Philip Berroll

Laparoscopic surgery pioneer, educator, researcher – Dr. Celia Divino wears many hats, but still keeps her equilibrium.

 

By P.H.I.Berroll

While chatting with a visitor in her office, Celia Divino picks up a tiny plastic rake and slowly pulls it back and forth across a miniature sandbox on her desk.

“It’s a Japanese garden,” Dr. Divino explains. “When you’re stressed out, you rake it and it relaxes you. It’s kind of Zen.”

It’s easy to see how Dr. Divino would be interested in stress reduction. Her life is a kind of tightrope walk, balancing a dizzying array of responsibilities.  A pioneer in minimally invasive gastrointestinal and hernia procedures, she was one of the first practitioners to perform laparoscopic hernia surgery. And while maintaining an active surgical practice, she also serves as  Chief of Mount Sinai’s Division of General Surgery; Professor of Surgery at Mount Sinai Medical School; Program Director of the General Surgery Residency Program… and head of the groundbreaking Surgical Simulation Center (SSC), where both new and experienced surgeons learn cutting-edge robotic surgery techniques.

“When I was in medical school,” she recalls, “it was my dream to be what was called a “triple threat” – a person who does research, teaches and has an active practice. I feel fortunate to be able to do all three.”

In her work, Dr. Divino also engages in another kind of balancing act: while teaching and advocating for innovative surgical procedures, she firmly believes that no new technique should be introduced without taking issues such as patient safety and quality of care into account.

“With any new procedure, I think that people should resist a bit when they have doubts regarding safety – after all, we’re doctors, we don’t want to endanger our patients,” she says. “So there has to be quality control, and appropriate credentialing. Not everybody can just go out there and start doing this.”

 

From ‘Heresy’ to Standard Procedure

How does Dr. Divino keep her equilibrium? By conserving her energy, keeping her sense of humor – and practicing a kind of synergy, where her experience in one area complements and enriches her work in another.

For example, take her position at the SSC, a state-of-the-art facility where both surgical trainees and experienced surgeons can learn and practice techniques using a “virtual surgery” construct – working at a computer-based tabletop, manipulating robotic instruments as in an actual operation, while  monitoring their progress in the digital image of the “patient” on a screen. It’s a process with many similarities to minimally invasive surgery; and there is a clear overlap between Dr. Divino’s advocacy for the center, her role as an educator, her quality-control concerns and her experience performing minimally invasive surgeries such as the groundbreaking hernia procedure.

“There were a lot of pioneers across the country, but I particularly focused my interest on many aspects of hernia surgery – not just inguinal [groin] hernias but ventral [abdominal] hernias,” she recalls. “I looked into it from a more academic standpoint; I did a lot of studies on it, on the durability, safety, and outcomes of this procedure. And I still have an interest in pushing the envelope and trying to see if there are other efficient ways of doing the surgery, with better outcomes.”

She cites several advantages for laparoscopic hernia surgery over traditional procedures: “With a laparoscopic procedure, you have a smaller incision than in open surgery. You still have a dissection, of course, but with much less pulling and tearing, so there’s considerably less trauma.  And the recovery time, the possibility of wound infection, the durability – all are much better.”

Dr. Divino makes a similar case for laparascopic methods in her other major field of interest, gastrointestinal surgery.

“For gastrectomies, small bowel resections, colon resections for both benign and cancerous growths – you have the same differences in technique and in the effect on the patient,” she says. “Or look at cholecystectomy [gallbladder removal] – that’s a three, four day hospital stay if you do an open procedure. As recently as 1992, people thought the idea of doing it in such a way that the patient could go home the same day was crazy – it was heresy. But we’ve since proven that when you do it laparoscopically, it’s a four hour stay in the recovery room. Colon cancer, gastric cancer, small bowel cancer, all of them can now be approached using minimally invasive techniques with the same outcomes in terms of survival and adequacy of resection. And that is really important.”

Not surprisingly, Dr. Divino has often encountered initial objections to new techniques – and not only on the grounds of patient safety.

“It can be harder for people who have done it a certain way to adapt to what is quite a steep learning curve,” she observes. “Do you want to start from scratch again when you’re able to do this and you’ve been doing it safely for 20 years? But I think our responsibility as leaders in the field is to reassure them – to say, ‘I don’t care if you’re at this stage of your career, you can still learn it if you want to.’”

It’s in that spirit that she declares the SSC “open to everybody – not only to train new doctors, but also those who have been in the profession for some time.”

 

“You Have To Take Ownership of Your Patients”

Dr. Divino feels that in one regard, the current generation of surgical students does have an advantage: their experience with video games gives them a leg up.

“One of the most difficult things in doing laparoscopic surgery is that it’s you can only work in two dimensions, as opposed to three-dimensional when you’re doing open surgery,” she explains. “In laparoscopy, you have at the most 4 degrees of freedom – you go this way or that way, or up, or down. You can’t turn the instruments around there because it’s a fulcrum.

“But kids who do video games, they’re playing in two dimensions,” she continues,  “so it’s second nature to them. Studies have shown that kids who play video games have better hand-eye coordination. Even my son, who naturally has done the Wii, the Xbox, etc., has been asking to use a surgical simulator to prove to me that he would be good with it,” she says with a hearty laugh. “And I’m like, ‘We’re not having a simulator at home!’”

The educational process has changed in other ways since she began teaching. “The mass of knowledge is expanding, but we have less time to teach it in the hospital because of the regulations that have been put in,” she notes. “Interns can’t work more than 16 hours at a stretch or have too many calls. You have to supplement their operating room experience because they can’t stay there all night long anymore. So you think of innovative ways to get the message across. When we teach our curriculum, we actually give them web-based modules and reading materials to study. We are also able to teleconference our teaching conferences to other hospitals, so they don’t have to physically be here. And on balance, I think it’s for the best.”

Again, she emphasizes the importance of patient safety and the quality of care. “There’s a lot more emphasis on those factors – it’s always been there, but now there are a lot more requirements and oversight,” she says. “It’s no longer that cowboy mentality of residents operating by themselves, making crazy decisions. And that has to play a part in education.”

But there are also some unchanging lessons that Dr. Divino has always imparted to her students.

“First of all, don’t lose track of why you’re here, and that’s the patients; they come first. Two – and this goes hand-in-hand with number one – you have to take ownership of your patients. Make sure that nothing falls through the cracks, and that all the people on your team know what’s going on. Three, you have to have a passion for what you do, or else you’re not going to do a good job. Fourth, keep on learning, whether it’s on the floor or by reading. Fifth, always maintain a certain amount of professionalism, whether it’s not wearing jeans on a Saturday even if you’re so tempted, or always being respectful of the patient’s race or religion, or the way you talk to your colleagues on a different service. And finally, before you do anything, stop and think. Because medical errors are unforgivable – and if you just stop and think for a moment, it may save a patient.”

Dr. Divino also wants her students to be knowledgeable on the subject of global health.  Born and raised in the Philippines – she came to the United States to study at University of California-Davis and UC-Berkeley – Dr. Divino is acutely aware of the differences between healthcare in the West and in the developing world. Under her leadership, surgical trainees have traveled to communities in Southeast Asia, Haiti and elsewhere to teach and help set up healthcare programs, and all senior surgical residents participate in a month-long surgical rotation in the Dominican Republic.

“Having come from that culture, I think our goal should be sustainability,” she says. “We try to go there and train the surgeons, the local people, not to do it our way, but to improve how they do it, or teach how we do it so that they’re able to do it on their own. We don’t convince them that the way to do it is using these fancy machines, because nobody there can afford them.”

 

The Unfinished Revolution

For all her pioneering efforts in surgical research and development, Dr. Divino has also broken new ground in another sense: as a female surgeon and surgical educator in what had long been a male-dominated bastion of medicine.

She considers it to be “revolutionary, unbelievable”  how much things have changed since she began her medical career. And while acknowledging that “there’s still a long way to go for female surgeons – we have plenty who are assistant professors, but very few who are at the tenured, full professor level,” Dr. Divino also notes that “45 to 50 percent of the applicants to surgical residency are very, qualified women from the best medical schools, some more qualified than the men. It used to be maybe 20 percent. The number of women in the American College of Surgeons, the number of women in residency programs – they’ve all gone up.”

But in her view, the rest of the country is just following Mount Sinai’s lead. “We were always ahead of the curve here,” she says, “because of Dr. Arthur Aufses [Chair of the Department of Surgery from 1974-1996], who was one of the trailblazers in bringing in a lot of women.”

Dr. Aufses, who is currently Professor of Surgery and Professor of Health Policy in Mount Sinai School of Medicine, agrees with Dr. Divino’s assessment.  “About a third of the surgical students at the medical school are women,” he notes.  “That’s real progress – though when you consider that for many, many years we’ve had 50% or more women overall as medical students, we’ve still got a ways to go to make it really equal in surgery.”

And Dr. Aufses is not surprised by the success of his former protégée.

“Every once in a while, you see somebody and you know they’re going to be a star,” he says. “She was destined to be a star from the beginning.”

 

By P.H.I.Berroll

It’s one thing to research and develop a new surgical procedure. It’s quite another to put it into practice, over and over again. The surgeons of Mount Sinai have been leaders in the use of the DaVinci robotic system and other minimally invasive techniques. Here, three of them talk about how those innovations have impacted their work.

Dr. Eric M. Genden is no stranger to innovative surgical procedures – he was the first surgeon in the United States to perform a jaw transplant. So it’s not surprising that he has been a pioneer of robotic surgery in his field of specialty, cancers of the head and neck. “It’s made a remarkable impact on our ability to take care of patients with these cancers,” says Dr. Genden, “without making large incisions and doing surgeries that take up a huge amount of time and resources.” Dr. Genden, the Chairman of the Department of Otolaryngology and Chief of the Division of Head and Neck Oncology, performed his first robotic surgery in 2006 and has since done close to 250 such procedures. The biggest advantage of the robotic procedure, he says, is its relative simplicity: “In the typical open surgery, patients have to undergo a 12-to-14-hour procedure to get to the tumor, and they’re usually in the hospital for 10 to 12 days. Using the robot, we’re able to remove the tumor in about two hours – and patients usually go home the next day, eating and drinking and swallowing.” Dr. Genden notes that the robotic technique “is being adapted widely, not only across the U.S. but now in Europe and Asia – because people are seeing that this has a tremendous impact on both the quality of patient outcomes and the cost of care.”

As Chief of the Surgery Department’s Division of Metabolic, Endocrine and Minimally Invasive Surgery, Dr. William B. Inabnet III leads a team that has done more laparoscopic surgeries than at any other hospital in New York City. Dr. Inabnet himself performed the first robotic thyroidectomy at Mount Sinai in 2010, and is a strong advocate of both robotic and non-robotic minimally invasive procedures to remove part or all of a diseased thyroid gland. In the most common procedure, a laparoscope with a tiny, high-definition video camera is inserted into the incision made by the surgeon, so that he and his team can have a bigger, clearer view of the operation on a television screen – “which promotes teamwork,” says Dr. Inabnet, “and greatly improves patient safety.” There is also a cosmetic advantage: The patient is left with a one-to-two-inch scar on the front of the neck, as opposed to four to six inches in a traditional operation. Dr. Inabnet is so impressed with the procedure that he has posted a video of it on Facebook (www.facebook.com/msthyroid), and looks forward to its becoming more common. “Every year,” he notes, “we graduate two endocrine laparoscopic surgery fellows who know these techniques. We’re training the next generation.”

Prostatectomy – the removal of a diseased prostate gland – has long been considered one of the riskiest of medical procedures; because the prostate is surrounded by nerves which control sexual and excretory functions, the slightest error can leave a patient both impotent and incontinent. But through the use of robotics, Dr. David B. Samadi has been able to perform close to 2,200 prostatectomies at Mount Sinai, with amazing results: “97 percent of patients retain continence,” he says, “85 percent, sexual function. 95 percent stay only one night in the hospital. Pain is minimal.” As Chief of Robotics and Minimally Invasive Surgery at Mount Sinai, Dr. Samadi, a urologist, performs almost 15 robotic prostatectomies a week, using a procedure he has named with the acronym SMART (Samadi Modified Advanced Robotic Technique). The main advantages of the technique, he says, are the ability of the DaVinci system to handle the prostate without disturbing “the delicate, sensitive nerves” around it, and to give him a clear, precise view. “In open surgery, you use ‘the touch factor’ because you can’t see the detail of the procedure,” he notes. “With the SMART technique, I can see the detail – so I can perform a precise operation.”

Originally published in Mount Sinai Science & Medicine magazine, 2012.