Robotic Surgery, Part I: Digestive Institute Tampa Surgeons Share Expertise

Allen Chudzinki, MD and Haane Massarotti, MD
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Five surgeons from the AdventHealth Digestive Institute Tampa (DI) participated in the virtual World Robotic Symposium 2020, the annual professional meeting of the Society of Robotic & Digital Surgery. The live event was held from Wednesday, July 29 through Sunday, August 2, and featured an international group of surgeons from all different surgical specialties. What they all had in common, however, is that they use the da Vinci Surgical System or another surgical robot to offer their patients advanced operations that involve only small incisions.  

Alexander Rosemurgy, MD, FACS, advanced foregut and HPB surgeon at DI, was the co-chair and moderator for the August 2 HBP session. (HBP is an abbreviation for “hepatopancreaticobiliary” referring to the liver, pancreas and bile ducts.) During the session, he and the following DI surgeons gave presentations highlighting their expertise in robotic surgery:

•    Alexander Rosemurgy, MD, FACS, advanced foregut and HPB surgeon 
•    Iswanto Sucandy, MD, FACS, advanced HPB surgeon
•    Sharona Ross, MD, FACS, advanced foregut and HPB surgeon
•    Allen Chudzinski, MD, FACS, FASCRS, colon and rectal surgeon
•    Haane Massarotti, MD, FACS, colon and rectal surgeon

This first blog of a two-part series looks at the DI surgeon’s talks about using the surgical robot for operations of the liver and bile ducts as well as metastatic colorectal cancer. Part two covers robotic surgery for pancreatic and esophageal conditions. It also summarizes Dr. Massarotti’s talk about the need for new surgeons to gain experience in robotic surgery.

Dr. Iswanto Sucandy: Robotic Surgery for Liver Conditions & Bile Duct Cancer

Dr. Sucandy spoke about “Robotic Major Hepatectomy: Indications, Contraindications, and Outcomes.” In this talk, he explained the types of cases that would lend themselves to a robotic major liver resection and what he, Dr. Ross and Dr. Rosemurgy’s outcomes with this approach have been like. He mentioned that with any major liver resection, bleeding during surgery is a major concern, and even more so when this procedure is done minimally invasively. Because of this, he advised other HBP surgeons to start their minimally invasive liver surgery practice with more minor liver operations and then build up to major liver resection as they gain experience. Dr. Sucandy pointed out that some liver operations are actually easier to perform with the surgical robot than with open surgery. He also mentioned that conversion rates – switching from minimally invasive surgery to open surgery – were less than 0.5 percent with robotic surgery but somewhere between 8 and 35 percent for laparoscopic major liver surgery. Also, unlike laparoscopic surgery, robotic surgery gives the surgeon a stable view of the surgical site, making it safer for patients.

In “Robotic Resection of Extrahepatic Biliary Tree,” Dr. Sucandy discussed treatment for hilar cholangiocarcinoma, AKA Klatskin tumor. Klatskin tumor makes up 6 or 7 of every 10 cases of bile duct cancer. Treatment involves removing parts of the main bile duct and reconstructing it so that bile can flow from the liver into the small intestine. 

“It’s probably one of the most difficult hepatobiliary operations out there,” said Dr. Sucandy. Complicating matters are that the structures of the bile ducts and surrounding arteries differ from patient to patient. Because of this, the surgeon has to be familiar with a few different structural variations. 

There aren’t many centers that offer robotic surgery for Klatskin tumor, and not much has been published yet in the medical literature about this approach. Dr. Sucandy reviewed two Chinese studies, one published in 2016 and the other in 2019. The earlier study showed poor results with robotic surgery for Klatskin tumor, However the second study, done by a more experienced center, found that patients had better outcomes with robotic surgery. Dr. Sucandy then discussed the excellent outcomes of the seven patients for whom he, Dr. Rosemurgy and Dr. Ross have offered this approach, including a patient who achieved complete cancer remission. Dr. Sucandy concluded that centers such as DI, with surgeons who have much experience with robotic liver surgery and the robotic Whipple procedure, should consider using the surgical robot for their Klatskin tumor operations. 

Dr. Allen Chudzinski: One Single Robotic Operation to Treat Colon Cancer & Liver Metastasis 

Dr. Chudzinski spoke about “Robotic Surgery for the Management of Metastatic Colon and Rectal Cancer to the Liver.” This is an important treatment because 1 out of 5 patients diagnosed with colon and rectal cancer will also be diagnosed with liver tumors. These tumors are colon cancer that has spread, or metastasized, to the liver. In this situation, surgery is the best treatment option and the only one that can potentially cure the cancer.
 
At most hospitals, patients have two separate different operations – both open – to treat the tumors in their colon and liver. This requires patients to recover from one surgery before having the other one, and then recover from the second surgery before undergoing chemotherapy. However, Dr. Chudzinski and his HPB colleagues, Dr. Sucandy, Dr. Ross and Dr. Rosemurgy, are able to offer cancer surgery for colon and liver as a single operation. This dramatically shortens recovery time so patients can start chemotherapy sooner. After Dr. Chudzinski showed video footage of himself and a DI HPB surgeon offering this operation, he shared the study results of five DI patients who had the operation. None had complications nor needed blood transfusions. Dr. Chudzinski also stressed that robotic surgery is also much easier on patients than an open operation. 

“Some of the studies that have been done have shown there is decreased operative stress on the patient … and thus less inflammation,” says Dr. Chudzinski. “That’s why I think our patients do better with robotic surgery,” he continues. Dr. Chudzinski adds that his patients tend to be able to walk around more, have less pain and be left with better bowel function after a robotic operation.

If you need surgery for a digestive condition, robotic surgery can give you excellent results with an easier and faster recovery. For a consultation with a Digestive Institute Tampa surgeon, call Call813-615-7557.

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