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Gastrointestinal Robotic Surgery: Developments and Perspectives
Minimally invasive robotic surgery has revolutionized gastrointestinal surgery by offering greater precision for complex procedures, resulting in improved patient outcomes. In this panel interview, Vitaliy Poylin MD, assistant professor of Surgery in the Division of Gastrointestinal Surgery, and Jonah Stulberg, MD, PhD, MPH, assistant professor of Surgery in the Division of Gastrointestinal Surgery, expand on the utility of robotic-assisted minimally invasive gastrointestinal surgery. They review the latest advances and outcomes and share how Northwestern Medicine is bringing robotic surgery for diseases affecting the GI tract to the forefront of care.
Featured Speakers:
Learn more about Vitaliy Poylin, MD
Dr. Stulberg is a General Surgeon and Health Services Researcher at Northwestern Memorial Hospital in the Divisions of Gastrointestinal and Endocrine Surgery. He earned his Ph.D. in Health Services Research with a concentration on Epidemiology and Biostatistics and a Master’s in Public Health in Public Policy at Case Western Reserve University in Cleveland, Ohio.
Learn more about Jonah Stulberg, MD, PhD
Vitaliy Poylin, MD | Jonah Stulberg, MD, PhD, MPH FACS
Dr. Poylin’s practice involves the operative treatment of disorders affecting the small bowel, colon, rectum, and anus. He has a particular interest in the surgical management of inflammatory bowel disease (Crohn’s disease, ulcerative colitis), colorectal cancer, and diverticulitis using minimally invasive robotic and sphincter-sparing techniques.Learn more about Vitaliy Poylin, MD
Dr. Stulberg is a General Surgeon and Health Services Researcher at Northwestern Memorial Hospital in the Divisions of Gastrointestinal and Endocrine Surgery. He earned his Ph.D. in Health Services Research with a concentration on Epidemiology and Biostatistics and a Master’s in Public Health in Public Policy at Case Western Reserve University in Cleveland, Ohio.
Learn more about Jonah Stulberg, MD, PhD
Transcription:
Gastrointestinal Robotic Surgery: Developments and Perspectives
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I’m Melanie Cole and today, we’re discussing robotics in GI surgery. Joining me in this panel are Dr. Vitaly Poylin, he’s an Assistant Professor of Surgery in the Division of Gastrointestinal and Oncologic Surgery specializing in minimally invasive and robotic colorectal surgery at Northwestern Medicine. And Dr. Jonah Stulberg. He’s an Assistant Professor of Surgery in the Division of Gastrointestinal and Oncologic Surgery specializing in complex abdominal wall reconstruction and robotic surgery at Northwestern Medicine.
Gentlemen, I’m so glad to have you join us today and Dr. Poylin, I’d like to start with you. Do you feel that robotics have really changed the landscape of GI surgery?
Dr. Poylin: Yes. Definitely in some of the procedures. Robotic surgery is extremely beneficial when we deal in the narrow spaces such as pelvis, or we deal with obese patients or the procedures that where we can minimize the size of an incision. So, in gastrointestinal especially, colorectal surgery, the pelvic procedures for colorectal cancer, for inflammatory bowel disease seem to be the most beneficial. It makes the surgery much, much easier on both patient and the surgeon. Whereas definitely some procedures that not just much easier but probably would not be possible to complete laparoscopically but we can do it robotically.
And then one of the recent advantages for us is that we can actually accomplish a much bigger part of every procedure robotically on the inside potentially leaving almost no marks other than the 8 millimeter ports on the body decreasing the chances of hernias and potentially taking some work away from Jonah, but I don’t know if you want to comment on that as well.
Jonah Stulberg, MD, PhD, MPH, FACS (Guest): Yeah, well thank you. I would say that the robotic platforms currently available allow for wristed motion of instruments and Zoom capabilities on our imaging that allow us to get into smaller and smaller spaces or go up and over intraabdominal contents in order to access areas and perform surgeries that we previously couldn’t if we only were using laparoscopic instruments which tend to be straight. And so, in the world of complex abdominal wall reconstruction, the use of robotic platforms, is really quite new. All of the procedures that we’re doing have been developed and are only now being perfected really in the last five, ten years and that’s because up until the current advancements, we didn’t have the ability to get into some of these spaces as Dr. Poylin was pointing out. Or get up and over something to complete the surgery.
So, it’s really fundamentally changed what we’re able to do and I would say have been able to convert many of the procedures I would have preciously had to do open into minimally invasive procedures which can have very clear benefits for patients.
Dr. Poylin: I would also like to add that even though a lot of procedures we can – in colorectal, we can do both laparoscopically and robotically, there are definitely some procedures now that I don’t offer patients laparoscopically anymore because robotic surgery makes it so much easier on me and the patient and makes the recovery so much quicker that we just go straight to a robot for that.
Host: Dr. Stulberg, I’d like it if you would expand a little bit for us and people hear, physicians are hearing about DaVinci. Is that the only robotic surgical instrument available today? Do you see it widely expanding in the industry in the future? And also, while you’re telling us about that, tell us about the learning curve because that I think is something that other physicians want to know if they’re considering the use of this or referral to Northwestern. Tell us a little bit about the newer robots and the learning curve and really, the benefits to the surgeon to expand on that.
Dr. Stulberg: As of today, in the general surgical space for complex abdominal wall hernia repair; the DaVinci System made by Intuitive Surgical, is the only platform available. It’s the only platform that’s FDA approved for the procedures that we’re performing. Now there are other robotic assisted devices being developed. There are other robotic assisted platforms that are available in other specialties particularly in orthopedics and in other areas. But with regards to General Surgical procedures, the other platforms are currently in the process of being approved. They are in development, different phases of development and there’s a lot of promise in some of the newer platforms that are out there but they’re not readily available.
One of the things that the DaVinci system has going for it, is that it really has been around for several decades. They’ve iterated and changed their robotic platform over the years. at Northwestern Medicine, we’ve upgraded to the newest platforms which are their XI Systems and they now have single port systems and another system that’s being used in thoracic called ION which we just received and really has the opportunity to change some of the thoracic and pulmonary procedures that we’re performing.
So, the question then, is with all of this change, and growth in robotic platforms, how do we make sure that we are performing surgeries safely for our patients and that means getting through the learning curve quickly. And this is an area where I really think that the current robotic systems shine. They have developed an incredible array of technical skill development simulations as well as now case simulations and at Northwestern Medicine, we’ve invested in the ability to have full access to those for our residents and for the surgeons across our system that are interested in learning how to use the robot safely. However, there is plenty of data that suggests you still need 50 to 100 cases for most of the procedures to sort of get through that learning curve and at Northwestern, we have a system set up to help support surgeons in practice who are going through that process so that we can minimize any harm to patients such as co-scrubbing, having proctors and other techniques but really that’s quite remarkable that you can get through the majority of the learning curve with so few cases if you think about it. because the other techniques that we learned in residency, we talk about 250, 500 case minimums before getting through residency.
So, the learning curve aspects of the robotic systems have really come a long way leveraging those newer technologies that allow for simulation and other techniques.
Host: Dr. Poylin, what does the Digestive Health Center at Northwestern Memorial Hospital offer in terms of robotic surgery, anything unique? Tell referring physicians what you’re doing there. I know that Northwestern Memorial Hospital now has a total of 8 da Vinci robotic systems, more than any other hospital in Chicago. Tell us a little bit about your team, how you all work together and why you feel that robotic surgery in GI specifically, is so exciting right now.
Dr. Poylin: Here at Northwestern, we offer essentially a full range of robotic surgery on all the small and large bowel including rectum and we use the robotic surgery on every part of gastrointestinal tract essentially. We have recently been much more aggressive using the XI Platform that Jonah mentioned that is much more kind of flexible and user friendly and allows me to do things much quicker with much ease. For example, we’ve been experimenting much more with doing a totally intracorporeal procedures when the resection is done o the inside, the specimen is actually extracted through the rectum and then everything is kind of sewn in on the inside. And with the current platform, we can actually do it very quickly, leaving patients with almost no marks on the abdomen, much less pain, much quicker recovery and seem to be much less stress on them after surgery.
We’ve been expanding the overall kind of range of similar procedures and extent of the procedures that we do and as you mentioned, it’s actually a whole team. We have a dedicated OR nurses and OR coordinators that specifically work on the robots and robotic team. We have a set of physician assistants that are incredibly skilled in helping us to do a robot and make it easier and we also use them actually to teach because we have an extra pair of hands that allows us now to get through a case much quicker but also help our residents get up to speed and be prepared for practice eventually much quicker.
We have a whole system where we oftentimes will discuss the cases ahead of time, what would be needed as well as in a day off so we have everything planned and everything anticipated as much as we can ahead of time to make it go as quickly and smoothly for everybody.
Host: Dr. Stulberg, tell us about your outcomes, how they compare for robotic assisted surgery versus traditional laparoscopic. What have you been seeing in the department?
Dr. Stulberg: Outcomes are at the forefront of why I converted so much of my practice into robotic surgery. When I first started, I started measuring all of the outcomes of patients that I could think of that might be relevant to their recovery to see whether or not I was seeing the results that others had reported. That included things like my length of stay, the pain that patients are experiencing, the amount of opioids that they take, their activity level, surgical site infections and I saw a marked decrease across all of those outcomes which I was quite frankly, sort of blown away by. When I started my journey into robotic surgery, I thought that I would have sort of this narrow niche where I used the robot only for the most complex cases that I can’t do laparoscopically, and I can’t do robotically. But what I found is shorter length of stay between robotic ventral and lap ventral. Less pain between robotic inguinal and lap inguinal. And so I’ve converted most of my laparoscopic hernia practice into a robotic hernia practice. And that’s really been outcome driven. And we’ve published some of this data and as part of my research, we’re actually currently studying across the Northwestern System, whether or not the opioid use following laparoscopic, robotic and open inguinal hernia repair, laparoscopic, robotic cholecystectomy are different. So, in each of those groups, is the opioid use not just the prescribing, not just the reported pain 30 days later, but the actual use in the three to five days after an outpatient procedure. And the early results suggest that opioid use is down as well. So, those are great results.
Dr. Poylin: I would also like to add that I think anecdotally, in colorectal surgery, even compared to laparoscopic surgery; we seem to be decrease in the use of opioids at least in the hospital for some of these folks. This is when we were looking at some of the outcomes before I came to this institution. For us, in colorectal surgery, there is definitely has been shown some decrease in some of the long term postoperative complications such as incisional hernia for example and that has been at this point, pretty well documented. There is some suggestion that for more difficult cases, in the pelvis, especially related to rectal cancer, we can do better robotically compared to that laparoscopically, but this is still under investigation here as well as at many other institutions.
Host: What a fascinating topic gentlemen and as we wrap up, I’d like to give you each a chance to tell your final thoughts to referring physicians and other physicians so, Dr. Poylin, I’d like to start with you. Tell the listeners what you’d like them to know about robotic surgery at Northwestern Medicine, why you feel what you’re doing is so unique and are there any studies you’d like to mention that the Digestive Health Center at Northwestern Memorial Hospital faculty are a part of, what you’d like other physicians to know.
Dr. Poylin: I think here in Northwestern, we – the institution and then Digestive Health Center invested heavily into utilizing and advancing robotic surgery which puts us in the unique position to train folks and have availability of robotic surgery that will allow us to do it probably more frequently than many other institutions can because of shortage of resources. That will give us much more experience and expertise in helping patients and get them through that as quickly as possible. It also puts us in somewhat of a unique position to study some of these effects. I actually just recently got a grant from American Society of Colorectal Surgery to look at interruptions in the robotic colorectal surgery and how to address them to make it much more efficient. And then we are considering to be part of some other multicenter trials as well but none of them are online quite yet.
Host: Dr. Stulberg, last word to you. What would you like listeners to take away from this segment and when you feel it’s important that they refer to the specialists at Northwestern Medicine.
Dr. Stulberg: My main take away would be that the ability to perform robotic surgery on more and more complex abdominal wall cases, abdominal hernia cases in particular, is really expanding rapidly. And I’ve been very impressed with our ability to offer a minimally invasive approach to more and more complex patients including a handful of loss o domain abdominal hernia cases which we’ve now completed successfully with patients who otherwise might not even be candidates for open surgery because of the stress of an open surgery. So, I would say the main take away is that we continue to really improve and offer more and more complex surgeries minimally invasively which we are very proud of. And if you are unsure of whether it can be done, it never hurts to ask, it never hurts to refer a patient over or simply shoot us an email or connect with us in whichever way that you can because we are always happy to discuss cases and try and improve together.
Dr. Poylin: I guess I would also like to add at the end that even though both me and Jonah perform a lot of our surgeries robotically and minimally invasively; at the end of the day, it’s an approach, it’s not a way of life. We approach every patient individually in trying to figure out what is the best possible way to get them through whatever problem that they have in the safest and most expeditious manner. And I think that at the end of the day is what’s important.
Host: Well it certainly is and what a fascinating topic. You’re both excellent guests. Thank you, gentlemen, so much for joining us today and telling us about GI robotic surgery at Northwestern Medicine. To refer your patient, or for more information, please visit our website at www.nm.org/dhc to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.
Gastrointestinal Robotic Surgery: Developments and Perspectives
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I’m Melanie Cole and today, we’re discussing robotics in GI surgery. Joining me in this panel are Dr. Vitaly Poylin, he’s an Assistant Professor of Surgery in the Division of Gastrointestinal and Oncologic Surgery specializing in minimally invasive and robotic colorectal surgery at Northwestern Medicine. And Dr. Jonah Stulberg. He’s an Assistant Professor of Surgery in the Division of Gastrointestinal and Oncologic Surgery specializing in complex abdominal wall reconstruction and robotic surgery at Northwestern Medicine.
Gentlemen, I’m so glad to have you join us today and Dr. Poylin, I’d like to start with you. Do you feel that robotics have really changed the landscape of GI surgery?
Dr. Poylin: Yes. Definitely in some of the procedures. Robotic surgery is extremely beneficial when we deal in the narrow spaces such as pelvis, or we deal with obese patients or the procedures that where we can minimize the size of an incision. So, in gastrointestinal especially, colorectal surgery, the pelvic procedures for colorectal cancer, for inflammatory bowel disease seem to be the most beneficial. It makes the surgery much, much easier on both patient and the surgeon. Whereas definitely some procedures that not just much easier but probably would not be possible to complete laparoscopically but we can do it robotically.
And then one of the recent advantages for us is that we can actually accomplish a much bigger part of every procedure robotically on the inside potentially leaving almost no marks other than the 8 millimeter ports on the body decreasing the chances of hernias and potentially taking some work away from Jonah, but I don’t know if you want to comment on that as well.
Jonah Stulberg, MD, PhD, MPH, FACS (Guest): Yeah, well thank you. I would say that the robotic platforms currently available allow for wristed motion of instruments and Zoom capabilities on our imaging that allow us to get into smaller and smaller spaces or go up and over intraabdominal contents in order to access areas and perform surgeries that we previously couldn’t if we only were using laparoscopic instruments which tend to be straight. And so, in the world of complex abdominal wall reconstruction, the use of robotic platforms, is really quite new. All of the procedures that we’re doing have been developed and are only now being perfected really in the last five, ten years and that’s because up until the current advancements, we didn’t have the ability to get into some of these spaces as Dr. Poylin was pointing out. Or get up and over something to complete the surgery.
So, it’s really fundamentally changed what we’re able to do and I would say have been able to convert many of the procedures I would have preciously had to do open into minimally invasive procedures which can have very clear benefits for patients.
Dr. Poylin: I would also like to add that even though a lot of procedures we can – in colorectal, we can do both laparoscopically and robotically, there are definitely some procedures now that I don’t offer patients laparoscopically anymore because robotic surgery makes it so much easier on me and the patient and makes the recovery so much quicker that we just go straight to a robot for that.
Host: Dr. Stulberg, I’d like it if you would expand a little bit for us and people hear, physicians are hearing about DaVinci. Is that the only robotic surgical instrument available today? Do you see it widely expanding in the industry in the future? And also, while you’re telling us about that, tell us about the learning curve because that I think is something that other physicians want to know if they’re considering the use of this or referral to Northwestern. Tell us a little bit about the newer robots and the learning curve and really, the benefits to the surgeon to expand on that.
Dr. Stulberg: As of today, in the general surgical space for complex abdominal wall hernia repair; the DaVinci System made by Intuitive Surgical, is the only platform available. It’s the only platform that’s FDA approved for the procedures that we’re performing. Now there are other robotic assisted devices being developed. There are other robotic assisted platforms that are available in other specialties particularly in orthopedics and in other areas. But with regards to General Surgical procedures, the other platforms are currently in the process of being approved. They are in development, different phases of development and there’s a lot of promise in some of the newer platforms that are out there but they’re not readily available.
One of the things that the DaVinci system has going for it, is that it really has been around for several decades. They’ve iterated and changed their robotic platform over the years. at Northwestern Medicine, we’ve upgraded to the newest platforms which are their XI Systems and they now have single port systems and another system that’s being used in thoracic called ION which we just received and really has the opportunity to change some of the thoracic and pulmonary procedures that we’re performing.
So, the question then, is with all of this change, and growth in robotic platforms, how do we make sure that we are performing surgeries safely for our patients and that means getting through the learning curve quickly. And this is an area where I really think that the current robotic systems shine. They have developed an incredible array of technical skill development simulations as well as now case simulations and at Northwestern Medicine, we’ve invested in the ability to have full access to those for our residents and for the surgeons across our system that are interested in learning how to use the robot safely. However, there is plenty of data that suggests you still need 50 to 100 cases for most of the procedures to sort of get through that learning curve and at Northwestern, we have a system set up to help support surgeons in practice who are going through that process so that we can minimize any harm to patients such as co-scrubbing, having proctors and other techniques but really that’s quite remarkable that you can get through the majority of the learning curve with so few cases if you think about it. because the other techniques that we learned in residency, we talk about 250, 500 case minimums before getting through residency.
So, the learning curve aspects of the robotic systems have really come a long way leveraging those newer technologies that allow for simulation and other techniques.
Host: Dr. Poylin, what does the Digestive Health Center at Northwestern Memorial Hospital offer in terms of robotic surgery, anything unique? Tell referring physicians what you’re doing there. I know that Northwestern Memorial Hospital now has a total of 8 da Vinci robotic systems, more than any other hospital in Chicago. Tell us a little bit about your team, how you all work together and why you feel that robotic surgery in GI specifically, is so exciting right now.
Dr. Poylin: Here at Northwestern, we offer essentially a full range of robotic surgery on all the small and large bowel including rectum and we use the robotic surgery on every part of gastrointestinal tract essentially. We have recently been much more aggressive using the XI Platform that Jonah mentioned that is much more kind of flexible and user friendly and allows me to do things much quicker with much ease. For example, we’ve been experimenting much more with doing a totally intracorporeal procedures when the resection is done o the inside, the specimen is actually extracted through the rectum and then everything is kind of sewn in on the inside. And with the current platform, we can actually do it very quickly, leaving patients with almost no marks on the abdomen, much less pain, much quicker recovery and seem to be much less stress on them after surgery.
We’ve been expanding the overall kind of range of similar procedures and extent of the procedures that we do and as you mentioned, it’s actually a whole team. We have a dedicated OR nurses and OR coordinators that specifically work on the robots and robotic team. We have a set of physician assistants that are incredibly skilled in helping us to do a robot and make it easier and we also use them actually to teach because we have an extra pair of hands that allows us now to get through a case much quicker but also help our residents get up to speed and be prepared for practice eventually much quicker.
We have a whole system where we oftentimes will discuss the cases ahead of time, what would be needed as well as in a day off so we have everything planned and everything anticipated as much as we can ahead of time to make it go as quickly and smoothly for everybody.
Host: Dr. Stulberg, tell us about your outcomes, how they compare for robotic assisted surgery versus traditional laparoscopic. What have you been seeing in the department?
Dr. Stulberg: Outcomes are at the forefront of why I converted so much of my practice into robotic surgery. When I first started, I started measuring all of the outcomes of patients that I could think of that might be relevant to their recovery to see whether or not I was seeing the results that others had reported. That included things like my length of stay, the pain that patients are experiencing, the amount of opioids that they take, their activity level, surgical site infections and I saw a marked decrease across all of those outcomes which I was quite frankly, sort of blown away by. When I started my journey into robotic surgery, I thought that I would have sort of this narrow niche where I used the robot only for the most complex cases that I can’t do laparoscopically, and I can’t do robotically. But what I found is shorter length of stay between robotic ventral and lap ventral. Less pain between robotic inguinal and lap inguinal. And so I’ve converted most of my laparoscopic hernia practice into a robotic hernia practice. And that’s really been outcome driven. And we’ve published some of this data and as part of my research, we’re actually currently studying across the Northwestern System, whether or not the opioid use following laparoscopic, robotic and open inguinal hernia repair, laparoscopic, robotic cholecystectomy are different. So, in each of those groups, is the opioid use not just the prescribing, not just the reported pain 30 days later, but the actual use in the three to five days after an outpatient procedure. And the early results suggest that opioid use is down as well. So, those are great results.
Dr. Poylin: I would also like to add that I think anecdotally, in colorectal surgery, even compared to laparoscopic surgery; we seem to be decrease in the use of opioids at least in the hospital for some of these folks. This is when we were looking at some of the outcomes before I came to this institution. For us, in colorectal surgery, there is definitely has been shown some decrease in some of the long term postoperative complications such as incisional hernia for example and that has been at this point, pretty well documented. There is some suggestion that for more difficult cases, in the pelvis, especially related to rectal cancer, we can do better robotically compared to that laparoscopically, but this is still under investigation here as well as at many other institutions.
Host: What a fascinating topic gentlemen and as we wrap up, I’d like to give you each a chance to tell your final thoughts to referring physicians and other physicians so, Dr. Poylin, I’d like to start with you. Tell the listeners what you’d like them to know about robotic surgery at Northwestern Medicine, why you feel what you’re doing is so unique and are there any studies you’d like to mention that the Digestive Health Center at Northwestern Memorial Hospital faculty are a part of, what you’d like other physicians to know.
Dr. Poylin: I think here in Northwestern, we – the institution and then Digestive Health Center invested heavily into utilizing and advancing robotic surgery which puts us in the unique position to train folks and have availability of robotic surgery that will allow us to do it probably more frequently than many other institutions can because of shortage of resources. That will give us much more experience and expertise in helping patients and get them through that as quickly as possible. It also puts us in somewhat of a unique position to study some of these effects. I actually just recently got a grant from American Society of Colorectal Surgery to look at interruptions in the robotic colorectal surgery and how to address them to make it much more efficient. And then we are considering to be part of some other multicenter trials as well but none of them are online quite yet.
Host: Dr. Stulberg, last word to you. What would you like listeners to take away from this segment and when you feel it’s important that they refer to the specialists at Northwestern Medicine.
Dr. Stulberg: My main take away would be that the ability to perform robotic surgery on more and more complex abdominal wall cases, abdominal hernia cases in particular, is really expanding rapidly. And I’ve been very impressed with our ability to offer a minimally invasive approach to more and more complex patients including a handful of loss o domain abdominal hernia cases which we’ve now completed successfully with patients who otherwise might not even be candidates for open surgery because of the stress of an open surgery. So, I would say the main take away is that we continue to really improve and offer more and more complex surgeries minimally invasively which we are very proud of. And if you are unsure of whether it can be done, it never hurts to ask, it never hurts to refer a patient over or simply shoot us an email or connect with us in whichever way that you can because we are always happy to discuss cases and try and improve together.
Dr. Poylin: I guess I would also like to add at the end that even though both me and Jonah perform a lot of our surgeries robotically and minimally invasively; at the end of the day, it’s an approach, it’s not a way of life. We approach every patient individually in trying to figure out what is the best possible way to get them through whatever problem that they have in the safest and most expeditious manner. And I think that at the end of the day is what’s important.
Host: Well it certainly is and what a fascinating topic. You’re both excellent guests. Thank you, gentlemen, so much for joining us today and telling us about GI robotic surgery at Northwestern Medicine. To refer your patient, or for more information, please visit our website at www.nm.org/dhc to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.