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Melanie Cole: Welcome to GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. Joining me is Dr. Matthew Ng. He's an assistant clinical professor of surgery in colon and rectal surgery at George Washington University School of Medicine & Health Sciences. And he's affiliated with The George Washington University Hospital. He's here to highlight today robotic technology as it relates to colon and rectal surgery.

Dr. Ng, I'm so glad to have you with us today. I'd like you to start by telling us a little bit about robotics. Give us a little bit of a background and how widely it's been accepted. Has the utilization of robotics really changed the landscape of medicine for you and specifically GI surgery?

Dr. Matthew Ng: Hi. Yes. Ms. Cole. Thank you for having me on the line and. I'm very grateful for the opportunity to speak about something that's very near and dear to my heart and the specialty. So robotic surgery has definitely changed the landscape of how we do surgery. And I remember many years ago, kind of the advent of laparoscopic surgery, which is minimally surgery. We were very limited to what we could do. Minimally invasively based on the instruments that we used, the instruments were colloquially known as a straight stick, meaning the instruments would just go in and you can just open and close them.

And doing laparoscopy was just very difficult in certain cases, specifically in rectal cancer where you're kind of operating down in a hole, but with the creation of robotic surgery, it changes the landscape significantly. It allows us to have more degrees of freedom when we're using instruments. It gives us a wrist like motion to grasp tissue. And also it's a more stable platform. So things aren't moving around and the camera and how we can see things is in three dimensions, which is very unique in robotic surgery.

Something you don't get in minimally invasive laparoscopic surgery. And how that translates to colon and rectal surgery, well, it allows us to perform operations in a quicker fashion. We can extract specimens through smaller incisions, and we have demonstrated that patients recover quicker. They go home from the hospital faster. Their pain is a lot. Then laparoscopic or open surgery. And we've also demonstrated that the outcomes between open or laparoscopic surgery and robotic surgery with cancer is the same. So we're not delivering an inferior operation.

Melanie Cole: Well, thank you for that. And so what are you using this in terms of, for GI surgery at the George Washington University Hospital? Speak about what surgeries you're performing with robotics.

Dr. Matthew Ng: Yes, definitely. So with the robotic platform and we do basically everything in the colon and the rectum. And so we're talking about colon cancer. We're talking about rectal cancer, for people with diverticulitis and we've removed the colon for that. And we also used a robot for Crohn's disease where we have to remove a small intestine. Now this is specifically geared towards colon and rectal surgery, but at George Washington University, we also do robotic surgery for gallbladders hernias weight loss surgery, such as gastrectomy, and also lung surgery as well, where we remove part of the lung for lung cancer.

So it's widely used amongst many different specialties. One I should also mention is the ears, nose, and third doctors also use it as well. And the urologists use it for prostate and the GYN doctors use it for endometriosis and fibroids. So, across a wide vast of specialties, the robot is definitely being utilized here.

Melanie Cole: What an exciting time to be in your field. So speak about patient selection. Is everyone a candidate for robotic colorectal surgery? Speak about the indications for use and when it might be contraindicated.

Dr. Matthew Ng: Yeah. So I consider everybody to be a candidate for robotic surgery, regardless of weight, regardless of size. I think everybody that is being presented for a colon or rectal surgery should be considered for robotic surgery because we have demonstrated that recovery and outcomes are on par of not better than the traditional way of doing surgery. Now, there are certain patients that would not qualify for robotic surgery, and those would be patients that cannot tolerate general anesthesia with insusating the abdomen.

Meaning patients that have relatively low cardiac reserve that cannot tolerate the increased pressure in the abdomen. Then also those patients that have had multiple abdominal surgeries or patients that have very big hernias that makes it difficult to have any working room because with robotic surgery, similar to laparoscopic minimally invasive surgery, we need to be able to have some type of working room inside the abdomen to be able to use the robot or do anything minimally invasively. And if that's not possible, then robotics would be a futile in that sense.

Melanie Cole: How do the outcomes compare Dr. Ng, For robotic assisted surgery versus laparoscopic and traditional methods?

Dr. Matthew Ng: Yeah, so, there have been many clinical trials specifically looking at cancer demonstrated that robotic surgery is equivalent to the laparoscopic surgery when performing for cancer. And what I mean by equivalent, I mean, equivalent outcomes. Talking about being able to adequately remove the cancer. And as well as the long term survival from that cancer being removed in either a laparoscopic or robotic fashion. But I will say that there have also been studies that demonstrate that in the immediate short term robotic surgery is not inferior to laparoscopic surgery in terms of immediate complications, such as bleeding and infection.

But robotic surgery has also demonstrated a small increase in The ability for the patient to leave from the hospital quicker. And so length of stay is decreased in patients who undergo robotic surgery and anecdotally patients are also in less discomfort afterwards.

Melanie Cole: Dr. Ng in many podcasts, we talk about the benefits to the patient with robotic surgery, but I'd like you to speak about the benefits to the surgeon. What is it doing for you? But while you're telling us that, please speak about the learning curves that have been involved. And if you are teaching residents, how to use this, what are you finding are the biggest challenges?

Dr. Matthew Ng: Sure. So the benefits to the surgeon is that it allows the surgeon to pretty much work effortlessly in performing the operation because we don't have to fight and push against structures and stand at the bedside to operate the laparoscopic instruments. Or on the flip side, if we're doing an open operation, be at the bedside and stretching and straining and try to see dissect things. Also with the robotic platform, the camera stable and it doesn't move. And so that allows us a clear feel to see things.

And the surgeon is seated at the console and allows them to operate with very, minimal ease. And so the amount of stress that is on the neck and the joints and the back is greatly reduced by operating robotically. And in turn, I think that allows for longevity of that surgeon. But at GW we are also training our next generation surgeons to be robotically trained and in this day and age with robotic surgery being more and more prevalent, residents and trainees are looking for programs that will also teach them how to do robotics.

Now it's a fairly steep learning curve because you one, has to understand the basics of the operation before even trying to attempt to do anything robotically. And so not being able to have that background will really hinder a trainee. And so what we do at GW is we have a very step wise approach. You know, we have simulation, we have simulations, we have cadavers, and then we have models for the residents to practice on. And then as they feel comfortable and progress through that, then we have them at the bedside next to the patient, assisting with exchanging the instruments and assisting the surgeon that's operating.

And then finally, once they've met all these milestones and also feel comfortable, then we have 'em on the console. And at GW, we actually have a room with two consoles. And so the operating surgeon and the resident are side by side on their own console and they can switch back and forth and point and take instruments and whatnot. So throughout the entire session, the patient is a hundred percent completely safe and the surgeon is in control.

Melanie Cole: Wow, this is fascinating. What's happening these advances in medicine today, and please speak as we wrap. About the unique areas that set you apart and why it's so important to refer to the specialists at the George Washington University Hospital. And if somebody wants to refer their patient in for robotic surgery for colorectal issues, when is the best time to do that Dr. Ng?

Dr. Matthew Ng: Yeah. And so at George Washington University Hospital, we were known as the first hospital in the DC area to do robotic colorectal surgery. So there is a tradition here and there is an understanding and a motivation to continue providing our colorectal surgery patients the best care with the most up to date technology and innovative healthcare. And so patients who undergo colorectal surgery should always go to a center that's high volume, surgeons that do a lot of these cases.

Because study and study has demonstrated that patients that go to a center that have surgeons that operate in high volume, they do a lot better than a center that maybe does one or two of those cases a year. For cancer, it should be referred to a colorectal specialist for removal. And in terms of that timeline, it should be from the moment one is diagnosed with a colon or rectal cancer, it should be seen fairly quickly by the surgeon to evaluate for the possibility of removing that cancer for cure. And we have a very streamlined process to do that with a nurse navigator in the colorectal surgery clinic.

Melanie Cole: Well, it's certainly a multidisciplinary approach. Yes. Just speak about that and tell us about your team.

Dr. Matthew Ng: Yeah. So, treating colon and rectal cancer is definitely multidisciplinary and it's not just a surgeon. We also have an oncology department, we have radiation oncology, and we also have our pathologists who look at the cancer under the microscope, makes the diagnosis and our radiologists and our gastroenterologist as well. And every other week we have a meeting, it's our gastroenterology tumor board meeting where all of the specialties come together and we discuss all of our patients. We discuss the best course of treatment.

We go over the imaging and we discuss the surgical practices as well. And so, it's not one person that's leading the group, the patient is discussed by multiple specialties and we all kind of come to an agreement to create the best and individualized and focused plan for that patient.

Melanie Cole: Thank you so much, Dr. Ng for joining us today and sharing your incredible expertise with robotic surgery with us today. And for sharing your incredible expertise with other medical providers on robotic technology today. To refer your patient, please call 1-888-4GW-DOCS. If you have questions for one of our specialists, please email physicianrelations@gwu-hospital.com.

That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. Thanks so much for tuning in today.

Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.

Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.