D-H’s Thoracic Robotics Program Grows Under David Finley, MD
Since joining Dartmouth-Hitchcock (D-H) three years ago as chief of Thoracic Surgery and director of the Comprehensive Thoracic Oncology Program at Dartmouth-Hitchcock Norris Cotton Cancer Center (NCCC), David Finley, MD, has helped D-H become the largest Thoracic Robotics program north of New York City.
“Dartmouth-Hitchcock's and Norris Cotton Cancer Center have embraced robotic surgery since I came on staff in January 2015,” says Finley, who previously co-founded the robotic surgery program at New York City’s Memorial Sloan Kettering Hospital in 2011. “Based on volume, we do more robotic cases and more complex robotic cases than any other program in New England.”
Finley, who also holds the Louise R. and Borden E. Avery Clinical Chair in the Department of Surgery, notes that their department has two robots. “The robots enable us to perform surgeries that were previously done as both open and minimally invasive surgeries, including esophagectomy, thymectomy and lobectomy. Patients still receive the same cancer care, but thanks to the robots they experience less pain, a shorter hospital stay, improved long term outcomes and they are able to return to normal life sooner.”
How do patients benefit?
Finley explains that robotics let surgeons take minimally invasive surgical approaches to diseases such as esophageal cancer, lung cancer and tumors of the mediastinum as well as thymic resections for myasthenia gravis. Previously, these surgeries could only be done through a large incision.
“The benefits of a minimally invasive procedure are that 50 percent of our patients go home by day two while the average for an open incision is about five days,” says Finley, adding that 20 percent of their D-H patients go home the day after surgery. “So, that’s a dramatic drop in terms of the cost for the patient, the hospital and our health care system. And 20 percent of our patients are on Tylenol and ibuprofen when they go home. With the opioid epidemic, it’s even better if we can reduce the amount of pain medications they are taking by reducing their pain with smaller incisions.”
While some patients envision a robot standing by their bedside when they hear the term robotic surgery, Finley explains to patients that the robot is just another tool, more like a mechanical helping hand. “The robotic platform allows us to have increased dexterity, improved visualization with 3-D viewing and magnification, as well as enhanced optics,” says Finley. “Having these improvements allows us to do more technically challenging surgeries through a minimally invasive approach and avoids a large incision for our patients.”
Finley has been building a robotics surgery team at D-H since his arrival. He was joined in 2015 by Timothy Millington, MD, and in 2016 by Joseph Phillips, MD. They use robotics mainly for the removal of anterior mediastinal tumors, as well as lung and esophageal resections for cancer (the surgical removal of all or part of the lung and esophagus). Over the past two years, the team has done more than 70 percent of these surgeries robotically. Throughout most of the country, many of these same surgeries are performed with a large incision rather than robotically, says Finley.
As the number of robotic lung resection surgeries have increased at D-H, the overall complication rates have dropped. Patients requiring the intensive care unit (ICU) post-operatively fell from three percent in 2016 to one percent in 2017. The median hospital length of stay for lung resection patients who have robotic surgery is two days. This is in contrast to when the surgery is performed through a larger incision, where patients are usually in the hospital for five to six days.
Compared to the national mortality average for patients who undergo a lobectomy (the surgical removal of a lobe of the lung), D-H has a lower incidence of mortality for lung cancer patients who undergo robotic surgery. According to Medicare data across all institutions, the national average mortality rate is 5.5 percent at 30 days for men in the United States undergoing a lobectomy.
Following the data
Finley has “always followed my data,” and he videotapes most surgeries he performs with consent from his patients. “It is very important to me to know what I am doing well and finding when I can make things better for patients,” he says. His research coordinator Kayla Fay has created a database that documents more than 1,000 data points for each patient who goes through any thoracic surgery at Dartmouth-Hitchcock Medical Center (DHMC). The data includes details like their smoking history, medical comorbidities, any complications they may experience and tracks how long they are in the hospital.
“We can then go back and determine who does well and who doesn’t do well and that helps us determine what we can change in our practice to make things better for our patients,” says Finley. “For example, we looked at esophageal cancer patients and found that patients who have a drop in their weight before surgery do worse in terms of complications and readmission rates. So, we engaged NCCC’s Oncology Nutrition Services team to contact these patients who have esophageal cancer and are undergoing treatment. This way, the patients get the education they need and don’t unnecessarily lose weight before the surgery and lessen their chance of having a complication.”
Finley’s group is also engaged in 10 active research projects, including national clinical trials and 17 total projects, ranging from how to minimize the risk of air leaks in lung tissue post-surgery to the effectiveness of remote monitoring to motivate patients to exercise at home. On the latter, they are partnering with the C. Everett Koop Institute at Dartmouth and with Kathleen Lyons, ScD, in the Psychiatry Department.
“If patients exercise and get themselves in shape, and then also exercise while they are in treatment, then we might be able to reduce hospital admissions, prevent reductions in their chemotherapy and radiation therapy and allow them to get full dose treatment with a better quality of life and improved survival,” says Finley. “That’s what we are trying to do—improve both survival AND quality of life.”
Finley continues, “Whether it’s research in how smoking cessation can minimize your major complication rate post-surgery or how being physically fit may reduce the production of stress hormone levels during surgery, which can negatively impact your immune system, we’re always looking for ways to help our patients have the best possible outcomes.”