Transcription:
Updates in Robotic Cholecystectomy

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Kyle Mueller. He's an Assistant Professor of Gastrointestinal Surgery at Northwestern Medicine, and he's here to offer updates in robotic cholecystectomy, Dr. Mueller, it's a pleasure to have you join us today. So historically, what have been some of the different techniques used to surgically remove the gallbladder? Give us a little evolution here in what's been done.

Dr Kyle Mueller: Thanks for having me. So historically, the original way that the gallbladder was removed was what's called an open cholecystectomy, which involved a 12 to 18-inch incision in the patient's abdomen, opening up the abdomen, very traumatic to the abdominal wall and muscles; and a long recovery, two to three days stay or longer in the hospital, two to three weeks recovering at home, kept patients out of work for several weeks. And then, the evolution started in the late 1980s and the early 1990s towards laparoscopic cholecystectomy, which involved using a small video camera, four small incisions, and that carried on through the next decade.

And then, the advent of robotic surgery came in the early 2000s and it really infiltrated primarily urology surgery and was heavily influenced in the use of robotic platforms for prostate surgery. General surgeons were a little later to adapt. But over the last decade or so, it has become widely accepted and used for general surgery, especially gallbladder removal. So that's where we're seeing the shift a little more towards robotic-assisted laparoscopic cholecystectomy, replacing standard laparoscopic cholecystectomy.

Melanie Cole (Host): So fascinating, Dr. Mueller. And thank you for telling us a little bit about the evolution. So now, let's do some comparing and contrasting about the advantages of performing a robotic-assisted laparoscopic cholecystectomy compared to the standard laparoscopic that you just discussed.

Dr Kyle Mueller: There are several distinct advantages of performing a robotic-assisted cholecystectomy over a standard laparoscopic cholecystectomy. The first and most important is that the surgeon controls the robotic platform, which allows a much greater precision of motion and control of the instruments over standard laparoscopic cholecystectomy surgeries. We can actually articulate and rotate our wrists and instruments, allowing for much more precise control in a tight space inside the patient's abdomen.

In addition, the camera that we use in robotic surgery provides a three-dimensional view as compared to a standard view in laparoscopic cholecystectomy. This three-dimensional view allows for a much greater detail of identifying small structures and blood vessels and other vital structures. Also, the robotic platform has a built-in technology that enables the surgeon to visualize the important biliary structures, such as the common bile duct and the cystic duct by employing a fluorescent marker given to the patient about 45 minutes to an hour before the surgery. All of these unique advantages allow for a safer surgery for the patient with less blood loss and for less damage and injury to important vital structures.

Melanie Cole (Host): So then, speak about the criteria for a robotic-assisted approach and patient selection. Is everybody a candidate or are there any contraindications?

Dr Kyle Mueller: The criteria for a patient to undergo a robotic-assisted laparoscopic cholecystectomy is primarily that the patient can tolerate and undergo a general anesthetic. This is very similar to the criteria for a patient to undergo any standard laparoscopic surgery. The only contraindications where a patient should not undergo robotic surgery is if they cannot tolerate a general anesthetic or any type of sedation of any form.

Melanie Cole (Host): So then, how does the robot equate to better surgeries? Tell us a little bit about outcomes. And while you're telling us that, tell us a little bit about the benefits to the patient as far as recovery and what that looks like.

Dr Kyle Mueller: So there still remains quite a bit of research and extensive studies that will need to be performed. But the early results are showing very significant decreases in injury to the bile duct, decreased postoperative bleeding and overall quicker recoveries and quicker return to work. Overall, what I have seen in my practice, and also this is demonstrated in some of the early studies that have been released, is that the recovery for patients undergoing a robotic cholecystectomy are similar to standard laparoscopic cholecystectomy with several unique advantages, in that patients have much less postoperative pain at the incisions after a robotic cholecystectomy. The robotic platform allows the robot to manipulate the instruments with much less trauma to the abdominal wall of the patient. And therefore, they have less pain and I've seen a dramatic decrease in the use of postoperative opioids in my patient population. And overall, this leads to a quicker return to normal daily activities and work and the things that patients enjoy.

Melanie Cole (Host): What about learning curves, Dr. Mueller? Do you have any technical considerations for other providers? How much does the experience of the surgeon matter for these advanced robotic technology procedures?

Dr Kyle Mueller: The learning curve I will admit is steep. The training involved to perform robotic surgery can take significant time. It's well worth the time. It involves the surgeon spending several months going to courses, practicing on what's called a robotic simulator. And overall, once you're certified and have completed your training, the learning curve is pretty steep for the first maybe 15 to 20 cases. After that, the experience that you have as a surgeon, the more of the robotic gallbladder surgeries and other types of robotic surgeries, all just allow for much better patient outcomes and the surgery times and the time that a patient is under anesthesia becomes significantly less and less.

Melanie Cole (Host): Now, I'd like to talk about the ways that Northwestern Medicine is uniquely qualified to perform this procedure. Tell us a little bit about your team and your approach at Northwestern.

Dr Kyle Mueller: What makes Northwestern Medicine uniquely qualified to perform robotic surgery and especially cholecystectomies is that we are a tertiary care center that has made a large capital investment to employ a large fleet of surgical robots. These robots are located in our inpatient and our outpatient surgical facilities. This allows us to provide much better access to this cutting edge robotic technology for our patients. In addition, we perform a high number of robotic surgeries, especially cholecystectomies with outstanding patient outcomes. We have an excellent robotic team. This includes nursing staff, surgical first assist that all support one another and allow us to provide excellent results for our patients. And we've seen a significant growth in our patient volumes and excellent outcomes over the last several years.

Melanie Cole (Host): And in what ways do you think laparoscopic cholecystectomy will continue to evolve in the future? What do you see? Give us a little blueprint for maybe 10 years down the line.

Dr Kyle Mueller: I think what we're seeing is the field of robotic surgery is changing so rapidly that there's new technology coming into the field yearly. I think what's probably coming down the pipeline very soon, one of the things that has been difficult is that robotic surgery, there is no what is called tactile feedback, meaning when you're working on the robot, you cannot sense what you're grasping and get a feel for how something feels. And I think what we'll see in the near future is that the company is going to build in what's called the tactile response. So we'll be able to sense what something feels like when we're grabbing it with the robot. I think that will be important and it will just make the surgery that much more advantageous.

Also, I think what we'll start to see is the use of artificial intelligence working its way into the robotic field. And what I mean by that is I think that we will start to see the artificial intelligence mapping, where it will kind of outlay for us as we start a surgery where the most important vital structures are most likely to be located. I don't think we can rely completely on such technology, but I think it can give us a good roadmap of where things are going to be as we anticipate starting the surgery. And I think those are the things we have to look forward to in robotic surgery all in the effort to provide better care for our patient.

Melanie Cole (Host): What an exciting time to be in your field and all these technological advancements. Dr. Mueller, as we wrap up, what would you like other physicians using a robotic-assisted approach to keep in mind?

Dr Kyle Mueller: I think the most important thing that we as surgeons who are performing the robotic techniques for surgery to keep in mind are first and foremost is we want to provide the safest and the best outcomes for our patients. This involves us, as a surgeon, staying current on the latest technology. We need to continue to train. We need to continue to be advocates for our patients. And in addition, we need to collect and track our patient outcomes. These can guide us in the future and help us to adjust and change our patterns of care that we provide for our patients. And we just need to remember that technology is always changing and we need to stay on top of these changes.

Melanie Cole (Host): I agree with you completely, Dr. Mueller. And thank you so much for such an informative podcast. You are an excellent guest. Thank you again for joining us. And to refer your patient. Or for more information, please visit our website at breakthroughsforphysicians.nm.org/gastro to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.