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Robot expands capabilities for
operating on children
A system developed to mend wounded soldiers in remote battlefields now
enables surgeons to double their dexterity and perform difficult
procedures inside the bodies of small children.
The da Vinci Robotic Surgical System, developed by the U.S. Department
of Defense (DOD), was introduced to MUSC in May by Andre Hebra, M.D.,
chief of the Division of Pediatric Surgery; making MUSC part of
an elite group of facilities that use the system. MUSC is one of only
about four institutions in North America and the only one in the entire
Southeast that uses the robot-assisted surgery on children.
A child undergoes
minimally invasive surgery performed with the da Vinci system.
“One of the most important medical-technological achievements of the
20th century has been the development of optical and surgical
instruments that set the stage for the advancement of minimally
invasive surgical techniques,” said Hebra. “The 21st century is
witnessing a new revolution in the field of surgery with the
introduction of the da Vinci Robotic Surgical System.”
Currently, without computer-assisted technology, minimally invasive
laparoscopic and thoracoscopic surgery would have limited applications.
The da Vinci system improves the ability to expand the applications of
minimally invasive surgery to a new level of complexity, Hebra said.
The da Vinci system is a computerized four-arm robot that is entirely
controlled by the operating surgeon from a separate console that
functions as the command center for the machine.
“We could operate from the control booth here in Charleston on a
patient in Alaska,” Hebra explained.
The robot arms are capable of holding and manipulating the
surgical-laparoscopic camera, fine surgical instruments, and various
sources of energy during the operation. It is not a robot in the sense
of one you would imagine in the automotive industry assembly line but
one that integrates the latest advancements in robotics,
computer-enhanced technology and the surgeon’s skill. It allows the
surgeon to perform delicate and complex laparoscopic and/or
thoracoscopic procedures with great precision and superb visualization.
Dr. Andre Hebra
performs robotic surgery from this station.
“It gives the surgeon another pair of arms to work with; it’s like
having four arms working simultaneously,” said Hebra, a pioneer in
laparoscopic surgery who is among a unique group of surgeons trained to
use the da Vinci on children. “One can see with great precision and
magnification inside the body, due to the high definition,
three-dimensional images projected by the da Vinci system.”
Hebra noted that the robot cannot perform any movement or procedure
without the surgeon’s control and that da Vinci does not replace the
surgeon or eliminate the need for a surgeon’s skills. The operating
surgeon has the ability to control each one of the robot’s four arms
throughout the operation. Fine and delicate movements performed by the
surgeon via the robotic arms and instruments are fully visualized in
true 3-D, allowing the surgeon to perform as if he/she was inside the
body. The system allows for delivery of highly-precise movements and
maneuvers that frequently are superior to what the human hand can
accomplish during open surgery. “I call all the shots. It doesn’t move
unless I move,” Hebra said, adding that the device also filters out
involuntary movements, such as tremors. “It’s a surgical tool, so
operating it still requires skills of a surgeon that is familiar with
The da Vinci robotic system allows surgeons to perform more complex
operations that could not be easily accomplished using conventional
laparoscopic or thoracoscopic techniques. With more precise control in
the surgical field, complications are decreased and outcomes are
“This new technology will allow surgeons from many other specialties to
push-the-envelope of minimally invasive surgery and to develop new
indications for robotic intervention. The only limitation is the
surgeon’s imagination,” said Hebra.
Of the four cases performed on children so far here at MUSC, one was a
complex rectal resection and “pull-through” procedure for treatment of
Hirschsprung’s disease on a 5 Kg (11 pounds) infant. “This would be
difficult to do with the conventional laparoscopic surgery,” Hebra said.
Hebra has five years experience working with the da Vinci and he is
very enthusiastic about the incorporation of robotic technology by MUSC
Hebra, who returned to MUSC last year after having left in 2001,
developed new robotic applications for pediatric patients while he was
director and lead surgeon for the center of Robotic & Minimally
Invasive Pediatric Surgery at All Children’s Hospital in St.
Petersburg, Fla. “One of my goals in coming back to MUSC was to bring
robotics not only to pediatrics, but to all surgical specialty areas,”
In response, MUSC invested more than $1 million to acquire the da Vinci
“The beauty of this new robotic system is that it allows surgeons to do
so many different and innovative procedures. It’s also important that a
major academic center like MUSC is able to expose residents and
students to this new technology,” Hebra said.
Because operating the da Vinci requires unique surgical skills,
surgeons are required to participate in a special training program with
proctorship before they can start utilizing the system during surgery.
Hebra has served as a proctor to other specialists learning to use the
robot. Robotic surgical assistants, which could be a surgeon or
physician’s assistant, also require special training. The surgical
assistants and operating room nurses must also be trained on how to
utilize the robot at the patient’s bedside in the operating room.
Special credentialing requirements have been developed at MUSC to meet
the needs of this new technology. At the present time, Lisa Roberge,
Hebra’s physician assistant, is the only first assistant trained for
robotic surgery, and Hebra is the only surgeon trained to perform da
Vinci procedures. “We have identified a great group of nurses in the
operating room that have dedicated a significant amount of their time
to learning and working with da Vinci. It has been a great pleasure to
work with this incredibly enthusiastic group of nurses,” Hebra said.
The application of robotic technology is poised to grow here at MUSC.
Urologists and gynecologists are already scheduled to undergo training
in robotic surgery. Other surgical specialists such as cardiothoracic,
transplant, thyroid, and plastic surgeons have expressed an interest in
robotics. Because setting up and using da Vinci is time-consuming and
expensive, it is not recommended in all surgeries. For example, it
would never be used in an emergency situation or for conventional
Regarding the future for robot-assisted surgery at MUSC, Hebra said,
“No one who looks at the data on minimally invasive surgery objectively
can doubt the benefits to adult and pediatric patients. There is no
greater advancement in the surgical sciences in recent years than that
provided by minimal access surgery.
“This new century should continue to witness exciting advances that
will improve our ability to provide surgical care to the unborn fetus,
children, and patients of all ages. The modern surgeon must embrace
technology and apply it to a new level,” Hebra said.
The use of robotic surgical techniques originated from a DOD project
that focused on remote field management of wounded soldiers. The
project included a plan to develop systems of operating on patients via
a computerized-robotic interface. Such systems would allow for remote
surgery, in which the operating surgeon would be located at a different
site from were the operation was being performed, Hebra explained.
Despite the successful development of a computerized-robotic surgical
system, the research sponsored by DOD was abandoned. Fortunately for
medicine, it was quickly adapted for clinical use by Intuitive Surgical
Corporation and applied to civil use in 1997.
Friday, July 11, 2008
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