Dr James Porter has completed more than 3,000 procedures using the da Vinci robotic surgery system, making him the most experienced surgeon using the robot in the Pacific Northwest and one of the top five practitioners in the US. Dr Porter is the Medical Director for Robotic Surgery at the Swedish Medical Centre in Seattle, and the Director of Robotics for Providence St Joseph integrated healthcare system — responsible for the implementation of robotic surgery through 51 da Vinci robots in 51 hospitals across seven states.
Providence St. Joseph is made up of individual hospitals, but we try and work as a team — doing the same procedures to a high standard across a variety of locations. One of the benefits of robotic surgery is that the platforms are consistent — my da Vinci robot in Seattle functions in the same way as the robot in Oregon, or anywhere else in the country.
Because of this similarity, we are able to create guidelines and programmes and recommendations for individual hospitals that may not have the same level of experience performing robotic surgery. One of the key measures that we created many years ago was a credentialing document to ensure that surgeons using the robot were safe, competent and maintaining a certain level of expertise to perform surgery. Although each speciality uses robotic surgery, there is a considerable difference in the number of cases a surgeon will do — because it’s not every procedure in those specialities that lends itself to robotic surgery. In urology for example, it would be very common for a surgeon to do around 50 cases a year, whereas an ENT surgeon might only be doing 10 cases a year.
When you see a difference in case volume like that, it raises the question about how someone is maintaining their competence and skill on the robot. One of the things that’s unique to robotic credentialing — at least in the US — is that case volume is being used and tracked to determine the ability of surgeons to maintain robotic credentialing. This is very unique to robotic surgery — there is no other procedure credentialing that uses case volume — and though not perfect, case volume is the easiest and most accurate thing we have. What we’d really like to measure, however, is certain outcomes that would provide a much better indication of somebody’s skill and competence.
This is where a remote surgical assistance platform like Proximie is extremely useful. If a surgeon doesn’t meet their case volume, you need another means of assessment. What we’ve been doing — and what’s recommended in the credentialing document — is that the surgeon be observed. Not proctored, but just observed to ensure that they’re practicing safely and feel comfortable on the da Vinci platform.
“A remote surgical assistance tool is ideal for this purpose, allowing you to observe a surgeon to the same degree as you’d be able to from within the room, but without the need to travel.”
For the same reasons, a remote surgical assistance platform is an excellent tool for training new surgeons. Historically, when a new surgeon is starting to gain robotics experience, they are proctored — essentially observed by a more experienced surgeon. They are assessed for safety, efficiency, troubleshooting the robot and things like that. All this proctoring can now be done remotely, thereby saving a considerable amount of time and travel expense by allowing a surgeon like myself to observe the operation on camera — just as I would if I were physically present.
I opted for robotic surgery myself when I had prostate cancer, and it provided me with an ocean of insight from the perspective of a patient. There’s just no other way to know what it feels like to be on that side, and I was able to truly understand what my patients went through in a way that really changed how I practised.
“The only way my work as a surgeon can happen is through a tremendous amount of unspoken trust — the trust of a patient who is putting their faith in me to do my absolute best for them.”
It’s not really talked about much, but when a patient seeks you out to take care of a problem that threatens their life, they are trusting you on a level that they trust very, very few people, and that was a revelation for me. I came away knowing that a patient has one chance for a perfect outcome — and that’s my job. That has shaped my entire practice ever since.
Remote surgical assistance can now help ensure that perfect outcome anywhere in the world. Using Proximie, I recently guided consultant urologist Archie Fernando while she operated on Mo Tajer to remove a large mass of testicular cancer which had been left behind after chemotherapy. The location of the mass was not insignificant, between the aorta — the largest artery in the body — and the vena cava — the largest vein in the body — so these are very large vascular structures that carry a lot of blood.
It’s a very dangerous procedure and Archie asked for my support because I have a lot of experience doing it and I was one of the pioneers of the operation. Ideally, I would have been there, but it wasn’t possible because of COVID. Another option that we talked about was Archie coming to watch me to learn the techniques and gain firsthand experience, but that wasn’t possible either.
So, we were able to use Proximie to broadcast my presence into the operating room, to guide Archie and collaborate with her from Seattle, where it was 1:30 in the morning and I was sitting at home in my robe with my laptop.
I was able to use a cursor that looks like a pen to mark out what Archie was looking at on her screen, and support her through the initial steps of the procedure — which is a lot clearer and quicker than trying to provide verbal guidance. I know verbally describing it doesn’t work because I train fellows every day, and if I try to explain where I want the surgeon to go, it’s inefficient and there’s always doubt about what I’m describing. What I remember most about helping Archie was that with a few subtle moments of guidance we were able to create the exposure and operative setting that was needed to complete the operation successfully. With remote assistance, Archie was able to do an excellent job of carrying out extremely difficult surgery that very few people are able to do.
Philosophically, when I do a surgery, that patient is benefiting from decades of experience — from people before me, who have passed on their expertise to me through teaching. That’s the big picture. All that was going on during that operation with Archie and Mo was that the technology was enabling me to support Archie on something, and allowing me to pass on my experience to her, so that she could pass on the benefit to Mo. There’s no question that my ‘presence’ impacted the outcome.
This is what is exciting about robotics working hand-in-hand with remote assistance; the hugely increased ease of access to expertise, guidance and proctoring that has tremendous potential to promote best practice and better equip us to capitalise on that one chance for a perfect outcome.