Translating Research to the Patients

One of the purposes of establishing CASIT was to foster a world-class minimally invasive surgical program. The Departments of Surgery, Urology, Gynecology, and Neurosurgery, and the VA Telehealth (Telemedicine) Center, UCLA Simulation Center, and UCLA Center for International Emergency Medicine (CIEM) are all involved in this program.

Department of Surgery

General Surgery

Two recently recruited faculty members, Dr. Erik Dutson and Dr. Amir Mehran have greatly expanded the quality and quantity of the minimally invasive program. In addition, Dr. Joe Hines has become an active leader in the minimally invasive program in General Surgery. Plus, an MIS fellowship program has been developed. An example of the contributions of this team is the bariatric surgery program, which was recently completely reorganized and restructured. An interactive website has been established for the program, and over the past two years, this team has performed more than 500 laparoscopic roux-en-y bypasses for obesity, without any anastamotic leaks or deaths. The UCLA MIS Bariatric Program has exceeded all United Health Consortium benchmarks for quality among academic centers across the US. The quality has become nationally and internationally recognized as one of the superior programs in the country. It is preparing for designation as a Center of Excellence through the American Society of Bariatric Surgeons.

Additionally, the overall volume of general surgery procedures now being performed laparoscopically has increased by over 300% over the last three years. The ratio of complex to basic laparoscopic procedures also has increased fourfold, with nearly 70% of all laparoscopic cases now being more complex operations (e.g., pancreatic and esophageal). Complication rates and length of hospital stay for these cases are significantly reduced.

Thoracic Surgery

The Division of Thoracic Surgery includes Dr. E. Carmack Holmes, Executive Director of CASIT; Dr. Robert B. Cameron, Chief of the Division; Dr. Mary Maish, Surgical Director of the UCLA Center for Esophageal Disorders; and Jay M. Lee, Surgical Director of the Thoracic Oncology Program. The focus of the division is in thoracic and foregut surgery, including the use of minimally invasive and robotic techniques. With more than 30 years of clinical experience in thoracic surgery and 10 years as Chairman of the Department of Surgery at UCLA, Dr. Holmes guides the Division’s initiatives in MIS. Since his recruitment of Dr. Cameron nearly 10 years ago, the minimally invasive program in this division has expanded, so that now more than 75% of all lung resections are performed via thoracoscopic techniques, including resections for cancer as well as for intrinsic lung disease such as lung-volume reduction surgery for emphysema. Dr. Cameron also has applied minimally invasive mediastinal techniques for resections of mediastinal tumors and the esophagus. Dr. Maish has expanded the esophageal program to include minimally invasive esophageal procedures for benign and malignant disease.

Thoracoscopic and laparoscopic esophageal surgery for cancer, achalasia, and GERD account for more than 50% of the esophageal surgery performed. The group is performing robotic-assisted surgical resections of the thymus gland, the esophagus, and mediastinal tumors, as well as initiating novel uses for robotic-reconstruction of the chest wall. Training young thoracic and general surgeons, the Division has a competitive fellowship that includes comprehensive teaching of minimally invasive techniques for thoracic and foregut surgery.

Cardiac Surgery

Dr. Richard Shemin, Chief of Cardiac Surgery, has initiated a robotic cardiac surgery program at CASIT. So far more than 30 robotic cardiac cases have been completed, including mitral valve repair and coronary artery bypass procedures. Dr. Shemin is also exploring the application of CASIT-developed technologies to cardiac surgery and robotic cardiac surgery, including robotic haptic feedback, thin film nitinol prostheses, flexible ultrasound imaging, artifical muscles, and others.  Dr. Dan Levi of Pediatric Cardiology is currently working with Prof. Greg Carman of Mechanical and Aerospace Engineering to explore the use of thin film nitinol materials for heart valves and prosthese. Additional research at CASIT is ongoing to develop implantable actuators for ventricular assist devices (VAD).  Dr. Colin Keally of General Surgery and Prof. Carman are working to develop a peizoelectric actuator-based VAD, and Prof. Warren Grundfest of Bioengineering and Prof. Qibing Pei of Materials Science are researching artificial muscle-based VADs.

Vascular Surgery

The minimally invasive team has been working with Vascular Surgery and performing minimally invasive vascular surgery procedures, including aortic reconstructions for aneurysm and occlusive disease, as well as other conditions. A clinical and research program to develop new hybrid laparoscopic/endoscopic procedures for a comprehensive minimally invasive approach to aortic disease is underway under UCLA’s leadership. It involves partnering with key industry leaders, and UCLA will direct a US-based consortium to develop, study, and teach in this field.

Liver Surgery

Together with the Liver Transplant team, the Division is developing techniques for minimally invasive liver surgery, which would include resections for tumors, treatment of metastatic hepatic lesions, and harvesting living related liver segments for transplantation. This program will be activated in the clinical arena imminently.

Education & Training

This team also has set up a curriculum to teach students and residents minimally invasive surgical techniques and has given numerous invited lectures, both in the US and around the world, and national and international presentations including videos as well as research papers. This team has established an outstanding Fellowship Program in MIS as well, and currently there are three fellows in the program.

Urology

Dr. Peter G. Schulam is Chief of the Division of Minimally Invasive Urologic Surgery. It focuses on novel laparoscopic and endoscopic treatments for kidney stones, adrenal lesions, and kidney and prostate cancer. Currently, the team is investigating novel ablative technologies, including laser, radiofrequency, and cryotherapy, to selectively treat renal tumors while preserving normal renal tissue. In addition, the Division is collaborating with the Department of Bioengineering, and is investigating the incorporation of microelectromechanical systems (MEMS) into surgical instrumentation to create tools that will provide greater information to the surgeon and potentially improve surgical outcomes. Clinically, the Division has greatly influenced urologic surgery here at UCLA by advancing minimally invasive treatments for prostate cancer, kidney cancer, kidney reconstruction, and pediatric urologic surgery. The Division has markedly expanded the living kidney donor program at UCLA. Prior to Dr. Schulam’s arrival, the Department of Urology had performed less than 10 laparoscopic live donor nephrectomies. Currently, the program performs 150 procedures each year. UCLA is recognized as one of the top three programs nationally for kidney transplantation. As a result of the success of this program, more than 95% of all living kidney donations at UCLA are performed laparoscopically. The surgeons are now performing two to three robotic prostatectomies per week. The program also has a competitive fellowship program, and its graduates have become leaders in the field. Recently, graduates have taken positions as chief of laparoscopic surgery at Loyola and University of Maryland. Last year’s fellow is director of the minimally invasive kidney cancer program at Roswell Park in New York.

Gynecology

The Department of Obstetrics and Gynecology became involved in Robotic Surgery in November of 2005, as one of the first groups of gynecologists to be trained on the da Vinci Robot in Southern California. Dr. Jeannine Rahimian, Chief of the Generalist Division of Obstetrics and Gynecology, performs various minimally invasive gynecologic procedures, including Robotic assisted hysterectomy, myomectomy, and oophorectomy.

Dr. Robin Farias-Eisner, Chief of Gynecologic Oncology at UCLA in the Department of Obstetrics and Gynecology has performed robotic surgery for both cancer and benign indications. Dr. Farias-Eisner has performed, in the state of California, the first supracervical hysterectomies with bilateral salpingoophorectomy for patients at high risk for the development of ovarian cancer, who desired to preserve their cervix. Use of the robot allows for a minimally invasive approach to cancer surgery and staging procedures, which would improve surgical outcome and recovery time.

VA Greater Los Angeles (VA GLA) Telehealth Program

Dr. Leonard Kleinman Director, MD – Telehealth Director
Jolea McGinnis, BSCS – Telehealth Program Coordinator
Jane Montgomery, RN – Coordinator, Home Telehealth

This large, diversified telemedicine program based at the West Los Angeles VA Medical Center (WLA VAMC) serves about 75,000 veterans in a 5 county area of Southern California that extends from Los Angeles in the south to San Louis Obispo CA in the northwest and over to Bakersfield CA in the northeast. It is an affiliate of the nationwide VA telemedicine program supported by the Veterans Health Administration Office of Coordination of Care. Services are provided in the categories of home telehealth, real time clinical videoconferencing (VTC), and store and forward digital image consultation.

The VA GLA Coordination of Care/Home Telehealth program (CCHT), provides chronic disease management to frail patients through interactive telecommunications. CCHT has resulted in a significant decrease in emergency room visits, hospital admissions, and VHA nursing home admissions for its patients. There are 5 major disease management programs in use that employ in-home asynchronous text-messaging through telephone line connectivity. Patients keypunch replies to questions that have been programmed for their particular set of co-morbidities which are reviewed by nurse care coordinators, who promptly contact patients with “red flag” responses. Videophones are also employed for case management for homeless veterans at a large residential care program in the Los Angeles inner city remote from WLA VA.

The VA GLA Telemental Health Program provides VTC consultation to outlying primary care clinics in Gardena CA, Lancaster CA, Oxnard CA, San Luis Obispo CA, and Bakersfield CA. VTC is also used to provide consultation to diabetic patients at Bakersfield. WLA VAMC is an end point in the VA Polytrauma Network that employs VTC to coordinate multi-disciplinary team services to severely injured veterans returning from Iraq and Afghanistan.

Store and forward digital imaging is used for screening for diabetic retinopathy, as well as teledermatology. Teleretinal screening is offered at 4 different locations. Teledermatology consultation is available at Bakersfield and Santa Barbara.

The GLA Telehealth Program is the leading telemedicine program in Southern California and one of the benchmark programs in the US. It serves as an example of how telemedicine programs can effectively make an important impact on access to high quality, complex healthcare services over a wide geographic area.

For more information contact Dr. Leonard Kleinman

UCLA Simulation Center

Randy Steadman, MD, Department of Anesthesia – Director

The UCLA Simulation Center opened its doors in 1996 with the acquisition of the Human Patient Simulator, a life-sized, computer-controlled mannequin originally developed at the University of Florida and manufactured by METI in Sarasota. The simulator has a realistic cardiopulmonary system that interfaces with standard physiologic monitors to display vital signs, the electrocardiogram, and pulse oximetry values. The mannequin has palpable pulses and audible heart and breath sounds and reacts realistically to a wide variety of medications.

With the increasing emphasis on interactive, hands-on learning in all areas of medical education, the simulator program has grown steadily over the last eight years to meet a growing list of educational objectives within the David Geffen School of Medicine at UCLA. With the acquisition of two additional simulators in 2003, simulation has replaced the animal lab component of the physiology course. The fourth-year simulation exercises are one of the most highly rated aspects of the final year of medical school.

Since 1996, more than 2500 hours of education have targeted multiple groups including medical students, residents, nurses, paramedics, respiratory therapists, fully trained physicians, and industry representatives. A description of the simulator and several of the ongoing programs is included in the UCLA Simulator Training Program brochure available online here.

Collaborations with other innovators within the field of simulation have helped UCLA maintain its role as a leader in this technology. Laerdal Medical delivered its SimMan product to UCLA in January 2004, bringing the total number of simulators in use at UCLA to four, which reflects the increasing use of this technology. In the future, as anatomic simulators are merged with high-fidelity physiologic models, the scope of training offered by simulation will be further enhanced.

UCLA Center for International Emergency Medicine

Eric Savitsky, MD – Director

The UCLA Center for International Emergency Medicine (CIEM) is dedicated to improving global health and living conditions through education, training, and technology. CIEM specializes in interdisciplinary research and the translation of knowledge and technology toward improving global living standards. It is unique in its ability to combine disciplines within the physical, biological, and social sciences in order to provide practical solutions to problems requiring an integrated approach.

Services provided:

Health education seminars
Creation of training materials (e.g., Internet-based, CD-ROMs, DVDs)
Development of international training programs
Healthcare services development
Research and development

CIEM has been involved in providing educational programs throughout the United States and within Indonesia, North Africa, China, Seychelles Islands, French Polynesia, and Armenia/Nargorno Karabagh. This program will help move CASIT into the international arena in training, telementoring, and telecommunication.

Neurosurgery

Neil Martin, MD, Chief, Division of Neurosurgery
Paul Vespa, MD
Val Nenov, PhD

GCQ for the ICU of the Future: GCQ consolidates and integrates all of the ICU patient data and delivers it to the intensivist, surgeon or critical care specialist on any computing platform: desktop workstation, Tablet PC, notebook computer, WiFi PDA, or cellular “smartphone.” The intensivist can monitor patients not only from a hardwired “control room,” like the VISICU solution, but also from any internet-connected computer or mobile phone. Intensivists and neurosurgeons are not desk-bound physicians, but they are called upon to evaluate and manage patients in more than one ICU, in the ER, on the wards, and in the recovery room. Furthermore, the intensivists may have to intervene: put in a Swan-Ganz catheter or insert an arterial line or ventriculostomy – clearly not possible if the intensivist is sitting in a remote control room. Given that intensivists and surgeons are mobile physicians, their information platform must have a mobile component like GCQ.

GCQ for the OR of the Future: Surgeons are often called or paged while in the OR – to make decisions about patients in the ICU, ER, recovery room, or on the ward. GCQ provides real-time access to comprehensive patient data that can be displayed on the OR monitor system, allowing the surgeon to evaluate data and scans, and make management decisions without having to leave the operating table. GCQ also can provide telemedicine links to surgical pathology for real-time review of biopsy histopathology without the need to scrub out. Through the GCQ server linked to the OR audiovisual system, the remote surgeon can view the OR or the surgical video from his or her desktop computer, wirelessly connected laptop, or even on a Pocket PC PDA or smartphone.

For a complete electronic ICU or OR solution, a telemedicine link to the ICU nurse and to the ICU patient is important. We are currently providing this connection in the form of robotic telemedicine or “virtual presence”, in collaboration with InTouch Health.