The Future of Surgery Here

In 2017, Larry Cain and his wife, Helena, marked their 27th wedding anniversary in a Toronto hotel room. It was a muted celebration. Just the day before, the Quispamsis man had undergone prostate cancer surgery in Canada’s largest city, though he was discharged after just one night. A few days later he was on a plane, flying home to Saint John.

That kind of speedy discharge and the smooth, quick recovery that followed was what had convinced Mr. Cain
to go to Toronto in the first place. There, he could have the surgery assisted by a robot. When he was first diagnosed, he hadn’t heard of robotic-assisted surgery. But when he began looking into his options, he liked what he read about the technology and its associated patient outcomes.

“At first, I was concerned about whether there was a real advantage to going and having this done robotically
versus conventional surgery,” he says. “The research I did suggested that the recovery time would be faster, it’s less invasive and more accurate in terms of getting everything on the first go-around. It suggested to me that it was the way to have the procedure done.”

While he praises the excellent care he received in Saint John before and after his procedure, robotic surgery simply wasn’t an option locally, or even in Atlantic Canada, at that time.

It will be soon. The Saint John Regional Hospital Foundation recently launched an ambitious $6.2 million campaign to acquire a da Vinci, an industry-leading surgical robot that is transforming operating rooms around the world.

“This is exceptionally progressive for us,” says Eileen MacGibbon, Vice-President of Clinical Services for Horizon
Health Network. "It sets the stage for the next level of surgical program excellence and creates significant opportunities for new types of collaboration."

The da Vinci will be used for prostatectomies, such as the one Mr. Cain underwent, along with a host of other surgical procedures in urology, cardiac care, bowel surgery and gynecology.

“I felt fortunate that going to Toronto for the procedure was accessible to me,” says Mr. Cain, who has been cancerfree for over four years. “But it will be nice to have it in the province. The standard of care here is exceptional but there is always room to adopt new technologies to advance care. I think robotics is one of those cases.”

While robots in the operating room may evoke Jetsons-esque images of autonomous helpers (remember Rosie, the robotic housekeeper?), da Vinci is just the latest in an evolution of surgical tools harnessing advanced digital technologies for better outcomes and more sophisticated health care.

In the same way that new cars equipped with advanced assistive technology still need a skilled driver behind
the wheel, surgeons remain central to robotic-assisted surgery. They are in the operating room with the patient and the surgical team conducting the procedure. The robot augments a surgeon’s eyes and hands, providing extra-human levels of dexterity, vision and control.

In this cutting-edge surgery, the virtuosity of the physician and the powerful virtuality of the robot combine.

“The movements are so intuitive, it really does mimic everything that you're doing,” says Dr. Matt Acker, a urologist at the Saint John Regional Hospital who trained in robotic-assisted surgery during his fellowship in the United States. “If I move my hand, the robot is translating that into the exact same motion but in a much finer, scaleddown way.”

While robots may sound futuristic, in fact, they’ve been in the operating room for decades, as far back as the late 1980s, when the first computer-assisted and image-guided systems proved the value of the approach.

Since then, the technology and its adoption have advanced rapidly. It has become the standard of care for many procedures in the United States, where it was pioneered, and beyond.

The da Vinci model that the Regional will acquire has three components: a surgeon’s console where the doctor sits, controlling instruments and a camera on a cart positioned beside the patient. These high-precision instruments mimic wrist movement, but with a 360-degree fully articulating arms that dramatically expand the range of motion and eliminates the natural tremors of the human hand.

The instruments also control cameras that provide highdefinition, stereoscopic vision at 10 times the magnification of the human eye, giving surgeons much greater depth perception and visualization. There’s also a monitor providing the operating roomteam with a 3D view of the surgical site.

Robotic-assisted surgery was initially used mainly for urological procedures. In the United States today, more than 90 per cent of prostatectomies are done with an assist from robots.

“It's fast becoming that way in Canada as well,” Dr. Acker says, with some provinces, including Alberta and British Columbia, already doing the majority of those surgeries robotically. And robotic-assisted surgery has expanded beyond urology for use in a wide range of procedures, including cardiac, gynecology, thoracic, general surgery, and more.

“That's evolved even over the last five years,” Dr. Acker says. “There has certainly been an incredible change in the distribution of cases. More surgeons are seeing the evolution of minimally invasive surgery and starting to use robotic technologies where it's appropriate.”

The Saint John Regional Hospital is perfectly positioned to integrate robotic-assisted surgery into its surgical programs. For one, there’s in-house expertise in the technology, with surgeons such as Dr. Acker already trained in robotic surgery.

For Dr. Ansar Hassan, a cardiac surgeon whose fellowship in the United States included studying under the surgeon who acquired FDA approval for robotics in heart surgery, came to the Regional in 2008. He says robotics “was always there in the background as something that I would eventually advocate for.”

But there was groundwork to be laid first. Before it could get a robot, the Regional needed to implement a minimally invasive surgical program. In 2010, it became the first hospital in New Brunswick to pioneer cardiac laparoscopic surgery, which uses small incisions through which the surgeon inserts a camera and instruments.

The surgeon can watch the procedure on a monitor and manipulate the instruments with greater precision than traditional open surgeries. The outcomes for patients are clear: less pain, less risk of complications, and faster recoveries.

Just as minimally invasive laparoscopic surgery was a revolutionary advancement over the open surgeries of the past, the advent of robotics goes even further. It offers greater precision, better patient outcomes and the ability to perform operations that would have been incredibly challenging and risky or even impossible using the techniques of the past.

The Regional now has extensive experience in minimally invasive and laparoscopic surgery, which are now routine for a wide variety of procedures, including in urology, cardiac care, bowel surgery and gynecology. Roboticassisted surgery was the next step.

“We had to work our way up to robotics,” says Dr. JeanFrançois Légaré, Clinical Head of Cardiac Surgery for theNew Brunswick Heart Centre. “We are ready.”

What is clear, he says, is that the best surgical programs marry minimally invasive approaches with robotics.

“You’re taking advantage of all that the robot has to offer: heightened visualization, increased dexterity, the ability to take on more complex procedures. That’s where I always saw this program going next.”

Dr. Légaré acknowledges the expense of the da Vinci. But the return on investment is there, he says.

“As a Canadian, you are conscious of the health care system. You’re conscious of fiscal restraints,” he says. “We try to find the easiest, cheapest and fastest way to do a procedure with the same result if not better.”

The largest tertiary-care hospital in New Brunswick and provincial leader in minimally invasive surgery, Saint John is the established provincial centre of excellence for cardiac surgery, one of the leading specialties for robot-assisted surgery.

“Saint John is the only centre for heart surgery and other related procedures within the province’s cardiology program, so all of those resources and programming already exist,” says Janine Doucet, Administrative

Director for the New Brunswick Heart Centre. “The da Vinci was a natural fit.”

The mobile da Vinci console and cart will make it easy to transfer between operating rooms and departments,
ensuring maximum use and impact across the Regional, where many of the doctors are eager to adopt this new technology into their practices.

“Our medical staff have been hearing about robotic approaches and techniques for some time,” Horizon’s
Eileen MacGibbon says. “There are many specialties that could benefit from the da Vinci, and we have a number of surgeons on staff who are very interested in exploring those opportunities.”

And the da Vinci builds on the Regional’s push to offer progressive, contemporary care.

“We've never shied away from offering cutting-edge technology,” MacGibbon says. “You can get the best care
that you can possibly receive, right here in New Brunswick.”

Surgeons like Dr. Acker aren’t the only ones clamouring for the da Vinci.

“I see a patient every week who says, ‘Can I have this done robotically?’” Dr. Acker says. “Patients are savvy. They're becoming more educated about their surgeries, their conditions and their options. They are asking for it because they see the evidence that there's a significant benefit compared to the old way.”

And the evidence, such as the research that convinced Larry Cain his best option was going to Toronto for robotic surgery, is clear and compelling.

Robotic-assisted surgery has better patient outcomes and patient satisfaction. It’s correlated with shorter hospital stays and less risk of complications. Robotic surgery patients as a whole recover faster, with less pain and fewer drugs. There is lower blood loss and fewer transfusions.

“It’s neat and tidy,” Dr. Acker says. “Even compared to laparoscopic surgery, because you have such great visualization and control of your hands, and it's a much cleaner operation. In many cases, it’s essentially a bloodless operation.”

For cardiac patients, they can return to a normal day-to-day lifestyle a month sooner on average.

In urology cases, it cuts the amount of time before removal of the urinary catheter in half, on average, from two weeks to one. Along with less patient discomfort, there are better quality of life outcomes as well, including decreased risk of erectile dysfunction and a quicker return to urinary continence after surgery.

There are also significant benefits for doctors. “It is very fatiguing for a surgeon to do a complex laparoscopic surgery,” Dr. Acker says. “It's hard on your neck, it's hard on your shoulders, it's hard on your knees. Often, you're in awkward positions for hours.”

Contrast that with sitting in ergonomic comfort in the adjustable da Vinci surgeon console.

“You’re relaxed,” he says. “It’s not wreaking havoc on your head and neck. I think the longevity of a surgeon is going to be prolonged by this technology.”

“Recruitment can be so competitive that the da Vinci is an advantage, an edge that certainly serves New Brunswick well,” Ms. MacGibbon says.

The da Vinci also allows for training, including practising on simulation modules, as well as offering the chance for on-the-job learning.

“There’s the ability to have learners right next to the surgeon in the operating room,” Ms. MacGibbon says. “That’s a whole other element to it.”

Beyond recruitment, the da Vinci also opens the door to networking and collaborating with top-ranking hospitals in North America and around the world along with the chance to lead and participate in clinical research. The Regional has already been in touch with other Canadian hospitals with robotic surgery programs, laying the groundwork for future projects and conversations.

“It creates a community of interest,” Ms. MacGibbon says. “It creates a really great opportunity for collaboration in lots of ways that are beyond what we are doing today.”