Transcription:
Benefits of Robotic Colorectal Surgery

Prakash Chandran: Colon cancer is a third leading cause of cancer related death in the United States. One of the options to treat this cancer is robotic colorectal surgery in which surgeons remove parts of the colon and rectum that may be cancerous. There are many benefits to this type of procedure, and we're gonna talk about them today. Joining us is Dr. Conan Mustain, a colorectal surgeon at University of Arkansas for Medical Science. This is UAMS Health Talk, the podcast from the University of Arkansas for Medical Sciences. My name is Prakash Chandran. So Dr. Mustain, thank you so much for joining us today. Really appreciate your time. I'd love to get started by you telling us a little bit more about what you do as a colorectal surgeon.

Dr. Conan Mustain: Sure, thanks Prakash for having me on. So as a board certified colorectal surgeon, I am an expert in the treatment of diseases of the colon, rectum and anus. So I am a general surgeon by training, and then I did fellowship training to specialize in colorectal surgery. So, my practice is a mix of benign and cancerous conditions. I take care of abdominal diseases like Crohn's disease, ulcerative colitis, colorectal cancer. I also do outpatient endoscopy procedures, colonoscopy and sigmoidoscopy. And I also take care of a range of anorectal disorders, such as hemorroids and anal fissures and things of that nature.

Prakash Chandran: Okay. So you're seeing patients kind of across like different levels of severity. So it can be something like a routine colonoscopy, but also something that's more serious that requires surgery?

Dr. Conan Mustain: Absolutely. Yeah. And that's one of the things that I found appealing about this specialty is that it's not all doom and gloom cancer all the time. I mean, we do cases that are as big as any specialty out there in terms of multi visceral, resections, and complex robotic procedures and life Threatening and life saving cancer operations, but we can also have a day where we do 10 outpatient, he mammies, or morning of colonoscopies.

Prakash Chandran: Okay. So today, we're talking about robotic colorectal surgery. Can you just talk broadly about colorectal surgery and how it had been traditionally done?

Dr. Conan Mustain: Sure. So, the basic principles for surgical treatment of colorectal cancer is to remove a section of the colon that has the tumor in it. Along with what are called the regional lymph nodes, which are in an area called the mesentary next to the colon. That's the Venus drainage from the colon and the place where cancer cells are most likely to spread. And then if possible we try to put the two pieces of the bowel on either side back together. So historically dating back, 200 years, this has been done through opening the abdomen and controlling the blood supply to the bowel and cutting across the pieces and trying to put them back together.

As technology has advanced, we've gone from doing that through a giant open incision and suturing it back together with our hands to using a variety of stapling devices and energy ceiling devices to control the blood supply. And then eventually transitioning to doing that procedure through smaller and smaller incisions with the aid of cameras to help us see what we're doing on the inside.

Prakash Chandran: Okay. Awesome. And so when we talk about robotic colorectal surgery, just talk to us about what has brought on that innovation, how long it's been around and what are the benefits?

Dr. Conan Mustain: Yeah. Sure. So, robots are utilized across multiple industries from auto manufacturing to healthcare, to other things, and there are a variety of different types of robots for surgical procedures, from knee replacement to spine surgery, to other things. What we're talking about when we talk about robotic colorectal surgery is the use of particular robot, which is called the DaVinci robot which is a tool that enables essentially advanced laparoscopic surgery.

So the principles are to put small incisions and then trocars into the abdomen to connect a camera and then working instruments to a central tower called the patient cart on the DaVinci robot. And then that feeds electronically to a separate surgeon console where the surgeon can sit. Separate from the patient and control the camera and all three of the robotic working arms from that remote location. So it's across the room. The advantage there is that it allows the surgeon, the ability to drive the camera, to see where they need to see.

That they can control more than just the two instruments that they could otherwise hold in their hands. And that the robotic instruments have a wristed motion similar to a human hand. So instead of just reaching up down left, right, the arms are able to reach around corners and underneath vessels. So it enables a little bit of additional dexterity, visualization, and control for the surgeon.

Prakash Chandran: Okay. And just to be clear, because I think this is important just because we say a robot, it doesn't mean that the robot is doing the surgery, it just means that it is an extension of your hands and you have complete control. Is that correct?

Dr. Conan Mustain: Absolutely. Yeah. There's no part of the procedure in any way is dictated by the machine. We tell it where we wanna work. We tell it how we're gonna work. We point it in the right direction. And then it's completely under my control during the entire procedure. So I'm not enabling the machine to do the operation. The machine is enabling me to do the operation in a way that I feel is better and allows me to be more precise at it.

Prakash Chandran: I want to cover some of the benefits of robotic surgery. And so obviously the incisions are smaller, which then I suppose means that the recovery time is faster. Can you at a high level, talk about some of the benefits that people get by going through robotic surgery?

Dr. Conan Mustain: Sure. So I'll back that question up just to a level to cover minimally invasive surgery broadly. So when we talk about minimally invasive surgery, we're talking about the concept of avoiding opening the abdomen completely, and instead trying to accomplish the operation with a camera in small instruments. And we've been doing this in colorectal surgery since the early 1990s. So, as I was starting my training in general surgery around 2004, I was very excited to find a place to train where there were colorectal surgeons using laparoscopy to do colorectal resections. It was pioneering work at the time.

The evolution of laparoscopic or minimally invasive colorectal surgery has taken a couple of forms. Initially, and still today, many surgeons will make a small incision that's big enough for them to put one hand into the abdomen and then a couple of small incisions to put a camera in and then do the work. The rationale there is that you have to make about a three or four inch incision in order to pull a colon out at the end of the operation anyway. So if they can put their hand in at the beginning and feel around and do the operation in a way that's more familiar to them, it may be a bridge to getting the operation done without a large incision .

As technology advanced and surgeon's comfort level increased, we've found more and more surgeons doing colon operations, laparoscopically, where they would stand at the patient's side with an assistant, holding the camera for them, and then use straight stick instruments in order to do the operation. That's a technology that I used for years. I was lucky enough to train under some amazing laparoscopic surgeons. I feel like I'm very good at that technology. And my practice was probably 80% laparoscopic before our hospital invested in the DaVinci robot.

The advantages the DaVinci robot brings over conventional laparoscopy are multiple, like I said the camera for the robot is binocular. So there's a left eye camera and a right eye camera, which results in almost a three dimensional image when you look into the surgeon console. As I said before, the instruments are wristed, so it allows me a lot more flexibility and control when maneuvering in the abdomen. And then I'm able to control more than just what I can hold in my hand. So I'm not constantly asking an assistant to look left an assistant to look right.

And what this has done for me is it's enabled me to work in places that are harder to see. It's allowed me to work. Longer in the day because of less fatigue, it's allowed me to accomplish more of the operation inside the patient's body. Before I make a small incision to take the specimen out at the end, as opposed to doing, 90% of the work and then pulling it out and finishing it off on the outside. So we know from decades of research that minimally invasive surgery for colorectal operations has an advantage over open surgery.

It leads to pain for patients which leads to low, less opiate use faster recovery of bowel function, faster return to work, faster discharge from the hospital, lower rates of surgical site infection, ecetera. these are outcomes that have been proven across multiple prospective studies over the last 30 years. Question is whether doing the operation with the robotic surgery, as opposed to laparoscopic surgery offers some advantage? And the data there's been a little less clear. I mean, there are surgeons who are extremely skilled at laparoscopy who are able to achieve exceptional outcomes with that approach.

I was one of them for a long time. And that's a perfectly reasonable way to do it. But like I said the robot does offer to me some specific advantages that make the performance of the operation a bit more technical. And my data since transitioning my practice to robotic surgery has reflected that in terms of a decrease in length of stay, fewer readmissions to the hospital, ecetera,

Prakash Chandran: Yeah, just by the nature of it being faster in that you can get through it faster, less readmission, all of the things that you mentioned, it seems like overall that switching to robotic surgery, at least for yourself, has been beneficial. And it's hard to imagine a world where you'd go back. Is that fair to say?

Dr. Conan Mustain: Definitely hard to imagine a world where I'd go back faster is a moving target. I mean, with any adoption of any new technology, there's a learning curve. Right? And one of the actual barriers to surgeons adopting robotic technology in their practice sometimes is time. They say that, look I get in, I get started. I get going. I know I do the operation, it is routine. Everybody knows it. Now we're gonna talk about, I have to learn a different way to put my trocars in and then I have to move this machine in and reconnect it. And then, is anesthesia gonna be okay with it?

And there, there can be frustrations. I mean, that's the nature of progress is that there's some learning curve to get through. So I wouldn't say that increasing time is necessarily the immediate advantage. In my case, actually it was the opposite. It was costing me more time in the operating room to get through the operations initially. But what I was seeing on the back end was it just improved outcomes for my patients. And so, as opposed to having. 60% of my patients go home on day two, day three after surgery.

And then about a third of patients develop slow bowel function and start throwing up and have to stay for an extra couple of days. Now it's more like 85% of my patients are going home day two day three, which has led to a significant job. And my average length of stay fewer readmissions, ecetera. And then I think about that is that success baguettes success. So if I'm sending more and more patients back to the referring provider with decreased pain and ready to go back to work after two weeks and better outcomes, then my volume of practice has gone up exponentially during that time as well.

Prakash Chandran: Yeah. Makes a lot of sense. So it really does sound like it's all upside for the patient. Are there any disadvantages for the patient that they should be aware of?

Dr. Conan Mustain: A potential disadvantage is if you have a surgeon who doesn't know how to use the technology, or isn't familiar with it, that decides to do something beyond their Comfort level that could clearly be a disadvantage. there are disadvantages, I mean, across the board simply in terms of cost, I mean, technology is expensive, right? So for a hospital system to purchase a DaVinci robot is a significant output of expense at the beginning. There are costs associated with maintenance of the robot.

There are disposable instruments that have to be used on every case, analogous to what we were doing with laparoscopy, but those costs have to be calculated. They have to be weighed against what the institution's getting paid to do the operation and what the outcomes are. So I think that's why it's been important for me as I made this transition to be transparent and critical of what are we opening? What is it costing? How are we doing it? How long is it taking us and what are the results? And in my practice, it has proven to be a beneficial thing, not only for my patients, but also for the hospital.

Prakash Chandran: Well, I think that's the perfect place to end Dr. Mustain, thank you so much for your time.

Dr. Conan Mustain: Prakash thank you for having me on, I really enjoyed it.

Prakash Chandran: That was Dr. Conan Mustain, a colorectal surgeon atU niversity of Arkansas for Medical Sciences. Thanks for checking out this episode of U AMS Health Talk. For more information on this topic and to access the resources mentioned you can visit UAMShealth.com. You can also call 501-296-1200 to book an appointment today. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. My name's Prakash Chandran. Thanks again for listening and we'll talk soon.