Lankan doc in UK plays key role in life-saving robotic surgery on cancer patient
Aminimally-invasive surgical feat spanning the Atlantic Ocean giving a new lease of life to a young man stricken by cancer!
A specialist in scrubs and Personal Protective Equipment ( PPE) in the United Kingdom (UK) skilfully manoeuvring ‘da Vinci’ for this keyhole procedure, while another specialist in his pyjamas across the seas in America watching and advising and a little tear- drop shaped island in a different direction having a tiny stake in this feat.
For, the specialist at the da Vinci robot, has strong roots in Sri Lanka, having been born and raised here.
Consultant Urological Surgeon Dr. Archana Fernando ( fondly called Archie), of Guy's and St Thomas' NHS Foundation Trust in London, who made headlines in the UK recently for her ‘pioneering’ and ‘revolutionary’ robotic procedure on the cancer patient, Mo Tajer, has one request when the Sunday Times seeks an interview.
“I am delighted to be able to share my story in case it is interesting to people and on the off- chance it might inspire someone into medicine/ surgery but I am really keen it doesn’t seem like self-promotion please,” says this high-achiever in all humility.
With much simplicity, Dr. Fernando – whose areas of expertise include kidney cancer, retroperitoneal fibrosis and open and minimally invasive urological surgery – says that there are a huge number of people who have done truly pioneering and revolutionary things and “I am sadly not one of them”.
Some aspects of the Tajer case, however, represent surgical progress, she concedes:
It was the first time in the UK that a testis cancer mass of this size had been removed using keyhole surgery. It was a “definite” step forward when considering the next level collaboration between a surgeon in the UK and a surgeon 4,700 miles away in Seattle, in real time, to deliver the best outcome for a patient.
The use of software that allowed the Seattle surgeon to see exactly what Dr. Fernando could in her console view, which enabled communication between them as if they were in the operating theatre (OT) together, which she describes as “fantastic”.
The origins of this surgical feat performed on May 21 began when Tajer, a 31-year-old Harrods salesman, was persuaded by his girlfriend to seek medical help after experiencing abdominal pain. Subsequently he was diagnosed with advanced testicular cancer.
Delving into the complex surgery involving the aorta (the largest artery in the body) and the inferior vena cava (IVC – a large vein) that she performed using the robot da Vinci Xi, Dr. Fernando says that she had to remove a five-cm residual tumour following chemotherapy and all the adjacent lymph nodes - retroperitoneal lymph node dissection (RPLND).
“The tumour was located between the abdominal aorta and the IVC and was adherent (sticking) to these which is often the case after chemotherapy. These operations are usually performed using open surgery due to the risk of injuring major blood vessels causing severe intraop bleeding. We have been doing increasingly complex robotic-assisted surgery for other indications such as tumours up to15cm of the kidney, ureterolysis and ureteric reconstruction,” she says. (Ureterolysis is a surgical procedure to expose the ureters, the tubes which carry urine, to free them from external pressure or adhesions, while ureteric reconstruction aims to preserve renal function and ensure urinary continuity.)
As they had experience and expertise with robotic surgery, she and her team felt it would be possible to do the surgery using robotic- assisted techniques safely in this case. If not possible, then the plan was to convert to open surgery. However, the patient was keen to at least try keyhole surgery earlier because of the advantages of less pain, shorter hospital stay, quicker recovery etc., the Sunday Times learns.
The disadvantage, explains Dr. Fernando, is that it can sometimes be slower than open surgery and if there is bleeding, the camera can get covered with blood and you lose your view. So it is important that the surgeon performing the operation has the skills to be able to convert to open surgery immediately, if required.
The surgery began around 9.30 a.m. in the UK, while it was 1.30 a.m. in Seattle, where Dr. Jim Porter, the Medical Director for Robotic Surgery at the Swedish Medical Centre was.
“Jim is one of a handful of surgeons who performs this sort of complex surgery. I hadn’t done such a large testis cancer mass robotically before and I knew he had done a few (probably 5-8 cases of this size). So I emailed him and asked if there was any chance he would dial-in for the first hour to help get the initial exposure right which is one (of several) key step in this operation. He linked in for about an hour of the five-hour op and was able to make some very helpful suggestions regarding anatomy and dissection,” says Dr. Fernando.
The procedure began with four small incisions of 8- mm each on the abdomen of the patient for the robotic ports, with Dr. Fernando not hovering over the patient as is usual in open surgery, but more than two metres away at the da Vinci console. A 12-mm port was for the surgical assistant who was at the bedside of the patient at all times.
This surgical robot, the most advanced platform designed for keyhole surgery, has four articulated arms fitted with cameras and surgical instruments, it is understood, while the whole da Vinci Xi system comprises the three components of a surgeon console; a patient side-cart;
and a visual cart.
The pre-procedure planning was not without its challenges and Dr. Fernando paints images of the COVID-19 fallout of ‘restricted’ operations.
She says: “Restricted operating means we have to justify/ fight for every case we think should be done without delay. We have to fit the operating between doing other COVID- 19related activity. Very tricky for the patient because having surgery has increased risk if he were to contract COVID. At the same time deferring surgery could lead to a bad cancer outcome for him. Building a relationship with the patient so that he can understand these issues was very important, especially as he’s young and none of his family were allowed to come to clinic visits with him or to hospital before/during/after his surgery.
“Our whole team has to wear full PPE during operations. This op took 6 hours in total – 5 hours for RPLND and 1 hour to remove the testicle/put in a prosthesis (an artificial body part) – so the entire team had to be in full PPE for that whole time, which wasn’t the easiest thing to do.”
The efforts of the team have paid off. Mo Tajer is “doing really well”.
When he first presented with the symptoms he had a tumour marker count of 96,000 ( normal level 5). He responded well to chemotherapy but still had residual disease. Now that we have removed this residual disease, he is disease-free which is fantastic, says Dr. Fernando, pointing out that he needs close follow-up, of course, but he is delighted.
He was in hospital for two days. He could have gone home on Day 1, but Dr. Fernando wanted to keep him an extra night to make “absolutely sure he was ok”. He was pretty much back to normal two weeks after, in contrast to open surgery which would be an average of 5-7 days in hospital and 6 weeks’ recovery.
And what lies ahead for Dr. Fernando……“My focus has always been to keep improving, honing a skill, trying to do operations better each time to get the best result for the patients…… so will have to see where that takes me.”