A public presentation given about the robotic surgical platform. There were several video slides that were removed due to space limitations.

1. Anthony R. DeSalvo, M.D.
1842 E Market St
Warren, OH 44483
330.856.7212
warren-obgyn.com

2. Anthony R. DeSalvo, M.D
 Bachelor of Science – Kent State University
 Medical Degree – Northeastern Ohio Universities
College of Medicine
 Residency – Beth Israel Medical Center, New York, NY
 Board Certified – American Board of Obstetrics and
Gynecology
 Personal information
 Professional information

3. Why am I here?
 Educate the public some common gynecologic
conditions that may require an operation
 Discuss the types of operations that are available
 Introduce the concept of robotic surgery to the
public
 Dispel some common myths about robotic
surgery

4. Common conditions treated by
hysterectomy
 Heavy menstrual bleeding
 Pelvic pain
 Fibroid uterus
 Endometriosis
 Prolapse
 Cancer

5. Heavy menstrual bleeding
 Defined as bleeding that lasts for longer than 7 days
per month or greater than 80 mL per cycle
 Difficult to estimate the true amount of blood loss
 Bleeding that soils clothes, bed sheets or requires the
significant planning
 Very subjective but usually a person knows it when it
happens to them

6. Pelvic pain
 Chronic pelvic pain refers to pain of at least six
months' duration that occurs below the belly button
and is severe enough to cause functional disability or
require treatment.
 In the United States, this problem accounts for
approximately 10 % of all visits to a GYN.
 It is considered the principal indication for
approximately 20 % of hysterectomies performed for
benign disease.

7. Fibroid uterus
 Fibroids are tough balls of muscle that form in the uterus
 People sometimes refer to fibroids as “tumors.” But fibroids
are not a form of cancer. They are simply abnormal growths
in the muscle of the uterus
 Fibroids often cause no symptoms at all. When they do
cause symptoms, they can cause:
 •Heavy periods
 •Pain, pressure, or a feeling of “fullness” in the belly
 •The need to urinate often
 •Too few bowel movements (constipation)
 •Difficulty getting pregnant

8. Endometriosis
 Endometriosis occurs when tissue normally found in a
woman’s uterus grows outside of the uterus .
 This tissue, which does not belong outside the uterus, can
then break down, bleed, and cause symptoms
 Some women with endometriosis have no symptoms. But
most have pain in the lower part of the belly that can occur:
 •Before or during monthly periods
 •Between monthly periods
 •During or after sex
 •When urinating or having a bowel movement (often during
monthly periods)

10. Prolapse
 When tissues that support the organs in the lower belly relax. The
organs drop down and press against or bulge into the vagina.
 If the bladder bulges into the vagina,, this is a“cystocele.” If the rectum
bulges into the vagina, it’s a “rectocele.” Uterine prolapse means the
uterus has bulged into the vagina.
 Many women with this problem have no symptoms. But some women
with pelvic organ prolapse have symptoms that include:
 •Fullness or pressure in the pelvis or vagina
 •A bulge in the vagina or coming out of the vagina
 •Leaking urine when they laugh, cough, or sneeze
 •When they use the toilet, some women need to press on the bulge in the
vagina with a finger to get out all their urine or to finish a bowel movement.

11. Cancer
 As a benign gynecologist, I do not treat women with
gynecologic cancers
 These women are best served by a referral to a GYN
oncologist
 We are very fortunate to have several world class
cancer centers within a 1 hour drive

12. Procedures
 Hysterectomy – removal of the uterus
 Total hysterectomy – removal of the uterus and
cervix
 Sub-total hysterectomy (Supracervical) –
removal of uterus only with the cervix left in
place
 Oophorectomy – removal of the ovaries
 Confusing terms – complete , partial and total

14. Hysterectomy facts
 Approximately 525,000 hysterectomies are performed
each year in the U.S. for non-cancerous conditions
 By age 60, 1 in 3 women in the U.S. will have had a
hysterectomy2
 90% are performed for elective benign indications
 Fibroids
 Abnormal uterine bleeding
 Endometriosis
 Chronic pelvic pain

15. Route of Surgery
Abdominal
 Requires a large
abdominal
incision
 Usual hospital
stay is 2 to 4
nights
 6 to 8 weeks of
recovery

16. Vaginal hysterectomy
 The entire operation is performed through the
vagina
 Requires good access to the uterus
 More challenging in patients with prior
abdominal surgery or previous cesarean
section
 More challenging if the uterus is enlarged
 Limited visualization of the pelvis and ovaries

17. Laparoscopic hysterectomy
 Better visualization
 Shorter hospitalization
 Shorter recovery
 Good visualization of the pelvic organs
 Can be performed in a wide variety of
patients
 Traditional laparoscopy requires a unique
skill set and commitment to the procedure

18. US Hysterectomy Modalities 2005 vs. 20124
Jan 1,
2005
Lap – 14%
Vag – 22%

19. The Impact on Hysterectomy Adoption of MIS for Hysterectomy
80%
70%
60%
50%
Adoption
Laparoscopy
40%
da Vinci
30% Vaginal
Open
20%
10%
0%
Year
Farquhar et al. "Hysterectomy Rates in the United States: 1990–1997" Obstet Gynecol 2002;99:229 –34
Becker et al. "Inpatient Surgical Treatment Patterns for Patients with Uterine Fibroids in the United States, 1998-2002" Journal of the National Medical Assn.
Vol. 97 (10) October 2005
Wu et al. "Hysterectomy Rates in the United States, 2003" Obstet & Gyn VOL. 110, NO. 5, NOVEMBER 2007
Solucient data through 2010 for Lap, Open and Vaginal Trends

21. Natural Evolution of Technology

22. Natural Evolution of Technology

24. Evolution of Technology
Konrad Zuse’s Z1 (1938)
First binary computer UNIVAC I – UNIVersal Automatic Computer (1951)
Mechanical calculator First commercial computer
U.S. Census Bureau
Original price: $159,000
Ultimate price: $1.5 million
46 systems built and sold
IBM 701– (1953)
First commercial IBM computer
$15,000/month rental fee
Only 19 systems built and sold

25. Evolution of Technology
Altair (1974)
Scelbi (1974)
First personal computer
Kit that user had to put
together, make it IBM 5100 – First IBM PC (1975)
work, and write software 50 pounds
256 Byte RAM Programming language (APL or BASIC)
$400 64K storage version
$19,975

26. Which would you rather have?
Versus

27. Robotics
Current applications
 Auto industry
 Space industry
 Multiple other industries
 Military
 Laboratory test processing
 Automated research equipment
 Radiation therapy
 Toys

28. What’s the difference?

29. The natural evolution of computers
into the operating room

30. Minimally Invasive Surgery
Benign hysterectomy in the US 2003
Mean LOS=1.7 days*
Mean LOS=2.0 days*
Mean LOS=3.0 days*
*P-value<0.001
Wu JF. Et al. Obstet Gynecol 2007;110:1091-1095.

32. da Vinci® S Robotic Platform

33. da Vinci® Surgery (Minimally Invasive)

34. Robotic Platform
General thoughts
 A tool
 Not new surgery or procedure
 A tool that makes minimally invasive
surgery easier
 Very rare to have “robotic” complication if
used properly
 Surgeon who’s using the robot has a
complication as with any other tool

35. Advantages of robotic surgery
 Much improved 3D visualization over traditional
laparoscopy
 Keep in mind, that traditional laparoscopy was still
better than open surgery
 Full wristing instruments with 7 degrees range of
motion
 Complete surgical control of the operative instruments
 Mimics the hand movements of open surgery

36. da Vinci® Awareness
President Obama Jeopardy CNN
(Cleveland Clinic)
The Doctors
The Daily Buzz
Private Practice
Law & Order

37. Summary
 The addition of computer technology into the
operating arena is a natural evolution and progress
 The addition of robotic platform for surgery is a
continuation of this progress
 Man’s tools continue to add great value to our lives
 This tool will greatly reduce or nearly eliminate the
need for open surgery
 The societal benefits of a surgical platform are vast and
numerous