New Frontiers: Robotic Surgery Program at UAB
UAB surgeons are pioneering procedures for robotic surgery for head-and-neck, lung, and other cancers to help push the technology far beyond its original emphasis on prostate cancer. In the process, UAB has become one of the busiest, most diverse, and most comprehensive robotic surgery programs in the nation with more than 20 surgeons in nine specialties performing more than 900 surgeries annually.
Of the surgeries at UAB, fully 75 percent are oncologic.
In this exciting segment, Dr. John R. Porterfield joins the show to share how UAB is setting new surgical standards and pushing the robotic surgery platform into previously untouched frontiers in a variety of fields.
For more information about our Surgical Training Programs, explore the webpages below.
General Surgery Residency – www.uab.edu/medicine/surgery/education/residents/gsr
OBGYN Residency - www.uab.edu/medicine/obgynresidency/
Urology Residency - www.uab.edu/medicine/urology/education
Otolaryngology, Head & Neck Surgery Residency - www.uab.edu/medicine/otolaryngology/education/residency
John R. Porterfield Jr., MD
John R. Porterfield Jr., MD, joined the UAB Department of Surgery in 2008, returning to Alabama, his home state, after training at the Mayo Clinic. He has since achieved associate professorship and additionally serves as director of the General Surgery Residency Program. A skilled instructor, with a gift for teaching, he has won numerous awards including several UAB Faculty Teacher of the Year awards.Learn more about John R. Porterfield Jr., MD
Dr. Porterfield has the following financial relationships with commercial interests:
Intuitive Surgical, Inc. - Consulting Fee
Dr. Porterfield does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Melanie Cole (Host): UAB MedCast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category One credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Our topic today is robotic surgery, often heralded as the new revolution and one of the most talked about subjects in surgery today. My guest today is Dr. John Porterfield. He’s associate professor and the director of General Surgery Residency Program at UAB Medicine. Welcome to the show, Dr. Porterfield. Explain a little bit about the robotic surgery program at UAB, and what’s the evolution of it?
Dr. John R. Porterfield Jr., MD (Guest): Good morning, Melanie. Thanks for having me. It’s so easy to talk about the Robotic Surgery Program at UAB because we’ve been able to be right on the ground level as this has developed particularly in general surgery, and that story really began in 2011 whenever one of our thoracic surgeons was doing a lot of robotic thoracic surgery, and we needed an opportunity for our residents to be able to train before they got to thoracic surgery and that was whenever we built our first robotic surgical curriculum to train our residents in the techniques for robotic surgery, which we saw as the future.
Melanie: So, what types of conditions, and before we talk a little bit about the education and training, what types of conditions are you using it for and where do you see it being used as it’s increasing in use?
Dr. Porterfield: So, we use it at UAB everywhere from transoral surgery, surgery in the chest, as well as surgery in the abdomen and pelvis. So, we use it in almost every field now. Where I particularly use it is in relation to the surgical approach to adrenal tumors as well as in more straightforward conditions affecting the gallbladder, inguinal hernias, like groin hernias and ventral hernias.
Melanie: Do you feel Dr. Porterfield that robotic surgery’s still in its infancy, and its niche hasn’t been well defined yet?
Dr. Porterfield: Well, I think that’s where we were a couple of years ago, but I think that now, I think, it really has, it has found its niche, particularly in the abdomen and chest, and I think what’s in its infancy is how we’re applying it to some transoral-type approaches and those type of things, but I think it has really come into its own now, particularly with the adoption by general surgeons and application to more common procedures. I think surgeons are finding that they can do things robotically more efficiently and more safely than they could have done it laparoscopically in the past.
Melanie: So, I’m not going to ask you about advantages for patients because we know those, we hear about those, you know, shorter recovery time, all of those sorts of things, but what about advantages to you surgeons as far as the learning curve and the position that you are in when you’re using this equipment?
Dr. Porterfield: I think it’s a great point. You know, as the residency program director, I’m keenly interested in the learning curves of all aspects of surgery because I’ve got to take these 26-year-old surgeons, and our faculty train them through, you know, through five years, and so we watch every procedure as far as how quickly they adopt it. The robotic surgical platform, number one is very comfortable because you’re seated at a computer console with your face resting against a computer looking at two monitors, one with each eye, which gives you 3D vision, and it’s very adjustable. Sometimes during cases, even I will move it just so that I can be in a little different position, but it allows you to sit in a much more comfortable position. I think that’s really important.
Also, as far as the learning curve because we have a simulation module, a computer program built into the console that you sit at so that you can practice and get used to the console. So that once the residents are proficient with using the console, how it manipulates the robotic instruments, it’s much easier for them to transition between different types of cases because they’re sitting in the same place. They’re looking at the same thing, and they are manipulating the exact same instruments regardless of whether it’s a needle driver that’s inside the patient, whether it’s a grasper, whether it’s a pair of scissors, whether it’s a stapler, a suction device, what they’re actually touching with their hands is the exact same thing every time.
Melanie: Wow. That’s fascinating. Now, so as far as position, learning curve, education, those are all great things, what about some disadvantages? Do you see any? Is it difficult for some people—maybe vision-wise or is there voice control? Speak about some of what you might perceive as some disadvantages, including cost of equipment.
Dr. Porterfield: Yeah. I think that cost is always an issue as we adopt a new technology, and Intuitive Surgical, the company that makes the da Vinci robot that we use, has been very sensitive to that as institutions have adopted it, and as entire groups such as urology or gynecology and now general surgery have adopted it. So, cost is always an issue as we adopt new technology, but I think what’s probably a bigger concern or is more difficult for surgeons is just availability of the robot because it is a large capital investment, and it is a limited resource in most facilities such that it can be difficult to start a robotic surgical practice if the robot is already being heavily utilized by other divisions and departments. I think that’s probably one of the hardest things to starting a practice. Once you’re established, I think it actually flows pretty seamlessly.
Melanie: What a good point because if it is being used by other service lines, you know, then it’s difficult to get that initiated and get it going. Is there a stand-out case that you’ve been involved in? Can you tell us something interesting about a particular case or diagnosis?
Dr. Porterfield: Yeah, I think one of the cases that comes to mind that was really an “aha” moment for me was within the first 25 robotic single incision cholecystectomy procedures, and I’ve done hundreds of them now, but as I was doing one of the ones in the first early phase of my learning curve, I came upon a mass that was right at the infundibular cystic duct junction that was involving the cystic artery lymph node, and had I been doing this laparoscopically, the board answer and the kind of the next best step at that point would have probably been to either have stopped or to have opened and performed an open procedure on that patient, but because of the additional technical ability of the robot from a precision standpoint and from a quality of vision standpoint, I just kept doing the next best step that I would have done if I had made an open incision. And before we knew it, we had isolated all of the structures in the hepatoduodenal ligament that we needed to see. We were able to divide the structures, completing an oncologically safe operation for this tumor, exactly how we would have done it open, and we were then able to reconstruct that patient’s biliary tree in an identical fashion to how we would have done it open, and at the end of the procedure, we removed the specimen. We realized that we had done that through one 2-cm incision at the belly button, which I could never have done laparoscopically, and I think would have even been more challenging open, but yet it occurred even early in my learning curve. So long as, you know, we just took the right next step, very methodical, very safe, could see everything we needed to see, and it really—that was really a kind of a catalyst moment for me to move over to think, wow, I can’t plan for when I need the robot because there are unexpected things in cases that come up, and I can tell you, case after case, there are opportunities that I’ve been able to do something technically robotically that I would not have been able to do laparoscopically that I think has really benefited our patients.
Melanie: That’s very cool. What are you doing at UAB—via treatments or research that other physicians might not be aware of and what does current research indicate for future developments? Give us a little blueprint.
Dr. Porterfield: Yeah. So, I guess the biggest thing that we’re doing at UAB is how we’re involving our surgical residents in robotic cases during their first year of training such that when they come out, they are fully trained. So, if physicians are hiring our alumni that are coming straight out, they don’t need an additional fellowship to be fully trained in the techniques of robotic surgery. That’s really unique. There’s four or five programs across the country right now that can boast that. Many of which I’ve been able to collaborate with our curriculum, and the blueprint for the future for general surgery is for us to roll that out to all of the 250 plus general surgery residency programs so that they will be up to that same level. From a physician standpoint, if there’s a procedure that appears complicated, and it appears as it may need to be done open, I’ve really appreciated the phone calls from physicians all across the country to be able to just ask and send me a CT scan and for us to look at it and say, do you think this is something that ya’ll could do robotically? And we can’t do everything, but we’ve really been impressed with how we’re not limited by sizes of tumors, like we might have been in the laparoscopic era, and our reconstructive abilities with having everyone from urologists and gynecologists as well as our transplant surgeons, our hepatobiliary surgeons. To be able to have so many expert surgeons trained on the robot and trained in those techniques that we can work together with multiple different service lines on the same case, and we’ve been able to have some surprisingly successful cases that others might have thought, there’s no way we could have done this robotically.
Melanie: In summary, tell us a little bit about your team, and why UAB is so great to work for.
Dr. Porterfield: Yeah, so, we really are—I really do feel blessed to be surrounded by a team that I’ve worked with for 9 years, and I really am appreciative from the administration’s wisdom of allowing teams to be built. Because particularly with robotic surgery, being able to come into the OR and see the same people every day that are draping and positioning the robot and handing us instruments and standing at the bedside, our advanced-practice providers that work with us in these cases are second to none, and so it makes it so comfortable to come in knowing that I’m going to see the same people. They’re going to be greeting my patients the same way, and they’re going to be able to provide that really expert level of care at the bedside, at the head of the bed with our anesthesiologist. It’s really nice, and as I talk to my colleagues across the country, I think that’s one of the things that I realized that is such a huge benefit here that not every surgeon gets to enjoy that luxury of walking in to see the same team every day.
Melanie: Thank you so much, Dr. Porterfield, for such a great segment and really great information. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.