Many fields including the number of cases performed by the Liv Hospital surgeons and complications rates, readmission, reoperation, complication rates, their educational backgrounds and qualifications, the symposiums and trainings they attended in regular manner, assessment of tasks, competencies and responsibilities of the persons from physicians to nurses, from janitors to allied health personnel, proper consultation and equipment, safety of the anesthesia and surgery processes, infection control, safe use of drugs, patient rooms, emergency unit, examination rooms, protocols of the clinical care standard, informant consent forms, from institutional commitment and support groups to building safety were scrutinized and went through a stringent audit.

Qualification of the concerning physicians and the number of operations performedby documenting, complication rates, survival rates, infections ratesin the robotic surgery have to be provided in the international standards or better.

After the Center of Excellence Accreditation based on the SRC’s corporate data analysis awarded the Center Of Excellence Accreditation:

Complications decreased by 65%;

Costs decreased by 35%;

Productivity improved by 47%;

Patient safety increased by 71%;

Coordination between teams increased by 59%;

Awareness increased by 59%;

Patient satisfaction increased by 53%;

Patient volume increased by 53%;

References increased by 35%.

LIV HOSPITAL BECAME THE FIRST CENTER OF EXCELLENCE OF TURKEY IN THE FIELD OF COLORECTAL SURGERY

Liv Hospital was co-authorized after completing the “Center of Excellence Accreditation” in the field of colorectal surgery by succeeding the stringent audit conducted by the Surgical Review Corporation (SRC) which is an impartial international commission. The Center of Excellence Accreditation which can be achieved by very few companies in the world was granted to an organization outside the Unites States for the first time by the concerning authority.

Why Center of Excellence?

First of all, it must be proven to the auditor delegation that the qualification of the physician in the related fields, specific studies, to treat patients equivalent to the world-class criteria and in certain number, complications, readmission, and analysis and functional results of the clinical data are equivalent to the organizations accredited before. In addition, it must be proven during the audit that the patient treatment protocols are determined by making decisions through joint meetings conducted with other disciplines, that the healthcare services and their results are integrated, and that they are created by planning from past to the future. Also, achieving a certain quality in institutionalization and treatment outcomes is among the basic application criteria.

Many fields including the number of cases performed by the Liv Hospital surgeons and complications rates, readmission, reoperation, complication rates, their educational backgrounds and qualifications, the symposiums and trainings they attended in regular manner, assessment of tasks, competencies and responsibilities of the persons from physicians to nurses, from janitors to allied health personnel, proper consultation and equipment, safety of the anesthesia and surgery processes, infection control, safe use of drugs, patient rooms, emergency unit, examination rooms, protocols of the clinical care standard, informant consent forms, from institutional commitment and support groups to building safety were scrutinized and went through a stringent audit.

Qualification of the concerning physicians and the number of operations performed by documenting, complication rates, survival rates, infections rates in the colorectal surgery have to be provided in the international standards or better.

What is robotic surgery?

The introduction of the robotic systems into surgery in the first half of 21^st century was very exciting and significantly important. The development of such a system started with the leadership of NASA in order to facilitate the treatment of astronauts on space with a remote control in 1970s. Depending on this concept, a prototype of da Vinci robotic system came into existence in 1997 and got FDA approval in 2000. Since then, the application areas of robotic systems have expanded a lot. Now, they are used in many surgical operations such as cardiovascular surgery, urology, general surgery, and thoracic surgery, maternity and pediatric operations.

The superiority of robotic surgery depends on its ability to provide three-dimensional image having the depth almost like reality, error-free precision with its “Endo Wrists” trilateral robotic hands and that it provides mobility and to reduce the vibration to the minimum. The spread of the robotic surgical operations around the world is the forerunner of the new era in laparoscopic (also known as minimally invasive surgery and keyhole surgery) surgery.

Modern Robotic Surgical Systems

Modern robotic systems are divided into three different categories: active, semi-active and robot-slave systems. While first two categories provide artificial mind and autonomy in some level, the feature of the mostly used robot-slave systems is that the surgeon has the absolute control of the robot via the remote control console. These systems were firstly developed for the absent treatment of the astronauts on space by NASA and for the first time, “da Vinci” TM robotic system got the official approval in the USA in 2000.

What are the advantages of robotic surgery?

Besides the classic advantages of laparoscopic surgery, the most important benefits of robotic surgery are listed below:

• Less Pain: Minimal trauma on skin and in muscles means that the pain and discomfort after the surgery will be less.
• Lower Possibility of Infection: Since the contact of organs in the ventral cavity with the air in surgery room is minimized, the infection risk is lower in comparison with the open surgeries.
• Safer Surgery: Three dimension and magnified images provides better vision and protection of blood vessels and nerves. For example, the blood loss during the surgery significantly decreases.
• Smaller Wounds: Compared to 20-25 cm cuts in open surgeries, wound sizes become minimal with 1-1.5 cm incisions.
• Fast Recovery: Since moving and oral feeding start earlier after the surgery, the patient recovers faster.
• Decrease in the Length of Hospital Stay: Most of the patients are discharged 3 or 4 days after the operation
• Quicker Return to Work and Daily Life: Patients return to their daily lives quickly thanks to fast recovery and healing.

Which operations can be made with robots?

Although robotic surgery has mostly focused in urologic surgeries for the last ten years, now it is widely used in general surgery, gynecologic surgery and cardiovascular surgery, too. And now with the newest MAKOplasty technology, knee replacement surgery is at Liv Hospital.

KNEE REPLACEMENT SURGERY: MAKOplasty®

Up to now, MAKOplasty® has only been available in advanced medical centers in the USA and some other countries.

Now Liv Hospital is bringing this method changing the lives of many osteoarthritis (OA) patients now to Turkey for the use of our international patients.

What is MAKOplasty®?

MAKOplasty® is the partial knee replacement operation designed to stop the pain caused by joint degeneration created by OA with the help of a robotic arm. Targeting one part of your knee damaged by OA, the surgeon can replace your knee via protecting the healthy bone and the bonds.

MAKOplasty® Partial Knee Replacement:

• Provides the opportunity of renewal of only knee’s part with arthritis for the surgeon,
• Protects healthy tissues and bone,
• Facilitates the placement in best location and creates a natural knee feeling after the surgery,
• Faster recovery and less length of hospital stay than the conventional total knee replacement surgery.

Unlike other more invasive methods, MAKOplasty® can generally be applied from little cuts both on femur and tibia and 10-15 cm cuts on your knees. Besides the protection of your own bone and tissues, patient can feel his or her knee more natural thanks to ideally placing the implant special for the patient. Since the healthy bone is protected, total knee replacement is still possible later in the future.

Your Liv Hospital doctor will give you information about the risks of MAKOplasty® and other treatment options. Moreover, the surgeon or his or her assistants will inform you about the before and after the surgery.

In some cases, depending on the fact that the surgeon chooses the most correct treatment for you, MAKOplasty® can be applied without staying at hospital.

• • Is MAKOplasty® a correct choice for me?

  If your knee is diagnosed with osteoarthritis, you can be a candidate for MAKOplasty®. MAKOplasty® is the partial knee replacement operation designed to stop the pain and provide the ability to move with the help of a robotic arm. It is a new treatment option for adults having early or middle stage osteoarthritis moving all three parts of the knee.

  Liv Hospital provides the international patients the opportunity of benefit from MAKOplasty®.

  As the first step, you should contact with our International Office to learn whether you are a suitable candidate for MAKOplasty® and get an appointment from a specialist.

  • What should my expectation be when MAKOplasty® is applied in Liv Hospital?

  MAKOplasty® can be applied both as in-patient and outpatient care according to your surgeon’s decision. The length of staying at hospital can averagely change 1 to 3 days and outpatients can go back to their houses on the same day.

  Liv Hospital International Office will assign you Support personnel that can communicate with you so that he or she can coordinate all needs including medical and staying for you and your companions.

  In many cases, patients are allowed to walk for a little while after the surgery, drive after two weeks and return to the daily life after a while.

  Frequently Asked Questions

  Question: What is osteoarthritis?

  Answer: Osteoarthritis (OA) is a degenerative joint disease or is a form of arthritis characterized by the articular cartilage degradation and resolution. Cartilage is a protein content that makes a cushion between joint bones. The top layer of cartilage in OA begins to deteriorate and led to the rub of bones under the cartilage with each other.

  Question: What Causes Osteoarthritis of Knee?

  Answer: Although basic cause of OA is unknown, risk of symptomatic OA depends on several factors such as; age, gender and heredity, which determines the shape and balance of your joint. Other factors:

  • Previously injured knee
  • Repetitive strain on the knee
  • Non-conformities at the level of joint
  • Overweight
  • Applying pressure to the knee joint caused by exercise or sport

  Question: What are the symptoms of knee OA?

  Knee OA symptoms:

  • Pain while standing or walking for short distances, up and down stairs or getting up from a chair to sit
  • Pain during activity
  • Initial pain or stiffness during the transition into move from a sitting position
  • Knee joint stiffness after getting out of the bed
  • Swelling in one or more regions of knee
  • Sense and sound of friction while using knee

  Question: How OA is treated?

  Answer: Depending on the severity of OA, your doctor will suggest certain lifestyle changes in order to alleviate the pressure on the knee joints. In addition, disease and pain management strategies may include: Physical therapy, steroid injection and acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or analgesics such as topical creams.

  Please see your doctor if the symptoms are unresponsive to non-surgical solution or pain cannot be controlled with medication. You may be a good candidate for the operation.

  The most commonly performed surgical interventions for the knee, is the replacement of total knee. During this process, the natural joint is removed and replaced artificial implant. This treatment option is usually recommended for patients with advanced osteoarthritis.

  Total knee replacement is not always the best choice for people with only early or mid-stage, one or two sections osteoarthritis. Partial Knee makoplasty® may be the best solution for patients with partial OA.

  Question: What is makoplasty®?

  Answer: Makoplasty® partial knee replacement operation is a new treatment option for adults with medial (inner), patellofemoral (top) or lateral (outside) early and mid-stage section OA. Partial knee replacement operations have been strengthened by the RIO® Robotic Arm Interactive Orthopedic System, which allows a continuous reproducible sensitivity during implementation.

  • The diseased portion of the knee is removed during operation, protecting the patient’s healthy bone and surrounding tissue. An implant, which will provide smoother motion again, is placed into a joint. Makoplasty® with partial knee replacements:
  • IT is possible to facilitate to ensure the best positioned implants in order to provide a movement with a more natural feeling,
  • To provide a shorter hospital stay and faster recovery than traditional knee replacement surgery,
  • Being applied at the level of ambulatory treatment
  • It is possible to relieve the pain quickly and to accelerate the return to daily activities.

  Question: How can Makoplasty® be useful for me?

  Answer: Makoplasty® (Partial Knee Renewal) process is designed to alleviate the pain caused by joint degeneration and has the potential to provide the following benefits:

  • Better operation results
  • Less wear and loosening of the implant
  • Joint replacement
  • Bone protection
  • Smaller cuts
  • Less scarring
  • Less Blood Loss
  • Shorter length of stay
  • Fast recovery

  Question: How Does RIO® Robotic Arm Interactive Orthopedic System work?

  Answer: RIO® Robotic Arm Interactive Orthopedic System has a three-dimensional pre-operative planning feature. During surgery, RIO provides a real-rime, visual, tactile and audible feedback in order to help surgeon for replacing the joint and positioning the implant in the best way. This ideal placement allows for more natural knee motion after surgery.

  Question: Who might be a good candidate for the procedure of MAKOplasty®?

  Makoplasty® patients typically share the following characteristics:

  Generally, pain inner side of the knee and/or below the patella or pain on outer side of knee during movement

  Knee pain and stiffness began with movement after sitting for a while

  No response to nonsurgical treatments or steroidal anti-inflammatory medication.

• • Question: What is the life of the MAKOplasty® implants?Answer: All implants have different life long depending on the patient’s weight, activity level, bone density and alignment of medical advice.Proper alignment and positioning of implants during the operation and precision are critical factors that can increase the life of the implant. By using RIO, implants are aligned and positioned in an ideal manner to be useful for the longest duration. RESTORES MCK implants, makes it possible to treat one or two part of OA disease. Given OA spreads in cases which have unilateral involvement, treatment of the second part can be made in the future. Also during makoplasty® process, a very small part of the bone is actually taken, so implants can be placed with another process such as a total knee replacement, when it is required.* Individual results are various. Including Makoplasty®, every knee operations have risks associated with transaction. Your doctor in Liv Hospital, will explain those risks and help you to determine whether makoplasty® procedure is appropriate for you.

lthough its clinical endoscopic techniques are being successfully implemented, application which was stipulated for heart surgery could not be accomplished. Major causes of that condition are the fact that two-dimensional imaging system and the heart is complex with constant motion. Despite these challenges, our clinic has performed over 600 endoscopic mitral valve closure, ASD closure and myxoma resection. Thanks to our comfort and experience in these techniques, we were able to easily adapt to robotic technology.

Robotic Surgery

It provides a very significant advantage. 3D images are a significant advantage for cardiac surgeons who used to work with two-dimensional image. Also, being obliged to have manipulation delicately with long devices in a limited space, can increase fatigue and hand tremors. Robotic surgery eliminates these disadvantages.

However the earliest applications of robotic surgery were related to heart surgery, today urology (radical prostatectomy) is the most widely application field for it all over the world.

In US, Average 1700 of robotic cardiac operations are performed in every year. These operations are getting increase with a rate of 25% and number of 400 per year.

In Turkey, as a result of the introduction of new robotic system, the number of robotic procedures began to increase. As in the rest of the world, Liv Hospital has applications most commonly related to mitral valve repair and coronary artery bypass surgery. In recent years, Continuous improvement in technology, the development of the fourth robotic arm and automatic mitral separator have contributed to a relaxation and easiness in the surgery.

The advantages of robotic surgery can be listed as reduced blood loss, shorter hospital stay, less pain, less risk of infection, aesthetic superiority and early return to normal life and business life.

Which cardiac surgery can robotic surgery used for?

• Mitral valve repair and replacement
• Coronary by-pass (single or double bypass patients)
• ASD closure
• Arrhythmia operations
• Heart tumors

Today, it is not possible to say that robotic technology is used widely enough for cardiac surgery. Robotic heart surgery is in process of constant development. The centers, who obtained this technology without providing the essential infrastructure and trainings, have faced a huge disappointment.
Robotic surgery requires a laborious and difficult training and experience. This type of surgery is based on proficiency in “OPCAB” (off-pump coronary artery bypass) surgery, peripheral tube passing techniques and development of expertise in endoscopic systems. Dominance in these three fields, provide assurance for faster and a successful robotic surgery learning process. One of the most important factors of the learning curve is the question of when it will be converted to open surgery. Conversion to open surgery should never be considered as a failure, because nothing is more important than the principle of ”do not harm patient”.

daVinciTM Robotic Surgery Systems

As shown in Figure 1; da Vinci system (combination of binocular, optical cameras and three robotic arms) consists of a robotic tower, a console which provides the high-resolution 3D image of operations area, and control unit of the three robotic arms which is managed by the surgeon.

Binocular as shown in Figure 2, provides a real-depth 3D image for control of the hands (left) via binary optics (right).

Recent Robotic Surgery Applications

Robotics technology is mainly implemented for especially surgery of cholecystectomy, varicose veins and bladder suspension in 1994. The first common clinical applications were the operations of 146 patients between 2001 and 1997 in Europe, using the da Vinci robot. Among these operations, two radical prostatectomy and a varicocelectomy procedures have taken place, and during these operations no complication was reported associated with the robot system, and computer & imaging systems performed a full functionality. Recent applications in US, have expanded functional fields of Vinci to include nephrectomy, it has proven that practical use of standard robotic surgery can be applied in parallel with laparoscopy.

These developments have transferred the application into surgical areas of chest, orthopedics, pediatrics and urology. Main applications in urology include radical prostatectomy, pyeloplasty, psoas bond, broaden flap, urethral reimplantation, radical cystectomy with ileal-neobladder, donor nephrectomy, adrenalectomy, radical and simple nephrectomy, partial nephrectomy and sacrocolpopexy procedures.

Robot Assisted Radical Prostatectomy

Since the first use of robotic surgery in Germany in 2000 and in US, radical prostatectomy is the most common application area. Since this process is highly sensitive and requires detailed dissection and suturing, da Vinci devices’ freedom of movement by six degrees and operations are perfectly corresponding to each others. Ability of swiveling around its axis by 540 degrees helps surprisingly to manipulation in operations of male pelvis as narrow and limited (Figure 3). As a result of 3D visualization and protection of neurovascular bundle via robot, it allows fine and detailed dissection during surgery. Comfortable and precise motion capability of the instrument, also allows a leak-free operation during ligaturing the urethra and bladder which is a difficult process.

Involving all of these advantages, use of robotic surgery has a rapidly increase in radical prostatectomy operation. In US, 2,648 of such operations have been performed in 2003, and this figure has reached to 55,000 in 2007, as a result of being applied in 65% of radical prostatectomy operations.

DA VINCI S SURGICAL SYSTEM

da Vinci S Robotic Surgical System brings ground breaking robotic technology with high-resolution 3D endoscopy together. Using this equipment, our surgeon can operate such as extremely complex operations such as; prostatectomy, gynecology and chin / face operations, applying minimally invasive keyhole surgery. It means that for the majority of patients; compared with traditional open surgery, that is as soon as possible faster recovery, less pain and minimal blood loss.

ACROBAT NAVIGATOR

Involving the GPS (Global Positioning System) technology, a type of robotic system provides a unique sensitivity and accuracy in the complex hip and knee operations. This system directs the surgeon at surgical incision through GPS trackers and wireless cameras, just like determination of your travel way by a GPS. In order to ensure the performance of surgeon with a break by some degree, accuracy and sensitivity is increased by creating a joint model f the individual as a guide via computer.

Prostate; a component of men system, is a gland that play a role in bladder emptying and sperm viscosity. It consists of the secretory cells of surrounding tissue. Prostate cancer is developed by an abnormal growth of the secretory cells. In case of early diagnosis could not be made, prostate cancer can spread to surrounding tissue via the lymph and blood vessels. The most widely spread (metastasis) regions are peripheral lymph nodes and bones. It can also spread to lung, liver and other organs.

There are various methods for treating prostate cancer. The most effective of these methods is

Radical prostatectomy. For patients who had radical prostatectomy and were diagnosed with benign tumor, the ten-year disease-specific survival rate is over 90%. Therefore, radical prostatectomy is most preferred treatment options among all available ones. Traditional open radical prostatectomy operation is performed with a large surgical incision. This means to prolonged hospital stay, prolonged healing process after the operation, risk of infection and a major scar. Robotic prostatectomy procedures which began to be applied in recent years, ensures smaller incisions and offers patients a minimally invasive and less traumatic alternative.

Advantages of Robotic Radical Prostatectomy

Less Blood Loss: During robotic radical prostatectomy surgery, abdomen is inflated with gas. Bleeding pressure of the gas is significantly reduced. End of the operation gas is discharged from the west. In addition, by using the high-resolution 3D (three dimensional) cameras which magnify the operation zone, bleeding is determined clearly and stopped earlier. Usually patient is not required a blood transfusion.

Shortening of Length of Stay: Since the cuts are smaller and bleeding is less during robotic surgery, patients stay in hospital less, compared to open surgery.

Shortening of Probing Time: Since robotic prostatectomy surgery allows to waterproof seam (anastomosis) of bladder and urinary tract, probe can be removed in 6-7 days.

Less Pain: As more small cuts performed, patients feel less pain and discomfort than open surgery.

Better Cancer Control: With the help of high resolution 3D images and 540 degrees movable tool, prostate tissue can be observed more clearly during robotic prostatectomy procedure. During robotic surgery, apex of the prostate can be seen much more clearly and may be intervened in a more precise manner. Consequently, positive surgical margins are significantly reduced.

Better bladder control: Robotic prostatectomy patients, gain bladder control earlier than the traditional surgery. Factors, which ensure a sooner bladder control sooner, a better imaging, less bleeding and longer involvement of the urinary tract.

Earlier Return to Normal Sexual Life: Robotic prostatectomy helps to protect neurovascular bundle around the prostate and allows patients to return to normal sexual life earlier than in conventional surgery.