Advances in Robotic Surgery for Improved Patient Care Sonnie Kim-Ashchi, MD, FACOG. Medical director of St. Vincent Southside robotic program

How many of you actually have seen and even tried daVinci robotic surgical systems?

Current understanding about daVinci robotic surgery with PCPs ; High Awareness, Fairly Positive Perception • 87-100% are aware of da Vinci Surgery • 63-75% view it positively Big Gaps in Knowledge of da Vinci® Surgery Among Referring Physicians 1 in 3 PCPs don’t know any local surgeons who perform da Vinci Surgery 75% of PCPs don’t know outcomes of da Vinci Surgery vs. open and lap surgery 50%+ OB/GYNs don’t know da Vinci procedures outside of GYN 60 % of PCPs don’t know da Vinci procedures for GYN, cardiothoracic, colorectal or general surgery

daVinci Robot Assisted surgery, Minimally invasive Surgery ( MIS) Cardiac- mitral valve repair, revascularization General Surgery- cholecystectomy, colectomy, colorectal esophagectomy, trans hiatal gastrectomy, hepatectomy, lower anterior resection, Nissen fundoplication, pancreatectomy, Para esophageal hernia repair, rectopexy, splenectomy, ventral hernia repair, bariatric surgery Head & Neck - trans oral surgery Thoracic- lobectomy Urology- cystectomy, nephrectomy, partial nephrectomy, prostatectomy, pyeloplasty, ureteral reimplantation Gynecology- Endometriosis resection, benign and cancer hysterectomy, myomectomy, sacrocolpopexy List of procedures are GROWING! Plastic surgery-daVInci robot assisted latissimus dorsi flap retrieval for breast reconstruction after double mastectomy

Benefits of robotic surgery Less blood loss- less chance of blood transfusion Less infection Less complication Less chance of procedure converting to an abdominal procedure Short hospital stay (overnight stay vs. outpatient) Lower readmission rate Less postoperative pain = less narcotic use Quicker recovery-faster return to normal activities For example, patients go back to regular work and activities with no limitation by 3 to 4 weeks after daVinci benign hysterectomy, sometimes 2 weeks if office works

Advantage of well-organized robotic program- 46 % less complication Advantage of well-organized robotic program- 46 % less complication. 37% lower cost

daVinci robotic systems daVinci Si system daVinci  daVinci S Leonardo daVInci’s mechanical knight robot in 1495 daVinci Xi system FDA Cleared for daVinci gyn surgery in 2005

daVinci Surgical System; How does it work? High Definition 3D Vision Surgeon-controlled Stable and immersive view Up to 10x zoom Precision & Dexterity Mimics surgeon’s hands Scales down movements With tremor filtration Intuitive® Motion Advanced software enables intuitive control (instead of cross-handed) 3 cm 1cm

daVinci robot assisted benign gynecological surgeries Hysterectomy, myomectomy, adnexal surgery, endometriosis resection and pelvic prolapse Please note there are non surgical options for these conditions.

St. Vincent SS robotic OR

daVinci robot assisted benign hysterectomy- 80% by MIS!! TAH

Multicenter analysis comparing robotic, open, laparoscopic and vaginal hysterectomy by high-volume surgeons for benign indications Robotic patients had: • Larger uteri • Fewer complications • Shorter hospital stay • Similar conversions, readmissions & reoperation rate as other MIS approaches International Journal of Gynecology and Obstetrics 2016 Lim PC. Garza D.

Clinical Benefits Promote Positive Economic Value of daVinci Surgery in Gynecology * Common misconception - Robotic surgery is too expensive ! The cost of robotics must take into the account the total cost of care and how robotic-assisted surgery affects the rate of laparotomy to prove the benefits of minimally invasive surgery without increasing costs. Total cost of a patient’s care includes not only instrumentation costs, but also costs based on factors such as length of stay (LOS, daVinci 0.5 vs open 2.7 vs LSC 1.8 days), Operating Time , Conversion rates ( LSC 7.2 % vs daVinci TLH 0.3 %), complications, readmissions and reoperations. National cost average data- bed day $1,553. A conversion $3,162. Complication cost $3,632. OR time $11 per minute, Readmission $11,087 There are also societal cost savings to consider based on the patient’s quicker return to normal activities. Surgeons’ time – outpatient !

Benefits of robotic surgery Less blood loss-less chance of blood transfusion Less infection Less complication rate Less chance of procedure converting to an abdominal procedure Short hospital stay Less postoperative pain-less narcotic use Quicker recovery-faster return to normal activities For example, patients go back to regular work and activities with no limitation by 3 to 4 weeks after daVinci benign hysterectomy, sometimes 2 weeks if office works

Surgery: Single-Site® Abdominal (Open) Surgery Adaptation of MIS in benign gyn cases such as endometriosis resection, myomectomy and hysterectomy Robotic-Assisted Surgery: Single-Site® Abdominal (Open) Surgery Robotic-Assisted Surgery: Multi-port Laparoscopy Vaginal Surgery

Evolution of Surgical approaches

daVinci robot assisted benign gyn surgery One Large Incision Multiple Small Incisions One Small Incision in the Belly Button Open Hysterectomy da Vinci® Hysterectomy: Multi-port da Vinci® Single-Site® Hysterectomy or Traditional Laparoscopic Single Incision Hysterectomy Traditional Laparoscopic Hysterectomy

How to remove the specimen through 2cm umbilical incision? Not limited by incidence of prior surgeries, pelvic infection, large uteri or presence of single or multiple adnexal masses or/and severe endometriosis

1200 gram morcellated uterus

daVinci Single-Site benign hysterectomy or adnexal surgery Virtually , “scarless” surgery !!!

Please Remember the Benefits of robotic surgery for your patients  Less blood loss-less chance of blood transfusion Less infection Less complication rate Less chance of procedure converting to an abdominal procedure Short hospital stay/ Lower Rate of readmission Less postoperative pain-less narcotic use Quicker recovery-faster return to normal activities For example, patients go back to regular work and activities with no limitation by 3 to 4 weeks after daVinci benign hysterectomy, sometimes 2 weeks if office works

Thank you ! St. Vincent Southside Robotic Team

Please call me if you would like to come. 904-759-2328