Jeffrey Nix, MD, FACS, Director of Robotic Surgery at University of Alabama at Birmingham talks about single port surgery.
Interview conducted by Ivanhoe Broadcast News in April 2019.
What is the single port?
NIX: This is a continued evolution of minimally invasive surgery. So current robotic surgery for prostate cancer is an example or any other surgeries that we do robotically. We’ll have multiple different keyholes so or many incisions. And that’s how we get the laparoscopic tools into the areas that we need to get into. For prostate cancer surgery for example you might have five or six different keyhole incisions. The evolution of the single port is: could we make that one or two mini incisions instead of five or six. We did a procedure with two brothers with prostate cancer specifically and this has just been FDA approved. We’ve had one small incision plus one tiny assistant port but in the future our theory is that we’ll have all this down to just one incision. All of this is an effort to evolve minimally invasive surgery to a place where we could do these as an outpatient procedure for example. Could we move many of these cancer operations to less and less and less morbidity for patients and have quicker and quicker recovery. So that they can get back to their normal quality of life faster. That’s the idea. And so that’s the difference between a single port and the current traditional multi-port platforms is that we’ve gone from six or seven or five or six keyhole incisions to one or two.
How long has this been out?
NIX: It was FDA approved at the end of last year. There are only 15 centers in the United States that are currently using the single port. We were one of the first 15. And so it’s only been out for a few months.
Why is it only approved for urological surgeries?
NIX: A lot of that has to do with just how medical devices are approved. Urology has the longest narrative or history in terms of doing minimally invasive surgery robotically and so it was prostatectomy or prostate cancer was actually it’s not even just approved for urology cancers but it’s approved for prostate surgery. So once that takes effect then they’ll slowly start to add other service lines and other procedures. The reality is right now where it looks like it’s just going to be a small subset of patients that could be benefited by this. That won’t be the case. It’ll continue to evolve and continue to be helpful for more and more and more cancer patients as well as non cancer operations. A complex hernia repair is another good example of something that if it can be done minimally invasive it would require multiple little incisions. Could that come down to just one incision. Could those patients go from staying in the hospital one or two nights to going home the same day.
What’s the current recovery time for this single port compared to multiport?
NIX: We’ve just started doing these procedures. We have about (now we have done 50) of the prostates under our belts at this point. We’re already starting to do our first patients as outpatient procedure. So even that early on in the learning curve of this new tool, this new platform, we’re seeing good enough results that we think we can go from a traditional multi port approach, patients will stay one night in hospital and usually go home around mid morning to lunch the next day. Could we then go ahead and discharge them the same day. And I think we’re already starting to see that benefit for patients and again that’s obviously a benefit for the health care system as well.
Currently there are patients that are being discharged the same day?
NIX: We’re starting this week to send our first prostate patients home the same day.
And for the brothers, how long were they in the hospital?
NIX: They both went home the next morning right after breakfast. They were the first two procedures we had done that way. We went ahead and kept them overnight just to make sure.
Besides the fewer incisions, what other advantages does this have?
NIX: It’s not just cosmetic. The reality is if it was just a cosmetic approach just one incision versus two versus six I mean there’s not really a big difference because these are small incisions. This is a constant evolution. We’re trying to continue to push the frontier of what we can do minimally invasively. It becomes less about the number of incisions and more about what’s the end goal, right? What’s the target? Can we do surgeries that we couldn’t do before minimally invasive. For example, can we carry this off label. Can we use these skills in this minimally invasive approach to do things we couldn’t do before? Even in a multi port platform and again the pain control the morbidity for patients is really the end game. Can we do the same operation that we would do open and do it with less morbidity for the patients. And one of the factors that is constantly looked at here is length of stay in the hospital. And that’s because it’s an easy metric to follow. But what about time till the patient gets back to work. What if we can get patient back to work within a few weeks versus within a few months. You’ll see short term disabilities for cancer surgeries of six, eight weeks all the time but with minimum base of surgery we don’t need that could we even push that envelope even closer because again there’s lots of literature on the financial toxicity of health care these days especially cancer care. So if we can get people back to work quicker if we can do some of these patients in an outpatient fashion where they get back to work within several days could that make a difference for that patient for that fiscal year for them. I think absolutely the answer is yes.
And the patients that have done this. How soon after surgery have they gone back to work?
NIX: We’re slowly pushing that envelope of what we can get people back to. We’re definitely seeing reduced convalescence times. But again we’re comparing a large group of patients we’ve done multiple port versus just a handful of patients we’ve done single port. So in order to know if that’s a real finding over the course of a lot of patients. We have to just do it more and see.
But the patients have been going back?
NIX: Yeah. Our hope is that we can consistently do that. It’s not just a byproduct of the few patients we’ve done but that it’s a real finding across the board.
Are there any factors that trigger which patients you would do the single port?
NIX: It’s FDA approved for these prostate cancer patients but we’ve used it off label for removing part of the kidney for patients. It’s not even can we do the same operation but can we do it in new different ways. An example would be you have a patient who needs part of their kidney removed but they’ve had multiple abdominal operations and so they have what is considered to be a hostile abdomen. Can you do the procedure going through behind the main abdominal cavity and do it still in a minimally invasive fashion as opposed to an open surgery. Can we find ways to do even the most complex of patients minimally invasive and we’re seeing that. I mean we’re already using this tool for those sorts of approaches. I think it’s not only just reducing the number of holes that we make in patients and reducing the convalescence time it’s also trying to evolve surgery in terms of minimally invasive approaches. How do we do it. How do we access the areas we need to access and can we do it in a way that’s less invasive.
Are there any precautions that patients should take afterwards?
NIX: The typical complications you would see of a single port are similar to a multi port operation. The patient must be informed about what they’re getting into. Informed consent is always a big deal no matter what it is. And we’re very careful of letting them know we’ve just started doing this so that they understand our experience with these types of procedures but again we’ve had great success and I think the tool itself is very similar to the tools we’ve used before. For the surgeon it’s not a dramatically different experience in terms of how they do the procedures. And again we’re trying to mimic exactly what you would be doing if you were doing an open surgery just doing it with less morbid approach.
Is there anything else you think people should know about this?
NIX: It isn’t about having the newest tool or the newest gadget or the newest toy out in the market. We’re aiming, in terms of minimally invasive surgery that we want to continue to evolve that in a patient centric way how we look at our outcomes. So things that mattered to docs for a long time have been cure. We’re talking about cancer which is what I do cure and the complication rates traditionally in terms of blood clots and rebounds to the hospital. The patients also care about these but also other factors that are very important to them. Time to get back to work. Time to get back to their normal activities if it’s the matriarch of the family who takes care of the kids or works 2 jobs. How long does it take them to be able to get back to those types of things. When you look at patient centered outcomes they care a lot about that. And so it matters. It should matter to us too and so we’re evolving how we look at our outcomes in terms of these variables that are important to patients. This is just showing you that evolution of surgery is less invasive not more invasive. It absolutely does. Holding true to the same cancer principles that have always been true.
Is there advantage before minimally invasive surgery, you did it open. How long did that patient stay in the hospital?
NIX: We’re talking. It just depends on what surgery we’re talking about. So if we’re talking about a retroperitoneal lymph node dissection for testicular cancer, we can do that minimally invasively now. They were in the hospital for three to five days when we did them open. Now they go home in one day. There are other prostate cancer patients in an open prostatectomy who might go home in two days whereas we’re talking about now sending them home same day. There is an evolution about and again these as we get better at this the scale will be smaller in terms of the progression. But it’s all about the end result the end goal which is a continuous and constant evolution.
END OF INTERVIEW
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