Cheryl Martin (Host): This is St. Joseph's Health Med Cast. I'm Cheryl Martin. A team of surgeons is leading the way here in Central New York with cutting edge technology that allows complex procedures to be performed through a single small incision. It's called the Da Vinci SP Single Port Robotic Surgical System. Dr. Po Lam is part of that team.

He's a nationally recognized urologist and robotic surgeon affiliated with St. Joseph's Health and Associated Medical Professionals of New York. He's here to tell us all about this minimum invasive but maximum effective robotic surgery. Dr. Lam, so glad to have you on.

Po N Lam, MD: Oh, hi Cheryl. Thank you for having me. Yeah. I'm excited about talking to you about the SP surgical system today.

Host: So am I. So right off, what is the Da Vinci SP Robotic Surgery and how is it different from traditional multiport robotic surgery?

Po N Lam, MD: Well, the SP surgical system is made by Intuitive. It's same as the multiport, part of the Da Vinci Surgical System platform. The difference is that the technology of the SP is well beyond the multiport. The multiport as the name would signify, it requires multiple different sites and different incisions into the body for the robot to enter and perform surgery. With the single port, the incision required is a small, single incision allowing the multiple robotic arms for the camera as well as the working arms for grasping, cutting, and cauterizing and manipulation, could all fit into a small opening that's about an inch, I'd say about an inch in diameter. Typically the other ports are anywhere from eight millimeter to 12 millimeters.

So they're able to use all the instruments into a single port. Instead of a rigid or a straight instrument, all these instruments are flexible and are able to have multiple degree of freedom of movement of which they can angle and open up.

So the analogy would be going in like an umbrella and then all the instruments will open up like an umbrella and then be able to spread out and use those instruments to perform surgery. So the advancement is that one, that's smaller and single entry point. But then once you're inside, these instruments are flexible and they have arms that move and bend very similar to an octopus arm, that can then come together or spread out and allow you to manipulate and perform surgery.

Host: So what types of procedures have you performed with it, and what was your experience like?

Po N Lam, MD: Well as a urologist in the single port system, the SP system where it was initially approved for a use by the urologists. And of course the ENT doctors, if you can imagine having a single port that's small, that can fit into someone's mouth or throat would be ideal. And for urologists, which is on the opposite end of the world, it allows us to get into a small area in the pelvis. Of course for things that I use it mostly for is robotic prostatectomy to remove prostate for cancer and also to remove portion of the prostate for what we call BPH or an enlarged prostate. And because it's a single port and it's a small single port, I can go below the belly button or into the bladder to remove the prostate tissue. In addition, I've been able to use mostly urological surgeries because as a urologist for removing kidney cancers or kidney masses, fixing the kidney for congenital strictures or strictures or injuries to the ureter. I also have been using it to remove the adrenal gland, which is next to the kidney for adrenal masses and cancers.

And in addition to that, I've been able to remove larger organs, also urological, such as the bladder for bladder cancer and doing a reconstruction for that such as a urinary diversion. And finally other urological functions I've used it for are female patients who've had either a ureteral injury from a gynecological procedure or cancer and have been able to fix the ureter by reimplanting it back into the bladder.

And then another female application, a female patient application is what's called vaginal prolapse. There are patients who've had a hysterectomy or have a condition where their vagina prolapses and basically internal organs such as the intestine will fall through and pushes through the vagina coming out of the vagina or the bladder falling into the vagina, and then coming out of the vagina.

 And so one of the procedures called sacrocolpopexy, where we go in or I go in to pull the vagina back into its normal orientation and prevent these things from falling through. The analogy to that is if you have a tarp or a tent and rain water or things come through the tent and it gets all droopy, and what I do is I go back, I go in using the single port, go into the abdomen or not in the area where the vagina would be, and pull all of those supporting structures back so that you tighten up the tent and the tarp so that nothing is falling through. If you can imagine that and that's caused sacrocolpopexy. I do that especially for women who've had previous abdominal surgeries with a lot of scar tissue that are high risk for injuries to the bowel or because of the scar tissue and adhesions, you don't want to get into that space. And with a single port, you can go in through a different space called a retroperitoneal space to fix that type of vaginal prolapse. And so, it's been very helpful for women who cannot usually have a straightforward, or what would they call the routine sacrocolpopexy and the single port has allowed me to take care of patients with those problems.

Host: That's great. Now, how has this single incision approach benefited patients in terms of pain and recovery times?

Po N Lam, MD: With less incision and smaller to less incision, of course, if you only have one incision, but this is a, a foot long, it'd be just as painful as multiple incisions. But with the advent of the SP, the single incision is relatively small, as I said before, about an inch or so. And so patients typically have less pain after surgery. With the multiport, you're looking at on my typical urological surgeries, anywhere from three to six separate incisions. With the single port, often you're only using one port and sometimes you need the second port for certain surgeries and assistant port for things.

But regardless of that, going down from five to six incision down to one to two incision, definitely has the added advantage of decreased pain, quicker recovery. And also, of course better cosmesis. Yeah, less incision. You look better. Better scarring. Better healing.

Host: And you touched on this before, but if you can go into more detail about how this technology enhances your ability as a surgeon, for example, what can you do now that wasn't possible before?

Po N Lam, MD: So one of the big advantages of the single port aside from the cosmetic effect of having one single port or even the less incision being allowing patients to be to recover faster and having less pain. The single port technology and the platform allows me now to get into spaces I couldn't get before.

 I'm no longer limited in trying to get to a small area by making sure I have enough room to put four or five different holes. I can make one incision, and through that incision because of the adaptive nature of the robotic arms and the camera, which is a telescoping camera that can angle left, right, up and down; I'm able to dissect and get into a space which I was not able to get before, without creating that space. So instead of having to have a large space to put the instruments in to then do surgeries, now I can make a small incision and whatever small space I have, using these instruments and using the camera, I'm able to create a larger space, a working space at which I can get in.

Host: That's great. Now, how do you think innovations like the SP system will shape patient care over the next decade?

Po N Lam, MD: I think is that it will challenge the Surgeons to rethink how they do surgery, meaning we don't have to have a large space or occupy a large space. I think what's going to happen is that we're going to change our ideas of doing surgery to what I would call regionalized surgery, meaning you find a region of which you can perform the surgery and then focus on that region, then move on to a separate region adjacent to it and from there, starting at a small space, working into a bigger space to develop. So you don't have to look at the whole, the whole system or the whole room, but you start at one corner.

And then be able to address and build the whole house or the whole room starting at one corner or one small space. It regionalizes the surgery, allows people and surgeons to realize that any small space that you can get into or at least develop, you can do a surgery. And I see that this happening with of course, as I mentioned before, ENT or the ears, nose and throat surgeries are easily accommodated by patients being able to have this surgery going through their throat or their mouth instead of cutting open the jaw or cutting open the neck to get into that type of surgery. So, it'll be much less invasive. And then the opposite end, the colorectal surgeons are able now to go through the anus, which is a small opening, which is about an inch of which you can put all these instruments in.

And not only are the instruments now flexible in which you can go around corners and go up in, in the tunnel system of the colon and instead of using the straight instruments that, which wouldn't accommodate the tubular anatomy of a colon. I think this will allow not only the urologist, but colorectal surgeons as well as ENT surgeons and going forward will be general surgeons, GYN surgeons. All the surgeons will be able to utilize this technology for their space within the body for surgery.

Host: So you've outlined a lot of surgeries that can utilize SP, any that you've missed in terms of the type of patients who can benefit from this type of robotic surgery? I know you mentioned kidney, bladder, prostate, ENT, colorectal, any others?

Po N Lam, MD: Oh, yes, yes. One fascinating one, which I'm not that type of surgeon, but there are breast surgeons and we call nipple sparing mastectomies. This is still experimental or clinical research. There are still development in this, but there has been great progress in which for certain patients, a mastectomy, meaning a removal of breast tissue for cancer can be performed through an incision around the axilla or the armpit going in with this robot through one small incision into the armpit or axilla.

Then into underneath the breast tissue and removing the tumor and all at the same time sparing the nipples so that way the innervation and the sensation of the nipples are still preserved. I know that for a lot of women who have breast cancer and undergo breast surgery, nipple sparing is not usually able to be performed and there are a lot of complications or comorbidity from it.

But I think in the future as the single port SP surgeries develop and the development of nipple sparing mastectomies are fine tuned and better studied, I think a lot of patients can benefit from this type of surgery and this technology.

Host: Dr. Po Lam, thanks so much. You have educated us on the option of this minor invasive or minimum invasive SP robotic surgery for certain procedures, and you gave us great analogies as well. Thank you so much.

Po N Lam, MD: Yes. I like to add that, a lot of these procedures are still being evaluated and being approved for the FDA. So some of the things I've talked about are still under clinical research or IRB protocol and experimentation. They may not be a, you know, completely FDA approved yet, but I think in the future developments and fine tuning of all these surgical techniques will show some progress in the surgical world.

Host: Thank you so much for giving us your time. Thank you.

Po N Lam, MD: Okay. Thank you.

Host: If you are a patient interested in this option, please talk to your physician to see if you are a candidate for the SP robotic surgery. If you found this podcast helpful, please tell others about it and share it on your social media. You can check out our entire podcast library for other topics of interest to you.

Thanks for listening to St. Joseph's Health Med Cast.