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Knoxville, TN

More and more these days, Dr. Michael Fields is taking a hands-off approach to surgery.

Since he began using it in 2006, Fields, an obstetrician/gynecologist at St. Mary's Medical Center, has been one of the da Vinci surgical robot's biggest proponents. He quickly adjusted to the console that allows a surgeon, via a joystick-and-magnified-view-screen system, to manipulate various surgical instruments mounted on robot arms inside small spaces. He touted the advantages of needing only 1- to 2-centimeter incisions for many surgeries: less blood loss, less chance of infection, weeks knocked off of recovery time.

By the end of 2009, Fields had performed more than 400 of the robot-assisted surgeries, including the first hysterectomy in the nation using a new laser-robotic tool. He believes the robot has rendered open surgery in his specialty all but obsolete, necessary in just a "fraction of a percent" of cases.

Now he's ready to give a hand to others who want to learn robot-assisted surgery.

Last month, St. Mary's became the only hospital in Tennessee to be named a Robotic Epicenter for training physicians in robot-assisted gynecological surgery. Mercy Health Partners, which owns the hospital, spent $2.1 million for an upgraded teaching model robot, with two control consoles. It was used for the first time with three Dec. 15 cases.

"The guest physician can sit at the second console and look, with 3-D vision, at what I'm doing" during a procedure, Fields said. "This learning technique is very visual because you don't have touch feedback with the robot" as a surgeon using his hands during an open surgery would.

Fields, who has already trained some area surgeons on robot-assisted procedures, now will train physicians from around the country at St. Mary's, traveling to their hospitals afterward to proctor their first robot surgeries. He expects colleagues Dr. Chris Ramsey, a urologist, and Dr. Thomas Pollard, a cardiothoracic surgeon, both of whom use the robot frequently, to do some training in their specialties as well.

New 'standard of care'

Knoxville's first da Vinci robot was put into use at Fort Sanders Regional Medical Center in 2005 after staff urologist Dr. Jeff Flickinger saw one elsewhere and returned to tell his employer that he was sure a Knoxville hospital would get one soon, and he hoped it was Fort Sanders.

"I think people got pretty excited right away," said urologist Dr. Edward Tieng, who said Fort Sanders surgeons were already doing a lot of laparoscopic surgeries, but the robot "kind of takes it to a whole new level."

Tieng said Fort Sanders urologists use the robot for about 95 percent of prostectomies, and doctors there keep finding new uses for it.

Doctors at sister Covenant Health hospital Parkwest Medical Center also have access to the robot. Three years later, Methodist Medical Center at Oak Ridge had its own, the money partially raised in a hospital foundation campaign.

The robot, introduced in 2000 by Intuitive Surgical Inc., has become almost a standard of care in America, with the majority of large hospital systems boasting at least one. Three hospitals each in Chattanooga and Nashville have it. In 2007, University of Tennessee Medical Center bought a robot, which is used for heart, prostate and gynecological surgeries. The hospital recently recruited gynecologic oncologist Dr. Larry Kilgore, a Knoxville native who practiced at the University of Alabama-Birmingham for the past 20 years, in part because of his skill using the robot for gynecologic cancer surgeries.

And doctors at Baptist West succeeded late last year in convincing Mercy to invest in a robot for that hospital. Installed a few weeks ago, the robot will be used for urologic and gynecologic procedures beginning Jan. 27.

"My (robotic surgery) patients have seen great outcomes with less pain and discomfort in the recovery period," said urologist Dr. Christopher Harris, who has used the da Vinci robot at other hospitals and is scheduled to perform Baptist West's first robot-assisted procedure - removal of a prostate gland. "Now it is great to be able to offer them this service at Baptist Hospital West."

A monitor shows the robotic tools of the da Vinci surgical system operating on a patient in an operating room.

Mercy Hospital gynecologist Dr. Michael Fields has been a staunch advocate for robot surgery in the Knoxville area and has now been selected as a trainer for other surgeons.

Trickling down

Even smaller community hospitals, such as Johnson City Medical Center and Jackson-Madison County Hospital, are making the da Vinci investment - usually about $1.3 million for the robot and several hundred thousand dollars a year in maintenance fees. Blount Memorial Hospital in Maryville purchased a da Vinci SI surgical system late last year, which surgeons (some trained by Fields) began using for urological and gynecological procedures in early December.

On Dec. 21, bariatric surgeon Dr. Mark Colquitt of Maryville's Foothills Weight Loss Specialists performed the area's first robot-assisted gastric bypass weight-loss surgery, which he did laparoscopically, with several small incisions.

"The robotic technology makes hand-sewing much easier by allowing surgeons better access to some of the hard-to-reach abdominal and gastrointestinal areas," said Colquitt, adding that he thinks robot-assisted surgery will become the "preferred method" for bariatric surgery. "This allows us to perform the delicate and challenging bypass procedure with even greater precision. The most important advantage is the ability to make very precise incisions and sutures, resulting in the most effective surgical outcomes for our patients."

Sonya Newman, Blount Memorial's chief nursing officer and assistant administrator, said the hospital plans to offer robot-assisted thoracic procedures as well.

Cookeville Regional Medical Center also has a da Vinci robot, which has been used primarily for prostatectomies, although its use in other fields is growing, said hospital marketing director Melahn Finley.

"We've done a lot of marketing," Finley said.

Finley said she thinks patients are beginning to expect even smaller hospitals to have the robot, and that area patients, desiring smaller incisions and quicker recovery times, "are starting to request it" and are being referred from places that don't have da Vinci.

She said the hospital considers the robot a good investment.

"It elevates the perception of your medical center, that you can offer such state-of-the-art technology," Finley said.

Future applications

Fields said the robot also can make surgery easier on the surgeon by eliminating fatigue from standing during a long procedure and by keeping a physician's hands from shaking during delicate motions.

Using the console is like having one's hands inside the patient, but allows for more range of motion, making it easier to get up under tissue or do precise dissections, he said. In addition, the video screen provides the surgeon with a better, clearer view, he noted.

Fields said the robot is now gaining use for cardiothoracic, colon and ear-nose-and-throat surgeries.

"You can reach and access spaces in the throat areas without having to disarticulate the lower jaw," he said.

And he wonders if, someday, only a minority of surgeries will not be robot-assisted. After all, he's become amazed at all he can do better with the robot - and he's excited to pass that knowledge on.

"All of our hard work over the last three years has been to prepare us" to become a training center, Fields said. To "transfer our knowledge and our incredible patient outcomes that we have to these physicians, for their benefit and for their patients' benefit."