Minimally invasive is currently a buzz phrase in the medical field.
New technology, groundbreaking operations and improved equipment allow patients to see minimally invasive incisions during surgery, quicker recovery time and direct contact with leading specialists in the comfort of their hometown clinic or hospital.
Jefferson City’s three leading health systems are not only following suit; they are leading the way with these technological medical advances in central Missouri and the state. Learn about the new da Vinci robotic surgical system at Capital Region Medical Center, the Lapiplasty procedure to correctly fix bunions at JCMG and SSM Health Mid-Missouri’s telehealth equipment that allows patients to connect with specialists miles away.
Minimally Invasive With da Vinci at CRMC
The da Vinci surgical system became the first robotic-assisted surgical system cleared by the FDA for general laparoscopic surgery in 2000, and other central Missouri hospitals have used it for a variety of operations.
Dr. Teri Deffenbaugh, a obstetrician at Capital Regional Medical Center since 1997, became the first gynecologist to be certified in offering advanced laparoscopy and laparoscopic techniques using the da Vinci robot in Jefferson City. She performed surgeries with the equipment at University of Missouri Women’s and Children’s Hospital in Columbia, long before CRMC starting using its own da Vinci surgical system in June 2017.
The system has been used for minimally invasive procedures in specialties including urology, general surgery such as hernia repair, thoracic surgery, cardiac surgery and gynecology, most of which are performed at Capital Regional Medical Center.
“We use this in about every specialty we have,” Deffenbaugh said. “It used to be we were trained for open surgery. It had to be big enough to get your hand through and look around. However, everything is evolving to minimally invasive. Instead of using our hands, we are using tools that make small incisions. … The da Vinci is the next big thing on the horizon for that.”
During a da Vinci robotic-assisted surgical procedure, the surgeon sits on a console while viewing a high-definition, 3D image of the patient’s target anatomy, according to the company website of the da Vinci surgical system’s creator Intuitive Surgical, Inc. The surgeon’s hand, wrist and finger movements are made at the console, outside of the surgical field, and translated into real-time movement of surgical instruments attached to three to four robotic arms, the website said.
“It is more like a video game. It is not a joystick, but your thumb and your finger are doing all the manipulation,” she said. “Dexterity is the big thing. We can get to it quicker, easier and with less pain for the patient.”
Deffenbaugh said the da Vinci microscopic equipment can go at angles, which allows her to work around objects without additional ports needed for the surgery. Deffenbaugh takes out ovaries, performs hysterectomies and uterus suspension, and looks for endometriosis using the robotic-assisted surgical system.
“There is a special dye that will light up bits of endometriosis, and the da Vinci allows us to see them even better,” she said. “With suspensions, you can do the surgery vaginally but you can also do it laparoscopically. The da Vinci makes that one a little easier. You can see ovarian cysts better with the 3D camera. The visualization is very good.”
With many advances for the surgeon, the da Vinci surgical system also provides additional benefits beyond small incisions and targeted accuracy. Hospital stays are shortened, blood clots and recovery time are reduced, and pain control is heightened.
Deffenbaugh said an open hysterectomy could leave the patient with a six- to eight-week recovery period. With the da Vinci surgical system, they are often back to work in a week with lifting restrictions.
“If they want to go back to work that soon,” she said with a laugh. “The other bonus is the da Vinci instrumentation creates a reduced need for narcotics. In fact, five of my patients didn’t even use them in the hospital. … When the port goes in, it rotates without torquing or bending. The instrument is able to make that turn without pushing on them. I was pleasantly surprised during post-op that there was less pain for the patient. I would send them home with Motrin and sometimes give them something more, but most of them came back with the prescription, not even using it.”
Deffenbaugh has done more than 15 surgeries using the da Vinci surgical system since it arrived at CRMC. She is appreciative that Dr. Carl Doerhoff, a general surgeon with Capital Region Physicians-Surgicare, was a champion to help bring the da Vinci equipment to the health system.
Even though her surgical procedures have all been done laparoscopically in the last 10 years, she said the added tool on the right people allows her to get the surgery done in a shorter window, with less recovery time and discomfort for her patient.
“The big thing I tell patients is just because their mom had a big incision doesn’t mean you need one. There are still some that expect that, and we let them know there are other ways to do it,” she said. “The difference from recovery and pain, this hysterectomy (with the da Vinci surgical system) is the best type and simplest type out there. The direction should be and is moving toward minimally invasive.”
JMCG Brings the First and Best Bunion Procedure to Missouri
About 330,000 bunion surgeries take place in the United States each year. However, there are no standard, systematic approaches to correcting the bone prominence and enlargement of the great toe joint (first metatarsal phalangeal joint). This results in drifting of the big toe that causes irregularity, limited motion and even permanent deformation if not treated.
Dr. Jody McAleer, a podiatrist at JCMG, said surgeon experience, training and preference has driven procedure selection, and traditional surgical procedures do not always address the triplane nature of bunions, which can often lead to recurrence.
“The traditional procedure is essentially the fusion of the first metatarsal joint. We would accompany that by shaving the bump on the side of the foot,” McAleer said, noting multiple incisions are used and only corrects two planes. “This is something (JCMG podiatrist and colleague Dr. William Duke) and myself have been trained on and has been around for many, many years.”
McAleer’s colleague then introduced him to Treace Medical’s Lapiplasty procedure. The Florida-based company developed the Lapiplasty that provides benefits of a standard reproducible surgical approach, achieves triplanar correction and supports immediate weight bearing for mild, moderate and severe bunion deformities, McAleer said.
“A doctor in Iowa, Paul Dayton, was working on this concept where you are correcting three planes and not two. … That is what this system does, corrects in three planes with specialized instrumentation,” McAleer said.
Those instruments are designed to manipulate and reduce the bunion prior to making the initial bone cuts. It allows for minimal bone removal, which nearly eliminates the rest of significant bone shortening, McAleer said. It also uses a biplane plate fixation on the correction site, which makes immediate weight bearing possible, he said.
“Before with the traditional approach you weren’t able to walk on the foot for approximately six weeks, using crutches or a knee scooter and then a walking boot for six weeks. You had a 12-week recovery process, which was very inconvenient for the patient,” Dr. Duke said. “With the new system and its technique, it allows the patient to bear weight, using a walking boot for six weeks.”
In working with Treace Medical, McAleer was able to bring it to JCMG, making the health system the first to perform this procedure in Missouri. He and Duke have now done more than 50 Lapiplasty procedures at JCMG since they started offering the operation in April 2017. Duke and McAleer said Lapiplasty is not just for women, many men have the same problem with bunions, which is genetic like the vast majority of foot problems.
“Men will say this hurts so I’m going to wear my sneakers or comfy dress shoes,” McAleer said. “Men’s shoes are naturally more comfortable and the shoe options for ladies tend to be very narrow, which leads them to suffer more.”
“Most of the guys I’ve seen with bunions are really bad. They have a big jump on the side of their foot. We can do things ourselves to exacerbate that problem; wearing certain shoes or constantly doing activities that put more pressure on that area,” Duke added. “People come in also depending on their pain threshold. What really bothers you may not affect someone else. … Guys in labor-based jobs also don’t tend to complain about pain as much, concentrating on their back, wrist or other areas that hurt them.”
With Lapiplasty, the three-step process ensures the bunion is corrected without chance of recurrence, Duke and McAleer said. The positioner tool is engineered to quickly close the angle and de-rotate the metatarsal to establish and hold true alignment of the metatarsal and sesamoids in the foot, according to Treace Medical’s website. Doctors like Duke and McAleer then utilize a Lapiplasty cut guide to make precise, parallel cuts with the metatarsal held in the correct position, ensuring the proper cut and eliminating the risk of metatarsal shortening, the website said. Two very small titanium-based plates are then used to provide stability, using standard-sized locking screws to accommodate anatomic variations without the need for intra-operative measuring.
“That is a question we receive from patients: am I going to feel them and will they need to come out? When the bone is healed, the hardware is superfluous; it doesn’t need to be there anymore,” McAleer said. “But, it is a surgical trauma to go in and remove them. If the patient has no complaints of pain or discomfort then you don’t remove the hardware. … We have had no complaints from patients.”
In late September, Duke and McAleer held a seminar discussing the Lapiplasty surgical procedure for bunions, and one patient spoke about having a traditional bunion surgery on one foot and getting the Lapiplasty procedure done on her other foot.
“She told the whole audience about her experience, how happy she was and how the results on both sides were good, but the overall beginning to end for moving again was much smoother and easier with Lapiplasty,” McAleer said.
Even though patients can immediately bear weight, they do advise patients to wait before doing daily activities until the boot comes off and do more strenuous exercising and sports after three to five months.
Duke and McAleer have seen patients come from as far away as Hannibal and Kansas City for Lapiplasty, willing to drive to get the procedure done.
“We have people say they saw our seminar presentation on Facebook and we’re doing way more to let people know this is the way to get your bunion corrected and fixed,” Duke said.
“Ninety-nine percent of our patients who needed to correct their bunions had this procedure done now, and they have been so happy they had it done,” McAleer said. “The results have been excellent.”
Telehealth Connects SSM HEALTH Patients Directly to Top Specialists at Home
When a telehealth machine was placed in front of a 3-year-old child during a medical visit last fall at SSM Health Pediatrics clinic in Jefferson City, there was no apprehension from the child.
The “robot” sat still, wearing a tie and offering up common tools like a stethoscope and otoscope for the nurse to use. However, the tools were technologically advanced, allowing a specialist at SSM Health Cardinal Glennon Children’s Hospital in St. Louis to see and hear results in real time. His face appeared on a screen as part of the telehealth “robot,” allowing him to see his patient and talk to his parents and clinic staff, with them being able to do the same via a top-quality camera and wifi connection. The 3-year-old found this enhanced form of communication highly entertaining.
“He was trying to hide from the specialist, not realizing the camera could follow him around the room,” said Suzanne Massman, SSM Health Pediatrics clinic manager and nurse practitioner. “The doctor would say, ‘I can still see you’ and the boy would try to hide again. … He just thought it was hilarious.”
SSM Health Cardinal Glennon Children’s Hospital has used telehealth, or telemedicine, the last couple of years, connecting with hospitals in Missouri and Illinois, and some clinics in nearby areas. It is used to deliver inpatient and outpatient care, educate physicians and patients, and even conduct medical research via electronic communications in real time. Beginning in August, they piloted its telehealth program to include SSM Pediatrics Clinic, allowing the same specialists and parents and their children to continue consultations without waiting or traveling long distances.
“We have pulmonology and cardiology specialists that visit from Cardinal Glennon. … They came once a month for a long time but then switched their schedule to every other month. Those schedules were being filled months in advance,” Massman said. “This technology became available and they wanted to use it here. Now, we have telehealth once a month and they come in person the next month. … Currently, the specialist comes to see new patients in person and then follows up with them through telehealth.”
Massman said the telehealth visits are primarily for pulmonology follow-up consultations for children with issues such as chronic asthma or pulmonary disease. However, they are planning to expand those services to include gastrointestinal, dermatology and cardiology in the future. Before the telehealth machine comes into the room, the nurse takes the child’s vital signs, asks about medications, etc. Then, a message is sent to the doctor to let him/her know their staff is ready for the telehealth consultation.
“You hear a little sound and the screen comes on with the specialist now in the room with you,” Massman said, noting the doctor is sitting at his computer during the telehealth visit. “He starts his visit with the parents and the child, asking them how they are feeling, if they needed their inhalers and how often they are still using them, etc.”
Then, the nurse will use the bluetooth stethoscope and/or otoscope, being the hands for the specialist and allowing him to hear the child’s breathing and view the child’s ear, nose and mouth.
“When we were listening to the heart or lungs he can change how he wants to hear it. When I have the stethoscope in my ear, I can hear him changing it to hear it differently. When he talks to the patient, he will turn the camera to them and when he needs to talk to us, he will turn it to face us. It is like he is looking at you at the same time,” Massman said. “The specialist will also look at the child’s fingers, because if they are not getting enough oxygen their fingers will show it. The camera can really zoom in to the fingertips.”
Dr. Jennifer Krause, a pediatrician at SSM Health Pediatrics, said the way the pediatrics clinic is using the telehealth machine is different than how the one at St. Mary’s Hospital will be used, beginning in early 2018. Dr. Theodore Willmore, head of the emergency department at St. Mary’s Hospital, said when a patient is in the ER currently consultants are called to describe an immediate issue over the phone.
“This technology allows us to interact with the specialist in real time, get that second opinion and have visualization of the patient. It is not a phone call,” he said. “They have X-rays, labs, can hear and see what we hear … The only limitation (for the specialist or linked-in doctor) is they can’t physically reach out and touch the patient, but they have real-time access. That is very important for everyone involved.”
Michael Hyde, director of emergency and interventional services at SSM Health of Mid-Missouri, said ER physicians see a higher volume of critical patients, and telehealth will allow an expert to be in the room to help decide if he/she needs to be transferred or help getting that patient the immediate medical help he or she needs.
“Telehealth is the same as having a footprint of a human doctor in the room with our staff,” Hyde said.
That presence is also important in keeping the family together, particularly for mothers and their newborn babies. Leslie Charlton, manager at St. Mary’s Family Birth Center, said often depending on the baby’s cardiac or respiratory diagnosis or situation, it can be sent to Columbia or St. Louis for additional treatment or to be seen by a specialist. The use of telehealth will add another tool for physicians and nurses to use in taking care of sicker babies and keeping moms and babies in Jefferson City.
“It is hard on a mom, who knows their newborn is already not feeling good and then having the baby shipped off. They may be separated for a couple of days,” Charlton said. “The main intent for using it here (at the Family Birth Center) is to keep the family together and take care of the babies that are here.”
Charlton said telehealth can be used for getting a specialist to look at respiratory issues, a possible minor twitch like a blood sugar issue, small seizure or rash or even full-blown resuscitation with extra support in the room using telemedicine.
“It can really run the whole spectrum,” she said.
In fact, SSM Health is also planning to add lactation consultations via telehealth in the near future. Jessica Royston, marketing and communications manager for SSM Health Mid-Missouri, said the health system already offers lactation consults as a free service to all mothers who deliver there.
“We have a certified lactation consultant on staff and she will be able to do these with this new technology so that moms don’t have to travel to the hospital to meet with her. They can do it in the comfort of their home,” she said. “This is especially helpful for moms who don’t live very close to the hospital but are having issues breastfeeding.”
The importance of telehealth in the ER, at the Family Birth Center or at the pediatrics clinic is to allow patients to see a specialist without traveling a long distance and ultimately improve a patient’s clinical health status more immediately. The reaction to the machine is a hit with the children, a pleasant surprise and relief for parents, and a needed tool for physicians.
“It takes two hours to get here and two hours back home. That is about eight patient visits they can fit in that time frame. It is a more efficient use of their time to visit with patients electronically through telehealth,” Krause said. “It can also be stressful for a parent on top of having a sick kid to travel to see a specialist. They don’t have to take off a half day or full day from work and pull the kids out of school. They can visit with them right here close to home.”
For more information about telehealth, visit ssmhealth.com/cardinal-glennon/pediatric-telemedicine. For more information about SSM Health Mid-Missouri, visit ssmhealthmidmo.com.