More than a decade old but still startling to some, the advent of robot-assisted surgery has the potential to change the face of the possible for today’s physicians and surgeons, enabling newfound exploration and unprecedented precision. Taking stock of the newest developments, SRQ assembled some of the region’s foremost experts and practitioners in this exciting field straight out of science fiction.


For what procedures or problems do you most often turn to robotic-assisted surgery? Dr. James Fiorica, director of GYN Oncology and Chairman of the Robotic Steering Committee, Sarasota Memorial Hospital: The procedures would be complex hysterectomies, cancers of the uterus. Now we’ve expanded it into cervical cancers with radical hysterectomies. We’re now doing lymph node dissections robotically. We’re even starting to enter into treating ovarian cancer patients robotically.

Is that a significant hurdle for the technology, moving from the uterus to the ovary? Fiorica: Yes. In the ovaries, if the cancer has spread, how do you get all the cancer out? More importantly, how do you get it all out of the body through a small hole? The purpose of robotic surgery is to do minimally invasive surgery through small scars, so if you have a large specimen how do you technically do that without harming the patient? Dr. Paul Vesco, FACS, Cardiovascular, Thoracic and Robotic Surgery, Sarasota Memorial Hospital: Lung cancer is the most common. Cancer killer is the most common thing that we do. We also do thymomas. We also address any kind of mass or lymph node dissections in the test. We do esophagus with the robot and then some of the cardiac or heart applications—you can do heart bypass for one or two vessels, as well as the mitral valve and sometimes tricuspid valve lend themselves to robotic surgery. Dr. Kenneth Meredith. Gastrointestinal Oncology and Robotic Surgery, Sarasota Memorial Hospital: Robotic esophageal surgery, either benign or malignant including esophagectomies, gastroectomies, whipple procedures involve taking out the head of the pancreas, bile duct, gall bladder, duodenum—bottom part of the stomach—distal pancreatectomies. I prefer to do the robotic surgery because of the degrees of freedom and articulation and the three-dimensional view that it allows us to have over conventional laparoscopy, which is absolutely phenomenal for either benign or malignant diseases. 

What makes a procedure or situation a good candidate for robotic surgery? Fiorica: The question is, can the patient recover quicker? Can you do technically the same procedure and help the patient recover quicker so she can lead a normal life quicker, get back to work quicker, get on with additional treatment? That’s really the ideal situation.Can you take a big operation and do that same operation and have them recover faster? Vesco: In the chest, the previous normal for lung cancer was an incision from the front to the back and spreading the ribs. And then the healing of actually taking the lung out was nothing compared to the healing of the ribs, which might take six to nine months. Doing it robotically, a lot of people are back to normal in two to four weeks. Similarly with the heart or thymomas, it used to be sternotomy, or splitting the sternum in half, which again acts like a broken bone and for that to heal you’d normally wear a cast for six to eight weeks, so that sternum bone that you’ve opened and now wired back shut takes a minimum six to eight weeks just for the bone to heal. If you do it robotically, you don’t cut the sternum, you don’t cut in between the ribs, so we’re talking a couple weeks versus months. Fiorica: Think about the difference in pain when you do a big incision, or cut through bone or big abdominal muscles, versus going between or next to bone or muscle. The post-op pain is so much less when you can avoid those large incisions. Meredith: You’re talking a change in hospitalization from six days to three days. Liver surgery is an upcoming thing with robotic surgery. The first and second generations of robots haven’t lent themselves to have an application for robotic liver surgery, but more and more we’re doing major liver resections. Patients in the past have had two-foot incisions, even for some of the smaller liver resections, and had to be in the hospital five to seven days. Now, a lot can go home either the same day or the next day.

Does it allow the surgeon to be more efficient or proficient in surgery? Fiorica: I’m not sure that’s true. They’re long. They take longer and there’s a longer learning curve. You really have to be dedicated and want to do those procedures because it does take longer to learn and technically there’s a lot of equipment that has to work properly. You have to have a skilled operating room team doing it and there are a lot of extra things that have to happen, so there’s a lot frustration from a surgeon’s point of view. But it’s for a good reason: patient care.

What sort of things? What does the operating room look like when prepped for a robotic-assisted surgery? Vesco: You come in the room and there would be a console—almost a cubbyhole—where the surgeon would actually sit, but it’s hard-wired to a bedside set of arms that actually do the procedure or are controlled by the surgeon to do the procedure. Typically it’s like any other operating room except for this large machine docked in the room. It doesn’t decrease the number of people in the room that would help out; we have people at the bedside like anything else. Anesthesia is there. The nurses are at the bedside. It’s not too scary.

What can these different arms do? What kinds of tools do they have? Fiorica: When you’re doing an open operation, you have to have scissors and you have to have suture. At different times in the procedure you have to have scissors, sutures or instruments to hold tissue out of the way. When you’re doing robotic surgery, it’s the same thing except you make these five little holes in the patient. They’re connected to a circular port like a big fat straw and in there you put those same instruments; they’re just small instruments. You put the scissors or the needle holder or whatever you need at the time through these ports, and you’re doing the same procedure, just through small ports. But you’re working through a computer so you can enlarge that or magnify that to whatever degree you need to accomplish it. You’re basically performing the same operation, but instead of large kitchen scissors you’re doing it through manicure scissors.

Is there a cauterizing tool on there too? Fiorica: There is. In fact there are a couple different types of cauterization, what we call monopolar and bipolar cauterization. You have different techniques for different purposes. 

So in terms of surgical extractions and excisions, particularly minute ones, robotic surgery seems to be the way to go? Vesco: With cancers, you don’t want anything remaining. There are some radiologic and percutaneous, meaning through-the-skin, approaches where you just ablate or destroy the tumor while it’s still inside of you, but still the gold standard with most tumors is actually cutting out the diseased part and removing it from the body.

Are there any negatives to the advent of robotic surgery or aspects that give you pause? Fiorica: There’s a learning curve. It takes a long time to be proficient. Only one person can sit at that console and do the procedure; it’s not like an open case where you can have a surgeon and an assistant running the machine. They have machines like that for training, but the bottom line is it’s a long learning curve to be comfortable with that machine and what it can do and what it can’t do. Likewise, there’s a long learning curve for the OR team. They have to be on the same page or your cases are going to take much longer, and the longer they take, the greater the risk. That’s probably the biggest downfall. Meredith: There are longer operative times initially. As you learn, you get past your learning curve and operative time will decrease substantially. Look at when we started doing robotic esophageal surgery and compared it to the thoracoscopic or open approach; you could do an open esophagectomy in three or four hours whereas robotic was initially taking six to seven hours. Now you can get the robotic approach down to about four or five hours. For a big operation like a whipple, you’re still looking at anywhere between six to eight hours for a robotic approach and three to four hours for an open approach. My concern is this is a technology that needs to be used carefully. There are a lot of people that want to use the robot as a marketing tool. They may not have the volume to really support a robotic approach. If your practice doesn’t have a high volume, you shouldn’t be doing robotics because you will never get past your learning curve. It takes about 30 cases to get past your learning curve and most low-volume surgeons are doing anywhere from three to five a year. You’re not going to get past your learning curve for five to seven years. That’s not feasible for most practices. Those patients that have lung disease or advanced GYN disease probably shouldn’t be done in a small-volume practice; those should be sent to a surgeon with a high-volume practice. Vesco: Part of it is volume and part of it also is that the robot is an expensive device for a hospital to have. It’s expensive for patients as well when it’s applied to things that can easily be done in a different fashion—laparoscopic or with a small incision. Some of the gall bladder tumors, I agree that a robot is probably helpful for most surgeons. For a straightforward gall bladder removal, to do it with a robot is blowing up an anthill with a nuclear weapon. It’s a little bit overkill and probably anyone could do it otherwise.

What is the training process like to become certified for or proven in use of the robotic-assisted program? Meredith: It’s practice-specific and site-specific. If you want to have credentialing for esophageal surgery, then you need to go watch someone who does robotic esophageal surgery. That’s the first step. Then there are online modules that you have to complete. Then you have to be proctored. I’m a proctor and I watch people do this operation and I will not sign off on their credentials if I don’t think they’re safe to do it. That’s a responsibility that we have for our patients. In the past, to do GI oncology you basically could go and watch someone do a rectal resection or a colon resection and you could take that application and do whatever in the abdomen that you wanted. We know that’s not a good scenario to be in, so now we actually have pockets of specific training. If you want a pancreatic resection, you have to go see somebody who does robotic pancreatic. Fiorica: It’s very structured. There’s a cadaver lab to practice on cadavers before you even touch a patient. When you touch a patient, you have a live proctor at your facility watching over you that’s skilled in that procedure and there’s a whole criteria for being a proctor. You can’t just serve because you’re credentialed to do one; you have to have a certain expertise above and beyond to be a proctor. There are tight guidelines and we encourage the hospitals to create those tight guidelines and maintain them.

Does the robotic assistance enhance what you already knew how to do, or is it allowing wholly new things to be done? Fiorica: There are a lot of things that would be hard to do beforehand. A good example is for infertility—tubal reanastimosis. If someone was having problems with their fallopian tubes and had to have microsurgery, that was a big deal—doing microscopic surgery with 2D microscopes and fine sutures. Now with robotic surgery, it’s so much easier for a specialist to be competent and do that procedure safer. Meredith: There’s a lot of different technology now with the robot. Most people are familiar with the articulation of the instruments that allows us do to a more thorough dissection, but the other technology, which wasn’t on the previous generations of robot, is a cut-and-seal technology that allows us to actually go through tissue. In the past, the robot was really nice in theory but there weren’t any instruments to do a thorough dissection and burning of vessels. When they came out with the vessel sealer, it allowed us to mimic some of the laparoscopic technology, only articulated it so we could get into places. And now we have technology called Firefly, which allows us to inter-operatively assess blood flow. We can inject this dye and a special camera allows us to see the patterns of blood flow. I was doing an esophagectomy and the top of the stomach looked completely normal. We injected the Firefly and you could see that the top of the stomach was completely ischemic.

Regarding mimicking laparoscopy, particularly with OB/GYN procedures, there was concern whether robotic surgery was a real evolution or an unnecessary update for competent operation. Where does the debate lie now? Fiorica: There’s been a lot of overuse of robotic surgery in GYN, unfortunately. For a basic hysterectomy or basic removal of an ovary or tubal ligation, laparoscopy is clearly the better way to go. You can use both, but why use this expensive equipment when you can do it quicker, smoother and more comfortably in your learning curve? You want to reserve that high-tech equipment for things that you can’t do laparoscopically. For example, a 400-pound patient is a problem. If you have to do an open incision, there’s a big, deep incision and lots of wound-healing problems. A 400-pound person laparoscopy is very difficult as well. It’s smaller incisions, but it would be very technically challenging. But to do it robotically is actually quite easy. It’s much easier because the hydraulics of the robot overcome a lot of the weight issues, so technically it’s a much better procedure. But you want to reserve it for the things you can’t do laparoscopically. GYN laparoscopy has been developed and perfected for years and years and it’s those complicated cases that you want to do robotically. 

It’s commonly called robotic surgery, but it’s perhaps more aptly called robotic-assisted surgery, correct? It’s still the doctor operating and the robot is a tool. Vesco: Yes. They don’t have independent technology or programs. There is some planning software for different platforms and things that you can program it to do, but currently 100 percent is under our control.

Do you see an upper limit on this technology? Will there be a time when you won’t even need to be in the room? Meredith: We’re not even remotely close. I’m thinking of just the tremendous amount of volume and data that would go into planning a robotic whipple. There’s anatomic variance and in order for a system to have that much storage and then to have that many contingencies, you’re talking many, many years away.

In terms of this technology, what do you think is coming next in your field? Fiorica: They need it to be smaller, lighter equipment—more manageable equipment. That’s the only downside to the equipment now. It takes a very large operating room. It’s an expensive piece of equipment and it’s very bulky. It’s like the first generation of computers. They evolved and now we have these little tablets that can actually do more. That’s where things need to evolve into something more practical so most operating rooms can have that ability. Most operating rooms now have a computer terminal, they have X-ray screens hooked up to it, they have a lot of technology, but we’re a long way from putting a robot in every operating room. Laparoscopy can go into any operating room, but a robot can’t. Meredith: The instrumentation is going to get better. There are two components to robotic surgery. There’s the part that’s at the patient and then there’s the big console that we sit at, which basically is the virtual reality. In the future, we’re going to move away from that giant apparatus and we’ll have goggles and gloves that communicate wirelessly. We’re going to be able to be any place, anywhere and be able to communicate with the instrumentation. And as the instrumentation gets smaller, it’s going to allow us to do more. If I had a wish list, we would actually have a single instrument that allows multiple interchanges without ever having to take that instrument outside of the patient. Fiorica: One of the goals that would be nice from a cancer perspective—and I see this coming in the not-too-distant future—is how you document a cancer response. X-ray equipment is nice, but it’s not perfect. It’s certainly not the same as going in and looking. If you do a CAT scan, a PET scan or an MRI and you try to define where the cancer is and where it is not, it’s not the same as going in. You give them chemotherapy and defining that response is also complicated. Wouldn’t there be a way to use this as a method of communicating response? If you do a surgery at the beginning and send that off to a main office where they quantitate response and then at the end of treatment you do another procedure and quantitate it, your data for drug development would be more accurate than relying on X-ray equipment. That’s not too far away.

You mean to use the technology not just for surgery, but also for information gathering? Fiorica: To gain information others can use across the country and across the world for similar cancers.

Closing thoughts? Vesco: Surgery has been the gold standard for most cancers for the last 70 to 80 years. The big push in cancer especially is how can we hurt the patient the least and get the same benefits. The development of radiation and different forms of ablative or destructive therapies for cancer come about to compete with surgery, but all those are compared with actual resection. So as we move into robotics and now can do the same operation—the same thing that’s been considered the gold standard—with less downtime for people, we’re redefining what the landscape should be. Fiorica: If you look at what we can do now with robotics when you use it for the right procedure, [Vesco] is right. Essentially all uterine cancers are now treated robotically as an overnight in the hospital as opposed to five days in the hospital. For people who stay in the hospital or are immobile when they get home after, the complication rates—the risk of blood clots, the risk of wound healing problems, the risk of pneumonias—are so much greater. If you use it for the right purpose, you shorten the hospital stay and really help the patient.

About Our Participants 

Jim Fiorica, MD

Earning his medical degree from Tufts University and serving his internship and residency both at the University of South Florida College of Medicine, where he became certified in gynecology/oncology, obstetrics and gynecology. Fiorica serves as director of GYN oncology at Sarasota Memorial Hospital and chairman of the Robotic Steering Committee. Leading development of the robotic surgery program for women with gynecological cancer at SMH, Fiorica was the first in the region to utilize the da Vinci Surgical System. He also serves as medical director of Sarasota Memorial’s Women’s Cancer Specialty Program.

Paul Vesco, MD FACS

Graduating from the University of Kentucky, Vesco completed his internship and residency at Allegheny General Hospital and his fellowship at Ohio State University Hospitals, becoming certified in general, thoracic and cardiovascular surgery. An early practitioner of robotic-assisted surgery, before joining SMH Vesco performed the first closed-chest, robotic coronary artery bypass and since performed the first closed-chest lung lobectomy and themectomy at the hospital and its first robotic-assisted esophagectomy.

Kenneth Meredith, MD

A University of Louisville graduate, Meredith went on to the University of Kentucky for his internship and the University of Wisconsin for his residency, before heading to the Moffitt Cancer Center for his fellowship. Recently joining SMH, Meredith previously served as director of robotic surgery at the University of Wisconsin Hospital and Clinics. A pioneer of robotic esophageal surgery, Meredith has been credited as having performed more than any other physician in the world.