Robotics surgery

The future is now at North Big Horn Hospital

By David Peck

Cutting edge technology in the form of a state-of-the-art robotics surgery program will transform surgical services at North Big Horn Hospital in Lovell, according to Dr. Michael Hill, who pioneered the practice at the Billings Clinic before moving to Lovell nearly two years ago.

The new Intuitive da Vinci Xi was recently acquired by the North Big Horn Hospital District and is the first surgical robotics program in the Big Horn Basin. The system promises to elevate surgical outcomes for patients and improve recovery time in the skilled hands of Dr. Hill, who has years of experience in the practice. The net result is a healthier patient and a happier provider, hospital and insurance company.

Dr. Hill started with the Billings Clinic in 2014 and made his first visit to Lovell, with NBHH an affiliate hospital, that same year to meet the staff. He then moved to Lovell to practice medicine at North Big Horn Hospital full-time in May of 2022.

Hill has years of experience with the da Vinci system, first training on the da Vinci Si in 2017, he said, though he noted that he first “met a robot” in 2004 when interviewing for medical school at the University of Washington, where he ended up getting his degree.

Tried and true technology

While surgical robotics may seem almost futuristic, the practice has been in use for decades, Hill said.

“Intuitive as a company has been around since 1995,” he said. “They’ve been around for three decades-plus of designing surgical robots.”

Surgical robots were originally developed by the military to provide surgical services for members of the armed forces in the field, Hill said.

“Surgical robots have had FDA clearance since 1992,” Hill said. “The military was doing battlefield robotics in, like 1993. The first robotic gall bladder removal was in 1997. So we’re talking decades of being able to do this. It’s incredible how long this has been going on.”

Robotics experience

After getting exposed to robotics in Seattle, Dr. Hill got some further training at Dartmouth University in New Hampshire, but the training was “fairly minimal” in general surgery, he said, while robotics in urology and gynecology, with the need for delicate, “micro level” work, was taking off among surgery residents.

“A lot of the stuff that happens in general surgery is still kind of on the macro level,” he said. “The reason it took off in urology was it was on the micro level. They’re in this narrow space in the pelvis trying to remove the prostate, so now having very finite movements of articulating wrists down in a narrow pelvis for prostate surgery, urologists said, ‘We’re never going back to anything else. This is a total game changer.’ There was, maybe, delayed adoption by the general surgery community, but now there have been over 12 million robotic surgeries done on the da Vinci system. There have been over 34,000 peer reviewed scientific articles on robotics.

“And so we talk about it being cutting edge and we talk about it being new, but what I would like to convey to the community at large is: It’s not a risk, it’s not scary, it’s not territory that hasn’t been foraged through.”

Around 2015-16, Dr. Hill decided robotic surgery was “clearly where surgery is going,” he said, adding, “The trends are clearly going toward more and more robotic surgery, and every continuing medical education course or seminar or program I went to was all on robotics. … I just thought there was no reason to delay the inevitable, and there was no other general surgeon at the Billings Clinic that was trained in robotics, so I just decided this is where my emphasis should be.”

So in 2017 Dr. Hill went to California and trained on the da Vinci robotics system, first operating on pigs but mostly figuring out how the robot works.

“The thing to remember is that the robot is a tool. It is not a surgery. I already knew how to do these surgeries. I was just learning how to use this new tool,” he said.

The tool has “several incredible advances that enhance my capabilities as a surgeon,” he added. On the micro level, for instance, there is “motion scaling” for microsurgeries with which he can move his hand on the outside a full movement, and the robot can microscale that to microscopic movements.

“So when you’re reconstructing an artery or putting things back together, and these are very, very small structures, I can zoom all the way in. The camera has two lenses, so it is 3D on the inside,” Hill said. “When you talk about the huge advancement that laparoscopic surgery was, going from open surgery where patients had big incisions and were staying in the hospital for a long period of time, had long recoveries and lots of pain medications, and then you move to laparoscopic surgery, and it was huge.

“(But) The limitation to traditional laparoscopic surgery is, first of all, it’s two dimensional. It’s 2D. … You also only have four degrees of freedom. Your instruments can open and close, they can twist and they can move side to side. And that’s it. When you go to robotics, you now have improved magnification. You can really magnify the image. You can zoom way in. You can eliminate all tremor. So it eliminates some of that human error that exists. … I can make it do something that a human wrist can’t. I can make the robot twist all the way around. It literally can do things that my hands cannot. It can fit in spaces that my hands cannot.

“The robot turns a two-handed surgeon into a four-handed surgeon. I’ve got four arms all under the control of the surgeon. To turn a two-handed surgeon into a four-handed surgeon just incredibly maximizes my capabilities in the operating room.”

He added, “There’s no area in surgery where there’s not some robotics components: vascular, thoracic, cardiac, spine, orthopedics, general surgery, gynecology, urology – every single area of medicine is now using robotics.

He continued that with the use of florescent medical dye, he can check structures on the inside and do things like check the blood supply to the area he’s operating on, which enhances his ability to put healthy pieces of the body together after a section has been removed, such as in colon surgery.

“Historically surgeons would rely on visual cues or markers, but sometimes we were wrong. You would put those two pieces back together and it would either break down or open up because there was inadequate blood supply,” he said. “Now, with the robotic visualization system, the camera, it will show me what the blood supply is so I can know that these two pieces of the colon that I’m putting back together are healthy.

“If I’m taking out a patient’s gall bladder, the dreaded complication of gall bladder removal is injury to the common bile duct. … The problem is that human patients don’t always follow the anatomy book, so sometimes there’s variant anatomy. But a lot of times that tissue is buried under the patient’s fatty tissue and connective tissue. Well, you put in a green (dye) an hour before the surgery, and now that patient’s biliary anatomy will glow. You can see it underneath the connective tissues so that you know where to safely start your dissection to reduce your risk of injuring the common bile duct.”

He said dye administered two hours before surgery can even show where the lymph nodes are to check for cancer.

The next version of the robot, likely to come out in 18 months or so, will have integrated CT Scan overlay so if a patient has a cancer in a portion of the colon, for instance, a surgeon can tell the robot to make the cancer bright pink so that the surgeon can make sure that the cancer is complete removed. It will also identify other anatomy to, for instance, avoid injuring the ureter during colon surgery.

Likewise, having 3D imagery with the robotics is like operating with virtual reality, allowing the surgeon to maneuver around structures and go behind structures that are historically difficult to see. And with seven degrees of motion in the articulating wrist, he can not only maneuver behind structures but also protect nearby delicate structures like nerves, arteries and veins in a way that was difficult laparoscopically. The increased magnification allows the surgeon to identify the important structures.

Better outcomes

The end result of the delicate work of the robotic system is that the patient suffers far less trauma at the incision point.

“As it (a surgical instrument) goes through the abdominal wall, if you are operating laparoscopically, all of your movements on the outside are transferring energy to the patient’s abdominal wall, so if I lift up on the instrument, I’m going to lift up on the abdominal wall, which increases the amount of trauma, force, tension on the patient’s musculature,” Hill said. “The robot holds the instrument perfectly still in the abdominal wall and works on a fulcrum to minimize trauma to tissues that you’re not operating on. That results in faster healing, less prescription strength pain medications, shorter hospital stays and return to activities of daily living faster. And because of those safety measures that I mentioned before, there are fewer complications, fewer readmissions, and so with those improved outcomes, patients, hospital systems, insurance companies, physicians, everybody is happier with all of those outcomes.”

Another aspect of the North Big Horn Hospital surgical robotics program is that, in Dr. Hill, the hospital has a surgeon with a great amount of experience in robotic surgery – 130 surgical cases with robotics at the Billings Clinic.

His first robotic surgery in Lovell was Tuesday, and there were eight robotic surgeries on the schedule as of last Friday.

“I am excited for our region,” he said. “I just think it’s great for the patients in our region to have access to these advanced technologies.”

Hill said he has years of experience with robotic surgery with a variety of different types: inguinal (groin) hernias, abdominal wall hernias, colon resections, gall bladder removal, acid reflux surgeries and more.

“I just have a huge spectrum of surgeries that I’ve been able to complete robotically, which I think brings a great skill set to our region,” he said. “What it (also) does for North Big Horn Hospital is allow us to recruit a urologist, a gynecologist, other specialties that otherwise would not have been interested in coming and doing outreach surgeries at North Big Horn Hospital because 100 percent of them are trained robotically in residency now. And so when we did not have a robot to entice them to come here, they just weren’t interested. They would say, ‘Well maybe we’ll come and do a clinic,’ but every patient that they would recruit for surgery they would take back to their other locations.

“I anticipate in the near future as we recruit a urologist or a gynecologist to be able to come into our community once or twice a month to do surgeries, those individuals will be able to have their surgeries in their hometown. We just didn’t have the ability to recruit those specialties without the robot.”

And finally, robotics surgery can extend the career of the surgeon, as well, allowing the surgeon to sit at a console rather than standing over an operating table for long periods of time.

“Studies are showing that we’re getting extended life out of surgeons because of the ergonomics,” he said. “They’re able to last much longer. They’re able to stay focused longer, and they’re able to have longer surgery days, because you reduce that fatigue that takes place. You’re getting years more out of surgeons.

“My senior partner at Billings Clinic, John Gregory, is in his 70s and doing robotics, and he had all but given up laparoscopic surgery just because of the torque. The angulation on his ergonomics was just taking a toll that he couldn’t sustain day after day. Robotics is rejuvenating him with extra, extended life.”

Financials

The hospital district has acquired the da Vinci Xi on a lease to own basis over a five-year period. Hill said, depending on the type of surgery, the district will break even on the $2 million system with four to five surgeries per month.

“Four to five surgeries a month will pay the lease payment and all other maintenance costs and everything else,” he said.

“It’s lease to own,” North Big Horn CEO Eric Connell said. “At the end of five years we own it. It’s a piece of equipment suited to the types of things we have been doing here for many years. It (the lease to own) does give us a little bit of flexibility to update technology.”

Hill said the operating room team went to St. Vincent Hospital in Billings for observational training with an expert robotics team, with St. V’s being a regional training facility in robotics, to learn the mechanics of the robot but also operating room efficiencies.

Dr. Hill also traveled to Chicago recently for a refresher course with Intuitive plus a surgeon led 300 level course on advanced surgical techniques on colectomy and hernia repair, accompanied by emergency room provider Michael Asay, PA-C, with both Asay and fellow ER provider Jack Carpenter, PA-C serving as surgical assistants during procedures in the OR since 2016.

With the robot, Asay and Carpenter will provide “first assist” in the OR, Hill said, adjusting the robotic arms and changing instruments on the arms during surgery.

A great step forward

Dr. Hill said he wants the public to understand what a great advance the da Vinci robot is for North Big Horn Hospital, noting, “I could not be more excited for the patients in the Big Horn region to have access to top quality care through this new technology. And it provides the hospital the ability to expand services through other specialties.”

“This is a game changer for our facility and the community to be able to offer the highest level of technology coupled with Dr. Hill’s skill set,” Connell agreed. “We couldn’t do it without Dr. Hill. That’s what sets us apart (Hill’s experience). It’s an amazing thing to bring this technology here and move into the future.”

Added Billings Clinic Vice President of Regional Operations Nichole Hobbs: “Having a resource like the da Vinci surgical system provides another tool to expand services locally while keeping care close to home. Billings Clinic has used this technology for years to provide innovative, minimally invasive and life-saving procedures to patients when they need us. We share that commitment with North Big Horn Hospital and are always grateful to see our partners grow their offerings to enhance care in the region.”

The future is now, Hill said, noting that 100 percent of surgical residents are training on robotics, but he said he wanted to leave the public with one major thought: The robot is not doing the surgery. He, with his years of experience, is doing the surgery, albeit using a wonderful tool.

“It’s me controlling the robot the whole time,” he said. “It’s not an autonomous machine.”

North Big Horn Hospital is planning a pair of public exhibitions of the da Vinci system in the near future, where people will be able to see what the surgeon sees through the optics of the system and manipulate tiny objects.