Amanda Wilde (Host): Colon cancer is the third leading cause of cancer related death in the United States. The good news is that one of the most successful options to treat this common cancer, is robotic colorectal surgery. There are many benefits to this type of procedure and we'll be talking about that today with colorectal surgeon Dr. Thomas Kang. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. I'm Amanda Wilde. Dr. Kang, so glad to have you here to explain this latest technology.

Thomas Kang, M.D.: Hey, thank you very much for having me. It's a, it's a privilege.

Host: So as I said, this is the latest technology, but to put that in perspective, can you first talk broadly about what traditional colorectal surgery looks like and how it's traditionally been done?

Thomas Kang, M.D.: Yeah, of course. So, a lot of this stems from surgeons who've been doing intraabdominal operations. So obviously the most you could say rudimentary, but still has a very vital role in our surgical care is open operation. You know, those traditional big midline incisions that you sometimes see on patients.

And then starting in about the eighties, nineties, physicians started coming up, OB GYNs and also obviously general surgeons as well, started coming up with ways to insufflate the abdominal cavity, with carbon dioxide so that we could have smaller incisions rather than having big incisions to perform our operations.

And from there, I guess you could call robotic surgery as more of an advanced laparoscopy where, we have a separate console and the actual robot's docked at the patient bedside.

Host: Laparoscopic surgery is something we heard quite a lot about about a dozen years ago. This is the next step beyond, isn't it?

Thomas Kang, M.D.: So robotic surgery actually, has been around since about the late 90s really in going through animal trials and, eventually human trials. And so, the latest iteration of the most widely used robot as of right now is, from the Intuitive Surgical and it's called the DaVinci. It's currently in its fourth generation, and that came out about 10 years ago. So compared to the overall history of surgery, yes, it's a relatively new technology.

Host: And in this iteration, just because we say it's a robot, it doesn't mean a robot is doing the surgery. It's an extension of your hands and you have complete control. Does that mean using the robot means you can make finer movements than your hands could make?

Thomas Kang, M.D.: So to answer your first question, you're absolutely correct. So the initial, entry into the patient's abdominal cavity, to place the ports, to dock the robot and to insert the instruments, that requires hands on at the patient bedside. However, once the robot has been docked and, the patient's obviously appropriately positioned, the surgeon actually goes to a corner of the room where the console is located. And, it's the size of maybe a small fridge maybe? And you sit at the console and it's a pretty amazing technology where there really is no lag time between the movements that I make with my hands and the movements that are obviously now being translated within the patient via these instruments.

And you really do get rid of a lot of the possible hand tremors that you might have. It kind of mitigates a lot of those factors.

Host: And so, obviously, with the robot, you've mentioned it's less invasive, the incisions are smaller. I suppose that means the recovery time is faster?

Thomas Kang, M.D.: So, that's the thought process. There was a trial, about two, three decades ago now, that looked at the patient outcome, short term and long term outcomes, between laparoscopy and open colon surgeries. And it did shorten the overall length of stay for the patients, as well as, the narcotic usage.

Now, I just want to make a point that I do think that, being able to do minimally invasive surgery, whether that be laparoscopy or robotic, is beneficial to the patients because it makes sense that a smaller incision will probably translate into a shorter recovery time, faster time home, to spend time with your family, to go back to work.

However, I think ultimately, these are just tools, whether it be open, laparoscopy, or robotic, and it really is a surgeon's ability to do these operations that make these tools great. So whether that be open, laparoscopic, laparoscopic or robotic, as long as a surgeon can accomplish the goal safely and do it right, I think that's what the patients really need to hopefully understand, it's great that the surgeon can offer these, all these different things. But really it's ultimately up to the surgeon to be able to accomplish it safely and do it right.

Host: And how do you keep up with that, Dr. Kang, when the technology is changing so rapidly?

Thomas Kang, M.D.: We're lucky to be at UAMS where we have a pretty robust minimal invasive surgery presence. And we have a lot of good support for that, not only from the OR staff, but obviously from, organizations that make these, or develop these instruments. So from Intuitive for example, the rep and I are in constant contact and I get updates about the kind of the newest, the biggest thing coming out. So, for example, we have the fifth generation of the robot, that's being slowly dispersed, out into the surgical world right now. Only select places have it at this time. UAMS does not have it yet. But, it comes with the job to try to stay current with the technology.

Host: Yeah, apparently. And as I said, it's developing ever more rapidly. With the robotic colorectal surgery, can you talk about some of the specific benefits besides the ones we've covered, shorter recovery time, leaving the hospital faster, being with your family more? Can you talk about some of the other benefits you've seen that people get by going through this robotic surgery?

Thomas Kang, M.D.: Of course, I think first and foremost, being able to essentially, be up close to my dissection field is very helpful, and so the camera that we use for the robot actually has two lenses and it processes these images real time and makes it so that when you're sitting at the console and you're operating, the field is perceived by our brains as three dimensional.

 So that is extremely helpful for me to be able to kind of get up close and personal with my dissection field so that I can literally see every single blood vessel and the important structures that I know not to injure. The other thing too is obviously traditionally when we do open surgeries, the incisions hurt more. And even when you do laparoscopy, oftentimes, you need to the term is extracorporealize, so essentially after you complete your dissection of the pathology of the colon, you make a slightly bigger hole to take that out to cut out the cancer or whatever it may be and make the connection.

Now on the robotic platform, it makes it much easier for us to be able to do all that inside the patient. Meaning I do the dissection, I resect the diseased portion and I make the connection all on the inside of the patient without having to make a bigger cut to take that out. Obviously, I have to sometimes extend one of my incisions to take out the actual specimen. But that's a pretty incredible thing that we can do nowadays.

Host: So it allows you to be very specific.

Thomas Kang, M.D.: Yeah, I guess you could say that, yeah.

Host: Are there any disadvantages to the robotic surgery that patients should be aware of?

Thomas Kang, M.D.: So in my opinion, once the robot is docked at the patient bedside, if say, I need to tilt the bed so that I can get bowel loops out of the way or kind of reposition the patient, the robot oftentimes has to be either undocked or the operation has to be paused in order for us to be able to safely do that.

Whereas if I was doing that same operation laparoscopically, I can kind of tilt the bed real time as I'm operating because there's no limitation with the robot being physically docked at the patient bedside, so. That's probably the biggest downside that I see to the robot.

Host: So how would you assess your success rate with this surgery?

Thomas Kang, M.D.: I keep a personal database of all my operations and outcomes. Being a surgeon, unfortunately, I'd be lying to my patients if I said, I can guarantee you that I will never have complications, because that's just, unfortunately, the cost of being a surgeon. However, I do have a list of patients, without their personal information, obviously, and the operations that I've done and their outcome, length of stay, what the final pathology was.

So I keep track of all my own data so that I can go back and look and also obviously follow up with my patients. I call them to see how they're doing. And, that's how I keep track of my own performance, you could say.

Host: So this is fairly exciting in the world of colorectal surgery. This is truly the latest and greatest way to do this sort of surgery where you may be taking out part of the colon and then putting it back together.

Thomas Kang, M.D.: It's pretty amazing, as a colorectal surgeon, we also do a lot of pelvic operations. So, rectal cancer, anal cancer operations, and, traditional laparoscopy, admittedly makes it a little bit challenging to be able to see very deep down into the pelvis, especially when it comes to, say, male patients or maybe patients who may be obese. But using the robot, pelvic operations, I wouldn't say it's a breeze by any means, but it definitely facilitates the ease of being able to see deep down in the pelvis to operate in those tiny, small, narrow areas, whereas, with laparoscopy, some of those, maneuvers can be quite challenging.

Host: Well, Dr. Kang, I know everyone's at risk for colorectal cancers and should be screened. But when you are beyond screening and it comes to having surgery, as you said, you have to choose the appropriate surgeon who knows what they're doing. And when you do choose someone like you, at least it's comforting to know that this technology will make it as successful as it possibly can be.

Thomas Kang, M.D.: As physicians we obviously all take an oath, and the first one is to do no harm and, I really do think that I have been fortunate enough to have great mentors who have taught me not only good surgical skills, but also sound judgment, and to be able to have some of these platforms and tools at my disposal, especially at a place like UAMS where we're the only academic institution within the state, we're also the only surgical training institution in the state.

So, quite fortunate to be able to be in a position where I can hopefully, serve the patients in the south and make a positive impact.

Host: Dr. Kang, thank you so much for explaining this robotic technology. I feel that in your hands, it's in safe hands.

Thomas Kang, M.D.: Well, that's very kind. Thank you very much for the opportunity. I really appreciate it.

Host: To make an appointment at UAMS, please call 501-296-1200. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for additional topics of interest. This is UAMS Health Talk from the University of Arkansas for Medical Sciences.