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DaVinci Hysterectomy Public Lecture

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Anthony DeSalvo
Anthony DeSalvo

A public presentation given about the robotic surgical platform. There were several video slides that were removed due to space limitations.

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Anthony R. DeSalvo, M.D. 1842 E Market St Warren, OH 44483 330.856.7212 warren-obgyn.com
Anthony R. DeSalvo, M.D ? Bachelor of Science C Kent State University ? Medical Degree C Northeastern Ohio Universities College of Medicine ? Residency C Beth Israel Medical Center, New York, NY ? Board Certified C American Board of Obstetrics and Gynecology ? Personal information ? Professional information
Why am I here? ? Educate the public some common gynecologic conditions that may require an operation ? Discuss the types of operations that are available ? Introduce the concept of robotic surgery to the public ? Dispel some common myths about robotic surgery
Common conditions treated by hysterectomy ? Heavy menstrual bleeding ? Pelvic pain ? Fibroid uterus ? Endometriosis ? Prolapse ? Cancer
Heavy menstrual bleeding ? Defined as bleeding that lasts for longer than 7 days per month or greater than 80 mL per cycle ? Difficult to estimate the true amount of blood loss ? Bleeding that soils clothes, bed sheets or requires the significant planning ? Very subjective but usually a person knows it when it happens to them
Pelvic pain ? Chronic pelvic pain refers to pain of at least six months' duration that occurs below the belly button and is severe enough to cause functional disability or require treatment. ? In the United States, this problem accounts for approximately 10 % of all visits to a GYN. ? It is considered the principal indication for approximately 20 % of hysterectomies performed for benign disease.
Fibroid uterus ? Fibroids are tough balls of muscle that form in the uterus ? People sometimes refer to fibroids as ＾tumors.￣ But fibroids are not a form of cancer. They are simply abnormal growths in the muscle of the uterus ? Fibroids often cause no symptoms at all. When they do cause symptoms, they can cause: ? ?Heavy periods ? ?Pain, pressure, or a feeling of ＾fullness￣ in the belly ? ?The need to urinate often ? ?Too few bowel movements (constipation) ? ?Difficulty getting pregnant
Endometriosis ? Endometriosis occurs when tissue normally found in a woman¨s uterus grows outside of the uterus . ? This tissue, which does not belong outside the uterus, can then break down, bleed, and cause symptoms ? Some women with endometriosis have no symptoms. But most have pain in the lower part of the belly that can occur: ? ?Before or during monthly periods ? ?Between monthly periods ? ?During or after sex ? ?When urinating or having a bowel movement (often during monthly periods)
DaVinci Hysterectomy Public Lecture
Prolapse ? When tissues that support the organs in the lower belly relax. The organs drop down and press against or bulge into the vagina. ? If the bladder bulges into the vagina,, this is a＾cystocele.￣ If the rectum bulges into the vagina, it¨s a ＾rectocele.￣ Uterine prolapse means the uterus has bulged into the vagina. ? Many women with this problem have no symptoms. But some women with pelvic organ prolapse have symptoms that include: ? ?Fullness or pressure in the pelvis or vagina ? ?A bulge in the vagina or coming out of the vagina ? ?Leaking urine when they laugh, cough, or sneeze ? ?When they use the toilet, some women need to press on the bulge in the vagina with a finger to get out all their urine or to finish a bowel movement.
Cancer ? As a benign gynecologist, I do not treat women with gynecologic cancers ? These women are best served by a referral to a GYN oncologist ? We are very fortunate to have several world class cancer centers within a 1 hour drive
Procedures ? Hysterectomy C removal of the uterus ? Total hysterectomy C removal of the uterus and cervix ? Sub-total hysterectomy (Supracervical) C removal of uterus only with the cervix left in place ? Oophorectomy C removal of the ovaries ? Confusing terms C complete , partial and total
DaVinci Hysterectomy Public Lecture
Hysterectomy facts ? Approximately 525,000 hysterectomies are performed each year in the U.S. for non-cancerous conditions ? By age 60, 1 in 3 women in the U.S. will have had a hysterectomy2 ? 90% are performed for elective benign indications ? Fibroids ? Abnormal uterine bleeding ? Endometriosis ? Chronic pelvic pain
Route of Surgery Abdominal ? Requires a large abdominal incision ? Usual hospital stay is 2 to 4 nights ? 6 to 8 weeks of recovery
Vaginal hysterectomy ? The entire operation is performed through the vagina ? Requires good access to the uterus ? More challenging in patients with prior abdominal surgery or previous cesarean section ? More challenging if the uterus is enlarged ? Limited visualization of the pelvis and ovaries
Laparoscopic hysterectomy ? Better visualization ? Shorter hospitalization ? Shorter recovery ? Good visualization of the pelvic organs ? Can be performed in a wide variety of patients ? Traditional laparoscopy requires a unique skill set and commitment to the procedure
US Hysterectomy Modalities 2005 vs. 20124 Jan 1, 2005 Lap C 14% Vag C 22%
The Impact on Hysterectomy Adoption of MIS for Hysterectomy 80% 70% 60% 50% Adoption Laparoscopy 40% da Vinci 30% Vaginal Open 20% 10% 0% Year Farquhar et al. "Hysterectomy Rates in the United States: 1990C1997" Obstet Gynecol 2002;99:229 C34 Becker et al. "Inpatient Surgical Treatment Patterns for Patients with Uterine Fibroids in the United States, 1998-2002" Journal of the National Medical Assn. Vol. 97 (10) October 2005 Wu et al. "Hysterectomy Rates in the United States, 2003" Obstet & Gyn VOL. 110, NO. 5, NOVEMBER 2007 Solucient data through 2010 for Lap, Open and Vaginal Trends
DaVinci Hysterectomy Public Lecture
Natural Evolution of Technology
Natural Evolution of Technology
DaVinci Hysterectomy Public Lecture
Evolution of Technology Konrad Zuse¨s Z1 (1938) First binary computer UNIVAC I C UNIVersal Automatic Computer (1951) Mechanical calculator First commercial computer U.S. Census Bureau Original price: $159,000 Ultimate price: $1.5 million 46 systems built and sold IBM 701C (1953) First commercial IBM computer $15,000/month rental fee Only 19 systems built and sold
Evolution of Technology Altair (1974) Scelbi (1974) First personal computer Kit that user had to put together, make it IBM 5100 C First IBM PC (1975) work, and write software 50 pounds 256 Byte RAM Programming language (APL or BASIC) $400 64K storage version $19,975
Which would you rather have? Versus
Robotics Current applications ? Auto industry ? Space industry ? Multiple other industries ? Military ? Laboratory test processing ? Automated research equipment ? Radiation therapy ? Toys
What¨s the difference?
The natural evolution of computers into the operating room
Minimally Invasive Surgery Benign hysterectomy in the US 2003 Mean LOS=1.7 days* Mean LOS=2.0 days* Mean LOS=3.0 days* *P-value<0.001 Wu JF. Et al. Obstet Gynecol 2007;110:1091-1095.
DaVinci Hysterectomy Public Lecture
da Vinci? S Robotic Platform
da Vinci? Surgery (Minimally Invasive)
Robotic Platform General thoughts ? A tool ? Not new surgery or procedure ? A tool that makes minimally invasive surgery easier ? Very rare to have ＾robotic￣ complication if used properly ? Surgeon who¨s using the robot has a complication as with any other tool
Advantages of robotic surgery ? Much improved 3D visualization over traditional laparoscopy ? Keep in mind, that traditional laparoscopy was still better than open surgery ? Full wristing instruments with 7 degrees range of motion ? Complete surgical control of the operative instruments ? Mimics the hand movements of open surgery
da Vinci? Awareness President Obama Jeopardy CNN (Cleveland Clinic) The Doctors The Daily Buzz Private Practice Law & Order
Summary ? The addition of computer technology into the operating arena is a natural evolution and progress ? The addition of robotic platform for surgery is a continuation of this progress ? Man¨s tools continue to add great value to our lives ? This tool will greatly reduce or nearly eliminate the need for open surgery ? The societal benefits of a surgical platform are vast and numerous

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DaVinci Hysterectomy Public Lecture

  • 1. Anthony R. DeSalvo, M.D. 1842 E Market St Warren, OH 44483 330.856.7212 warren-obgyn.com
  • 2. Anthony R. DeSalvo, M.D ? Bachelor of Science C Kent State University ? Medical Degree C Northeastern Ohio Universities College of Medicine ? Residency C Beth Israel Medical Center, New York, NY ? Board Certified C American Board of Obstetrics and Gynecology ? Personal information ? Professional information
  • 3. Why am I here? ? Educate the public some common gynecologic conditions that may require an operation ? Discuss the types of operations that are available ? Introduce the concept of robotic surgery to the public ? Dispel some common myths about robotic surgery
  • 4. Common conditions treated by hysterectomy ? Heavy menstrual bleeding ? Pelvic pain ? Fibroid uterus ? Endometriosis ? Prolapse ? Cancer
  • 5. Heavy menstrual bleeding ? Defined as bleeding that lasts for longer than 7 days per month or greater than 80 mL per cycle ? Difficult to estimate the true amount of blood loss ? Bleeding that soils clothes, bed sheets or requires the significant planning ? Very subjective but usually a person knows it when it happens to them
  • 6. Pelvic pain ? Chronic pelvic pain refers to pain of at least six months' duration that occurs below the belly button and is severe enough to cause functional disability or require treatment. ? In the United States, this problem accounts for approximately 10 % of all visits to a GYN. ? It is considered the principal indication for approximately 20 % of hysterectomies performed for benign disease.
  • 7. Fibroid uterus ? Fibroids are tough balls of muscle that form in the uterus ? People sometimes refer to fibroids as ＾tumors.￣ But fibroids are not a form of cancer. They are simply abnormal growths in the muscle of the uterus ? Fibroids often cause no symptoms at all. When they do cause symptoms, they can cause: ? ?Heavy periods ? ?Pain, pressure, or a feeling of ＾fullness￣ in the belly ? ?The need to urinate often ? ?Too few bowel movements (constipation) ? ?Difficulty getting pregnant
  • 8. Endometriosis ? Endometriosis occurs when tissue normally found in a woman¨s uterus grows outside of the uterus . ? This tissue, which does not belong outside the uterus, can then break down, bleed, and cause symptoms ? Some women with endometriosis have no symptoms. But most have pain in the lower part of the belly that can occur: ? ?Before or during monthly periods ? ?Between monthly periods ? ?During or after sex ? ?When urinating or having a bowel movement (often during monthly periods)
  • 10. Prolapse ? When tissues that support the organs in the lower belly relax. The organs drop down and press against or bulge into the vagina. ? If the bladder bulges into the vagina,, this is a＾cystocele.￣ If the rectum bulges into the vagina, it¨s a ＾rectocele.￣ Uterine prolapse means the uterus has bulged into the vagina. ? Many women with this problem have no symptoms. But some women with pelvic organ prolapse have symptoms that include: ? ?Fullness or pressure in the pelvis or vagina ? ?A bulge in the vagina or coming out of the vagina ? ?Leaking urine when they laugh, cough, or sneeze ? ?When they use the toilet, some women need to press on the bulge in the vagina with a finger to get out all their urine or to finish a bowel movement.
  • 11. Cancer ? As a benign gynecologist, I do not treat women with gynecologic cancers ? These women are best served by a referral to a GYN oncologist ? We are very fortunate to have several world class cancer centers within a 1 hour drive
  • 12. Procedures ? Hysterectomy C removal of the uterus ? Total hysterectomy C removal of the uterus and cervix ? Sub-total hysterectomy (Supracervical) C removal of uterus only with the cervix left in place ? Oophorectomy C removal of the ovaries ? Confusing terms C complete , partial and total
  • 14. Hysterectomy facts ? Approximately 525,000 hysterectomies are performed each year in the U.S. for non-cancerous conditions ? By age 60, 1 in 3 women in the U.S. will have had a hysterectomy2 ? 90% are performed for elective benign indications ? Fibroids ? Abnormal uterine bleeding ? Endometriosis ? Chronic pelvic pain
  • 15. Route of Surgery Abdominal ? Requires a large abdominal incision ? Usual hospital stay is 2 to 4 nights ? 6 to 8 weeks of recovery
  • 16. Vaginal hysterectomy ? The entire operation is performed through the vagina ? Requires good access to the uterus ? More challenging in patients with prior abdominal surgery or previous cesarean section ? More challenging if the uterus is enlarged ? Limited visualization of the pelvis and ovaries
  • 17. Laparoscopic hysterectomy ? Better visualization ? Shorter hospitalization ? Shorter recovery ? Good visualization of the pelvic organs ? Can be performed in a wide variety of patients ? Traditional laparoscopy requires a unique skill set and commitment to the procedure
  • 18. US Hysterectomy Modalities 2005 vs. 20124 Jan 1, 2005 Lap C 14% Vag C 22%
  • 19. The Impact on Hysterectomy Adoption of MIS for Hysterectomy 80% 70% 60% 50% Adoption Laparoscopy 40% da Vinci 30% Vaginal Open 20% 10% 0% Year Farquhar et al. "Hysterectomy Rates in the United States: 1990C1997" Obstet Gynecol 2002;99:229 C34 Becker et al. "Inpatient Surgical Treatment Patterns for Patients with Uterine Fibroids in the United States, 1998-2002" Journal of the National Medical Assn. Vol. 97 (10) October 2005 Wu et al. "Hysterectomy Rates in the United States, 2003" Obstet & Gyn VOL. 110, NO. 5, NOVEMBER 2007 Solucient data through 2010 for Lap, Open and Vaginal Trends
  • 21. Natural Evolution of Technology
  • 22. Natural Evolution of Technology
  • 24. Evolution of Technology Konrad Zuse¨s Z1 (1938) First binary computer UNIVAC I C UNIVersal Automatic Computer (1951) Mechanical calculator First commercial computer U.S. Census Bureau Original price: $159,000 Ultimate price: $1.5 million 46 systems built and sold IBM 701C (1953) First commercial IBM computer $15,000/month rental fee Only 19 systems built and sold
  • 25. Evolution of Technology Altair (1974) Scelbi (1974) First personal computer Kit that user had to put together, make it IBM 5100 C First IBM PC (1975) work, and write software 50 pounds 256 Byte RAM Programming language (APL or BASIC) $400 64K storage version $19,975
  • 26. Which would you rather have? Versus
  • 27. Robotics Current applications ? Auto industry ? Space industry ? Multiple other industries ? Military ? Laboratory test processing ? Automated research equipment ? Radiation therapy ? Toys
  • 29. The natural evolution of computers into the operating room
  • 30. Minimally Invasive Surgery Benign hysterectomy in the US 2003 Mean LOS=1.7 days* Mean LOS=2.0 days* Mean LOS=3.0 days* *P-value<0.001 Wu JF. Et al. Obstet Gynecol 2007;110:1091-1095.
  • 32. da Vinci? S Robotic Platform
  • 33. da Vinci? Surgery (Minimally Invasive)
  • 34. Robotic Platform General thoughts ? A tool ? Not new surgery or procedure ? A tool that makes minimally invasive surgery easier ? Very rare to have ＾robotic￣ complication if used properly ? Surgeon who¨s using the robot has a complication as with any other tool
  • 35. Advantages of robotic surgery ? Much improved 3D visualization over traditional laparoscopy ? Keep in mind, that traditional laparoscopy was still better than open surgery ? Full wristing instruments with 7 degrees range of motion ? Complete surgical control of the operative instruments ? Mimics the hand movements of open surgery
  • 36. da Vinci? Awareness President Obama Jeopardy CNN (Cleveland Clinic) The Doctors The Daily Buzz Private Practice Law & Order
  • 37. Summary ? The addition of computer technology into the operating arena is a natural evolution and progress ? The addition of robotic platform for surgery is a continuation of this progress ? Man¨s tools continue to add great value to our lives ? This tool will greatly reduce or nearly eliminate the need for open surgery ? The societal benefits of a surgical platform are vast and numerous

Editor's Notes

  • #4: Because I like to hear myself talk
  • #20: Here is a chart showing the correlation between the decline in open hysterectomy and an increase in da Vinci surgery. It¨s also worth noting that since the first laparoscopic hysterectomy in the US was performed in 1989, the adoption has been rather slow (18% penetration in 2010) and fairly stagnant since 2004. In just 5 years of clinical use, the da Vinci system has been used in more procedures than laparoscopy has been used over 20 years. Lap and vaginal approaches have remained relatively flat or have declined over this same time period. Why?Laparoscopic Surgery (Drawbacks of conventional laparoscopy C use only if needed during presentation.)Lack of MIS penetration in complex pelvic procedures is due to technical limitations of conventional laparoscopy:2D visualization lacks depth perception &amp; rigid instruments limit the surgeon¨s precision and accuracy C both make complex surgical maneuvers difficult.Counter-intuitive movement (to move left the surgeon needs to move the instrument right), which is difficult to sustain over long, complex procedures´ and even more difficult for a novice to learn.Vaginal Surgery is also difficult to perform:?Limited access to uterine structures: uterus must be pulled out of the vagina to ligate the uterine arteries?Limited workspace (surgeon, assistant and nurse are working in the same space)?Limited view of the anatomy (vascular structures and Comorbidities are very unlikely to be seen or addressed)?Difficult to determine the source of intraop bleedingWould you agree these are limitations to both approaches? And with the rise of da Vinci adoption, the benefits of MIS extend to all women facing surgery for pelvic conditionsC not just hysterectomy.