By KRISTA CONGER

Two-month-old Daniel Pham doesn’t know it yet, but he recently made history. Of course, like any techno-savvy kid these days, he had a little help – namely in the form of a 6-foot-tall, three-armed surgical robot known as “da Vinci” and two highly skilled pediatric surgeons.

On Jan. 9, Craig Albanese, MD, and Thomas Krummel, MD, used the robot to reconstruct a faulty connection between Daniel’s liver and small intestine that, if left untreated, would have required a liver transplant. Although da Vinci had lent an arm or three in one other pediatric surgery since its arrival at the medical center last fall, Daniel’s operation marked the first time in the world that the robot had been used to perform the technique, called the Kasai procedure.

Surgeons used a robot in an intricate laparoscopic procedure on an infant at the medical center. The robot, called da Vinci, enabled surgeons to be more precise while increasing their surgical range of motion. Photo: Robert Dicks

“We’re changing the culture of surgery,” said Albanese, chief of pediatric surgery. “Usually we have our hands in there, feeling and doing. Even with the more recent laparoscopic techniques we were still right at the patient’s bedside. Now we’re taking several steps away to sit at a remote console.”

The console, which looks somewhat like an overgrown version of a child’s Viewmaster toy but sporting hand grips and foot pedals, sits against the wall of the operating room about 10 feet from the patient.

During Daniel’s surgery, Albanese manipulated the surgical instruments from the console while Packard Children’s Hospital surgeon-in-chief Krummel assisted at the bedside. Both physicians are also professors of surgery at the School of Medicine.

Daniel’s brush with fame was caused by a congenital abnormality called biliary atresia. About 300 infants each year in this country are born with the condition, which results in destruction of the duct that delivers bile from the liver to the small intestine. The accumulation of bile in the liver leads to severe jaundice within roughly three weeks of birth, followed by irreversible organ damage and death.

Like the more traditional manual surgery, Daniel’s procedure was performed using minimally invasive techniques that required only five small incisions in his abdomen. Although minimizing pain and allowing for a faster recovery, such small entry points lead to unavoidable technical problems. For instance, surgery must be viewed in two dimensions on a monitor above the patient; the surgeon can’t control the surgical instruments and the camera simultaneously; and the instruments’ range of motion is hampered by the anatomical restrictions of the human arm, wrist and hand.

In contrast, the da Vinci, which is manufactured by Intuitive Surgical Inc., treats the surgeon to a 3-D view of the ongoing procedure. It gives total control of two instruments and a camera via a console; hand and foot movements are translated into steady, precise and unrestricted movement of the robot’s arms, which hold surgical instruments that have been scaled down for use in children. Other members of the team view the action on a monitor perched next to the operating table.

As the president of the International Pediatric Endosurgery Group, Albanese is no stranger to minimal-access surgery. His years of experience help him appreciate another, equally important benefit of robotic surgery.

“It’s incredibly comfortable,” said Albanese. “Surgery can be tiresome and ergonomically uncomfortable. With the robot, I can place my head in a comfortable viewing box and rest my arms on a cushioned armrest. Then I go about moving my hands and arms just like I would in a traditional surgery.” A microphone connected to a speaker near the bedside monitor amplifies the surgeon’s voice for the rest of the surgical team, instructing them when to swap instruments, commenting on the procedure or conferring with the surgeon at the bedside.

The robot’s lack of some human characteristics also can be an advantage.

“The robot filters out any hand tremor and scales motion,” said Albanese. “I can move my hands five centimeters and the instrument moves only one. This allows more sweeping motions and increases the comfort and precision of the surgery. ”

As for this particular procedure, “The surgery went really nicely,” said Albanese. “Daniel’s doing very well.”

All this might not matter much to Daniel now, but he – and the many other children at Lucile Packard Children’s Hospital that will likely experience the robot’s ministrations in the coming years – will appreciate it later.