Cutting-Edge Surgery

A few scars measured in centimeters on his side, or a full “zipper” scar down his chest and another down a leg? About 14 weeks to recover and get back to work, or six months to a year?

Glenn Courington, of Smith Lake, didn’t take long to make a decision about what he preferred when he found out he needed single bypass surgery earlier this year. Courington, 60, quickly accepted the opportunity to be the first Birmingham area patient that Dr. Clifton Lewis of St. Vincent’s Hospital performed a heart bypass on using the da Vinci® robotic surgical system. As with similar but less sophisticated minimally invasive surgical devices, the robotic system requires much smaller incisions than open surgeries, and therefore, leads to less painful and faster recoveries with a much lower risk of infection. The benefit for cardiac patients is especially exciting, because it eliminates the need to cut open the full chest and divide the breast bone.

Many large hospitals in the state have a da Vinci robotic surgical system and commonly use them for prostate and gynecological surgeries, among other uses. Other Birmingham area hospitals have been moving toward or have started performing some cardiac procedures with the da Vinci, or have hired surgeons trained on the system to start a program.

Lewis has the benefit of essentially having his own da Vinci system dedicated to cardiac surgery — a gift to the hospital for him. His partners are now being trained to do various robotic cardiac and thoracic surgeries, too.

Lewis, who went to medical school in Birmingham and practiced about 20 years in Sarasota, Fla., had just joined St. Vincent’s when Courington came in. Courington’s relatively simple single problem made him a good (meaning safe) candidate for the hospital’s first robotic bypass, Lewis says, and Courington was ready to do it the next day.

“This particular day, I was standing at the right place at the right time,” Courington says.

But, Courington still asked some questions any patient should ask, after he heard the benefits: “I said ‘that’s fine, but, I’ve got two different questions … how many patients have you done this on … and my main question was ‘what’s your success rate?’”

Lewis did hundreds of cardiac surgeries with the robotic system when he was in Sarasota, and the success rate is more than 99 percent overall, he says. Lewis acknowledges hundreds is still small relative to the thousands of standard cardiac surgeries he’s performed, and success rates from any cardiac surgeon using the da Vinci come from a similarly relatively small pool of patients. The operating room staff and surgeons are prepared to quickly convert to traditional open surgery if necessary.

The da Vinci method is not the ideal option for all cardiac surgeries, such as complicated surgeries with more than one issue to address, including multiple bypasses, which is still best done in open surgery, Lewis says. Others, such as mitral valve replacement, can be done equally well with other minimally invasive techniques.

Mitral valve replacements are performed with a different type of minimally invasive surgery equipment because they require a larger incision to insert the prosthetic value, so there’s no benefit to using the robotic systems.

But when it can be used, the da Vinci offers many benefits over other minimally invasive techniques, Lewis says.

“Everything is true — your movements are true,” Lewis says. “Instead of having to learn how to make your arms move the instruments, basically it just takes your instruments and translates them into your regular true motion. And, you see 3-D … the depth of field makes things easier and safer.”

These types of technological advancements are changing how surgeons and hospitals operate — in the literal sense in the OR and as businesses, Lewis says. “Medicine’s competitive and volume driven.”

Patients today often are already aware of the benefits of minimally invasive surgeries in general, and there’s going to be an ever-growing demand, he says. “I think that demand is not going to be well served right now,” Lewis says. “The learning curve is so unpleasant that I think the growth in the number of robotic surgeons is not going to be rapid.”

Lewis says as he sees it, surgeons tend to be excited, reluctant, resigned or repulsed by the idea of robotic assisted surgery.

Some see it as a great advancement — and as a way to keep surgery interesting decades into a career — and are eager to learn to do it. “That’s basically my approach … I became enamored of it, and it’s good for people.”

Others see it as a good thing, he says, but would rather hire someone else or get another partner to learn it.

Some don’t want to do it at all, and just hope it won’t hurt their business too much too soon, he says.

“The final (response) is ‘it’s an instrument of the devil and a bad idea; stay the heck away from it, and tell all your patients they’re doing a terrible job.’ I’ve seen all four of those. The latter two are the most common,” Lewis says.

“I think that heart surgeons in particular, and surgeons in general, don’t come to change very well, because, first of all, if they change and they’re wrong, somebody gets hurt. There are all kinds of issues,” he says. “And if you change, there is a learning curve,” when people might get hurt, too.

The only downsides Lewis sees to the da Vinci or whatever comes next are a current scarcity of training options and the cost of adding the systems. The da Vinci robot alone is about $1.8 million, Lewis says. “It takes a significant investment in infrastructure … personnel, equipment … to make it work.”

—Tara Hulen