Sheldon Black, MD often performs surgery at St. Vincent’s Hospital while sitting ten feet away from the patient. The head/neck surgeon with ENT Associates of Alabama controls the da Vinci® Transoral Robotic Surgery system at a computer screen across the room.
Surgery with robots requires the same aptitude as traditional surgery. But in addition, “you have to have the hand/eye coordination to do the operation through the robot,” Black says.
The robotic unit resembles a huge cabinet with three robot arms, one for optics and the others for holding and cutting tissue, all controlled by the surgeon’s direction. “The other part of your team is at the head of the patient, suctioning and keeping the field clean,” Black says.
About 12 years ago, Black partnered with Jon Holmes, DMD, MD, an oral and maxillofacial surgeon, to create a head/neck cancer surgery team.
Head/neck cancer surgery requires a multidisciplinary approach, often including surgeons to remove the tumor, along with reconstructive surgeons, radiation oncologists, and medical oncologists. “Head and neck surgery can be very deforming,” Black says, “and can cause problems with swallowing and speech.” As such, speech therapists, nutritionists, and gastroenterologists are also frequently part of a patient’s treatment.
“Using the robotic system, surgeons have the ability to visualize around corners,” Black says. “The robot has helped us take out some tumors in the back of the throat that otherwise would require much bigger operations. With cutting devices and clamps made for the oral cavity and upper airway, the robot arms can grab, cauterize and remove tumors difficult to access. You can move the robot arms 360 degrees, which allows you to get into spaces that you typically wouldn’t be able to do.”
Unless there is a clear-cut reason to recommend traditional or robotic surgery, Black includes the patient in the decision. “Sometimes the old- fashioned way is the perfect way to manage the cancer,” he says. “But I now have a different procedure to offer the patient. I like being able to do that. It’s like a medical doctor who used to be able to treat blood pressure with two drugs who now has five drugs.”
The head and neck cancers most amenable to robotic treatment are in the tonsil and base of the tongue. “For certain situations such as back of the throat cancer, robotic surgery has allowed us to operate on tumors that otherwise would have been treated with radiation therapy and chemotherapy,” Black says. “They can be curative but they can also cause a lot of side effects.” If these treatments can be eliminated, the patient is spared the nausea, vomiting, weight loss, and hospitalization of chemotherapy as well as the long-term side effects of radiation therapy.
The robotic system does not help in inoperable situations. The system is usually most appropriate for early stage lesions, Black says. Recovery may be easier if the use of robotics has allowed for smaller incisions and less reconstructive flaps.
Black points out that the technology is merely a tool, not a guarantee. Robotic technology “doesn’t mean that the patient will be cured of their head and neck cancer,” Black says. “The robot is just another way to remove tumors. It’s still very important that patients are managed nutritionally and that they have high quality radiation and oncology doctors taking care of them.”
While the cost of traditional and robotic surgery is the same for the patient, the initial outlay for the multimillion dollar equipment and its upkeep as well as the surgical training fall to the hospital. The team formed by Black and Holmes transformed St. Vincent’s into a regional referral hospital for these types of procedures. “We went from doing just a few cases a year to now doing about 250 head/neck cancer cases annually,” Black says. St. Vincent’s and UAB are the only two Alabama facilities to operate at this level.
“Ten years from now, these robots will be so much better and allow us to do much more,” Black says. Still, he doesn’t foresee a day when the technology will replace a trained surgeon. “I don’t worry about that ever. You have to have a surgeon who has not only the surgical skills, but also the technical skills, the cognitive skills and the knowledge of the disease process. The robot is just a tool.”
