In yet another example of PAH’s innovative teams coming together to create advanced approaches and ensure better patient outcomes, this past fall saw another first-of-its-kind achievement at the nation’s first hospital. The combined expertise of Suhail K. Kanchwala, MD, section chief of Plastic Surgery and an associate professor of Surgery, Ian S. Soriano, MD, FACS, a clinical assistant professor of Surgery, and the breast surgery, GI surgery, plastics, anesthesia, nursing, and OR teams resulted in the world’s first use of a surgical robot to assist with a bilateral DIEP flap breast reconstruction.
This procedure involves harvesting deep inferior epigastric perforators (DIEP) — i.e. blood vessels — and the connected skin and fat from the lower abdomen and transferring them to the chest to rebuild the breast following a mastectomy. These tissue-based reconstructions typically yield a more natural appearance and a more permanent solution as opposed to implant-based reconstructions, which often require follow-up procedures. For Jack Sariego, MD, MBA, FACS, vice president of Perioperative Services, the ability to provide these natural results is critical to patient satisfaction, and “any advance in the field provides a special opportunity to ensure better outcomes and increased satisfaction. In this case, the success of the procedure was not only a big deal for the patient, but also for Pennsylvania Hospital and the field. And in true Pennsy style, it was all made possible by a tremendous amount of teamwork.”
Collaboration has been at the core of the development of this “game-changing” approach since Kanchwala conceptualized it last year. He and Soriano trained together at Intuitive Surgical — the facility behind the da Vinci robotic surgical system — in California and realized that adapting a new, minimally invasive approach to breast reconstruction would allow them to reduce pain, get patients home more quickly, and all but eliminate the need to introduce potentially addictive narcotics.
Kudos from Leadership
“Congratulations to you for your dedication to providing this innovative approach for this patient. Thank you for leading your team to this outcome and for celebrating with them.”
— Theresa Larivee, CEO
“I am in awe of what you accomplished as a team! Looking forward to moving this innovative program forward.”
— Dan Feinberg, MD, chief medical officer
“This is a really outstanding achievement and just the beginning of innovative approaches to improve care for our patients. Thanks to the entire dedicated team for making this happen. Another first for the Nation’s First!”
— Dahlia Sataloff, MD, chair of Surgery
“After that experience, we realized that the robotic approach would best be performed when someone was undergoing another robotic procedure for the sake of efficiency,” Soriano noted. Over the course of more than 120 cases, their minimally invasive strategy evolved from endoscopic to laparoscopic and now to robotic, and their ability to seamlessly adapt their technique has resulted in decreased average OR times, reduced lengths of stay, and minimal post-op narcotic use.
The minimally invasive flap harvesting procedure omits the need to cut into a patient’s lower abdominal muscles to remove the tissue utilized in the reconstruction process. Kanchwala noted that while most people tend to equate the size of a skin incision with the “seriousness” of a surgery, it’s really the size of the muscle incision that matters, as that is the main source of pain and potential complications. These minimally invasive approaches (and particularly the most recent robotic technique) ensure surgeons can spare the muscle from a large incision and collect blood vessels more easily.
In addition to employing pain- and complication-reducing surgical techniques, patients are enrolled in a coordinated Enhanced Recovery Protocol, meaning that from admission to discharge, their care team is focused is on fast-tracking their recovery and helping them resume their normal activities as quickly as possible. Effective pain management ensures patients can stick to over-the-counter pain relievers, and many of them “wake up as if they haven’t had a surgery. We’ve seen patients who would normally be in the hospital for five days go home in just one or two days [after the laparoscopic procedure],” Kanchwala said, adding that the patient who underwent the robotic procedure was home in a mere 36 hours.
“I’ve had the opportunity to work in many different health systems, and I’m not aware of many places that could have set up a case as complex as ours in such a short amount of time and make it seem routine, even though it’s never been performed before,” Soriano said. Kanchwala echoed this sentiment, adding, “Together, we have developed a nascent minimally invasive pathway that will hopefully turn into a program. We’ve paired our surgical innovations with progressive ideas in anesthesia and postoperative care, and all of that combined makes it possible for our patients to get ‘back to normal’ faster.”