarran yeah okay there's

there's the ring right there that we're

gonna kind of come down to so we're

going to start over here on the right

hand side first this is called the you

drove Arian ligament I'm going to turn

my instruments around it connects the

ovary to the uterus and we're going to

just take this gradually so she's got

some pretty prominent vasculature here

so we're gonna try and take our time and

right now I'm cauterizing that's why the

tissue Blanche's so that's what we're

seeing it's just that's just yeah we've

got it right we've got a smoky evacuator

that's hooked up so it does kind of take

a second or two to get rid of it

so vasculature is blood vessels right to

dump it down for everybody

yeah we're cauterizing the blood vessels

here and then we're going to make after

we get it cauterized we're going to go

ahead and try and make a little cut here

and start to procedure here and we just

continue to go on downward I found that

with time that you can cut too far with

the first cut it looks like there's

Qadri that's going further than it does

and then you get some bleeding so I'm

trying to be careful that we go the nice

thing about I can with my wrists over

here at the console I've got pretty much

control I'm gonna actually elevate my

machine my optics a little bit there we

go

all right now this is the fallopian tube

that we're gonna come across now after

that's done though there will be no real

point for the fallopian tube is that

correct well the fallopian tube is

hooked on to the ovary as well and come

to India - it will just kind of stay

there the remainder of it it'll just

kind of hang out with the ovary there's

no real use for it anymore since she's

not planning on having more children

obviously taking the uterus out seals

that seals that yeah and we're going

over here again to a another area just

underneath what's called the round

ligament one of the suspense Ettore

ligaments - the uterus is there a

ligament we're coming up to that now I

think one of the things to point out

here dr. Rosenbaum - is that if you were

to watch this procedure done

laparoscopically you would see that the

instruments themselves look like long

chopsticks that sort of rotate and

really these instruments almost act like

little hands in there I mean they're

worth the risks and the way they turn it

in with the dexterity that you have it's

one of the reasons that you can get such

precision in this particular procedure

very true the procedure before this we

did one of the suspense Ettore

procedures where we took a graft and for

things that were falling out vaginally

we took the graft and hooked it up to

the top of the vagina and then to the

hollow the sacrum or the tailbone

actually connecting the two and the fine

delicate instruments that we have is er

even more important for that type of a

procedure dr. Brisbane we or dr.

McCarran we got a question from Holly in

Mount Vernon she's wondering do in

Demetria endometriosis patients need

their ovaries removed is that correct

you know it's

what's going on very often that is

thought of as the definitive procedure

because the ovaries produce hormones

that will keep the endometriosis tissue

alive so that is that is often true this

the ligament that dr. Rossum just went

through is a round ligament and for

those of you who had particular aches

and pains during pregnancy we often will

say there's round ligament pain and

that's the culprit right there that

ligament stretches during pregnancy and

can cause a fair amount of discomfort I

mean it looks like I know this is a kind

of a gross analogy but you know the

electric scissors that you can use to

cut Christmas paper and wrapping paper

with it looks like that's how I mean

it's moving just like I'm going to see

that yeah it is and this what we're

doing now this is called the anterior

and the front in the back of the broad

ligament where we're heading down to the

I can feel more or less they're not lies

doctor rip and drop said there's now a

lot of tactile sensation but I can feel

that the ring is right there so we're

going to come the bladder lives right

here so we have to dissect the bladder

off of the off of the cervix here to get

the cervix out so we're doing now is

delicately releasing some of these

attachments here there's a blood vessel

there it will prophylactically take care

of we want to pass along to to everybody

watching the webcast today if you go to

st. Luke's er org there is a list of all

the doctors in Cedar Rapids that are

trained on The DaVinci we've determined

that there are 11 doctors that are

trained so and again you know if your

doctor isn't that doesn't mean that you

can't get the surgery right right and

there there are other ways for those

that don't do robotic and do regular

laparoscopic the procedures that doesn't

mean that's wrong or inferior for some

of us were just more comfortable with

this but certainly traditional

laparoscopic procedures although they

have some limitations aren't very good

and some of the surgeons are

extraordinarily well trained at doing

it's a traditional way so I don't think

is one should be led to believe that

this is the only way of doing this

procedure by any means

so it's up to the surgeon doing it to

decide whether or not right

what which one is the best option okay

now once again here I might get a bit

quiet for a minute I get a little more

into the delicacy of the okay so we're

doing now is got the peritoneum open

we're gonna try and develop a bladder

flap here and just to give an idea of

size what you're looking at here

remember everything in this particular

system is magnified anywhere between 5

to 20 times and so you know those

scissors look like they're quite big but

in reality if you're when they're all

the way open it's really only about a

centimeter across just like the plane

there else what you're seeing there is

quite enlarged in terms of your actual

visualization so allows you to see

things a little bit more accurately you

know the blood vessels that you're

seeing there they look quite quite large

but actually if you were looking at them

in an open fashion off and you wouldn't

even see a lot of those yeah how many

different and I mean obviously you've

got several robotic arms that you're

working with how many different

attachments are there can you customize

the attachments or that they always do

the same - no they're due I'm sorry go

ahead doctor it and drop off I just keep

operating here yeah you do fine the

there's actually lots of different

attachments and they continue expand on

that at all times and and they're

they're interchangeable and so at some

point here you'll see them take these

out and probably put in some some needle

drivers things that can hold suture but

there's all sorts of different

applications and instruments that

they're developing all the time and even

different sizes for them for the

pediatric cases I was gonna say you

mentioning you know operating on a baby

that's quite a delicate procedure you

know I mean small everything small

miniature I'd like to get that down a

little bit

Karen you think there's no much room

there you know in the adult population

the boy when he started to undercover

that's here that's a horse of a

different nature we want to read this um

from Dan he actually just had a

prostatectomy done by dr. Wu who dropped

five weeks ago he wants to say he was

discharged the following day he had

virtually no pain and a week ago we

could go was cleared to resume all

normal activities including getting back

to running so that's just five weeks

after surgery back up to four miles a

day now it's a great procedure and you

are a very fine surgeon he says so that

again from Dan and former patient thanks

Dan

that's it softly face I think we'd go

right through here yeah okay well I

guess this is a good question to follow

up on that right over here

they prefer you dr. Rose boom or dr.

McCarran how soon can someone return to

work after a robotic hysterectomy

for work and it depends on how

everything went but we've been hearing

from our patients that they're feeling

ready to go back to work a lot sooner

than definitely open surgery

I have had some patients be pretty ready

to go back to work in a week or two when

they have not a physical type job which

is compared to a traditional open

procedure which would be more like four

to six weeks let's talk a little bit

about the incisions that you were making

earlier how big are they how many are

there compared to what you would see

with a traditional laparoscopic

procedure you know traditional

laparoscopy is relatively close to the

same incisions we made a 12 millimeter

incision in the belly button and then

two eight millimeter incisions on either

side and then the port in the on the

left upper side as a 12 millimeter as

well those are pretty pretty standard

for laparoscopy will often use 12 and 5

millimeter ports so we're talking very

tiny very very small we have Stacey has

a question are there more robotic arms

for a prostatectomy versus a

hysterectomy we use the fourth robotic

arm for the prostatectomy you guys have

the fourth arm in right now we did one

on the first case but this one we don't

it kind of depends on which case and in

the nature of what's going on it's

interchangeable in terms of whether you

have to use that fourth robotic arm or

not and so

that means one less incision she has

some very large vessels that were and

she has a lot of a scripture that blood

fall yeah she's got some very large

vessels there that were I think we'll

deal with this one here to start with

actually that's called the bladder

pillar and we're just going to make sure

that that doesn't cause any further

problems now we're hearing a little beep

is that every time you that's oh that's

my vision or my auto audible signal

about what I'm what type of quadri I'm

using and when it's accomplished what it

wants supposed to accomplish so that

happens to be what's called bipolar

cautery here just and there's called the

unipolar car that and that's in my right

hand a little bit different type of car

evoke both quaderi what we're doing now

is trying to dissect and expose the

uterine vasculature the uterine artery

comes from the internal iliac system

which is a big blood vessel if that

supplies most of our pelvic structures

or at least the deep pelvic structures

and by skeletonizing those for us

exposing them it makes the cautery of

them more effective and it also is safer

because the one concern we always have

with this surgery is at the ureter which

is the tube that connects the kidneys to

the bladder runs right down along the

cervix and if you happen to cauterize it

even close to it and injure the ureter

they lead to some problems that we have

to get dr. ripman trough involved with

we always feel slightly bad and we have

to involve dr. rip and drop in these

cases no problem just urination post-op

[ __ ] no it's more of if you've got a

blockage to the vessel right there you

can see if you've got a blockage to the

from the bladder the kid needle

you actually back everything up and

that's just that's not good just makes

me uncomfortable thinking about it

actually well it's fairly infrequent as

well yeah dr. poseable so they do a nice

job making sure they try and stay away

from those structures again she thinking

a little longer here than some discs

because she has larger blood vessels in

some patients do we're taking a little

extra care what we're doing now is again

skeletonizing see all those large blood

vessels these are all vessels coming in

from the backside and even though we

have her and up in the air which drain

those blood vessels River quite

prominent frankly again we just want to

write everybody that you're watching a

live hysterectomy live on the web we are

here at st. Luke's Hospital and of

course I'm Ashley Hanson this is doctor

I've been shopping in the operating room

we've got dr. mccarran's dr. Grossman as

well we have a couple questions from

that have been emailed in with the small

incisions could have seven centimeters

sis to be removed that is currently on

one of the ovaries and still be tested

for cancer while in surgery I don't know

if that was a clear enough question but

you know it depends on what the cyst

looks like Ashley but often times we can

in the way that that's done is when the

cysts or the ovary is removed they

actually can take it and put it in a

little bag and then pull the bag up

through the small incision and that way

not spill anything and send it off to

have it tested so in certain

circumstances we certainly can do that

okay we we have a couple reminders we

want to pass on for our the viewers that

are watching us from KCRG calm stream

meet many of you probably know the the

TV 9 News at midday is next time I'm not

going to be there today not going to be

anchoring the news from here today but

they're going to continue the live

stream of this surgery until right about

before the news starts so it'll be like

10 58 or so so you'll have about 21 more

minutes of the surgery here yeah we

won't be done by that time yeah and that

if you're watching us you can also on

KCRG comm or st. Luke's er comm if

you're watching us we do want your

questions and you can email those to us

live at CRC live.com all right let's go

back in there and see what they're doing

again right now okay there you go

and we just dr. mccarran's instrument

just happened to come off a little bit

so we're gonna put it back on looks like

a clamp that's a clamp that just again

moves not everybody does it this way but

we do we found that it really helps to

mobilize the uterus and help us to

expose things well we're just about

ready to do the uterine vessels on this

side and then we'll go over the other

side and do the same thing and then

we'll release you can see these are all

these are all uterine vessels coming up

here now these bulges here are all the

vasculature this is the cervix of the

cone in it so I'm going to make an

incision down to here and then release

all this laterally because the ureter

lives right over underneath here

somewhere we just don't want it and we

want to let everything fall off to the

side safely so we're going to do now is

cauterize these here's a question on we

talked a little bit earlier about what a

hysterectomy actually includes but this

person Kathy wants to know is there an

increased risk of inter abdominal

pregnancy when the ovaries and tubes are

left not after the uterus is gone no

there's no chance of pregnancy at all no

it would be extraordinarily rare a split

that way never say never be on the

National Enquirer yeah anything like

that we also have a question about

preferred method for closing the vaginal

canal is one more comfortable than

another yeah I will in a minute if those

are watching I think on we'll be able to

show how we close that we close it with

the interrupted stitches which means

that it's just like suturing a wound

shut we don't run it we we just calls it

was several about four or five stitches

generally and they plays from three to

five you know all this tissue that

you're cauterizing in this place these

are all uterine blood vessels and this

was where we take the most time because

this is the main blood supply to the

uterus and getting those loose and

bleeding just makes the case far less

pleasant frankly so we're very cautious

about going through this area

and once you cauterize it though is our

need for stitching it all they're

generally not sometimes if the pottery

for the really big blood vessels there

are times where pottery is not

sufficient in which case then we will

throw a few stitches in but we're just

about we're coming I think the main one

is right here that's why I spend a

little extra time on it as often time do

you think you have it cauterised and

you'll cut into it like now and you'll

get a little bleeding

so far so good

I think we're about ready to turn the

clamp over that's my Karen

again we want to remind people that if

you have questions about what you're

seeing right there also the lingo that

they're using is you know what you may

not be used to at home so if you have

any questions about what you're hearing

even just phonetic spelling get it to us

and we can figure it out repetitive

stars that want to email address that

you can send in those questions too

there's a great picture that you're

looking at of actually the robotic

courts working there and in the left

side of your screen you can see document

Aaron's hand holding that clamp that's

on the uterus currently this is the

uterine artery here and we'll see if we

got it you can see the lumen to the

artery now that's the main artery right

there and that's not a nice thing about

the optics with the three-dimensional

objects I've seen blood vessels that I

never knew existed in the pelvis I knew

they existed but we've never seen it but

the optics are so good and see right

down that uterine artery there they're

trying to separate it off now to drop it

off flat or you can see them a little

bit of blood at the end of it not much

and everything is magnified through so

if you see a little bleeding it's not a

big deal frankly now those attachments

on the end of the the robot arms they're

basically mimicking exactly what your

hands on mister yeah exactly it really

is essentially the surgery is like

having my hands in the pelvis without

having my hands in the pelvis and I'd

like I tell the patient's pre-op it's

like having the three-dimensional skull

is like having my head in the pelvis

without having my head in the palace we

should probably good for everybody

involved that's a much bigger incision

yes that's some people would say that

yeah

morning oh yeah jokester Zinio or you

know okay well here's that here's an

interesting question probably it'll be

coming up here any minute how do you

take the actual uterus I don't I think

that well yeah let's do that I think

that's what I found is that we can

decrease the blood loss in that area by

getting the contralateral side they were

going over to the other side and I'm

sorry I missed that question how that

was talking there we're going over to

the other side and doing the same thing

this would be the tube over here in g20

not dr. Rosalind I get the uterus out we

do it vaginally we put some special

instruments in vaginally and some

stitches on the cervix once I open up

the vagina in a few minutes over the top

of that blue ring down there for those

who are still watching you'll be able to

see that we pull it right into the

vagina and at least for the smaller

normal-sized uterus like this one but

the larger uterus is where the opening

to the vagina is just too small we have

to morsel ate them in other words chew

them up somehow to get that to get them

out and that takes a little more time

this one should come out very nicely

vaginally does that patient feel then

like they've gone through any sort of

living processes if you know not only

because we don't have to dilate the

vagina at all it really is really they

don't notice vaginally any problem they

have the typical low back ache for a day

or two afterwards that's hysterectomy

pain is kind of just a most women say

it's just an aching us the pain relief

or the amount of pain after this surgery

for reasons I don't completely

understand that time to be very honest

with you has been dramatically less in

some cases than even our vaginal

surgeries have been

and I think part of it is it's just such

precise surgery and we have such little

blood loss associated with it that it

but is blood is a terrible irritant so

when there's a fair amount of blood that

gets into the pelvis and up along the

ball afterwards it takes a few days for

the body to reabsorb that and that leads

to more pain we think because again the

the pain after this for most patients

not everybody's different everybody's a

different threshold I don't want to

imply that this is a painless surgery by

any means but it is dramatically less

than what we've seen with the more

traditional ways of doing the surgery

once again that's the older that we're

working on right here tube over here

this is their other round ligament the

suspense story one of the Spencer story

ligaments that dr. McClaren was talking

about fairly good-sized once or just

taking a little extra time to cauterize

all the way process at and then we'll

hook up with my incision down low there

and we'll skeletonize that is expose all

the blood vessels on the left hand side

and cauterize those once we've done that

then there we're almost done frankly we

just have to get into the vagina and

drop the uterus down so most of it has

just taken time to get the

nice view of the robotic arms and remove

his hands move are there any cases that

you would choose after you get in

and see what you're working with that

you would actually remove the ovaries in

the fallopian tubes well yeah there are

certain times were and even even with

this patient we talked about the fact

that if we were to get in which we

weren't expecting any ovarian pathology

but let's say there was terrible

pathology that the ovaries by leaving

him would obviously be a mistake in that

case most time I'll have discussed with

the patients whether they'll let me

remove the Orbeez or whether they want

me to or want me to and so it's kind of

that trust relationship that you have

between your surgeon and the and the

patient that you would use judgment you

know it like you do for your own

relatives your own wife or your own

daughter and as of this morning I left

the house at least I was still getting

off my wife we'll find out later on when

I get home tonight we do have an email

that we want to read to everybody

watching um hello from the eighth grade

science class at Trinity Lutheran

schools we have a lot of students

watching today the students are

wondering how hot the cauterizing

instrument gets I'm hot enough that I

don't know the exact temperature hot

enough though that if you were to touch

Bowl with it it would burn bowel and it

that's just not a good idea either

frankly but it's easy to control with

your hands right yeah you know you can't

between your fingers it would be quite

hot it would burn you it only burns

though between the blades on this side

sorry I'm getting to get my little

attention here again close to the

uterine vessels so I'm being a little

extra this to that typo on that side

where it was quite just answer they go a

little bit further with F&E it's good

class you want to get a nightmare

surgery once again a technology very

similar to this in those instances those

it's risky no I don't want to have not

one or two pairs of it sir well I think

most of your vessels here so and leave

mark on you for a few weeks right so if

there is a lot of heat energy generated

there and so you have to be aware that

in terms of the structures that you're

at you're touching that instrument that

he has in his left hand right now works

with electricity between the jaws so in

theory the amount of heat electricity is

transmitted elsewhere is not not quite

as much whereas the scissors that he has

in his right hand actually has

electricity hooked up to it you can see

him kind of employing that now right now

to sort of open that up alright and

that's a little bit different so that

thermal energy is gonna be a little bit

more in that hand but it's hot you don't

want to get it away what other tools

would you attach theoretically to the

end of this besides the scissors and

again the clamp and cauterizing thing on

the left hand side well you'll see him

switch out here in a little bit but it's

one thing if you have to do any type of

sewing at all then you need to put in

instruments called needle drivers there

are different types of graspers the

things that are used for specific things

I know they're very similar to the

grasper that dr. McCarran has right now

into the top of the uterus there that

looks so like a long hooked thing they

have those attachments available for the

robot as well so they really tried to

make available for you the instruments

that you currently use when you do open

or laparoscopically so the best password

there's a fair amount of venous

congestion there is there I think they

can get on top of this I'll see once

he'll let me know quickly if this is

going to be vascular

I think I'd like to release this right

through yeah I agree

but I think there could be a sign might

just pique that bipolar that I think

there's some vascularity there you know

what we want to remind everybody too

that if you're interested in having the

surgery at st. Luke's we've been told to

schedule for a surgery so if you have

you know something pressing we just took

an email from somebody who said their

mother has ovarian cancer and obviously

that would be a pressing matter that

you'd want to get into this right away

prostate cancer how quickly after a

cancer diagnosis would you want to get

someone in for surgery as a preventive

thing well a lot of it depends on the

diagnosis of the type of cancer

specifically for prostate cancer often

it tends to be a tends to be a slow

growing disease and it allows the

patient time to make a decision about

what's best for them so it may be a few

weeks to even a month or more before we

actually do the surgery not necessarily

because of scheduling but sometimes just

because the decision-making process

obviously for things like ovarian cancer

and things you tended to try and

schedule those more quickly we have a

question from Emily she says she had her

tubes tied so where would the cut have

been made during about where we'd made

the cut across the the tubes here up

above that's about the same location

what I'm doing now here again is just in

it yeah about exactly where I came

across the tubes would be the same place

where they were cut for it sometimes we

put clamps on them or clips on them

there's a variety of way to do tubal

ligations do you do any of those with

the DaVinci or no that's or use the

traditional laparoscopy the da Vinci's

fix is really overkill for the tubal

ligations frankly but some people are

just learning to eventually they they

have an occasion advocated learning to

do them with like something simple like

a tubal ligation but the system is

frankly the setup and so on for a tubal

ligation I'd be done with the tubal

before we even got the setup complete if

it'd go in a traditional way so

it'd be much more quickly yeah I'd be

much quicker to do it the other way yeah

I think that's pretty good they're on I

think they'd have to go much further

we'll have some red in the field very

quickly now I had a double hernia

surgery done when I was five years old

so grand this is a long time ago but you

know would that be something that

nowadays would be done with a DaVinci to

try out that probably not the da Vinci

at this point I mean it probably could

be done again that's generally the type

of hernia would be the general surgeons

doing it but they would they would

probably choose to do it if they did it

laparoscopically most of them are doing

more traditional laparoscopy so I don't

I don't think that that's the standard

application for the DaVinci could be I

suspect and what are some of them we

were kind of talking about it earlier

what are some of the implications for

future uses of the robotic surgery

well gynecologic it's just really

getting and started the urologist are

way ahead of us that way frankly but

projections are that just like urology

that much more Oh gynecological surgery

will be done over the years to come with

the robot and and I've done a lot of

these since the beginning of the year

and I've done very few open cases if I

can count on one hand the ones I've done

open and we've done a lot of these I

think you know our office has done well

over a hundred of these this year and

I've done quite a few of those so I mean

it's not about number necessary but just

goes to show that I've converted over

for the most part to this procedure for

hysterectomies versus the more

traditional ways of doing it and that's

just my personal preference if I said

earlier I've got partners that are very

very skilled at doing its traditional

way with the laparoscopy and they're

just as good as I am with the

hysterectomy on the traditional route

and in fact they're better probably

better with traditional gynecological

surgery with a laparoscopy than I am I

found it the advantage is that this

offers though as far as visualization

and

just the tactile and the are tactile but

the how adept we are with it just mimics

so much like open surgery that I enjoy a

lot more than the traditional

laparoscopy we're going to separate this

- oh yeah

earlier about the pain and aesthetic

that you use when you made the incisions

and that you know you said it lasted

about 12 hours about what point did

patients typically start feeling you

know any pain possible that that just

covers the incision pain it really

doesn't cover the deep pain of a

hysterectomy and they we put we start

medication wise very soon on on

afterwards we try not to not get a lot

in our Chi so we don't want to sedate

patients so they can go home earlier but

we use something called toradol which is

essentially like a potent motrin I think

that's safe their own essentially like a

potent motrin IB for the first 12 to 24

hours some patients will go home the

same day if there's surgery maybe 10%

the other 90% will go home the next day

it's only rarely will if we do a real

complicated surgery with multiple

procedures they might stay an extra day

but in general they'll go home the next

day we have an email from Christy she's

having a total hysterectomy done in

December and we kind of touched on this

earlier but it'd be interesting to get a

gynecologist point of view as well what

should she be doing in the next month we

best prepared for her DaVinci surgery

well I think what I heard doctor rip and

chops comments and they are very

appropriate

really this short ahead of time not a

lot you can do other than like you said

if you have some less than desirable

habits like smoking it would be nice to

cut that back it just makes anesthesia

safer and a recovery easier you can see

a little bleeding from a small vessel

there looks like a lot maybe on the

skull but it really amounts to very

little yeah and again we're really

zoomed in here is that correct what's

that we're really zoomed in yes we are

really quite zoomed in right now the

ring like it feels over there so we're

gonna go back to the other side brief

and get a few more vessels over there

then we're gonna go into the vaginal

vault there you can see that uterine

artery is maybe losing just a touch here

so we're going to fix this to a red

wagon once more

can you think of either of you dr.

wertham dropped after macaron or dr.

Rose boom can you think of any downsides

to this surgery at all that's a question

from Stephanie

well the downside I guess I answer that

to you guys going to the downside this

is it's a surgery I mean I think that I

think sometimes when were these new new

advances that people begin to think that

because it is a neat way of doing it

that it's less surgery it's not it's not

major surgery this is still major

surgery and therefore it carries the the

surgical risk associated with any major

surgery and I think therefore it never

should be taken taken lightly you can

see there's a little vessel right there

that's not so little actually

so we'll take care of that having gotten

the other side makes it a little easier

there's called collateral blood supply

on both sides how quick is a reaction

pretty much in real time with what you

move with your hands you're right you're

seeing it as we go I mean it's pretty

much this what you're seeing is the way

it is and we're just about ready to get

into the vagina now we're just sealing

off these smaller vessels

okay this is a question from Katie she

said did you say that you could use the

DaVinci for pulling up the uterus and

bladder and securing it

we can pull out the uterus we don't

necessary pull the bladder of a week at

times we'll do some type of bladder

surgeries at the same time with the

DaVinci and it just depends what the

patient needs that or not obviously this

particular patient does not so we won't

be doing that okay we have John

wondering if um any neurosurgeons are

using machine probably not here correct

I don't know not here and I don't know

if there is a trip and tribe you know of

any neurological indications for it I

don't I'm not aware of any but I I don't

right now I could see how it would be

very use I would think it would be very

useful for potentially brain surgery but

yeah I don't know of any right no one

let's say I think I'd like to drop that

back yeah a little pesky area right

there

it kind of does drop yeah another run

and drop that down a little bit lower

because I might have to get to it yet

anyway

eventually yeah a little bit of a pesky

area let's go and zoom in a little bit

because as well what we're seeing down

below where you're working is that the

intestine yeah back here the intestines

and that's why we're very careful to

keep that out of the way right now we're

just setting the last little bit of a

blood vessels there here I think we got

it now even seen a pulse of a blood

vessel down in that system down in the

right hand corner there

now the anesthesiologist who's also in

the room with you

what are they monitoring specifically

dr. chemo no you're not Mike that's

right we did we didn't let anesthesia be

miked we don't let them talk

not really monitoring all the vitals

many different things oxygenation well I

think I can take this to here I think I

think that's that bladder killer on that

side if I don't do that it will bill

bleed when they come around on it and I

mean it there's a picture of doctor came

in right now gonna wave at us and she's

watching all the vitals and it's not

like the old anesthesia days you know

we're just to blood pressure and so on

we're being monitored it really they

monitor everything and we have an

extraordinary group of anesthesia people

in the Cedar Rapids area that's just not

giving them you know just to blow smoke

up their spirits so to say it's it

really they are they're extraordinary

okay I'm gonna take this off a little

bit more on yep and what are you pulling

at now that's the bladder area I can got

haven't got it quite as well cleaned off

as I like yes I'm gonna take this across

here and that will drop the bladder down

a little bit more here in a second

now as far as urination goes for this

patient they should have no trouble

everything should generally not we

removed the catheter after the surgery

she has a Catherine right now I'll

remove that after the surgery and then

most women will be able to avoid

sometimes just by monkeying around with

the bladder here what we're doing the

bladders right here the base of the

bladder is about right in this area so

we want to make sure that we have it

down before we open the vagina because

it's we stitched just below the bladder

just above the bladder to close the

vagina right now I'm cleaning that off I

think that looks pretty good okay okay

now we're going to go in till you'll see

what we put in earlier and you see a

little bit of char there I'll clean that

off there gotta clean my fork and knife

here we just want to remind our viewers

on KCRG comm as well the TV 9 News at

midday is set to start here in about two

minutes so you can continue watching the

operation live on st. Luke's please do

thank you and then you'll also be able

to do it as well later on KCRG combo

just so you know it will switch over the

live stream to the newscast here in just

about two minutes so keep that to see

how the uterus here doctor McCarran is

putting on is filling up a balloon the

vagina held it to hold our gas inside

did you see how the uterus and went from

very pink to now developing this

blanched white look too that means that

we've gotten all the blood supply to the

uterus at least the the vast vast

majority and that's what we like to see

we're doing the hysterectomy as you've

seen so far we've probably had ten drops

of blood loss not much and that's one of

the beauties of the procedure now about

how big is the actual uterus in size oh

how about it this one is probably a good

bigger than a pair a nice big Bartlett

fair maybe but bigger than a typical

pair smaller than a grapefruit but it

obviously has stretching capabilities

yes it do well at least it when we pull

and tug on yeah

and what we're doing now is you'll see

here in a minute we're cutting into the

top of the vagina right now and there's

that blue ring that we put in that's

over top of the cervix it's that's a

landmark that I will use to go all the

way around the cervix and release the

uterus there's that blue you were

talking about that's the blue yeah

that's our blu-ray now we're gonna come

over to this side you can see we're

gonna kind of run right through where I

release the vessels over here here's a

question that I guess any of you could

answer I'm is cancerous tissue a

different color if it's not suspected

prior to surgery would it be obvious

during surgery

well cancer the uterus occurs inside the

year so we wouldn't be able to see that

cancer the ovary is something that would

generally you can sometimes see when

it's obvious sometimes the tumors though

are not obvious and you have to first

give them to the pathologist to decide

whether there could be tells whether

cancer or not another question are there

any feature of locations for using

robotic assisted surgery and distance

surgery rural patients for instance or

let's say could you do a surgery that

was actually happening on a patient in

Chicago from here controlling a robot

after that dr. ripman track well the

actual reason that this whole thing

started was the US military wanted the

application to be used on the

battlefield

so the thought was that in the case that

someone was wounded or injured that they

would be able to actually put the

patient put the soldier into a medical

evacuation unit that would immediately

analyze the patient and potentially even

go so far as to put in the robotic arms

and things and had the trauma surgeons

start working on the patient before they

even arrive back at the at the mass

hospital or wherever they were

edited so that's really where this this

all this technology started they have

done some Robo some remote robotic

surgery it's still pretty a little bit

rare because you can imagine you know

we've had some feed problems today yeah

so feed problems when you're trying to

watch a surgery is one thing but feed

problems when you're trying to do a

surgery is obviously another as far as

they've gotten that I'm aware of I know

that they've done a cholecystectomy or a

gallbladder removal with a remote feed

like this as well as it happened ectomy

so surgeries perhaps without as much

implication in terms of bleeding's or

things

assuming they go smoothly but I think

the issue then becomes if you're doing

in a rural location and something goes

wrong who's going to be there in that

world location to finish up whatever

needs to be done and so that's the real

issue right now but they've talked about

using this type of technology even even

transcontinental where one person who

specialized in a very rare form of

surgery would operate on a patient you

know half a world away they talk about

it I don't think it's really happened

yet but you know the kind of thing like

nations or it will happen at some point

did by any chance the Cedar Rapids

surgeons assist in any input on the

development of DaVinci mechanics or

perhaps did you customize your own

machine

no really customize it I wish had been

in the original stock combining the

compass which I don't have any stock to

this particular procedure but they've

done very very well this it is but no we

didn't have any input into the actual

development of the machine or or

customizing so to say you can customize

order what you want what's available and

this this particular machine has

essentially everything available is

called the s system which is the the

most sophisticated system and it has

high di man look

in high dimensional optics here through

my skull so it's pretty cool frankly can

see the detail is is absolutely

marvelous is there anything you know

having used the the robot several times

to do surgery been completely trained on

it that you would have thought oh I wish

they would have added this or I wish

they would have done this differently so

far not whoever the engineers that came

up with this or they must have sat in a

quiet room for a long time to come up

with some of this because it is and it's

fairly fantastic frankly it is really

well thought out now you can see where

these are the called the uterus April

Aegon that's over here they are coming

up from the sacrum how the tailbone up

here all the way to the back of the

uterus and one nice thing about this

surgery that we can't do and we do a

vaginal hysterectomy we come through

from the bottom and we clamp off the

uterus acres which is one of the support

structures to the vagina when we do it

through the DaVinci you can see I'm

preserving the attachments of the of the

uterus April's so I think it adds

personally I think it adds extra support

to the vagina for lad later in life over

a vaginal surgery now that's some people

would argue about that so if there are

anybody gynecologists watching they're

probably saying I don't believe that

completely but you know that's just my

opinion maybe something we could talk a

little bit about - you know for women

who have a hysterectomy that doesn't end

there you know sex life so to speak

correct no it doesn't if you look at the

largest study it's a good question it's

a question I always address with my

patients frankly it's if you look at the

largest study out of the out of Britain

I believe it was on this it came back

that women with chronic bleeding films

particularly and pain that their sex

life either improved or did not change

so you know a lot of it has depends on

how well how good things are beforehand

obviously but but it will not

particularly you leave the ovaries now

you could take the ovaries out hormonal

e things change so that probably has a

greater chance of altering sexual well

would it change libido perhaps yeah it

could

a little bit menopause sometimes is

associated with that so whether it's

surgical menopause or whether it's

hormonal natural menopause certainly

there are some issues with libido sex

drive around that time maybe doctor roof

and top can expand on that in terms of

men and a prostate procedure does that

have any effect well not necessarily a

physiologic effect on sex tribe per se

erectile dysfunction is a well-known

potential side key and I would just

release some chart interrupt there

dripping chocolate you want to get my

earphone again please one last time

doctor McCarran is now pulling on what I

attached the cervix earlier and he's

gonna pull it into the vagina of the

uterus night to see him tugging it's

been released from all of its

attachments he'll pull it in he'll you

I'm gonna get my ear piece somebody

please you know leave it right there for

now so they're the kind of otherwise all

my gas would escape through the that I

have and though all the internal organs

would cave in so to say so you're gonna

leave that he's gonna switch the arms

now make a nice job getting that thing

out of there

nice case doc puzzle

so from here are you going to stitch now

we're now we're going to stitch and then

with the procedure will essentially be

done so the uterus has removed you know

you can see both ovaries are still there

like we talked about I'll show you the

bladder and a bit more and you see the

bladder from the front there but I'll

show you that a bit more we don't want

to stitch into that there comes one of

the instruments and the other needle

driver now that you're not doctor

McCarran will ask me a suture through

that one of the other ports that he's

been helping me through we have a couple

questions that both kind of relate to

the same thing one person Danielle's

wondering what is the blue thing which

we can't see right now but you can see

that was a it's a ring they essentially

around the cervix so it kind of loops

around the circuit we put that onto the

indicator that helps us to see or to

guide us as to where to make the

incision now here's the bladder right

above there is the where the bladder

starts that's dr. ripman wonder dr.

Ripon trumps places and we like to stay

away from that but we got a nice

separation of nice normal tissue here

this is all vagina so we're gonna do is

put some stitches in we're gonna start

over laterally and each time we want to

make sure that we get some of the lining

of the vagina so that we don't leave raw

areas in the vagina because it leads to

what we call granulation tissue and this

just takes longer to heal so there's

vaginal tissue right here and so we put

that stitch in there and then we'll go

back dr. McCarran happens to be holding

it here I get a nice bite here and go

once more right through let's just on

the inside of the uterus sacral ligament

there and then I'll come over here we do

figure of eights

they're nice hemostatic stitches

and it'll go right there again getting

vagina we had somebody who wanted to

know how long once you know all the

stitching is done the patient's wheeled

out how long before they wake up they go

back into the recovery room and they're

easy waking up they're not wide awake

but they're waking up within a half an

hour or so at most let's see here Owen I

got a loop here

it could go yeah let me get that out of

there a minute

and so they're you know they're not

wide-awake but they certainly are awake

we easily talk to them and tell them how

things went oh and I don't want to go

lateral to that uterine vessel area

there I think I'll go there here's a

question that would come right there you

could even answer this doctor from trop

but what was dripping earlier before

they actually pulled the uterus out what

was dripping from the instrument well I

didn't exactly see quite what is being

talked about but in terms of what was

dripping but oftentimes they'll be

condensation that may form on the

instrument while you have it in there

you may have a little bit of peritoneal

fluid which is that fluid you see down

below the area we're sewing right now

that sort of I guess you'd call it a

puddle yeah that looks like blood most

of it is not blood it's actually fluid

that's created by your bowels and

recycled all day long so you naturally

have sort of a fluid moving around in

there and it just kind of accumulates in

areas and that's where it is right now

so might have been something like that

and then on some of the instruments we

actually put a sort of like a little

oily film on it that helps when you use

the electricity or they electric cautery

to keep things from building up in terms

of actually scarring down or getting

stuck on too big so just like a nonstick

yeah kinda like it yeah cooking spray

there you go that's one stitch that we

just tied in there now we'll go to the

other corner and those the corners are

where most the blood vessels come in so

we like to secure the corners of the

vagina first and then we put a couple

stitches in the middle so we'll go over

to this side here and once again try and

find the lining to the vagina down in

there and there it is right there the

bladders up here we're going to stay

inside of that is that the uterine

artery right there - yeah that better

Yeah right like next - here's the

uterine artery that we cauterize and we

through it and doctor my parents kind

enough to hold that for a min then I'll

grab it from him too far over to start

with

so dr. McCarran really is very very

hands-on I mean while you're certainly

robot arms it's been estimated by some

people that the assistant is at least

thirty or forty percent of the surgery

as far as how well things go I mean it

is without a good assistant in this in

this kind of surgery it is can be a bit

of a nightmare frankly just because it

is so important to have the exposure and

since dr. McCarran also does this

surgery as I said like several other

partners they know exactly what what I'm

going to be doing next because they do

it to st. essentially the same way so it

is it is absolutely essential to have

somebody as skilled as making dr.

McCarran to deal with to take care of

this and there would be no way to do

this surgery solo just you own the

DaVinci only correct well no way it

would certainly not be very fun and it

would be it would be a struggle and

struggle means that it's more risky to

the patient more risky the patient it's

a suboptimal patient care in my opinion

so that's why we choose our group at

least we choose to have two surgeons

with each of the cases but it can be

done with only one surgeon with it with

a very skilled assist that's a non

surgeon that can be done as well in some

place to do it that way we have a one

nice thing about a sizable group like

ours is that we have the ability to do

that those kind of things

so the suture you're using right now dr.

rose boom is that absorbable yes it is

it's called Oh max on its delayed

absorbable the only restriction we put

on patients after this surgery frankly

is that there's no intercourse for eight

weeks and why eight weeks is because in

the literature there's about a one to

two percent instance that this vaginal

cut that I'm sewing will rupture at some

point and allow the intestines to fall

out that's a bit of a problem scares

people scares us and we have to go fix

it again well most of the time that lost

that that rupture occurs with

intercourse that starts too soon so we

really do tell patients that they cannot

resume intercourse till eight weeks and

these sutures getting back to the suture

will dissolve being a delayed absorbable

suture they'll dissolve right around

eight weeks or so so it all kind of

coincides and then it by that time it

should be fully healed and so they just

dissolve right into the the tissue just

absorbs it it dissolves yep so there's

no sutures that come out and again I'm

doing a stitch in a figure of eight

fashion here and I see you nodding

several times about how many times you

not each one no I usually do about five

or six throws maybe it's no a bit more

than that it's

I think going that the bladder still

the bladder the bladder is up here they

have some good there yeah you just

always double-check our landmarks to

make sure that we don't stitch something

in that would be a bit of a problem

and again we're and this is probably

between the this is where sometimes it

takes a little while to get used to the

DaVinci is how to suturing this is where

having I'd known I'm not a video game

player anymore I used to be but that's

the kids mine would be our cake compared

to what they have now he said our Atari

earlier yeah well Atari or you know what

was linked on the oh I can't remember

what it was anyway they would be very

very unsophisticated compared with the

kids you nowadays but it does help to

have some decent eye hand coordination

to do this I've heard that they actually

have training now for doctors on the Wii

so they're right yeah I wouldn't doubt

it operating room I wouldn't doubt it it

just goes to show the implications of

technology on surgery and medicine

Surgical here oh it's a guitar here one

more stitch this should just about do it

and then we'll look around a little bit

make sure everything is dry and then

we'll put a little sheet of what's

called inner sea that's to help prevent

any adhesions from forming do you have

any suction going on right now I mean

obviously we see some in the box we have

not suction anything yeah that's one as

I said the blood loss thus far probably

is estimated to be less than 10 cc's

frankly and that's like less than a

tablespoon so that's one beauty when

this goes well which this one has today

when it goes well the beauty of it is

that there is oftentimes very little

blood loss we have a question actually

for the anesthesiologist so maybe you

guys can pass it on I know she's not

miked up

are there any meds that can be used to

prevent sickness after the surgery they

know if somebody who vomits after waking

up because the anesthetic used any

specific minutes you used for nausea and

vomiting post-op

I don't know if you could pick that up

Ashley it was really faint but could you

repeat basically what she said um

she mentioned that she uses decadron

ahead of time and that tends to really

decrease the amount of nausea and then

she uses dilaudid as the narcotic and

finds that people do much better with

that than other narcotics now about how

big we've been talking about how you

know you'd really get the 3d the 3d view

about how big magnified wise what are we

looking at here in terms of the incision

that your suture suturing right now it's

about all what do you think dr. McCarran

2 3 inches long

yeah they're about about 3 inches long

and is this your last that's the last to

suture yep that should be it there and

well I said well irrigate for the first

time we'll use some irrigation that's

just running some fluid and look around

we'll do what's called a low pressure

test that's just to make sure there's no

losing from any of my medical sites we

call them tatical that's the what's the

the blood supply since they are now

pedicles and about the gas that you

pumped in how do you get that out we

open up pretty soon we're finishing up

we just open up those ports have little

valves on it and the valves will allow

the gas and we open them up to escape

there's always a little bit of

discomfort they called shoulder pain the

diaphragm which is that we looked at

earlier is the top of the the abdomen

essentially is innervated the nerve

supply is similar to a nerve to the

shoulder so a lot of patients have

referred pain from in here with the gas

to their shoulder the first day or two

afterwards and last a little longer for

some patients okay so now we're gonna

pull out and I'm going to do a little

zoom let's see what you say we already

just we just zoomed out a bit so you

have a more of a panoramic view this

also allows you to zoom that's the

standard view we're in and if I go once

more and getting closer closer and

closer and there's actually zoom for

that you really want to get into

delicate detail which we don't so now

we're gonna zoom back out and do a

panoramic view right there so we'll take

a look all the way around doctor

McCarran is down there suctioning now

just that very little bit of fluid

that's there let's drop the pressure

down please to eight millimeter at a

eight centimeters please excuse me

there's that a rinse basically we just

saw or some kind of air what supported

me we just saw like what looked like

almost sprinting yeah that's it's normal

sailing which is just fluid that we

flushed things with

as you as you look around there the

Orbeez everything we got the

low-pressure do it yeah okay and there's

no bleeding very nice if there's any

bleeding of be running down into here

right now to the bottom that's why it's

kind of watch that there's no bleeding

there was never any question about the

ureters so I'm not worried about them

there's actually a ureter that's a pair

of stalling right here is one of the

ureters and I just saw peristalsis which

means that it's moving urine through it

which means that it doesn't mean it

can't be occluded but it makes it less

likely that it so cluded and the other

year is going to be over here as well

it's gonna be probably right here I

suspect at what point do you we started

the procedure happened you propped her

up like you said you put her legs up so

that her bowels would go down at what

point do you bring her back down level

once once we finish up here we'll take

her out of the turn down what we call

Trendelenburg we have this have the one

peek at the bowel of U and J artists

okay okay yeah I don't I saw what you

had there but I don't think it was a

Alex kid I think it was right in here

yeah I think it just hooked those things

over overlap a little bit alright I

don't see any problem there this this is

the sigmoid colon that you can see when

you people have colonoscopies rectally

the anus will be down there at

colonoscopy we'll come all the way up

here looking at the inside of the colon

and you can kind of run all the runs all

the way around up there that's small

intestine up there as you go up top

here's some major blood vessels that we

just soon not knock out here not monkey

with today is that you right there

there's the ureter you see the ureter it

was peristalsis and that's coming from

up the kidneys about right up back here

that's where dr. ripman trough to be

operating one lisanna surround the

kidney this morning what we did this is

the tailbone right here that's the going

down into the pelvis what we did this

morning is we put the graft to the bone

right here opened all this up put the

graft in there and ran the graft all the

way down and hooked it up to the vagina

down here because her vagina was falling

out and so we took care of that this

morning too but anyway there's different

things we can do with the with the

proceed now this is a called intercede

it's a agen barrier that we found that

it may not be necessary but we just

found that it makes sense to cover our

surgical field with a little film that's

and prevents adhesions which is far too

issue from forming because the ball will

come right back down here and lay it

right against those sutures once we're

done with the case and we've just found

that be nice to keep that ball away for

the first few days this is the barrier

and dr. McCarran will put some water

against it that makes it stick to the

tissue underneath it and that covers all

my stitches up as you can see

and then that's the end of the case so

now we'll take these instruments out and

we'll sew up the little incisions with

stitch or two which really not a big

deal that will undock the robot and 5-10

minutes we'll be down here nice job guys

thank you thanks yeah thanks for letting

us take the peek in there as they did

that a robotic hysterectomy with the

DaVinci we want to pass along just an

interesting statistic here according to

intuitive which is the maker of da Vinci

st. Luke's as I was robotic leader of

2008 meaning that this hospital st.

Luke's has done the most procedures in

the state as a non university hospital

in 2008 379 procedures that's a lot of

DaVinci surgery so far yeah and there's

still a month and a half left so

definitely some cool stuff do you have

any closing remarks you'd like to add

just thanks for tuning in yeah we were

glad to have you for this robotic

surgery here online streaming live and

again you can continue to email

questions if you have them we are gonna

try and answer those for you so the

email address is live at CRS st. Luke's

calm again dr. Burke and Rob I'm Ashley

Henson and of course for the surgeons in

the operating room we want to say thanks

for joining us today and you can view

the surgery online as well KCRG comm and

st. Luke's er org