RISE OF THE MACHINES: Robotic surgery just beginning to scratch the surface of its possibilities

October 06, 2021
Surgeon Rana Pullatt works in the operating room while surrounded by several other doctors and nurses. They are all bathed in a green light
MUSC Health surgeon Rana Pullatt, center, is surrounded by his surgical team in the OR as they prep a patient for robotic surgery. Photos by Sarah Pack

A lime green light illuminates the entire room. On a table, draped in blue, lies a man intertwined in four arachnid-like arms, each numbered and covered with plastic. 

Fifteen feet away, with his face nestled against the eyepiece of a giant terminal, sits MUSC Health bariatric surgeon Rana Pullatt, M.D., his hands independently moving two joysticks, wrists slightly bowed. The light brown leather caster chair underneath him moves rhythmically as he works with rapid precision – he’s slipped off his clogs now, his socked feet resting next to colorful pedals – giving the impression that this is just a stroll in the park.

Back at the surgical table, the arms on the DaVinci XI surgical robot move in perfect concert with Pullatt’s commands. A slight twist of the left hand and a monitor above his terminal shows the reflected movement of the instrument in the patient’s abdomen. A buzzing sound communicates to the team that cauterization is happening. 

A team of eight doctors and nurses surround the patient, monitoring his well-being and making small adjustments to the robotic appendages whenever Pullatt requests. Occasionally, a tool will be swapped out, efficiently removed and slid back into place through one of the trocars – think of them as stainless-steel delivery tubes – connected to the robotic arms and running into the man’s abdomen.

tight shot of surgeon's face 
Dr. Rana Pullatt positions trocars in his patient before moving to the terminal to operate.

Pullatt – whose colleagues affectionally refer to him as “Mr. Robot” – has done more than 1,200 of these robotic surgeries. Not only was he the first surgeon in the state to perform a laparoscopic duodenal switch but he’s currently the only one doing it robotically. Reserved for only the largest of patients who have tried all other methods to drop weight to no avail, the duodenal switch is a radical surgery that takes gastric bypass to an entirely new level, sidestepping a significant portion of the digestive tract. It’s strictly for the kind of patients in which surgery isn’t elective; it’s necessary for their survival. Afterward, they will be on supplements and vitamins for the rest of their lives. But each will tell you it’s a life that most likely wouldn’t have been possible if not for this procedure.

“Why we need the robot for surgeries like this isn’t all that high-tech actually,” Pullatt says through his mask. Yes, the small, precise movements a surgeon can achieve with such a technical machine are helpful, he says, but in the end, it really comes down to sheer muscle.

“The torque required to move all these instruments around in larger patients is extremely difficult with conventional laparoscopic surgery for the length of time we need to be working on them,” he says. “It’s like trying to tie your shoelaces with chopsticks. That’s why these robots are so incredible. They allow us to give hope to the people who thought they’d never have it again.”

Weighty decisions

Jamie Holmes remembers the moment he hit rock bottom. 

Sitting in his car outside a gas station in the middle of the night, he was certain he was having a heart attack. The then-Uber driver was working an overnight shift when he suddenly had trouble breathing. 

“No joke, it was like somebody was sitting on me,” Holmes said. “I tried to get out and walk around, but that feeling just wouldn’t go away.”

The last thing he remembers is the clerk coming out for a smoke – a break Holmes would later acknowledge might have saved his life – and he just happened to notice Holmes slumping over. He ran back inside and called 911. After that: nothing.

“I was there, sitting in my car in agony, and then I wasn’t,” he said.

The attempts to rouse him, the EMTs surrounding him, the ambulance ride – all missing. Things only started to come back into focus hours later, when he woke up in a tangle of wires at the hospital. The episode he had just experienced, the doctor told him, was atrial fibrillation, or an irregular rhythm and rapid heartbeat. It’s a serious condition that can lead to stroke or even death. But that’s not the part seared into Holmes’ memory. It’s what the doctor said next. 

Jamie Holmes weighed 628 pounds. 

“You have no idea what it feels like when you can’t even go in the store to do your own shopping.
When you weigh that much, it’s like being in jail.”

 

Jamie Holmes, patient

“I’ve always been a big guy,” he said, “but I was healthy. Or so I thought.” 

In retrospect, his weight gain was inevitable. As with many other stories of those who struggle with their weight, it’s never any one thing but rather lots of little ones that build upon each other until one day, you find yourself so overwhelmed that it seems as if there’s no way out. 

“You have no idea what it feels like when you can’t even go in the store to do your own shopping,” he said. “When you weigh that much, it’s like being in jail. Everything stops. You want to do things, but you can’t.”

During his sophomore year at Socastee High School, Holmes tore his ACL playing football. It would be the last time the nose tackle would play competitively. Understandably, after the injury, he was less active. Around that same time, his eating habits changed. One value meal at dinner turned into two. Then two became three. Meals became more frequent. Throughout the remainder of his time in school and into his professional life, the weight kept adding up. In 2017, when he started feeling particularly lethargic, he went to his doctor, and he was diagnosed with diabetes. Then he developed sleep apnea. Things were beginning to snowball – culminating in that terrifying late night in front of the gas station. 

Jamie Holmes was faced with the sobering reality that if something didn’t change, he was going to die. He was just 34 years old. 

The very next day, after returning home from the hospital, Holmes began his search on the internet for help – anything that would help him to dig out of the massive hole he found himself in. After a few false starts with some other doctors, he finally happened upon the bariatric program at MUSC Health in Charleston. It was a connection that would prove critical.

Surgical lightning rod 

MUSC Health now boasts five state-of-the-art surgical robots – three in Ashley River Tower, two in the main hospital – making it one of the most robust DaVinci robotic programs in the country. It’s also the only hospital in the state offering robotic surgery in virtually all specialties. 

Cardiothoracic chief surgeon Marc Katz, M.D., performed one of the first robotically assisted FDA-approved procedures for a leaky heart valve in a patient. Colorectal surgeon Virgilio George, M.D., is able to do more complex procedures thanks to the new technology. And just recently, Bruce Crookes, M.D., chief of Acute Care Surgery at MUSC Health, had a patient with an abdominal stab wound that he was able to repair robotically as well as explore the abdomen to rule out other injuries – a luxury he never would have had just using traditional methods. 

“The torque required to move all these instruments around in larger patients is extremely difficult with conventional laparoscopic surgery ... It’s like trying to tie your shoelaces with chopsticks.”

 

Dr. Rana Pullatt, MUSC Health bariatric surgeon

This doesn’t mean technology is replacing doctors. It simply means surgeons are now able to do more complex procedures, less invasively, in less time. Not to mention patients have shorter hospital stays, with less chance of infection or complications, and return to work sooner. 

“No subject in our field is as much of a lightning rod as robotics is in surgery,” Pullatt said. “But the truth of the matter is once a surgeon is properly trained, procedures can be done just as efficiently, or in some cases better, with the robot.”

Pullatt estimates that 95% of all of his procedures are now done robotically. A couple of years ago, he was only one of the two MUSC Health gastrointestinal surgeons regularly using the technology. Since then, however, he has trained six others how to operate using the robot properly. 

“I think eventually all surgery is going to become computer assisted,” he said. “If we resist this, it’s very myopic. Surgery is such an invasive thing. We now have a tool at our disposal that allows us to make the entire process less taxing on the surgeon and safer for the patient.”

A collage of four photos. One is of surgeon at robotic terminal, one of the display on the robot itself, one of surgeons hands manipulating robot and one of what the surgeon is seeing as he works 
At top, Dr. Pullatt works from the terminal, which is located about 15 feet away from the patient. Below, from left, a close-up of the display that relays the positioning of the robot, Pullatt's hands manipulating the controls and a 2-D view of what Pullatt actually sees in 3-D during surgery.

Good reasons for hope

Holmes remembers the day he first met Pullatt.

“Up to that point, people kept telling me what things I couldn’t do,” Holmes said. “But Dr. Pullatt told me what I was capable of and not to get discouraged. He was going to help me.” 

But that help had to start from within himself, Pullatt had told him. So Holmes started eating healthier and doing water aerobics three times a week. He remembers trying to go for walks and getting winded after just a few steps. But he didn’t give up.

Pullatt told Holmes that he was a good candidate for a duodenal switch – a procedure that involves removing approximately 80% of the stomach and bypassing 70% of the proximal small intestine. 

“He said, ‘I can see you want this. You’re down to 618. Keep doing what you’re doing,’” Holmes said. As with any relatively new procedure, getting approval from health insurers can be tricky. It took months, but Holmes eventually got the green light from his provider, and Pullatt put him on the calendar. 

“I remember getting the call from them that it was going to happen, and I just panicked,” he said. “I totally freaked out. I wanted to back out. But my grandfather said, ‘What is wrong with you? You ain’t backing out now; you waited too long for this.’”

A shot of just the robot 
The DaVinci XI robot being moved into position.

And that’s how he ended up on the operating table, bathed in a lime green light, with the shoeless Pullatt a stone’s throw away, performing his duodenal switch. Ironically, the day of Holmes’ surgery was shrouded by a haze similar to the one he experienced during that trip to the ER back in 2017. Portions were missing, and there was plenty of pain. 

“I just remember them spreading me out like an airplane and putting something on my sides to keep me from moving,” Holmes laughed. “Then they told me they were giving me the anesthesia, and I was out of here.”

This time, however, when he returned home from the hospital, things started to get better.

“It wasn’t easy; I’m going to tell you that. People think you have a surgery like this and afterward, you just magically lose weight. It is nothing like that,” he said. 

At first, Holmes couldn’t make it up the stairs in his house. In-home therapy four days a week, coupled with daily exercises, led to incremental improvement. For six weeks, therapists would take him outside for walks. Each day, the walks got a little longer, and he got a little stronger. Holmes was finally losing weight – and fast. 

“Everybody else could see it, but I couldn’t,” he said. “But around two months later, I remember a specific morning when I got up and felt like I could move better.” 

He got back to water therapy. Met with his dietitian. His clothes stopped fitting. Today, just four months post-surgery, Holmes has lost nearly 150 pounds. Imagine giving a teenage boy a piggyback ride everywhere you go. And then one day, he’s gone. 

“I always kept the faith,” Holmes said. 

Instrument of change

Patient standing with surgeon 
Dr. Pullatt with Jamie Holmes, four months removed from his duodenal switch procedure.

“My friends still don’t believe me that they used a robot,” Holmes joked. “I am so thankful for Dr. Pullatt. He was incredible from day one. He was always patient. He explained everything. He didn’t make a single promise he didn’t keep.”

Each morning Holmes hops on the scale, but now, he’s not afraid of what he’s going to see. It’s his measuring stick. His reminder that he got a second chance. Still currently on disability from his property management job, he plans to eventually pursue a career in real estate, maybe flipping houses; he’s not sure. 

“There are so many possibilities now,” he said.

And he’s got a daughter he adores that he wants to be around for – for a very long time. He regrets not having mirrored the best behaviors when it comes to healthy eating. He knows he has an opportunity going forward to be a positive role model, an instrument of change for her. With heredity in mind, he never wants her to experience the pain that he has.

“I am eternally grateful to Dr. Pullatt and MUSC, but I don’t want my little girl to have to do what I did,” he said, emotion in his voice. “I want her to avoid being in that position in the first place.”

About the Author

Bryce Donovan

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