Performing Surgery With a Robot

Dr. Michael DiMaio
Professor of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center

ToughestCase5_robot Dr. Michael DiMaio photography by Adam Fish

I’d been following my patient for about six months. I knew about the tornado and how his house had been torn down. He had colon cancer, it mestastasized to his liver, and then a tumor was discovered in his ribcage.

At that time I was getting trained and certified to do the first complete robot-assisted cardiothoracic surgery in North Texas. There are a lot of guys doing it with the prostate and other parts of the body, but not with the heart and lungs.

I thought he’d be a good patient for this. With the robot, you don’t have to spread the ribs or use a saw to open up the bone, and that means patients will have less pain, heal faster, and go home sooner.

But it wasn’t really the tumor that made him a good candidate for this. I wanted someone with whom I already had a relationship and trust. And he’s an optimistic guy. Besides dealing with cancer and his house being destroyed, his finances were completely underwater. But when he comes into the clinic, he always has a smile on his face. You would never know what’s happening at home.

So I called him up and told him that I was doing my first robot and that I wanted him to be my first patient. I had been practicing many, many hours on animals and cadavers, but he would be my first living human patient. He’d been reading about it on the internet and communicating with a circle of cancer patients about different treatments, so he’s pretty tuned in. Not only did he say okay, he was excited about it.

From patients like him, I’ve learned that the human spirit is the most powerful thing going. Just because you have a wonderful physician, wonderful drugs, or a wonderful surgery, if the patient’s spirit, enthusiasm, and confidence are not with you, none of that matters.

The robot is named DaVinci; I call him Leo. He looks like an octopus with four arms, and at the ends of three of those arms are endoscopic wrists. They look like little hands, and they can turn, spin, and grasp. Various instruments—such as scissors, tweezers, or tongs—can be put on each wrist. The fourth arm has a camera on it.

A robot-assisted operation has a much more complex planning process than old-fashioned, big-open-incision surgery. I make the first incision with a knife, and then put a camera in the body so that I can scout around and determine where to put the other ports, or holes. I have to figure out how I’m going to manipulate the arms inside the body, because once I dock the robot over the patient, it’s extremely difficult to change that positioning.

I perform the surgery from a console, which sits about 10 feet from the patient. It looks like a flight simulator, so it’s very different for the surgeon who’s used to getting his hands quote “dirty.” With this, your hands are clean, you’re sitting in a chair, and it’s almost like playing a video game. It’s surreal.

Now imagine my patient’s tumor as a big fungus on the bark of a tree, and then imagine taking various tools to carve that fungus out. In this case, the tumor was sitting right on his ribs. So I put my fingers in these little straps in the console, and my hands are dedicated to moving those endo wrists. I use them to carve, dig, grab, and cauterize an area about inch around where the tumor is growing. I have an excellent nurse, Victor Lopez, who stands at the patient’s bed side and changes out the instruments.

I use my feet as well, so the robot is like a church organ. I tap a pedal that manipulates the electricity, moves the camera in and out, and switches from arms one to two or three. The surgery lasted about two or three hours, and we successfully removed the tumor.

Overall, I think my patient had a good experience with the robot. He’s been positive when he talks to other people about it on the internet, saying this is a good thing to do. I’ve done this surgery on a number of patients since then, and I’m simply amazed. Robotic surgery is truly one of the frontiers of medicine.

—As told to K.L.