1 of 2
Assisted by a da Vinci robot, Dr. Danny Shaban and the team at Dominion Women's Health have performed more than 1,000 minimally invasive hysterectomies. Photo by Isaac Harrell
2 of 2
The Gamma Knife uses gamma rays to pinpoint tumors, says Dr. K. Singh Sahni. Photo courtesy HCA Virginia Health System
As they say, there's more than one way to skin a cat — and in the world of modern medicine, that rather inartful phrasing takes on new meaning with the advent of the minimally invasive medical procedure. Everything from complex heart surgery to once-painful and debilitating arthroscopic surgery — even major brain surgery — sometimes can be done without the surgeon picking up a single scalpel. And Richmond, despite its small size relative to other major medical markets, offers a glimpse into the future of surgery.
Historically, advancements in women's health have been slow to take hold or even to be tried. But Dr. Danny Shaban, president of Dominion Women's Health, saw an opportunity when he read a medical journal article nearly a decade ago about robot-assisted prostate removal that happened to mention pioneering Richmond cardiac surgeon Marc Katz and his use of the da Vinci robotic device.
"I said to my partner, [Dr. Tom Mead], can't we do hysterectomies with a da Vinci robot?" says Shaban, who is also director of gynecologic robotic surgery for the Bon Secours Richmond Health System. That aha moment led to Dominion Women's Health undertaking its first da Vinci-assisted supracervical hysterectomy — and then another three the same day in relatively rapid succession — about seven years ago. Since then, Shaban says, "We've done over a thousand cases."
Meanwhile, other practices in Richmond recognized what Shaban and Mead were doing. Now, more than 30 gynecological surgeons use da Vinci for all manner of procedures, and minimally invasive gynecological surgery is available locally through the HCA Virginia Health System, VCU Medical Center and Bon Secours.
Despite the availability of the minimally invasive option, Shaban says, many doctors continue to perform the surgery in the traditional way, meaning that even today, about 75 percent of hysterectomies in Richmond are done abdominally.
"It's a crying shame," Shaban says. "In this day and time, there should be very few women undergoing an open procedure. When you do a case like that, you basically knock this lady out of work for six to eight weeks. She's got a risk for bleeding, of not healing."
By comparison, using the minimally invasive option, the patient returns to work within a week. She regains sexual function within two weeks. "Her quality of life is so much better," says Shaban. And after a thousand or more surgeries, "we haven't had any ... mortality or morbidity. We haven't had any complications. It's safer, it's less invasive and the blood loss is hardly anything."
The surgery involves three small incisions of about 8 millimeters or less. One incision in the belly button is paralleled by two more on either side. "When you're done, all we do is put this solution called Dermabond — I call it surgical crazy glue. The patient has a very minimal scar if any at all." And while Shaban and Mead were the first in Virginia to perform a da Vinci-assisted supracervical hysterectomy, the same process now is used to treat everything from infertility to endometriosis to fibroids, to removal of cysts or uteruses and full hysterectomies.
There was a time not so long ago when a torn rotator cuff spelled the end of tennis games, golf swings and all manner of active, outdoor hobbies. The cure was nearly as bad as the injury: A wide incision exposed the deltoid muscle, which was also cut and filleted from the bone — all this just to get to the rotator cuff, which then required drilling so the surgeon could tie off sutures to reattach the damaged tendon.
"We were breaking something normal to fix something that was not normal," says OrthoVirginia's Dr. David Nedeff, who performs surgery at HCA's Johnston-Willis Hospital. "It was a little counterintuitive."
And it was traumatic. Fast-forward to the arthroscopic surgery alternative. A 4-millimeter scope is inserted through a few small incisions in the skin, allowing the scope, which is equipped with specialized surgical instruments, to be inserted carefully through the fibers of the deltoid muscle. No muscle is cut, and recent advancements mean the bone is no longer drilled. Instead, suture anchors are implanted in the bone, providing a stronger way of securing the ligaments than the old method did.
"Now, I literally won't physically touch anything in the shoulder and yet I'll do a massive surgery on the patient," Nedeff says. Rather than taking hours, the surgery is done in 45 minutes and within hours, the patient heads home. And while he or she faces the same six-month rehab regimen to regain full use of the arm, there is immediate recovery of movement.
"You're going to have some soreness there, but it's just drastically different than the old-fashioned surgery," Nedeff says. "They start moving the shoulder immediately. The muscle is stronger. And the greatest part of moving it right away is it eliminates a lot of the pain that comes with the [old] surgery."
When is major heart surgery, in the words of the surgeons performing it, "not really surgery"? When that surgery is a transcatheter aortic valve replacement (TAVR) that's performed not by opening the patient's chest cavity, but instead by running a large IV to the heart through an incision in the patient's leg.
Rather than cutting out the old aorta, a sort of door-within-a-door replacement is inserted in the existing aorta. It's major surgery without the major pain, the major recovery time and the major risk of infection and other complications that are routine when cutting open a person's rib cage and causing significant trauma to the surrounding muscle and bone.
If the whole process sounds revolutionary and new, that's because it is. And it's being performed by comparatively few doctors, among them HCA Virginia's Heart Valve Team and Dr. Zachary Gertz and Dr. Derek Brinster, both of VCU Medical Center. Gertz is director of structural heart disease with the Pauley Heart Center there, while Brinster directs the center's Thoracic Aortic Disease program.
"The FDA has only approved it for sort of high-risk people," says Gertz. Essentially, the surgery first was made available in 2011 only for patients who otherwise could not undergo surgery, and since then — in just the past year — it was made available for high-risk patients. The FDA currently is conducting tests in moderate risk patients, with some predicting it may become among the standard for care within the next two years. Gertz was part of the first FDA trials at the University of Pennsylvania.
"This opens the door to patients who were not well enough [for surgery]," Brinster says. "These patients are typically older with several other diseases and it was too high risk."
Brinster and Gertz say the key to the surgery becoming more widely available would be a determination by the FDA that the replacement valve involved is as durable as the kind of replacement valve that's installed during more traditional surgery.
"The technology is not yet tested for younger, healthier patients," Brinster says, noting, too, that more testing is being done to determine whether a slightly increased risk of stroke outweighs the elevated risk of bleeding and other complications inherent in the traditional surgery. "But I think you're going to see this procedure liberalized so that it's available to more of the general patient population." When that day comes, the roughly six-day recovery time – down from two weeks for standard surgery — along with other benefits will be "a huge advance," Brinster says.
Brinster and Gertz aren't the only surgeons performing surgery that's not really surgery in the commonly understood sense. Dr. K. Singh Sahni, chief of neurosurgery at CJW Medical Center and medical director of the hospital's Gamma Knife Center, explains that even his knife isn't really a knife.
"The gamma knife involves no needles, no knives or any kind of thing like that," he says. Instead it's a pattern of about 200 highly focused and carefully calibrated gamma rays that zero in on a cancer or other tumor, sometimes deep within the brain, and do what traditional surgery and old-style, whole-head radiation treatment could never do.
"Without putting a hole in the head, without putting that patient to sleep and without ever opening up the skull," Sahni says, he's able to destroy tumors without destroying brain tissue. "Imagine the way the military fires a missile and they have a pinpoint targeting. The same principle being used by us, but in the head."
And obviously without the missile. But the effects are no less dramatic for patients. "It used to be if you had cancer that had gone to your brain, they would tell you [that] you have six months to live." But with the gamma knife, "We can treat the metastasis to the brain as many times as necessary. They don't die anymore of brain tumors — they might die of liver metastasis, but I don't let them die of brain tumors anymore."
And Sahni doesn't let them call in sick anymore, either. "This is outpatient treatment," he says. "Take a day off from work, go home and go back to work the next day."
Currently, Sahni is the only Richmond surgeon doing the gamma knife procedure. "I had to fight hard to get it and we got it in 2004," he says, adding that he's recently treated his 2,000th patient. "We get people coming from all over the country, not just Richmond."
The treatment method is so new, so revolutionary and so seemingly unbelievable, that Sahni says one of the biggest obstacles to surgery is persuading oncology doctors to send patients to him. "And it's not just cancers that can be treated," he says. "Surgery on benign tumors of the pituitary gland or aural tumors, as well as treatment for trigeminal neuralgia and even Parkinson's can all be performed with the gamma knife."
Considering that it was just about a decade ago that da Vinci first made its minimally scarring mark on Richmond, and considering it was just a bit more than half that time since gamma knife surgery arrived, the process of using robot-assisted surgery to create better outcomes has made broad strides in the Richmond region. In Shaban's eyes, it's put this town on the map. "For Richmond being a small town," he says, "we're probably one of the best at doing minimally invasive surgeries."