Dr. David Harrell and the da Vinci Robotic Surgery System

David Harrell, M.D., performed the first Whipple procedure using the da Vinci robotic surgical system in March at Physicians Regional Medical Center. Dr. Harrell, is chairman of the department of surgery at Tennova Healthcare’s Knoxville metro hospitals (Physicians Regional Medical Center, North Knoxville Medical Center and Turkey Creek Medical Center), has received extensive training in the use of robotic technology. He has performed more than 350 robotic-assisted abdominal surgeries, including colon, gallbladder, and gastrointestinal tract procedures as well as hiatal hernia repair.

“Pancreatic cancer is an aggressive disease that develops in the tissues of the pancreas and typically spreads rapidly to nearby organs,” Dr. Harrell said. “Treatment may include surgery, chemotherapy, radiation therapy, or a combination of these. For some patients, the Whipple procedure is curative, which means the entire tumor is removed with clear margins and no further cancer treatments are required.”

Dr. David Harrell, General Surgeon

According to Dr. Harrell, the complicated Whipple procedure involves removal of the “head” of the pancreas, the gallbladder, the duodenum (the first section of the small intestine), a portion of the bile duct, and sometimes part of the stomach. The surgeon then reconstructs the digestive tract.

Robotic-assisted surgery refers to minimally invasive procedures that utilize robotic technology and 3D imaging. The controls and surgical tools are guided by the surgeon. The robotic surgical system allows physicians to operate through smaller incisions, resulting in less pain and scarring.

Traditional open surgery for pancreatic cancer involves a wide incision (8 to 10 inches or longer). Patients of the robotic technique experience five tiny incisions.

“Although the outcomes are equivalent,” Dr. Harrell said, “the less invasive approach may result in a faster recovery, less pain, less blood loss, less inflammation, and fewer pain medications. A quicker recovery also means that patients are able to begin chemotherapy or radiation therapy as part of their cancer treatment plan much sooner than those who undergo the open procedure.”

Dr. Harrell noted that the first patient to receive the robotic-assisted Whipple operation in Knoxville was out of bed and walking on the day after surgery. The patient was discharged from the hospital after seven days, and is doing well.

“We are fortunate to have the latest technology and a talented team at Tennova. The Robotic surgical team is excellent and this surgery was only possible as a team effort,” Dr. Harrell said. “For our patients, that means access to high quality medical and surgical care.”

Dr. David Harrell is a General Surgeon at Premier Surgical’s Tennova North Knoxville location. He performs procedures at Physicians Regional Medical Center, North Knoxville Medical Center and Premier Surgical Papermill.

For more information about Premier Surgical at North Knoxville Medical Center call (865) 938-8121. Visit our General Surgery web page for listing of all Premier Surgical surgeons and locations.

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Melissa Smith, LPN

As a Premier Surgical Associates LPN, Melissa Smith answers a lot of questions from patients before and after surgery. She works with Premier General Surgeon Dr. David Harrell, and helps prepare and follow up with patients requiring a variety of surgeries related mostly to hernias, gallbladder, appendix, colon, thyroid, or pancreas diseases.

“I talk with each patient so they know what’s going to be done and why. We discuss what happens before, during, and after the surgical procedure, and then I follow up with them the day after their surgery to see if they have any questions,” Smith says. The following questions are common and relate to most surgeries.

How do I manage pain?

Patients typically are given a prescription for Percocet or Hydrocodone after surgery. Both of these medications can be taken as one or two tablets at a time, as frequently as every 4-6 hours. It’s also ok to use Ibuprofen or Tylenol (Acetaminophen) instead of the pain medication if able.

What should I do if I have a fever?

Most fevers in the first 2-3 days after surgery are due to lung congestion. If you experience low-grade fevers after discharge, the first step is to try to get out of bed, walk, cough, and breathe deeply as much as possible to open the lungs. If you experience a fever of greater than 101 degrees, please call your physician.

When should I change dressings, and what if there’s blood?

Change the bandages on your incision at the end of the first full day after surgery. The dressing will come off easily in the shower. Expect to see some blood on the incisions after discharge, which is very rarely a serious problem. If the incision is actively bleeding, apply firm pressure with a sterile 4×4 gauze over existing dressing for five minutes. Do not remove any dressings, just reinforce the existing one so as to not remove the clot. This should stop most minor episodes of bleeding, but if active bleeding continues through reinforced dressings, call your physician.

When can I shower?

Incisions can be washed in the shower at end of the first full day after surgery. Let water run over the incision, wash gently with soap and water, and pat dry. Soaking in a swimming pool or bathtub should be reserved for at least 7 days after surgery, or until the skin has healed together.

What can I eat?

Anesthesia medications are usually to blame for any nausea you may experience. Plan on eating lightly the night after surgery. Broths and ginger ale (except after Hiatal Hernia repair and Gastropexy surgeries, as carbonation can increase gas and put pressure on your stomach), are usual recommendations, or any comparable light fare. Typically, the day after surgery all of the anesthesia medications have been processed out of your system, and you can return to your normal diet. If you’re still queasy, continue with small meals of lighter foods.

When can I drive?

You’ll need a caregiver to drive you home after you’re discharged. Beyond that, it’s recommended that you don’t drive until you’ve been off of prescription pain medicines for at least 24 hours, and when you think that your reaction time if faced with a sudden crisis in traffic would not be compromised by pain from your surgery. This is typically 5-7 days after surgery.

How do I know if my incision is infected?

Many patients notice some mild redness around their incisions, and concerns about infection are common. Most infections occur between 5 and 10 days after surgery, and are characterized by pain, intense redness, and often drainage of yellow fluid or pus. Fever of 101 or greater can also accompany these signs. If these symptoms occur, contact your physician. Taking antibiotics by mouth is often sufficient treatment, but occasionally your surgeon will want you to come into the office early for an evaluation of the incision.

What kind of activity can I do after surgery?

While it’s expected that you will be sore, you should be able to walk on your own and will be encouraged to be up and about as much as you can tolerate. Expect your energy level to be decreased for at least a week after surgery, but be as active as you can. It’s generally recommended that you lift nothing greater than 10 pounds for 10 days for outpatient or day surgery. Do not lift more than 10 pounds for 6 weeks after open abdominal surgery, colon, or hernia surgeries.

How do I prevent constipation?

Anesthesia and pain medication can frequently cause constipation, so over the counter  Metamucil Colace stool softeners and MiraLAX can be used daily after surgery for prevention.

When do I need to see the doctor again?

Most physicians will want to see you 7 to 14 days after most operations. There are exceptions, and your doctor will give you instructions on when to schedule your appointment.

“Our difference is our continuity of care,” Smith explains. “We have protocols and systems in place to make sure we’re able to get in touch with our patients. And of course patients are always encouraged to call our office with any questions they might have—that’s what we’re here for.”

Premier Surgical Associates is the largest general and vascular surgical group in the Knoxville region, providing comprehensive surgical care, with referrals from across the entire East Tennessee region. To learn more about our specialties, visit Premier Surgical Associates.

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Laparoscopic surgery, sometimes called “keyhole” surgery or band-aid surgery, is a minimally invasive procedure using small incisions of around 0.5 to 1.5 cm. A laparoscope, which is a small tube with a camera at the tip, is passed through the incision to the surgical site and relays images from inside the body to a monitor. 

Surgeons are then able to perform procedures with small, thin instruments that are passed through the incision. Laparoscopic surgery often includes operations within the abdominal or pelvic cavities, such as removal of the appendix, gallbladder, colon, or kidney to name a few.

Casey Johnson, a certified Physician Assistant who works with the eight Premier Surgical Associates physicians at Parkwest Medical Center, says, “As a PA, I want patients to know that it’s amazing how much can be done laparoscopically now and most people don’t realize that. This means surgeries require much smaller incisions and recovery time is much shorter.”

He adds, “Some people fear the procedure so much that they put it off and then their illness becomes a bigger problem, which results in a more complicated surgery with longer recovery time. But with early detection, so much can be treated laparoscopically.”

There are a number of advantages of laparoscopic surgery, for both patients and physicians, versus traditional open surgeries, including:

• Smaller incisions, which shortens recovery time and results in less scarring.
• Less pain, leading to less pain medication needed.
• Shorter hospital stays, often with a same day discharge
• Shorter overall recovery time to return to normal activities.
• Reduced risk of hemorrhaging and reduced risk of infections.

Johnson says, “We often hear patients say they didn’t realize the procedure was going to be as easy as it was, and that the recovery was easier than they expected.” He advises all his patients to follow their primary care doctor’s recommendations for early detection screenings, and to not wait if they need a surgical procedure.

Premier Surgical Associates is the largest general and vascular surgical group in the Knoxville region, providing comprehensive surgical care, with referrals from across the entire East Tennessee region. To learn more about our specialties, visit Premier Surgical Associates.

The post What is Laparoscopic Surgery, and Why Do You Want It? first appeared on Premier Surgical.

The importance of service and helping others was instilled in Jose Luis Mejia, MD, FACS, at an early age. As the son of a politician and owner of a newspaper in the South American country of Ecuador, Dr. Mejia saw how his father served the community.

But it was his uncle, who was a surgeon, who inspired him to serve through medicine.

“When I was young, my uncle took me to the clinic where he operated. I loved cleaning wounds, removing sutures, and I especially loved the operating room. It came naturally to me,” says Dr. Mejia.

While in medical school at the prestigious Central University of Ecuador, Dr. Mejia trained with one of the pioneers of laparoscopic surgery techniques.

Dr. Mejia is an avid runner and is pictured in the 2013 Boston Marathon. He completed the race 40 minutes before the fatal bombing. He says the tragedy is a reminder of the importance of life and family.

“Surgeons were transitioning to minimally invasive surgeries. It was an  advantage that I trained in a time when we did a lot of both open and laparoscopic procedures,” explains Dr. Mejia.

Drawn by the medical technology available, Dr. Mejia moved to the United States in 1999 and completed his residency in General Surgery at East Tennessee State University. He worked at Veterans Affairs Medical Center in Johnson City for eight years, serving as Clinical Associate Professor and Chief of Surgery. Most recently, Dr. Mejia was on staff at Masssena Memorial Hospital in upstate New York, providing surgical and wound care to a variety of pediatric and adult patients.

Dr. Mejia and his family missed East Tennessee, so he recently joined Premier Surgical Associates in Knoxville as a general surgeon at the group’s Tennova North and Physicians Regional locations in June.

“We love it here! The mountains, the people – everyone says ‘Hello’,” says Dr. Mejia. “Premier Surgical has a great reputation and I’m excited to be a part of this group.”

Dr. Mejia, who speaks both English and Spanish, has found already his native language to be an advantage in communicating with patients.

“Communicating and always being honest with my patients is very important to me,” explains Dr. Mejia.”

Dr. Mejia, whose special interests include minimally invasive procedures for benign and malignant problems of the abdomen and breast cancer surgery, is currently accepting new patients at the Premier Surgical offices at Tennova North and Physicians Regional.

To schedule an appointment with Dr. Mejia, call 865-938-8121.

About Premier Surgical Associates
Headquartered in Knoxville, Tennessee, Premier Surgical Associates has 27 surgeons who perform general, vascular, endovascular, vein, bariatric, breast, laparoscopic (minimally invasive) and oncologic procedures. Premier has offices in Knoxville, Crossville, Dandridge, Lenoir City, and Sevierville.

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Gallstones can cause digestive issues and pain. However, unless there are symptoms, sometimes people may never know they have gallstones. When they’re asymptomatic we call them “silent gallstones.” Roughly ten percent of Americans have gallstones, but if there are no painful symptoms no treatment is needed.

But, when gallstones block the bile duct, the gallbladder can become inflamed or infected, causing several symptoms. People often have pain in their middle abdomen or on the right side that radiates to their back. This is usually accompanied by bloating or nausea. The symptoms often occur after eating greasy or fatty food.

The symptoms may appear chronically over a period of months or years, or be sudden and acute. Imaging tests are normally used to diagnose gallstones. When painful symptoms persist, or a gallstone blocks the bile duct, surgical removal of the gallbladder (cholecystectomy) is normally recommended.

Cholecystectomy is one of the most common procedures performed in the United States every year. It is usually done laparoscopically, with just a few incisions, and patients go home the same day. Recovery time is normally about a week.

The risk of complications is low and the gallbladder symptoms usually stop. The great thing about it is that everyone feels better after having their gall bladder removed. I’ve never had anyone say: “I want my gallbladder back”. It is a safe and effective way to resolve the pain of gallbladder disease.

William C. Gibson, MD, FACS, is a surgeon with Premier Surgical Associates at Parkwest Medical Center in Knoxville, Tennessee. He is board certified in general surgery by the American Board of Surgery and a Fellow of the American College of Surgeons.

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Authors of the article, a group of surgeons from the University of Leicester in England, looked at 49 studies involving 2,336 patients who underwent single-incision laparoscopic cholecystectomy (SILC). Based on their study the researchers concluded, “Outcomes from systematic reviews rather than market research must guide decisions about surgical procedures if we are to ensure that surgical progress is not dictated by commercial and industrial interests.”

Upon reviewing the article (http://www.medscape.com/viewarticle/767710?src=mp&spon=14), my colleagues and I enjoyed a healthy conversation about the potential merits of newer procedures, such as single-incision laparoscopic surgery and robotic surgery. The following captures some of our thoughts:

Dr. Michael Kelly: The results of the study come as no surprise and lend more support to my suspicion that many single-site and robotic-assisted surgeries are just another way to perform the operation. They are useful techniques and often enable some surgeons to operate in a minimally invasive fashion. Premier surgeons use these techniques safely, but I do not believe that they can be presented as superior, safer or better than the standard laparoscopic approach. So far, there is no good data to support these kinds of statements in general surgery, just anecdotal experience. Terms such as “painless” and “incisionless” are industry-driven and misleading.

That’s why discussions like this are beneficial to our practice and our patients. While currently there is insufficient data for patients to provide informed consent, we can share information from surgeons in our practice who are regularly performing these procedures.

Dr. Mark Colquitt: Having had the experience of nearly 100 robotic gastric bypasses under my belt, I can honestly say that, if possible, I will never go back to older laparoscopic methods. Currently greater than 90 percent of our gastric bypasses are done robotically. The patients tend to do better – less pain, no nausea and early mobility. More often than not we are sending patients home within 24 hours. We were never able to do that before. From a personal standpoint, doing robotic surgery is probably the most fun I’ve had in the operating room. Ergonomically, there is very little strain on your neck and back, and at the end of a long day you feel rested.

Dr. David Harrell: I agree, Mark. I wouldn’t want to go back to laparoscopic Nissens [a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia]. The dexterity, vision and ergonomics are far superior. I am able to repair and wrap much more securely because I can place sutures where I physically couldn’t laparoscopically. Also, don’t discount single-incision laparoscopic cholecystectomies. I agree they are not for most patients, but for the body-conscious patient it is amazing to have no visible scar. The key is that it can be done safely and practically with good triangulation and excellent vision of the critical view.

The bottom line is this: Newer isn’t necessarily better, nor is it necessarily worse. The key is for patient and physician to have a frank discussion, weigh the pros and cons, and move forward with the best interest of the patient in mind.

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In May 2011, a retrospective cohort study published in the Archives of Surgery stated: “Laparoscopy independently predicts decreased mortality from colon resection even when controlling for multiple factors.”

The study compared mortality rate and associated factors for laparoscopic and open colectomy, using the Nationwide Inpatient Sample database. In the United States, an estimated 1,314,696 patients included in the Nationwide Inpatient Sample underwent colectomy between 2002 and 2007. Of these patients, 1,231,184 underwent open procedures and 83,512 had colectomy by a laparoscopic approach.

Study authors Molly M. Cone, M.D., of the Oregon Health and Science University Department of Surgery in Portland, and colleagues concluded: “Laparoscopic colectomy was shown to be an independent predictor of a markedly decreased mortality rate when compared with open colectomy.”

A study posted in the Annals of Surgery in 2010 concluded that laparoscopic resection for treatment of colorectal cancer can achieve excellent results, even in high-risk patients. The study also confirmed what we’ve experienced in our local practice: Laparoscopic colorectal surgery produces better outcomes for high-risk cancer patients compared to open surgery.

Unfortunately, despite strong evidence, less than 10 percent of colon resections across the country are performed in the minimally invasive fashion. Premier surgeons were early adopters of laparoscopic surgery in Knoxville and now routinely utilize this technique in most patients requiring colectomies.

The American Cancer Society offers this advice to patients exploring surgical options for the procedure: “Laparoscopic-assisted surgery is as likely to be curative as the open approach for colon cancers. But the surgery requires special expertise. If you are considering this approach, be sure to look for a skilled surgeon who has done many of these operations.”

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Robotic surgery offers significant advantages, such as better magnification through use of a 3D camera, better instruments, and more degrees of articulation. It allows the surgeon to sew and operate as if using his own hands but with much smaller instruments that give much more control.

Dr. Roland Weast and I are in the early stages of using robotic surgery, and our colleague Dr. Marcella Greene was recently trained. As of the writing of this article, Dr. Weast and I have completed five robotically assisted microscopic Nissen fundoplications and one adrenal resection. We already see the clear benefits of using this procedure.

One of the Nissen procedures was used to treat a recurrent hiatal hernia. Without the robot, the procedure would have required a thoracotomy – a large chest incision. Thanks to the increased mechanical ability of the robot, we were able to get higher in the patient’s chest and perform the surgery without opening up the chest. By avoiding a thoracotomy, the patient had less pain, a shorter hospital stay and a quicker recovery time.

Other benefits of robotic surgery include:

• Greater safety. It allows us to place stitches more securely and to place them where we couldn’t otherwise reach, making the repairs more secure.
• Better vision. We’re able to clearly see the anatomy with 3D vision.
• Less fatigue. The surgeon is able to sit comfortably while the robot leans over the patient.

We see robotic surgery as a tool that makes the surgery better for the patient and better for the surgeon. We plan to use it for most Nissen fundoplications and for more complex procedures.

Dr. Weast and I are currently accepting patients. If you’re a referring physician or a patient who would like to explore the option of robotic surgery, please to contact Premier’s North Knoxville location.

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The post Robotic Surgery Revolutionizes Treatment of Acid Reflux and Hiatal Hernias first appeared on Premier Surgical.

Typically, there’s an early window of opportunity in acute cholecystitis where the inflammatory plane makes it relatively easy to separate the gallbladder from surrounding structures. After a few days chronic inflammation and scarring predominate and separating the gallbladder away becomes more difficult and risky. In general surgery, some surgeons have held to the belief that it is best to delay laparoscopic surgery; however, as indicated in the study’s findings, that may not be the best course of action.

The research team studied 4,113 patients who had laparoscopic cholecystectomy for acute cholecystitis at different times; 1,416 on the day of admission (i.e., day 0), 1,542 on day one, 530 on day two, 247 on day three, 218 on days four or five, and 160 on day six or later.

The investigators found that when surgery was delayed for six days or more: rates of conversion to open surgery increased from 11.9 percent on the day of admission to 27.9 percent; post-op complications increased from 5.7 percent to 13 percent; re-operation rates rose from 0.9 percent to 3 percent; and length of hospital stay increased from 6.1 to eight days.

Ideally, the gallbladder should be removed before it reaches the acute stage. Coming in through the emergency room with an inflamed, infected gallbladder increases the risk of problems such as bile leakage, infection and other complications. It also increases the odds of needing open surgery. That’s why I’d like to encourage medical doctors to go ahead and call the surgeon at the first sign of gallbladder problems. When we’re notified right away, we can help prevent problems, get people home sooner, and avoid open surgeries.

I don’t view the 48-hour recommendation as an absolute rule, but it does serve as a good guideline.

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As a bariatric surgeon, I am well aware of the risk of SSI for the severely obese. When performing open bowel surgery on a morbidly obese patient, the infection risk is 20-40 percent. The good news is that we now typically perform the surgery laparoscopically, which reduces the infection risk to only one percent.

I recently read an article, detailed further below, about a study which found that in patients undergoing colon surgery, obesity is associated with a 60 percent increased risk for SSI, with a 14.5 percent infection rate for obese patients versus a 9.5 percent risk for non-obese patients. I concur with the article, and was actually surprised that the infection rates for obese patients weren’t even higher.

The article makes good points in saying that, in addition to the risk of infection, obese patients undergoing colon surgery typically have longer hospital stays and a greater risk of long-term complications such as ventral hernias and stoma complications.

So, should an obese patient try to delay colon surgery until after they’ve had an opportunity to lose weight? For a person 20-40 pounds overweight, I don’t believe it would make that much of a difference. For an individual 100 pounds overweight with a medical condition that doesn’t require immediate surgery, losing weight through bariatric surgery prior to colon surgery would be an option worth exploring.

Delving Deeper

Medscape.com published an article on May 16, 2011, regarding a retrospective study, led by Elizabeth C. Wick, MD, from the Department of Surgery at the Johns Hopkins University School of Medicine (Baltimore, Md.) and colleagues, reported online May 16 in Archives of Surgery.

Article Overview

A new study has found that in patients undergoing colectomy, obesity is associated with a 60 percent increased risk for surgical site infection (SSI), and those developing SSIs had significantly increased costs and longer hospital stays than those who did not.

To evaluate this issue, the researchers designed a retrospective study of patients undergoing colectomy because of the greater risk for SSI with this surgery compared with other abdominal surgeries. The cohort included 7,020 patients undergoing colectomy. The authors reviewed administrative claims data from eight BlueCross BlueShield insurance plans and compared 30-day SSI rates among obese and non-obese patients and determined health care claims in the 90 days after surgery. Patients had undergone complete or segmental colectomy for colon cancer, diverticulitis, or inflammatory bowel disease between Jan. 1, 2002, and Dec. 31, 2008.

Study Results

The overall rate of SSI was 10.3 percent. Obese patients had a significantly higher rate of SSI compared with non-obese patients (14.5 vs. 9.5 percent, respectively; P <.001). Obesity was the strongest predictor of SSI after adjusting for laparoscopy, diagnosis, sex and age. Obese patients experienced a 60 percent increased odds of SSI compared with non-obese patients (odds ratio, 1.59; 95 percent confidence interval, 1.32 – 1.91). Open surgery vs. laparoscopy was also associated with SSI (odds ratio, 1.57; 95 percent confidence interval, 1.25 – 1.97).

Average cost was more than $17,000 higher in patients with SSI ($31,933) compared with the cost for those without infection ($14,608; P <.001). In addition, in patients with SSIs, hospital stays were an average of more than a day longer (mean, 9.5 vs. 8.1 days, respectively; P <.001), and these patients were more likely to be readmitted into hospital (27.8 vs. 6.8 percent, respectively; P <.001).

Summary of Findings:

Obesity was the strongest predictor of SSI after adjusting for laparoscopy, diagnosis, sex and age. Obese patients experienced a 60 percent increased odds of SSI compared with non-obese patients. SSIs increase the cost of care, lengthen hospital stays and increase the likelihood of hospital readmission.

Summary of Commentator Side Statements:

Dr. Wick and colleagues added:

• SSI rate is now considered to be one of the best measures of quality for surgical procedures. By far, the most common major SSI risk factor encountered is obesity — a condition that is increasing in prevalence and differentially affects certain minority populations.
• The costs to society of SSIs are far greater can be estimated in this study, as patients with SSIs have delayed return to daily activities after surgery and have increased risk of long-term complications such as ventral hernias and stoma complications.
• Pay-for-performance policies in surgery should account for the increased risk of infection and cost of caring for this population.

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