MVH History – Surgery
Flashback to 1990 and consider a patient in need of a hysterectomy, the removal of a woman’s uterus. The procedure would likely involve a large surgical opening in the abdomen, 10-14 cm in length, as well as more blood loss, pain and chance of infection than doctors would like. The patient might also spend up to six weeks off work and normal routines.
In the coming years that scenario would change mightily in the drive toward Minimally Invasive Surgery — first with laparoscopy in the 1990s, and then with robotic surgery in 2006 onward. In both approaches, surgeons use specialized techniques and equipment to operate through tiny incisions, or ports, that require only a stitch or two to close. Among a host of benefits, there’s less blood loss, less pain, less scarring and patients usually return to work within two weeks.
“It’s like a dream come true,” said MVH gynecologist Keith Watson, MD, who favors the robotic approach.
With robotic surgery, tiny mechanical arms are inserted into the patient. The surgeon controls the robot’s movements at a control console nearby. The robot translates the surgeon's hand, wrist, and finger movements into corresponding micro-movements of the instrument tip. Similar movements also control a camera to see inside the patient's body. The camera offers a bright, crisp, (10x) magnified high-resolution image of the surgical field and true-to-life 3D vision.
“The 3-D optics makes a world of difference. It’s like I have my hands inside the patient,” said Dr. Watson, who performed his first robotic surgery at MVH in 2006. “I can see better, I can operate better, and there’s less wear and tear on my body. I’m sitting down at a console instead of standing, turning, twisting at the patient’s side for hours and having back spasms.”
Investing in robotics
MVH purchased its first da Vinci® Surgical System, manufactured by Intuitive Surgical Inc., in December 2005 at a cost of roughly $1.5 million. The hospital became the first in the Dayton region to perform robotic surgery in March 2006, when surgeons David W. Key, MD, and Mark A. Monsour, MD, used the device for three prostate cancer operations.
"The introduction of robotic surgery at Miami Valley Hospital is history in the making," then MVH President and CEO Mary Boosalis said at the time. "This new technology positions our hospital at the forefront of leading-edge procedures, and it shows we're willing to make the investment to ensure our patients receive top-notch services."
Following the prostatectomies in March, the robot was used in July for a cardiothoracic procedure after traditional surgery failed because the patient's blood pressure fell to dangerously low levels prior to the operation. Ali Zaman, MD, a cardiothoracic surgeon now with Cardiothoracic Surgery Associates, used the robot to place a lead near the heart for a biventricular pacemaker.
"This was a relatively simple procedure, and the robot enabled the precision and accuracy we need for these operations to be effective," Dr. Zaman said.
Dr. Zaman’s 65-year-old patient was also pleased. “Dr. Zaman explained everything to me, and we had long conversations about how the robot would be a better choice for me with my weakened heart," Shirley Nadosky said. "He told me he would treat me like his own mother, and he certainly did. I have no regrets, and I am feeling great.”
Five years later, cardiothoracic surgeon Jose Rodriguez, MD, joined Miami Valley Hospital to help develop the Cardiothoracic Robotic Surgery program. Dr. Rodriguez, who focuses on tumors of the lung, esophagus and mediastinum, the central compartment of the thorax, had a team assembled and trained by April 2012. In less than a year, the team had performed more than 50 robotic thoracic surgeries. The team also performed esophageal cancer surgery using robotic technology, joining Ohio State University and Cleveland Clinic as the only institutions in Ohio to offer robotic esophagectomy for esophageal carcinoma.
“I love it,” said Dr. Rodriguez, adding that 75 percent of his thoracic surgeries today are robotic. “I really believe in the technology, and my patients do so much better.”
By 2012, MVH had a total of four da Vinci robots being used in numerous surgeries across several specialties, including bariatrics, colorectal, general surgery and interventional and surgical oncology. Also in that year the hospital ranked first in Ohio for total robotic cases performed for gynecology and rectal cancer procedures.
“It’s amazing, truly amazing,” said Dr. Watson. “Every surgical specialty is going to be impacted by robotic surgery, if it hasn’t been already.”
Committed to surgical advancement
In 2012, MVH continued to lead the way in robotics in the Dayton area with the December opening of the Brethen Center for Surgical Advancement in Robotics and Minimally Invasive Surgery, the first of its kind in the region.
An initiative of Premier Health and located in MVH’s Berry Women’s Center, the center is designed to explore potential applications of the emerging technology and to educate Premier Health physicians and allied medical staff on its use. A dual console robot, digitally connected to the operating room, allows real time
training. Physicians who train here will be certified in robotic surgery. Also, OB-GYN and surgical residents will graduate having already received the training.
Dr. Watson served as the center’s first director.
“From a surgeon’s point of view this is not only a marvelous opportunity for patients but also for physicians and clinical staff who will be assisting with robotic surgery,” he said in 2013. “The center is open 24/7, so surgeons, medical residents, nurses and other operating staff can practice as much as they want.”
The center was made possible by a generous gift to the MVH Foundation from Robert H. Brethen, Chairman and Chief Executive Officer of Celstar Group, Inc., a Dayton-based holding company. Mr. Brethen said at the time he wanted this innovative, less stressful form of surgery to be available to people throughout the region. He predicted the center’s training will help expand minimally invasive technology “across the country and around the world.”
The center is overseen by an advisory panel of Premier Health physicians who provide robotic services. All involved hope it will enhance the recruitment and retention of surgeons to the Dayton community.
Surgery’s future
MVH’s Robert Bowman, a nurse and vice president of hospital operations, said the number of surgeries performed each year at MVH (or anywhere, for that matter) will likely decline in the coming years because of growing technology and other advancements in medicine.
“As screening improves, as technology and health awareness improves, all of those things will have an impact on surgery,” Bowman said in 2013.
Whatever the future holds for surgery, Bowman and nurse Beth Heyse, director of Surgical Services, expect it to be every bit as mind blowing as the progress the two have witnessed in recent years.
Consider, for example, the abdominal aortic aneurysm, the dreaded “Triple A.”
“Twenty years ago, your mortality was huge even if it hadn’t ruptured,” Heyse said. “In surgery, you were opened up from your neck to pubis. Every organ is exposed and you’re in the O.R. for six to eight hours.”
“If you ruptured, you died,” added Bowman. “And even if you made it through the surgery, you were going to be in the hospital for weeks because of various side effects and complications.”
“Today we do endovascular stenting,” said Heyse. Endovascular stent surgery is a minimally invasive surgical procedure that uses advanced technology and instrumentation to place a small wire-mesh tube into the affected artery. The mesh tube acts like a scaffold to support the artery walls for a long-lasting improvement in blood flow and a decreased risk of heart attack or stroke.
Another advancement — ablative therapy, using chemical or electrical energy to destruct tissue. “We just go in and ‘poof,’” said Heyse. “We can freeze a tumor or fibroid to the point where it crumbles and then suck it out, or you can heat it until it bursts. There’s also a morcellating tube that can chew the tumor up and suck it out.”
Bowman and Heyse recalled when a total knee or hip replacement required four to five hours in surgery. “The hospital might have done two a day, if that, and the patient would have spent a week to 10 days in the hospital afterward,” Heyse reflected.
By 2012, the hospital could accommodate 12 to 15 such surgeries a day, thanks to minimally invasive technology and skills. The patient would likely go home in two to three days.
On the horizon, Dr. Watson and others expect the da Vinci robot will have more flexible instrumentation that will perform through a single port of entry.
Researchers also are studying techniques that would involve no external incisions at all. Called NOTES (natural orifice transluminal endoscopic surgery), surgeons would operate through an endoscope passed through a natural orifice (mouth, vagina, urethra, etc.), then through an internal incision in the stomach, vagina, bladder or colon.
“It’s exciting,” Dr. Watson said with a smile. “I don’t know where we’re going to go next, but it’s very exciting.”
Weight Loss Surgery
Debra Anderson Gold couldn’t tie her shoes without taking a break to catch her breath. She couldn’t cross her legs, couldn’t fit in most chairs and didn’t want to go out in public. Diets didn’t work, neither did diet drugs or acupuncture.
At 308 pounds, Debra had never been heavier, nor had she ever felt more depressed, lonely and defeated. That’s why in early 2004 the 42-year-old healthcare professional went for her “last hope” — weight loss, or bariatric, surgery at a Dayton-area hospital.
Fifteen months later and 140 pounds lighter, Debra felt like a new woman as she cycled, swam and ran along Lake Michigan in the grueling 23rd Annual Chicago Triathlon.
“I was about a quarter mile from the finish line and all of a sudden it strikes me: It’s been a little over a year since my surgery and here I am,” Debra recalls, nearly eight years later. “I was bawling by the time I crossed the finish line.”
Later that same year Debra partnered with her surgeon, John Maguire, MD, to establish the Miami Valley Hospital Weight Loss Center. As the Bariatric Service Line Director, Debra works with patients, surgeons, the bariatric team and the hospital to make sure patients have a good experience from the first meeting through years of follow-up.
The center completed its first surgery in January 2006. Since then, it has helped more than 2,300 morbidly obese patients, or about 330 a year, shed excess pounds and related health troubles.
“We have people who come here with multiple health problems, including some who show up in wheelchairs because they can no longer walk,” says Dr. Maguire. “But after weight loss surgery, many, and sometimes all, of their problems resolve and they’re mobile again. One of the most common things people say is, ‘You’ve given me my life back.’”
Some of the health problems that resolve include diabetes, hypertension and high cholesterol, sleep apnea, acid reflux and arthritis, as well as factors that increase the risk for heart attack, stroke and certain types of cancer.
“I never could have dreamed how different and how much better life would be after surgery,” says Debra. “I was completely overwhelmed by the transformation, and it wasn’t about appearance — it was about health.”
Growing need
Dr. Maguire says bariatric surgery in some form or another has been around for decades, but its popularity started to climb in the 1990s, just as the obesity rates in America started their meteoric ascent.
In 1990, according to federal figures, 12 percent of U.S. adults were obese. By 2005, that figure had almost doubled to 23 percent. It almost doubled again to 35.7 percent between 2009 and 2010. More troubling still, the U.S. Centers for Disease Control and Prevention predicts obesity will continue to rise in the years ahead, with some states exceeding obesity rates of 60 percent.
In 2013, the American Medical Association classified obesity as a disease, a move that instantly labeled one third of Americans as sick.
“It’s not just an American problem,” Dr. Maguire points out. “It’s really become a pandemic.”
Besides Dr. Maguire, the center’s team includes surgeons Mujeeb Siddiqui, DO, and the center’s director, Donavon Teel II, MD. The surgeons perform all types of open, laparoscopic and robotic weight loss surgery recognized by the American Society of Metabolic and Bariatric Surgery. These include Adjustable Gastric Band, Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and Gastric Bypass. The center also offers a new advanced procedure called the Sleeve Gastrectomy.
Dr. Maguire says most insurance plans cover bariatric surgery these days. He says most employers and insurance plans find the surgery “pays for itself pretty quickly.” (In 2008, medical costs associated with obesity were estimated at $147 billion. Add to that the billions lost in obesity-related absenteeism and lost productivity.)
He cautions that bariatric surgery is not a cure for obesity by itself, however. Patients must also adopt a healthy lifestyle, one that includes plenty of physical activity and good nutrition. The Weight Loss Center employs a multidisciplinary team (dieticians, nutritionists, exercise specialists and others) to help with this effort.
“It’s really not just about the surgery,” says Debra. “It’s about how patients live their lives after the surgery on their journey to good health. Our goal is to stay in touch with all of our patients so that we can help them maintain long-term success.”
STAND-ALONE BOX:
In 2007, just one year after it opened, MVH’s Weight Loss Center was named a Bariatric Surgery Center of Excellence by the American Society for Metabolic and Bariatric Surgery and the Surgical Review Corporation. This distinction, considered the "gold standard" in weight loss surgery, recognizes the safety, efficiency and overall positive outcomes of the bariatric surgical team. The center earned the distinction again in 2010.