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Surgeons use innovative robotic advance in breast reconstruction

Dawn Brazell | brazell@musc.edu | June 5, 2017

Nicole Ruiz, left, and patient Maritza Gonzalex
Photos by Sarah Pack
Nicole Ruiz, left, with her mother, Maritza Gonzalez. Gonzalez, a breast cancer survivor, had one of the first robotically assisted breast reconstruction procedures of its kind in the country.

Deftly working the mechanical arms of the robotics surgical unit, surgeon Chitharanjan Pullattrana, known to most patients as Rana Pullatt, sits at a computer console near an operating table where a cancer survivor is getting a breast reconstruction.

He and plastic surgeon Kevin Delaney have joined forces to do the robotically-assisted surgery in what is one of the first procedures of its kind in the nation. A sense of excitement hangs in the air as other surgeons and medical students drop by to observe.

Robotic surgery 
From left, Dr. Elizabeth Goodshall, Dr. Kevin Delaney and Dr. Vinay Gundlapall work with the robotic device during Gonzalez's surgery.  

Pullattrana, director of robotic surgery for the MUSC Health Department of Surgery, remotely directs the interactive robotic arms on a patient side cart. The arms go through a small incision, one of them carrying a camera that provides a magnified, high-definition 3-D view beneath the belly muscle. 

True to his jovial character, he cracks a joke about being “Dr. Robot,” getting laughs from some of the nurses. Delaney, who proposed the innovative idea to try a less invasive way to perform the DIEP, or deep inferior epigastric artery perforator flap, grins. The surgeons are excited to try this. The DIEP flap is a technique where skin, vessels and tissue are taken from the stomach to recreate the breast following a mastectomy.

Delaney already has harvested fat and skin tissue from above the patient’s belly muscles. Now, he works wedged in between the giant, plastic-encased arms of the robotic unit that drape him like a mechanical spider, as Pullattrana works below the abdominal muscle, hooking the blood vessels needed to support a transplant of tissue to the patient’s breast, their movements a ballet of synchronized movements. 

Dr. Rana Pullatt 
Dr. Chitharanjan Pullattrana, known to most patients as Rana Pullatt, remotely directs the robotic arms. 

The goal: avoid cutting through the abdominal muscle to allow for a faster recovery with less pain and enable the patient to maintain better muscle tone. 

“How am I doing?” asks Pullattrana, from his tucked-away position in the corner of the room. 

“Great,” Delaney answers.

“Oh, good. I was afraid if I didn’t perform up to your standards, you wouldn’t let me work with you again,” he jokes.

There’s little chance of that. Delaney and Pullattrana, top experts in each of their fields, know well what they are doing and how teamwork is critical to innovations in modern-day surgery. The procedure actually involved the handiwork of three surgeons, as plastic surgeon Jason Ulm already had prepared the breast site to receive the flap while Delaney and his team did the abdominal incisions. 

In addition to the robotics surgical unit, the surgeons used a fluorescence imaging system that allows them to visualize microvascular blood flow and perfusion in tissue as they operate. At one point in the reconstruction, the lights go off and the room is bathed in a soft green light. The surgeons check the screen on the SPY ELITE system to see their progress and if there are any black spots, which indicates a lack of blood flow. They make a few adjustments and finish the reconstruction.

DIEP flap surgery 
Dr. Kevin Delaney, third from left with his left hand raised, sees robotic surgery as a less invasive way to perform the DIEP, or deep inferior epigastric artery perforator flap, procedure. Here, he speaks to Dr.  Adam Franklin, far left, and Dr. Adeyemi Ogunleye. 

A few days after the operation, Delaney and another plastic surgeon, Vinay Gundlapalli, check on the patient. They’re pleased by Maritza Gonzalez’s cheery response. “I thought I was going to have a lot of pain but I haven’t had much,” she tells them.

That’s due in no small part to the fact that this procedure allowed for a small cut in the abdomen about the size of a quarter, versus the former method, which would have meant an eight-inch cut into her muscle and fascia. Delaney says Gonzalez didn’t have to have a pain catheter and was able to go home after three days. 

“She was up and walking around after day one. It’s a lot less painful method,” he says. “That’s all good news to us that shows we are on the right path in advancing the technique. We can use it as a stepping stone, so we can do more surgeries using this technique.”

The mother of three found she had breast cancer stage 3B in 2012 when she fell while cleaning the bathtub. She noticed her breast was swollen and went to the hospital to be checked, finding out she had cancer. Gonzalez had a mastectomy on July 26, 2013, but postponed reconstruction at that time because of concerns that her cancer might have spread and the need for more testing.

Maritza Gonzalez 
Gonzalez says doctors "need to be innovative." 

The timing worked out well. Gonzalez says she’s fine being among the first in the nation to have the procedure done robotically because she trusted her doctors. “They are amazing. They need to be innovative. You have to be willing to take chances and not be afraid. I’m thankful for the new options. I feel good. The three men here were outstanding.”

Delaney predicts plastic surgeons will use robotics more frequently in the future. A video describing the technique of this operation has been submitted for review to the American College of Surgeons for presentation at its annual meeting, and the technique is being considered for publication. “This robotic technique was in an effort to decrease her chance of developing a hernia or bulge in her abdomen as well as have less pain and a faster recovery, compared to a standard non-robotic DIEP flap,” Delaney said.

Pullattrana, who holds a special certification in the treatment of obesity, said it’s important to advance the field. “Robotics is an enabling technology. It makes a good surgeon a great surgeon.”

Laparoscopy should be the bedrock of surgeons’ training, and the great majority of the cases that are done in general — GI, surgical oncology — can be done well laparoscopically, Pullattrana says. These surgeries also are done through small incisions to be minimally invasive. “However, in tight spaces and when the patient is obese, the robot enables us to do these challenging procedures in a minimally invasive fashion with less fatigue and greater dexterity for the surgeon, both of which help the patient.”

MUSC offers robotically assisted procedures in many areas, including the duodenal switch, the mitral valve repair and now the DIEP flap. “These are procedures offered by very few centers in the country, and certainly we are the only center in the state doing these procedures.”