Look, Ma, No Hands

Like many women in the early stages of a pregnancy, Mary Bridgeman was accustomed to occasional bouts of nausea. But she wasn’t prepared for the stomachache that subdued her last September following a rich dinner. The pain was so severe that she landed in the emergency room. This wasn’t her first episode of gastric distress. Her symptoms went back to Easter, always occurring after heavy meals. The pain sometimes lasted a week.

Bridgeman PHARM’06—a clinical assistant professor in the Department of Pharmacy Practice and Administration at Rutgers Ernest Mario School of Pharmacy and a pharmacist at Robert Wood Johnson University Hospital (RWJUH)—was diagnosed with biliary colic, the term used to describe abdominal pain resulting from a diseased gallbladder, frequently caused by gallstones. She was advised to have her gallbladder removed despite her pregnancy, and her obstetrician referred her to Tomer Davidov, an assistant professor of surgery at Rutgers Robert Wood Johnson Medical School. He recommended a single-incision robotic cholecystectomy, or gallbladder removal, a minimally invasive, near-scarless procedure.

Until the 1990s, gallbladder surgery required a large open incision and a hospital stay of several days. In the 1990s, the procedure, still widely used, became laparoscopic, requiring only four small keyhole incisions for pencil-like instruments, resulting in a faster recovery. In 2011, the Food and Drug Ad­ministration (FDA) approved new technology that allows surgeons to perform this operation as a same-day procedure with a single incision in the navel with little scarring. The surgeon sits at a computer terminal, operating a robot to guide the tools. The technology was approved by the FDA in 2000, but only recently has it been approved for single-incision gallbladder surgery. RWJUH is one of the few hospitals in New Jersey offering this procedure.

Davidov, a self-described “serial inventor” who has devised methods for improving surgical instruments, has embraced the robotic systems, which have become a game changer for surgery. “The first robots were used primarily for prostate and gynecological cancer surgery,” he says. “The newest technology has broader applications, magnifying everything 10 times and in 3D. The instruments move precisely, without a hint of human tremor. New optical technologies allow the surgeon to see anatomy that cannot be seen with the naked eye. Patients benefit from imperceptible scarring, little or no pain, and a fast recovery.”

Biliary colic is not uncommon among women in their 30s and 40s, often mis­taken for heartburn when the cause is gallstones. A polyp in Bridgeman’s gallbladder was the culprit. “These polyps are almost always benign but need to be investigated,” says Davidov, pointing out that biliary colic can affect pregnancy. “Some studies show a fetal loss rate as high as 10 percent,” he says, “while the chance of fetal loss during surgery is 1 percent.” Bridgeman and her obstetrician opted for gallbladder removal.

The surgery was performed under general anesthesia, at the beginning of Bridgeman’s second trimester. Davidov made an incision in her navel and inserted the port, a small plastic tube flanged at each end. The port can accommodate three instruments and the tiny camera. He sat at the computer console, his voice amplified for everyone in the operating room to hear. He grasped the plum-sized gallbladder with an instrument called a crocodile clamp and gently removed it from the liver with a miniaturized cauterizer. He placed the gallbladder into a small plastic bag threaded through the port and extracted it.

The patient typically goes home the same day, but because of her pregnancy, Bridgeman spent the night in the hospital. Her pain medication options were limited: “I usually use a local anesthetic, which lasts for three days and makes the procedure virtually pain-free,” says Davidov. “But it hasn’t been tested in pregnancy, so we couldn’t use it.” Bridgeman was back at work in a few days, having experienced minimal pain, she says.

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Tomer Davidov and Susannah Wise are two of the four members of the Department of Surgery at Rutgers Robert Wood Johnson Medical School who are trained to perform robotic general, gallbladder, and colorectal surgery procedures.

Photography: 

John Emerson

Davidov is one of four members of the RWJMS Department of Surgery trained to perform robotic general, gallbladder, and colorectal surgery procedures. The others are assistant professors Craig Rezac, Nell Maloney Patel, and Susannah Wise. Wise NJMS’97 has also developed her own single-port gallbladder procedure, using newer laparoscopic instruments that do not require the robot’s services. She performed the first one three years ago and has done more than 200 cases.

“The robot is a phenomenal machine for many complex procedures, but I prefer my single-port procedure for gallbladder surgery,” she says. She makes a small incision in the navel, about 2 centimeters. It fits a port that holds a few long, thin tools and a camera, which is linked to a computer for visualization only. Wise operates the instruments manually rather than with a robot’s assistance.

“You’re sometimes working at a difficult angle, so this procedure requires a skill set that not all surgeons have,” says Wise. “I’m very comfortable with the procedure. There is only a tiny scar hidden in the belly button and very little trauma, and the recovery time is the same as for the robotic procedure.” Scheduling is another reason: “The robot is often in use. My procedure is easier to schedule.”

Davidov says that right now the robotic system is good for many, but not all, surgical procedures, working well for operations that require delicate movements in small areas. “We would not use it for large orthopedic procedures or emergency trauma surgeries, for example,” he says. “But this technology is here to stay. Much like the original computers of the 1970s, it will become miniaturized and far more powerful. I suspect we will see significant improvements in robotic surgery that will make many operations easier and safer.”