Jul 30, 2023
How does a robotic surgery work? [photos, video]
Friday the 13th turned out to be a lucky day on the Elk River for a float-fishing trip along the storied Ozark stream. Ron Duncan of Springdale and outdoors editor Flip Putthoff cast superstition to
Friday the 13th turned out to be a lucky day on the Elk River for a float-fishing trip along the storied Ozark stream. Ron Duncan of Springdale and outdoors editor Flip Putthoff cast superstition to the wind and enjoyed a stellar day of fishing and canoeing on the beautiful Elk River, near Pineville, Mo. Summer blended into fall on the 5-mile drift that took place Friday, Sept. 13. Staff photos by Flip Putthoff
More robots in Chattanooga operating rooms
It's 8:45 a.m. when the patient, a man in his late 60s, is wheeled into the second floor operating room, one of two (out of 31) dedicated to robotic surgery at CHI Memorial Hospital.
The robotic gear includes three separate parts - the controller, where surgeon Dr. Lee Jackson will sit to manipulate the robotic arms; the module that includes the arms itself and the vision system, including a miniature camera and almost a dozen monitors scattered around the room to allow everyone involved in the operation to see what is happening.
The module with four foot-long arms dangling down in front, what the manufacturer calls the "patient side cart," is off to the side of the room. Before they can be used, metal ports through which the robotic tools will operate must be inserted into the patient's body.
The nurses and anesthesiologists talk to him in a low murmur before anesthesiologist Dr. David Musgrave puts a cupped mask over his face. Within 10 minutes, the patient is in a deep sleep and Musgrave leaves the operating room. Nurse anesthetist Leslie Solakis will remain at the head of the operating table, watching the patient's vital signs on a monitor.
The patient is naked, but nurses Melissa Walker and Krista Ping move quickly to cover his body with a half-dozen cloths, each the size of a small bath towel. The table is tilted so the patient's head is lower than his feet, to give Jackson better access to the pelvic area. Foam wedges are pushed snugly into place on either side to prevent the man's body from moving, and finally a large blue cloth is draped over the entire operating table, covering the patient from head to toe and then some.
By 9:10, flaps in the cloth are peeled back to reveal an expanse of flesh about 18 inches square. For the next three and a half hours, the five to seven medical staffers in the room are focused intently on what is happening in the abdominal cavity below the patient's pelvic bone, an area just a few inches in diameter.
This is robotic-assisted laproscopic surgery, meaning the robotic arms will be operated through small incisions in the patient's abdomen, rather than open surgery, where his abdomen would be cut open.
It is a specialty of Jackson, who has performed the procedure more than 1,500 times. He will first cut through the fleshy tissue on top of the abdomen for an inch or so until he reaches the bladder. He then will cut the tissue holding the bladder in place until he can peel it back out of the way so he can reach the prostate.
Jackson will then cut around the prostate, slice through the urethra, the tube that runs through the penis down into the bladder and prostate, check the lymph nodes for tumors and take a sample for later examination, and sew everything back together.
While the surgery is labeled minimally invasive, it is still invasive.
Before the robotic arms are moved forward, Jackson bends over the patient with his scalpel and makes six incisions in the abdomen, each about 8 millimeters (less than half an inch) in length.
Each incision will hold a metal or plastic port for the robotic arms, the camera, a suction tool to collect liquid, and an arm operated by Jackson's longtime patient-side assistant, nurse Michael Albert. They have worked together in the operating room for 21 years.
On a nearby table about a dozen tool modules are lined up, each more than a foot long. Each tool plugs into the end of the robotic arm and has a particular function.
The one Jackson will use the most is a simple grasper, with serrated metal jaws, that can tug at tissue or an organ, or hold a needle for sewing up incisions.
There are scissors, which can cut and also use a burst of electricity to burn through flesh or cauterize a blood vessel, sealing it shut.
A tiny spatula, about the size of a large match head, also conveys an electric charge for cutting or sealing.
There is a pause as circulating nurse Mark Huber, who is in charge of managing the operating room during the surgery, picks up a clipboard. He states the time, and then reads off the patient's name and age and tells a bit about his life, listing his family members, jobs and even hobbies. It is to remind everyone in the room that this is a real person lying on the operating room table and not just a slab of flesh.
But by 9:20, as the lights dim and the video screens fill with the view from inside the abdomen, it is easy to forget this is a person whose life they hope to save by removing his cancerous prostate.
First the camera is poked through one incision. A mechanical voice intones, "Targeting complete." Initially, the dozen video screens arrayed around the room show the inside of the metal tube sticking out of the patient's abdomen, and then they fill with brightly-lit yellow and pink globs of tissue and organs, showing the inside of the abdomen, magnified 10 times by the camera. As the other ports are pushed through the skin and the tissue below it, Jackson can see the sharp end of each tool as it descends inside the body, straining against the tissue, stretching it until the metal tool finally punctures its way through.
When Jackson is finished, there are six metal or plastic tubes, each 6-8 inches long, sticking out of the patient's abdomen, which is now smudged with blood.
The robotic module slowly moves closer to the patient and the arms are attached to the ports.
At 9:32, everything seems to be ready.
Jackson takes off his green scrubs - he does not need to be sterile during the operation since he will not touch the patient again. He puts on a dark blue cloth jacket (to keep warm, he explains) and moves to the corner where his control module sits, about 30 feet from the operating table. Boxes of spare tools and other surgical supplies are in two racks against the wall.
The controller would not look out of place in a video arcade. It is about 5 feet tall, with a large hood on the top about 3 feet wide by 2 feet tall and deep.
Jackson taps a touchscreen on a wide bar beneath the hood, where he will rest his arms, and the module adjusts to a position he has customized to fit his body.
Jackson puts the thumb and middle finger of each hand into loops on the side of the hand control he will use to move the arms remotely. His index finger rests on a clutch. Push it in and the gears disengage, and he can move his hands around without moving the tools inside the patient.
Pedals on the floor allow him to adjust the camera or to order the tool to cut, staple or burn. Jackson removes his shoes to get a better feel for the pedals.
A microphone built into the console allows him to talk to Albert and the nurses on the other side of the operating table.
He is ready to begin and puts his head inside an opening in the rear of the hood, almost all the way up to his ears, to block out any peripheral vision.
To start, he must work his way down through several inches of tissue to get to the cavity where the prostate is located.
His hands are not visible in the dark as he uses a spreader on one hand to stretch out the tissue and then snips it away with scissors on the other hand - snip, snip, snip - a cut every second. At this magnification, the cutting tool resembles the wooden- handled shears a gardener would use to prune shrubbery.
Sometimes he grabs a gauzy white substance that resembles cotton candy and pulls it up to trim. He works methodically, clearing away what in reality is an opening about the size of a baseball, but magnified 10 times, the image fills all 50-or-so inches of the largest video screens mounted on the operating room walls.
By 9:45, he makes a final series of cuts and the abdominal cavity appears, almost like pushing aside spiderwebs to see into a cave. The bladder is just ahead, a large blob of yellow flesh.
The bladder blocks his access to the prostate, which is below it, so he now wants to cut some of its connections to the surrounding abdomen walls. He moves steadily, zooming the camera in and out for a better view.
It's 10:15 now and the room is dark and quiet. Albert is immobile at the patient's side, staring at the video screen with his hands on the tools he is controlling. The two nurses on the other side of the operating table chat inaudibly.
Jackson works around the three sides, top, and bottom of the bladder, cutting connections. It is about 45 minutes before he can pull it back out of sight.
Now his main target is in view. The prostate is normally about the size of a golf ball, Jackson says, but in this patient it has swollen to several times normal. He needs to be careful not to slice into it, for fear of releasing cancerous cells.
He works steadily, while Albert stands watch beside the operating table, staring intently at the monitor, sucking out fluids or removing small bits of flesh at Jackson's request.
There is a buzzing noise, a flash of light, and a puff of smoke or mist as Jackson cauterizes the flesh, leaving an opening. The mist clouds the camera lens and Jackson stops repeatedly so Albert can pull it out and clean the lens.
Jackson is cutting along the edge of the prostate now, close to a vascular bundle of nerves that are critical for sexual function.
He asks for the clip applier, clamps its jaws over a blood vessel and taps a pedal on the floor. With a click, the white plastic clip snaps into place. With the blood vessel now shut off, Jackson cuts through its connection to the prostate.
It is painstaking, tedious work. On the monitors, the prostate appears in two dimensions, but Jackson sees it in 3D on his screen. He can rotate his grabber and cutter and camera all around the tiny space in which he is operating, and the 3D view makes it easier to see just where his tools are located in relation to their targets.
By 11:30 he is almost finished with the prostate.
Now, one of the trickiest bits of the surgery. The bladder and prostate are connected to the penis by the urethra, the tube through which the patient urinates, and it is very close to a large bundle of nerves that are critical for urination and sexual function. He plans to slice through the urethra, but needs to avoid the nerves.
Even if everything goes well, most patients will have trouble urinating or functioning sexually for weeks or even months after the operation. An errant cut could result in permanent problems.
He slowly moves the arm into place and snips through the urethra.
Now Jackson needs to do some exploring. The lymph nodes are difficult to see, hidden by layers of tissue, but they are a prime haven for any cancerous cells that have spread. Jackson peels back the layers to remove a sample to send to a pathologist for examination.
Albert pushes a tool into the opening holding a small plastic baggie. Jackson snags the tumorous prostate with a grabber, pulls open the bag with his other grabber, and pushes the prostate and lymph nodes in.
The bag is moved aside and will be removed later.
His most impressive feat lies ahead. It is time to sew everything back together.
Jackson uses the spatula to burn shut the now-unneeded blood vessels that were connected to the prostate. Again, the clip applier appears.
After a few minutes he is ready for his final challenge - sewing the urethra back to the bladder. It is here that his skill as a surgeon seems most apparent. He has no tricks, no automatic robotic sewing machine. This is all done one stitch at a time, just as a seamstress would sew together a dress.
On screen, the urethra looks to be 6 inches across, but in reality it is about a quarter of an inch in diameter and Jackson needs to make 12 stitches to pull it back into place. He has already decided what size and shape of needle to use, and the type of thread or suture.
But he is sewing by remote control from 30 feet away, holding small curved steel needles the size of a dime with his grabber arms. As he twists his wrist, the grabber rotates, jabbing the needle against the tissue. It stretches, then the needle pushes through. Jackson snags it with his other grabber and pulls the thread through. He moves to the other side and again the needle punches through flesh. He pulls the stitch tighter, but leaves a gap of about a half inch. Then more stitches, and he ties knots in the filament. He alternates tools now, tying knots and pulling the ends of the filament taut so Albert can slice through them and remove the ends.
Four or five times, he needs a new needle and thread. This is a tricky moment, for Albert must reach in with his own grabber and capture the needle and pull it out.
"It is easy to lose a needle and they are impossible to find," Jackson says. As the needle is pulled through the port, Albert says, "clear," and Jackson responds, "thank you" before either moves on, to be certain that the needle is safely out of the abdomen.
In 20 minutes Jackson is finished, with 12 loops connecting the urethra to the opening in the bladder. He gently tugs on the individual strands to pull the bladder and urethra together, until they touch.
Jackson and Albert take a final look around to be sure nothing that has been cut loose is lying around the cavity. "Can you get that, Mike?" he says when he sees a tiny puddle of fluid.
At 12:14 the lights come back on. Jackson takes a deep breath, pushes his chair from the console and stands up.
Three hours and 29 minutes after the patient was rolled into the operating room, Jackson is finished.
The patient went home the following day, and was doing well a week later.
Contact staff writer Steve Johnson at 423-757-6673, sjohnson@timesfree press.com, on Twitter stevejohnsonTFP, and on Facebook, www.facebook/nooga.com.