Transcription:
Robot-Assisted Transplantation

Prakash Chandran (Host):  There’s a cutting-edge advancement in kidney transplant surgery happening at the Hume-Lee Transplant Center with robotic assisted technology. It’s innovative, minimally invasive and even helps patients recover faster. Let’s talk about it with Dr. Chandra Bhati, a transplant surgeon at the VCU Health Hume-Lee Transplant Center. 

This is the Healthy with VCU Health Podcast. I’m Prakash Chandran. So, Dr. Bhati, I actually understand that you were the first surgeon on the East Coast to complete this robotic-assisted kidney implant. So, tell us a little bit about your experience and about this new procedure. 

Chandra Bhati, MD (Guest):  Typically, kidney transplant has always been associated with a big surgery, and giving a big scar to the patient. We are one of a few centers in the country, as well as in the world, who perform this surgery using a minimally invasive surgery. This means doing a surgery with a keyhole. We were the first one to complete robotic — that means no hand assistant at all during the transplantation. We were the first to perform in the East Coast without any need or any assistance of hand.

Host:  Okay and so when you say minimally invasive, what does that mean?

Dr. Bhati:  Minimally invasive means making a very small hole inside the abdomen, about three or four small holes. Each hole is about eight millimeters to a centimeter in size, and performing the surgery through these keyhole incisions. That’s minimally invasive. Typically, invasive means a bigger surgery, having a large cut inside the abdomen and taking longer time to perform. What we do and call minimally invasive is make small holes and put an instrument through those holes and do the surgery. 

Host:  Okay, and just so I can understand. I’m assuming that the hole is much smaller because the robot is the one making the incision. Normally with a human hand, I’m assuming that’s when the incision is much larger. Is that correct?

Dr. Bhati:  The robot is still run by us. We drive the robot. When we talk about the minimally invasive approach, what it does is we basically make a smaller incision and connect to a robot and then we drive the robot. That helps a lot because when you do an open surgery and make a bigger cut, the tissue trauma, means the trauma to your body, is much higher, which takes everything longer to heal. When we make a smaller incision and connect to the robot, who does the surgery guided by us, it is smoother, much better vision and less trauma to the body. 

Host:  I’m really glad that you made that distinction because I’m sure a lot of people listening may be think that a robot is just doing all the work, but I think from what you’re telling me, it’s just an extension of your hands. Is that correct?

Dr. Bhati:  Exactly. So, the big benefit of a robot is it behaves exactly as my hand would behave. So, what happens is we put a small hole inside the body and connect it with the robot and if I move my hand, if I move my finger right side, that arm will move on the right side. If I move it on the left side, the robot will move on the left side. So, it is exactly whatever I am doing with my hand, the arm does exactly the same way. So, it’s exactly what you said is absolutely correct. It’s an extension of the human hand. 

Host:  That’s insane. I feel like we’re living in the future here. So, maybe talk to us a little bit about how traditional implants were done. I know that there’s a donor. I know that there’s a recipient. I imagine that’s all normally done by hand, but with this robotic assisted surgery, how does it work?

Dr. Bhati:  As I was talking before, traditionally we used to make about 15-to 20-centimeter long incision and cut the muscles, go inside the abdomen. When we were taking out a kidney, we would spend two to three hours and dissect the kidney and take it out and close the patient again. There are three big muscles to cut through in the abdomen to take it out, which will give a large incision to the patient. The patient will stay in the hospital longer and have much more trauma to the body.

While with the robotic techniques, as I said, we make a smaller incision. We go and do the surgery without making a huge cut, so no muscles are cut, no need to divide the three muscles. So, imagine having tiny three or four hole for whole surgery. The kidney transplantation, which was still a few years ago, was considered an open surgery. And still it is an open surgery in most of the programs around the world. As I said before, there are only limited centers I would count on my fingers who would do this with this latest technology and give a very small scar. Almost practically a scar less operation where you have only eight to ten-centimeter-long incisions just to drop the kidney in or take a kidney out. That’s all the scarring that is given to the patient. 

Host:  That’s incredible. So, tell us a little bit about how long the procedure normally takes and what the average recovery time is. 

Dr. Bhati:  When we do the surgery with the robot, the recipient operation — means the patient who is getting a kidney — will take about three to four hours. And when we do the donor operation it takes only between an hour and a half to two hours. When we talk about the recovery, previous time when we were doing the surgery with the open approach; the patient was staying in the hospital for five to six days. Now, the patient is out of the hospital within 36 hours after operation. So, they pretty much stay one day in the hospital other than the day of admission and they are out of the hospital. 

And when we are talking about the recipient side, typically the patient would stay in the hospital for four to five days. Now with the robotic surgery, patient is typically staying in the hospital for three days. If they are staying longer, they are not staying because they need to for the surgical purposes, they need to have more immunosuppression medication. But from surgical point of view, most of the patients leave the hospital by day three. 

Host:  Okay so, it seems like everyone would want to get robotic assistance here. But is there an ideal candidate for this type of procedure?

Dr. Bhati:  We are still in the early set up for these transplantation, and we have been doing it for nearly a year or two, so we are offering it to the people who relatively don’t have much disease in their bloodwork and where the sewing with the robot is not that hard. At the same time, we are doing it in the people who don’t have a significant heart history so that we are making sure we are not putting too much carbon dioxide in their abdomen while we are operating. So, these are the two to three people who we are excluding but otherwise, we are pretty much including every patient who can have a surgery through an open approach, we should be able to offer the same surgery with the robot. There is no compromise in the outcome. The outcomes are exactly as good as they would be with the open surgery. So, there is no compromise on a long term outcome with the same results with a much earlier, quick recovery and patients return to their work much, much quicker than they would return back through the open surgery. 

Host:  And I know you said there was no compromise in outcome but what about any additional risks or complications that are involved with robotic assisted technology? Can you talk about that?

Dr. Bhati:  Typically, we say that there are really in terms of additional risk, the only risks involved are the conversion to open surgery. But other than that, there is no additional risk involved which would have an open surgery and not having the robotic surgery. The complications are pretty much comparable in both groups. Outcomes are the same. Complications are the same. Recovery is much better. Trauma is much less. Return to work is much sooner and patient satisfaction is much higher with the minimal invasive approach or robotic approach than the open approach. The complication is no different from what they would have in the open surgery. 

Host:  Yeah, it seems like it’s a win all around. So, I have to ask the question, in addition to kidney transplants is robotic assisted surgery performed for other conditions at the Hume-Lee Transplant Center?

Dr. Bhati:  So, we do perform the robotic assisted surgery for liver cancer where we take out part of a liver, half the liver and we are doing this with more and more surgery. So, patients who have bile duct problems, where basically the liver produces bile and that goes from the liver to the bowel, and if there is anything happening during the way by which bile goes from the liver to the bowel, we operate all through the robot taking half of the liver, including the right lobe or left lobe, we perform with the robot. 

We are doing more surgeries with the robot as well where we are taking a gallbladder out of a patient who has a significant liver disease, including liver cirrhosis, where most of people would not operate on them; we do the surgery with the robot, and they are typically used to staying in the hospital for four to five days, and now they are going home on the same day or the very next day. 

Host:  It is really incredible to hear all of this and I imagine something that you see is that donors are more willing to donate an organ because of the recovery time and the advancements in technology. Wouldn’t you say?

Dr. Bhati:  Absolutely. We have definitely seen that the patients are much happier to have this surgery with the robot. To give you just one example. I have had a patient, not one like quite a few examples, where the patient returned back to work within four to five days after surgery. And, I remember when I was in training when we were doing these surgeries with the open approach the patient was taking four to six weeks off. And now, going back to work within a week and taking pain medication only for three to four days. It is revolutionized for them. They feel much better. They are eating and drinking. They walk and they go home much quicker or return back to work in a much, much speedier fashion than they used to. 

Host:  All right Dr. Bhati, we really appreciate the education today. That’s Dr. Chandra Bhati, a Transplant Surgeon at the VCU Health Hume-Lee Transplant Center. Thanks for checking out this episode of the Healthy with VCU Health Podcast. For more information about the Hume-Lee Transplant Center, please visit www.vcuhealth.org/transplant. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll see you next time.