An Inside Look Weight-loss Surgeon Offers a View to Life in Today’s OR

Dr. John Romanelli didn’t bother with round numbers.When asked how many robot-assisted gastric-bypass procedures he’d led, including the one he took part in days earlier, he paused for maybe a half-second and said ’157.’

And by his count — and it’s clear that he’s certainly counting — there are probably only a handful people in this country, and maybe the world, who have handled more. That makes him uniquely qualified to talk about this still-somewhat-controversial, often-misunderstood procedure and how it has evolved, as well as the introduction of the surgical robot for procedures such as this, and how it has in many ways simplified matters for physicians.

Romanelli, medical director of the Weight Loss Surgery Program at Baystate Medical Center, did all that and much more as he gave HCN a rare inside look — both literally and figuratively — as he and he his team carried out procedure 157 in operating room 7 on a Monday morning in mid-May.

Several days after it was completed, he described the surgery as “very routine,” and noted that, in the medical community, that phrase has an unofficial definition. “Operations have an expected outcome, with an expected length of time, and expected steps in the operation to complete, so there is ’routine,’ or baseline normal.”

And while this procedure met that standard, it also provided several intriguing glimpses into how life in the operating room has changed in some important ways over the past several years in terms of technology, but also communication and even the concept of teamwork.

The robot, Romanelli explained, has greatly simplified steps such as suturing, especially in laparoscopic, or minimally invasive, surgical procedures, thus saving precious time for OR teams and surgeons. In the meantime, it also reduces the physical strain on the surgeon, especially in a four-hour operation like a gastric bypass, during which he or she is standing and maneuvering around a large body.

“It really simplifies many complex tasks like this,” said Romanelli as he used the robot to suture a piece of small intestine roughly an hour into the procedure.

As for communication and teamwork, he said they have always been the keys to preventing missteps in the operating room, and today, teams are borrowing lessons from military and civilian avionics to make sure everyone in the OR is on the same page and ready to proceed. And with that he introduced another term — ’time out.’

This is a meeting of all members of the surgical team prior to to a procedure, he explained. Often there are introductions — some in the room may not know each other — but there is always a checklist, similar to those used by flight crews, before the team gets a green light to proceed.

“We employ a concept called crew-resource management, whereby anybody in the room can stop the proceedings if they feel there’s a threat to patient safety,” said Romanelli, adding that the system has been in place for several years now. “When you take off in an airplane, there’s a whole checklist of items that happen beforehand that the staff has to follow; if anything doesn’t come up normal, the plane is grounded until they fix it. It’s no different in the operating room.”

For this issue, HCN takes full advantage of its access to the operating room to get a first-hand look at how technology, communication, experience, and teamwork came together to make Romanelli’s 157th robot-assisted gastric bypass a routine procedure.

Shedding Some Light

As the surgical resident inserted a camera through one of several small incisions and into the midsection of the patient in operating room 7, an eerie, reddish light, or glow, could be seen through the skin.

Assisted by that light, the tiny camera provided the crisp, graphic images — displayed on four large monitors — of the organs involved in this procedure designed to help morbidly obese people eventually shed dozens if not hundreds of pounds. As the camera moved about, the stomach, which would be stapled to reduce its size to just larger than a golf ball, came into view, as well as the liver, which the team would have to maneuver around, and eventually the small intestine, which would be rearranged to connect to both portions of the stapled stomach to markedly reduce its functional volume. Henceforth, the patient will experience the rapid onset of the stomach feeling full, followed by a growing indifference to food, shortly after the start of a meal.

As he talked about gastric bypass surgery before, during, and after this procedure, Romanelli acknowledged that there are many risks associated with this operation. In fact, there are complications with roughly one-third of them, a number that is far higher than for most other procedures.

“If you told me there would be a three in 10 chance I’d suffer a major complication … I wouldn’t sign up for that,” he said, adding quickly that, for most patients who undergo the procedure, there really isn’t much choice — and this is probably the best choice.

Indeed, all of them have tried dieting, exercise, and other methods for losing weight, and have confirmed to their insurance provider that none of those options, or combinations of them, will work, leaving one of several gastric-bypass options as the best course. “The complication rate is high if you look over a five-year period,” Romanelli noted. “But in five years, most of those people are going to have problems without the surgery, and some of them are going to die.”

Still, there is a great deal of education required in advance of the procedure, said Romanelli, and much of it involves informing the patient that gastric bypass is not a quick fix or a cure. Rather, it is a tool (a word he would use often) to be used in conjunction with diet and exercise to achieve desired results.

Acknowledging that it’s not perfect analogy, but works nonetheless, he compared the procedure to the latest, greatest driver on the rack at the golf-course pro shop.

“That golf club is not going to hit the ball 300 yards for me,” he explained. “I still have to have a perfect golf swing to hit it 300 yards; the new driver might make it easier for me to reach my objective, but I still have to accomplish the objective, and the tool isn’t going to do it for me.

“And that’s the way I teach these patients,” he continued. “I’m giving them a tool to make the dieting and exercise a little bit easier to accomplish. But if they don’t do those things, my operation is guaranteed to fail; it doesn’t stop after the operation, and it doesn’t stop for the rest of their lives.”

Elaborating, Romanelli said gastric bypass differs from most other surgical procedures in some important ways that patients must understand before they sign on.

“About 95{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of surgery accomplishes one of two things — you fix or cure a problem, or you prevent a problem,” he explained. “If you have cancer and you cut the cancerous tumor out, ostensibly you’re curing that disease to the extent that it can be cured locally. If someone has a bowel obstruction, and I go in and relieve that obstruction, I’ve fixed the problem.

“Weight-loss surgery is neither of those,” he went on. “It doesn’t cure obesity, and it doesn’t prevent obesity. It creates a side effect that can be manipulated with proper education into a beneficial outcome. That’s what people don’t understand about weight-loss surgery.”

Romanelli started assisting on gastric-bypass operations while in residency at Morristown Memorial Hospital in New Jersey, and handled many more during his fellowship in minimally invasive surgery at UMass. He retured to New Jersey for his first hospital assignment, at Monmouth Medical Center in Long Branch. He remained in the Garden State for four years, but was restricted there professionally by sky-high malpractice rates for the kinds of the surgery he wanted to perform.

“I went through a period where I recognized that I liked doing what I was doing in terms of surgery, but also recognized that I wasn’t going to be an academic surgeon — medical malpractice there at that time was very malignant,” he said. “I couldn’t do complicated things like gastric bypasses in that malpractice environment without working for a hospital that was self-insured.

“My choice,” he continued, “was to stay where I was, my home state, and do hernias and gall bladders — general surgery — or I could try to focus on weight-loss surgery, for which I spent four years building up my expertise. I decided I didn’t want to give up on that and do simpler procedures.”

That choice eventually took him to Baystate in 2005.

Stitch in Time

As he scrubbed for his gastric bypass procedure just after 7 a.m. on that Monday morning, Romanelli explained that this tool, as he described it, has been in use for nearly a half-century.

Indeed, the first such operations were carried out in 1967, he noted, adding that two important changes have come over the past few decades — the advent of minimally invasive, or laparoscopic surgery (which has many benefits for the patient and the surgical team as well), and the introduction of the surgical robot.

“Imagine trying to tie your shoelaces with casts on both your wrists, so that only your fingertips moved,” said Romanelli while describing what traditional laparoscopic surgery is like. “You can move your arms up and down, side to side, and in and out, and you can rotate them, but that’s it; whatever angle your arm is at is how you’re going to approach the laces.

“You look like Frankenstein, and that’s laparoscopic surgery; tasks like suturing can be very awkward and complex,” he said, adding that the robot has greatly simplified many aspects of a procedure like gastric bypass.

But the procedure itself is essentially the same as it was in 1967, he went on, noting that are three basic components to the operation.

“First, we’re going to divide the small intestine in half,” he explained. “I’m then going to go downstream on the intestine from where we made that division and then hook it back to together. Then, we’re going to cut the stomach into a very small stomach pouch, then go back and grab the divided end of the intestine and hook that back to the stomach.”

And although Romanelli has led or assisted in roughly 300 bypass operations of different types, he stressed that each procedure is different because every patient’s anatomy is different.

“Everyone has a different body and a different set of anatomic structures,” he told HCN. “You have to tailor the basic core principle of the procedure to what you see in front of you; you have to play cards with the hands that you’re dealt.”

Upon completing preliminary preparatory work for the procedure, Romanelli moved behind the controls of the one-ton, $2 million da Vinci robot; he compared the controls to the yoke of a plane because of their ability to let him up or down and side to side.

While Romanelli is physically removed from the bedside to operate the robot, he is still very much in tune with everything going on with the procedure, and in constant contact with each member of the team.

Indeed, while he was maneuvering the robot’s arms, he could be heard giving instructions to the surgical resident while she was stapling the stomach, and often voicing praise as steps were carried out effectively and efficiently.

At one point, he stepped out from the robot to ask pointed questions about how the team had lost the pneumoperitoneum, or cushion of air (created by inflating the abdomen with carbon dioxide) that is needed to effectively carry out laparoscopic procedures such as this one, and help right the situation.

It was an example, he said, of the importance of communication in the ER and the constant focus on patient safety and that emphasis on crew-resource management he mentioned, and also the time out, or pre-operation huddle, as he also called it, to make sure everyone was in fact on the same page and knew what was going to happen that morning.

He called these sessions standard operating procedure, in every sense of that phrase.

“The most-commonly cited sentinel events to a bad patient outcome are poor communication between providers,” he explained. “Whether that’s doctor to nurse, doctor to doctor, doctor to resident … it doesn’t matter. Communication is critical.

“And that’s one of the things about robotic surgery that’s a potential downside,” he continued. “You’re physically separated from the rest of your team, so your communication skills need to be very finely attuned to that — so there are times when they need to see my face. The body language of getting up from the robot gets everyone’s attention.”

Sewing This Up

Summing up his latest gastric-bypass procedure, Romanelli said that, like the 156 that came before it — and the myriad other operations he’s performed — this one was another learning experience, for him and everyone else in the room.

In many ways, it offered a look at some of what has changed in the OR, but reinforced the notion that the most important things — like teamwork, communication, and commitment to patient safety — haven’t.

In those respects, it was anything but routine.

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