ORLANDO, Fla. (Ivanhoe Newswire) - Some of us have innies, others have outies, but besides collecting lint, what's your belly button really good for? Now, your navel is changing a surgery more than half-a-million people undergo each year.
Jannett Matthews loves doing some exercises.
"It's hard but just to know I can do it is exciting," Jannett told Ivanhoe.
She hates others, but she does it all.
"I was at 280 pounds and decided that wasn't going to work for me," Jannett said.
With exercise and bariatric surgery she lost more than 100 pounds. After the rapid slim down her gallbladder wasn't working right.
"There were days when the pain was so bad, I just didn't have the strength to train," Jannett said.
Removal was her best option. She already had several abdominal scars from her weight loss surgery and wasn't looking forward to more. Then doctor Keith Kim told her with a robot and just one cut he could do the surgery through her belly button.
He sits feet away from the patient and uses a robot to control the instruments. The doctor said the single incision laporoscopic procedure, approved by the FDA less than a year ago, offers surgeons better ergonomics, visualization and precision.
"It minimizes the number of incisions but it also tries to hide that incision so there's very little residual scar left over after surgery," Keith Kim, M.D., a general and bariatric surgeon at Florida Hospital Celebration Health, explained.
He said because the incision is only an inchand hidden by the belly button, the biggest benefit is cosmetic, but doctors also believe the single incision surgery helps reduce recovery time and post-operative pain. Jannett said after her surgery she was back home within hours and back in the gym in three weeks.
"It's really exciting to see how far I've come," Jannett said.
Pain-free and scar-free she's once again doing what she loves and hates.
Candidates for traditional laparoscopic surgery usually meet the requirements to have the single port procedure.
GALLBLADDER PROBLEMS: Cholecystitis is inflammation of the gallbladder. Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath your liver. The gallbladder holds a digestive fluid called bile that's released into your small intestine.
In most cases, cholecystitis is caused by gallstones that block the tube leading out of your gallbladder. This results in a buildup of bile that can cause inflammation. Other causes of cholecystitis include bile duct problems and tumors.
If left untreated, cholecystitis can lead to serious complications, such as a gallbladder that becomes enlarged or that ruptures. Once diagnosed, cholecystitis requires a hospital stay. Treatment for cholecystitis often eventually includes gallbladder removal. (Source: mayoclinic.com)
GALLBLADDER REMOVAL: Your doctor may recommend gallbladder removal surgery if you have gallstones that bother you or your gallbladder is not working normally (biliary dyskinesia).
You may have some or all of these symptoms:
Nausea and vomiting
Pain after eating, usually in the upper right or upper middle area of your belly (epigastric pain)
GETTING OUT BAD GALLBLADDERS THROUGH BELLY BUTTONS: The FDA approved the da Vinci robot's use as tool for single port laparoscopic surgery for gallbladder removal in late 2011, With this innovative approach, patients have little to no scarring because operating through the belly button actually hides the scar. Other benefits include reduced pain and need for pain medications as well as decreased risk of infection. Additionally, patients go home the same day of their surgery and get back to work or activity in only a few days.(Source: www.floridahospitaldigestive.com)
Keith Kim, M.D., Medical Director for the Metabolic Medicine and Surgery Institute at Florida Hospital Celebration Health, talks about a different approach to gallbladder surgery by removing the gallbladder through the belly button.
Who would need gallbladder surgery? Why is it important?
Dr. Kim: Gallbladder surgery is a commonly performed operation. The gallbladder does not have a synthetic function, but it stores bile and releases bile into the intestine in a coordinated fashion to mix with food. Sometimes people can develop gallstones and the gallbladder can get inflamed, or the stones can block the bile from being secreted from the gallbladder. The typical reason for having gallbladder surgery is for pain from it. Other problems could be gallstone pancreatitis, in which a stone passes and irritates the pancreas. Sometimes patients can have just a dysfunctional gallbladder, where it is not emptying appropriately and it causes pain when it is stimulated.
Can you just take it out?
Dr. Kim: Yes. It is not a necessary organ in terms of survival. It can be removed and typically has minimal effects on the patient.
What is the traditional surgery like and how invasive is it?
Dr. Kim: The standard of care today is to have it done laparoscopically, and it is typically done through 4 small incisions and as an outpatient procedure. It is one of the more commonly performed general surgery procedures. People tend to do well and the recovery is typically pretty rapid.
How does the newer procedure differ from the traditional procedure?
Dr. Kim: Single site was introduced probably back in the mid or late 90s with procedures like appendectomy. There was, out of India, a surgeon that did a transgastric appendectomy where he went in with an endoscope, opened the stomach, and actually took out the appendix by going through the stomach without making any incisions on the skin. This really launched the evolution of incision-less surgery and it spawned a lot of focus on cosmesis, or the cosmetic outcome, after surgery. It differs from the traditional laparoscopic approach in that it minimizes the number of incisions, and it also tries to hide the incision so that there is very little residual scar resulting from the surgery. This surgery is typically done through one incision at the umbilicus because a belly button tends to hide a scar pretty well, and is commonly referred to as single incision surgery.
Do you take it out through the belly button?
Dr. Kim: Yes. We do the entire surgery through the belly button. Traditionally when it is done laparoscopically, something called an access port is used. An incision about an inch long is made though the belly button and the access port is inserted into the incision. The access port allows 2-3 instruments to be inserted, as well as a fiber optic camera, to do the procedure. It is important to understand that the only demonstrated benefit of doing it this way is the cosmetic outcome; it does not decrease pain and it does not improve recovery. There is a theoretical increased risk of hernias from this procedure; however, I do not think the literature shows that that has been the case. There are some studies that show single incision surgeries, particularly gallbladder surgery done in this manner, show a slightly higher incidence of complications. More recently, in December of 2011, the FDA approved the robotic single site platform. The are many advantages to the robotic technique including superior visualization, that includes magnification, high definition and 3-dimensional visualization, as well as greater precision, and superior ergonomics for the surgeon. These advantages are likely to translate into greater safety for the patients; however, studies have to be done on large numbers of patients to prove this from a data standpoint. The robotic single incision gallbladder surgery should offer the advantages of superior cosmetic outcome while not increasing the risk of the surgery.
Is this becoming more common? Is this something people are asking for because of that cosmetic advantage?
Dr. Kim: It was thought that there would be a huge explosion in the single incision for the cosmetic outcome, but I do not think that has been true. I think part of it is because it takes an increased skill set, so there are not a lot of surgeons that are doing these single incision surgeries. Also, I do not think this is something that is being heavily marketed, which I think is appropriate. The most important thing is to do this safely. For the people that can do it safely, I think it is reasonable to offer it, but again, there is not a huge demand. For instance, we started doing the single incision robotic gallbladders in January and we have not really marketed it. We offer it to patients that are appropriate for it, but we have not really seen a spread by word of mouth or people coming in asking to have their gallbladder surgery done with the single incision technique.
Have you done other procedures with the da Vinci robotic system?
Dr. Kim: I do a lot of complex bariatric and revisional surgeries, and I have done over 600 robotic procedures. The da Vinci single incision platform was FDA approved in December specifically for the gallbladder, so it is not FDA approved for any other procedures. I have done other traditional single incision with standard laparoscopic instruments and I have done other single incision in more complex cases.
In those complex cases, what is the advantage of using da Vinci versus laparoscopic or traditional procedures?
Dr. Kim: It offers pretty much the same as a single incision: superior ergonomics, superior visualization with 12 times magnification, 3-D visualization, high definition, and incredible precision and dissection. Particularly for what I do, which is bariatric surgery; it minimizes the increased weight of the patient and it facilitates working in smaller spaces. So, I think it is a good match of superior technology with the increased demands from the complexity of the procedure, as well as the higher risk of the patients, given all of their comorbidities and their size.
Do you think that effect will wear off or we will see it become more of the standard for more procedures?
Dr. Kim: I definitely think that what has really evolved is when we went from open to laparoscopic. We, the surgeons, actually had hands in the patients to do laparoscopic; we were standing at the bedside, but we were operating, or we were operating with our hands outside the patient looking on a video monitor. The robotic system now takes it one step further where we are completely away from the patient; there is a digital interface. I think this is the future of surgery because it allows much more precision with what we do, and it allows us access and much more data. For instance, you can have stored imaging that is loaded up in the console that you can use like 3-D reconstruction and real time imaging, so it allows for much greater flexibility in the use of data to help what we do in surgery. I think that, clearly, it is going to be the future platform of surgery.
I was reading an article about prostate surgery and how the rate of surgery is going up using robotic systems, but at the same time, the incidence of prostate cancer and prostate-related problems are going down. It seems like some surgeons might just be using it because they can. What is your opinion on that?
Dr. Kim: I do not know specifically about the prostate data, but that is a great example of when you have new technology there are 2 factors that are very important in adoption of that technology in clinical medicine. One is: is it enabling technology? Prostatectomy is a great example where most of the prostatectomies are being done open because it is a very difficult procedure to do laparoscopically. The robot enables people to do it safely and minimally invasively, so I think almost 90% of the prostatectomies that are done in this country are done robotically. The second is: does it improve clinical outcome? A lot of the procedures that are being done minimally invasively are done very well by very skilled surgeons. So, that is a little harder to prove because it takes large numbers to prove definitively, for this statistical significance, that it does result in improved clinical outcomes. In the areas in the field where there is not a high penetration of laparoscopic or minimally invasive surgery is where I think you will see the adoption of the robot be the most rapid.
What kind of surgeries could that be?
Dr. Kim: Right now, benign GYN, colorectal particularly, low anterior resections, and colon and rectal surgeries because they are very difficult operations to do.
A little bit back to the single port for gallbladders. How big is a gallbladder?
Dr. Kim: The gallbladder varies in size. I would estimate it to be about the size of an egg, so it is relatively small. When the gallbladder is decompressed and all the bile is taken out, it can be taken out through a very small incision.
Do you have to cut it up and then take it out, or do you just take it right out?
Dr. Kim: Typically, it comes right out. The incision that is made is about 2.5 cm, so it is a very small incision and very well hidden within the belly button.
Is the recovery time any less for this type of surgery versus the traditional procedure?
Dr. Kim: No, the recovery time is about the same, and as I said before, the only advantage is the cosmetic outcome. There is very little difference in pain, no impact on the recovery time, and there is a theoretical risk of a slightly higher incidence of potential hernias at the incision.
How new is this procedure?
Dr. Kim: The single incision robotic platform is a relatively recent thing. We are one of the first, what we call early users, and I think we were one of the first five centers in the U.S. that started doing this, and its indication is currently just for performing cholecystectomies or removal of gallbladder through the single incision. We are gathering this data under IRB approval and we hope to be one of the centers that establishes a safety data for this technique.
How long will that take?
Dr. Kim: It will probably take at least a year or two. We are going to be cooperating with other centers in a multi-center prospective data collection.
As far as the single port, do you see that as something that has applications beyond just the gallbladder when it comes to robotics, and how do you see that trend advancing?
Dr. Kim: I think the current application was just gallbladder; I do not know how widespread that will be because you always have to balance the cost. In doing a cholecystectomy single port, there are a number of people that can do it laparoscopically without the robot and certainly most people are very comfortable doing it laparoscopically. Also, the scar from laparoscopic surgery is relatively minimal anyway, so it is hard to justify the cost. I think the reason why we have kind of embraced it and have been ahead of the curve is that there is great potential for other surgeries in the future. One of the nice things about being here at Celebration is we have world leaders in multiple disciplines around robotics and we are going to use the data that we collect around single site cholecystectomies to do other procedures under IRB approval. So, I think our center will be one of the leaders in developing other fields where the single incision technology could be applied.
What is the cost difference between laparoscopically and with the robot?
Dr. Kim: There is almost an additional $1000 in terms of the drapes, the port, the instruments, and some of the disposables for the single incision cholecystectomy. If you were going to do this laparoscopically, the gel port, or a lot of the ports that are used for access, run anywhere from $300 to $500 plus. There is also probably about a $500 to $800 increase in cost compared to just a standard single incision.
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