For the Minimally Invasive Vascular Surgery (MIVS) department at St. Vincent Mercy Medical Center, the predominant goal is enhancing patient safety through the use of cutting-edge technology. Though small in number, this multi-specialty team—which includes Medical Director Dr. Bernardo Martinez, Manger Jose’ Mendez, 3-D Imaging Specialist Joyce Moses, and Angie Gerhardinger, RN & Certified Vascular Nurse—is making a big medical impact.

Through their use of minimally invasive techniques, including the latest endoscopic, laparoscopic, endovascular, and robotic procedures, the MIVS team is helping to reduce surgical trauma and postoperative pain as well as decrease hospital stays and recovery periods for patients undergoing vascular surgery. In addition to state-of-the-art surgical procedures, the team provides training and education to doctors and new residents on all of the newest minimally invasive techniques and conducts extensive research in the field, as well.

In deciding which surgical technique a patient should receive, the MIVS team conducts a comprehensive clinical-anatomical evaluation, which involves examining the patient and reviewing different information to determine whether one of the minimally invasive techniques is appropriate or whether the patient is a better candidate for traditional surgery. “The most important thing is making sure that the procedure, whether it’s endoscopic, laparoscopic, endovascular, robotic, or conventional, is tailored to the particular patient in order to ensure optimal results”, Jose’ Mendez points out.

One of many important components of the clinical-anatomical evaluation is 3-D imaging. Joyce Moses, who is in charge of the MIVS 3-D imaging laboratory, develops a three-dimensional image of the relevant vascular anatomy, which is converted from a computerized tomography angiogram (CTA), so the team an visualize exactly what the surgeons will be working with, take measurements, and determine the best technique to correct the problem.

For example, if a patient has an aortic aneurysm that requires a stent, critical measurements are made from the CT angiogram to ensure that a stent of the correct size is used. The 3D model provides the physician with an anatomical image of the aorta and provides additional pre-treatment information in the assessment of the abdominal aortic aneurysm. “Stents can leak, which is why it’s so important to measure,” Jose’ Mendez explains. “The more accurate the measurements are, the less chance you have of experiencing a leak six months down the road.”

Pre and postoperative patient surveillance is also paramount for patient safety. This portion of the program Is coordinated and monitored by Angie Gerhardinger, the endovascular case manager. She coordinates pre and post CTA surveillance and identifies issues that need to be addressed by the team and again communicates findings to surgeons and patients.

The MIVS program was begun in 1998 by Dr. Martinez and Steve Mickus, now the CEO of Mercy Health Partners, and was a natural outgrowth of the revolution of minimally invasive procedures that began in the 1980’s. A pioneer in this area, Dr. Martinez was using an endoscopic technique as early as 1982 for the treatment of thoracic outlet syndrome (neurovascular symptoms in the upper extremities due to pressure on the nerves and blood vessels – similar to carpal tunnel syndrome).

“It was my idea to use a scope in the shoulder,” Dr. Martinez says. “I was a patient myself for an ACL rupture. My doctors said they had to do an endoscopic procedure on my knee, but I said that I would like to see the procedure performed first. As I walked into the room, I realized that if they could do it with a knee, then I could do it with a shoulder.”

Some of the most fascinating minimally invasive procedures utilized by Dr. Martinez and his team at MIVS involve robotic technology, which evolved from the endoscopic work begun in the 1980’s. The daVinci® System, for example, is an intuitive, robotic alternative to traditional open surgery and conventional laparoscopy, which enables Dr. Martinez to remotely perform very delicate, complex procedures through very small incisions. For the patient, this means significantly less pain, minimal loss of blood, minimal scarring, shorter recovery time, and, often, a better clinical outcome.

With the da Vinic® System, the surgeon sits at a console, viewing a magnified, three-dimensional image of the surgery site while manipulating instruments located below the display. The surgeon’s hand movements are translated, without hand tremor, into precise, real time movements of pencil-thin robotic surgical instruments positioned inside the patient. da Vinci® allows the surgeon the same intuitive control, range of motion, and ability to manipulate fine tissue that is possible with conventional open surgery while still working through very minimal incisions.

“The da Vinci® System differs from routine endoscopic approaches in that it utilizes a powerful camera with two binocular sources – sort of like two eyes and a brain – which is how it provides a three-dimensional image of the surgery site,” Dr. Martinez says.

MIVS has been doing surgeries with da Vinci® since 2003 and has since used it on a total of 78 patients (as of this writing). Dr, Martinez is a pioneer in the use of the da Vinci® System, as well as, being the first authorized vascular surgeon to obtain FDA approval to do aortic surgery with the unit and the only principal investigator in the USA for aorta replacement with da Vinci®.

In addition to the da Vinci® System, MIVS utilizes other state-of-the-art robotic systems, including AESOP (which stands for Automatic Endoscopic System for Optional Positioning), a robotic arm that is controlled by the surgeon’s voice. With AESOP, the surgeon has to master a relatively simple menu of commands and train his or her voice to deliver the commands correctly since the say the commands are given directly affects the movements of the arm. AESOP is used in coordination with the Hermes control center, which is a centralized system that enables the surgeon to control a network of computer-controlled medical devices, using only voice.

Asked what sets robotic surgery apart from more conventional endoscopic techniques, Dr. Martinez emphasizes two interrelated characteristics: precision and safety. “With robotics, the properly trained surgeon isn’t going to make gross errors. One millimeter wrong is unacceptable. There are also significant safety protocols. Before you even begin, every move has bee thoroughly studied and thought out, and bailout maneuvers are in place. It’s like a fighter pilot learning to fly a new plane. That translates directly into a much greater margin of safety for the patient,” he says.

Looking to the future of his field, Dr. Martinez is optimistic that the use of robotic technology will be significantly expanded to benefit surgeons and their patients in a variety of innovative ways. “We’re trying to get more physicians on board, not just for vascular, but also for cardiovascular, urology, gynecology, general surgery and other areas,” he observes. And that is where his strong emphasis on research and the education of future generations of doctors comes in. Toward that end, Dr. Martinez currently conducts a weekly vascular teaching conference, in which residents seek his input on various cases; regular endovascular conferences with a multidisciplinary team; dry laparoscopic training so physicians can learn to use the equipment and develop the necessary hand-eye coordination for robotic and endoscopic procedures; d Vinci® dry lab draining; and various other surgical workshops.

“I see all of the training and research we do as an investment in the future generation of doctors that will pay dividends in the form of greater safety and better outcomes for patients,” says Dr. Martinez.