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Article Type: Blog

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

An earlier blog looked at liver, bile duct and metastatic colorectal cancer talks from AdventHealth Digestive Institute Tampa (DI) surgeons at the virtual annual meeting of the Society of Robotic & Digital Surgery: World Robotic Symposium 2020. At the August 2 meeting, the following DI surgeons gave presentations about 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 blog highlights the DI surgeons’ talks about robotic surgery for pancreatic and esophageal conditions. It also covers Dr. Massarotti’s presentation about the current state of new surgeons’ training in robotic surgery.

Dr. Sharona Ross & Dr. Alexander Rosemurgy: Using Robotic Surgery in Tampa for Pancreas Operations

“If a patient is a candidate for an open [pancreatic] procedure, he or she is a candidate for a robotic approach,” said Dr. Ross as she presented on Major Robotic Pancreatectomies: Indications, Contraindications and Outcomes. “It all depends on the surgeon’s experience and proficiency with the robot,” she continued. She talked about how she and Dr. Rosemurgy got started in offering robotic Whipple surgery back in 2013 and how the procedure has become even better for them since then. Today, DI has one of the busiest robotic pancreatic surgery programs in the U.S. 

Dr. Ross reported on a recent study done at DI that showed that when she and Dr. Rosemurgy used the robotic approach to the Whipple procedure, it was superior in removing pancreatic tumors for more patients compared to the open procedure. Patients who had robotic surgery were able to begin their chemotherapy a week earlier and also were more likely to complete their full course of chemotherapy. These things improved their survival even more. Also, the robotic approach resulted in about two or three fewer days spent in the hospital and a greater likelihood of patients being discharged to their own homes rather than a rehab facility.

In his presentation, “Technique of Robotic Pancreaticoduodenectomy,” Dr. Rosemurgy talked about the practicalities that he, Dr. Ross and Dr. Sucandy face in offering the robotic Whipple procedure.  

“We found we had to divide the operation into steps,” said Dr. Rosemurgy, explaining that unlike in an open operation, the surgeon can’t skip around from place to place to do his or her work. “The order of the steps … has turned out to be very important,” he stressed. “It’s important to map it all out.”

Dr. Rosemurgy described the very complicated set of steps that he, Dr. Ross and Dr. Sucandy use while offering the robotic Whipple procedure. He mentioned that during the operation, surgeons need to communicate clearly with the pathologists – the doctors who examine the tumor specimen under a microscope to ensure the tumor has been removed completely. Dr. Rosemurgy stressed that the surgeon should know about the presence of precancerous cells at the margins of the removed tissue in case more surgery is necessary. Finally, Dr. Rosemurgy discussed DI’s patient outcomes with the robotic Whipple procedure. He showed that DI’s patients had far fewer complications and surgical site infections. Also, they were discharged from the hospital sooner than the average patient from hospitals participating in the National Surgical Quality Improvement Program (NSQIP). 

Dr. Sharona Ross: Robotic Surgery for Esophageal Cancer & GERD

In “Robotic Repair of a Giant (Type IV) Hiatal Hernias and Reoperative Fundoplications,” Dr. Ross presented about when robotic surgery would be appropriate for patients who need a fundoplication. Commonly used to treat gastroesophageal reflux disease (GERD), fundoplication is an operation that strengthens the lower esophageal sphincter (LES) between the stomach and the esophagus, or food tube. Robotic surgery can help patients who have large hiatal hernias and those who need to have a fundoplication redone. In fact, Dr. Ross says that the surgical robot makes these technically challenging operations a lot simpler.

“The robot is a very stable platform that is very useful to avoid complications,” says Dr. Ross. The robot helps the surgeons see the surgical site better and gives them more control during the operation than they would have with an open procedure. She also made the case for the surgical robot being able to handle unexpected bleeding issues better than open or even laparoscopic approaches.

In another esophagus-related session given later that day, Dr. Ross spoke about “Surgical Treatment of Esophageal Cancer: Robotic Esophagectomy.” She gave an in-depth overview about how she and Dr. Rosemurgy use the surgical robot for esophagectomy. They operate as a two-surgeon team, with one at the surgical robot console and the other near the patient’s neck.

“We really embraced the robotic approach because it’s so much easier to use,” said Dr. Ross. “It’s a stable platform, it makes your life as a surgeon and the quality of your care so much higher,” she argued. She talked about when surgeons should consider offering patients a robotic esophagectomy.

Dr. Ross compared her and Dr. Rosemurgy’s outcomes with robotic esophagectomy with those of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) outcomes. She noted that DI’s outcomes were particularly strong in resulting in fewer complications and surgical site infections and less need to return the patient to OR for more surgery. 

“We noticed that with our robotic transhiatal esophagectomies, patients survived even longer than what is expected, which is 75 months – pretty long when compared with the national database,” said Dr. Ross.

Training New Surgeons in Using Robotic Surgery

To round out the session, Dr. Massarotti presented on the importance of training the next generation of surgeons in how to use robotic surgery. In her talk, “Teaching General Surgery Residents and Colorectal Fellows in the Robotic Era: How Are We REALLY Doing?,” she mentioned that robotic surgery is not just the future but the present of surgery – it’s an indispensable tool for today’s surgeons to have in their toolboxes. 

“Robotics is a tool, not a technique,” said Dr. Massarotti, noting that the surgical robot may facilitate an operation, but the surgeon still needs to learn how to perform the procedure. Dr. Massarotti reviewed the barriers – some changeable, others not – of training new surgeons in the use of robotic surgery. Robotic surgery is still so new that it is not yet known when a surgeon should learn robotic surgery over the course of their training. However, it is key tool to learn and should be taught to more surgeons.

Dr. Massarotti is currently training a surgical fellow. She discussed how she used two consoles during a robotic colon and rectal operation to oversee an operation performed by her fellow. The AdventHealth Digestive Institute Tampa is blessed to have such a strong robotic surgery program with access to the latest developments in this advanced technology so that its surgeons can pass along their expertise with others.

To find out if robotic surgery is the right tool for your digestive operation, schedule a consultation with a Digestive Institute Tampa surgeon. Call Call813-615-7557 for an appointment.