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Robotic Colorectal Cancer Surgery

UAB, has strived to incorporate robotic surgery into as many disciplines as possible, as this technology allows surgeons to perform many types of complex procedures with unprecedented control and precision. Robotic-assisted surgery usually leads to shorter hospital stays, faster recovery and minimized complications and functions as a safe platform for teaching surgical residents.

UAB has three of the da Vinci Si surgical systems, a next-generation robot that retains and builds on the core technology at the heart of the existing da Vinci and da Vinci S systems. UAB also has one of the newest Xi systems and will receive delivery of another this month. Da Vinci Xi is the next frontier for minimally invasive surgery.

Listen as Dr. Jamie Cannon discusses surgery for colorectal cancer using the da Vinci Si surgical system.
Robotic Colorectal Cancer Surgery
Featured Speaker:
Jamie A. Cannon, MD
Jamie Cannon, M.D., FACS is an associate professor of surgery and directs the robotic surgical education program for the residency program. Dr. Cannon is double board certified in general and colorectal surgery. Dr. Cannon is a leader in minimally invasive approaches to colorectal disease, with an emphasis on robotics, colorectal cancer and sphincter-sparing operations. She is one of the highest volume academic colorectal surgeons in the country. Originally from Arizona, she is a graduate of the University of Arizona College of Medicine. She did her general surgery residency at Carolinas Medical Center in Charlotte, N.C., and her colorectal surgery fellowship with Georgia Colon and Rectal Surgical Associates in Atlanta, Ga.

Dr. Cannon's clinical interests include minimally invasive approaches to colorectal disease, and sphincter-sparing surgery for colorectal cancer; Crohn's disease, ulcerative colitis, diverticulitis, rectal prolapse, and colonic inertia.

Learn more about Jamie A. Cannon, MD
 

Dr. Cannon has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.

There is no commercial support for this activity.
Transcription:

Melanie Cole (Host): UAB Medicine has strived to incorporate robotic surgery into as many disciplines as possible as this technology allows surgeons to perform many types of complex procedures with unprecedented control and precision. My guest today is Dr. Jamie Cannon. She's an associate professor in the Department of Surgery at UAB Medicine. Welcome to the show, Dr. Cannon. How important are innovations such as robotic surgery in the medical world?

Dr. Jamie Cannon (Guest): Well, particularly when we talk about colorectal surgery, robotic surgery has really changed how many patients we can offer a minimally invasive approach to. The technology allows us to do more complex operations and things that were difficult to accomplish laparoscopically before, we can now do with a robotic platform.

Melanie: How do you take something like robotic surgery for colorectal cancer from idea to practice?

Dr. Cannon: Well, there's a very, very well-specified training program in order to do robotic surgery. I was initially trained about five years ago when it was sort of in its infancy, but robotics in colorectal surgery is becoming much more mainstream now and there are a number of surgeons that are doing it. So, there's a defined pathway that a surgeon will go down where they first learn about the robotic system, get practice with simulation and training on the system; they go for an actual training where they practice on pigs; and then, they'll be proctored by other surgeons when they first start using the robot in their cases.

Melanie: From the patient's perspective, how important do you think experience, case volume, and training are? Should a patient ask about that?

Dr. Cannon: I do think it's important. Now, that doesn't mean that if you're seeing a surgeon that's new to robotics that you should necessarily stay away from that. If your surgeon is well-trained in other techniques, if they're a good surgeon when they're doing an open technique and a laparoscopic technique, and if they're new to robotic surgery, they still have those surgical skills that they can use if they're not able to get the operation done via the robot. That being said, surgeons that do have a high volume in robotic surgery are much more likely to accomplish an operation robotically. We see that surgeons that have done over 100 robotic colorectal cases have very low conversion rates on the order of only a couple percent, which is much lower than what you see for rectal cancer surgery and laparoscopy.

Melanie: So, who are the best candidates for robotic-assisted surgery for colorectal cancer?

Dr. Cannon: Almost everybody can be a candidate for it as long as they don't have an advanced cancer that, say, is invading other organs that's going to require a multi-disciplinary approach and removal of other organs besides the rectum. Now, certain operations are more difficult to accomplish via a robotic approach. With rectal cancer surgery, we're challenged by males that have a narrow pelvis, patients that have bulky tumors, and obese patients because you don't have a lot of working space present within the rectum. But, that's actually one of the ways that the robot can really help us. Once a surgeon is beyond their learning curve and has a lot of experience with robotic surgery, those more complex patients, they will actually find they get an even greater benefit from using the robotic approach as compared to a patient where the operation might be easier. Now, that being said, if a surgeon is early in their learning curve, these more complex, difficult patients are probably not the best ones to try and tackle when you're learning robotics. But, I think as a surgeon becomes more advanced, the number of patients that are a candidate for robotic surgery increases. I've done almost 500 robotic operations and I've been doing it for about five years, so, at this point, I don't really find that there are very many patients that wouldn't be a robotic candidate. I actually find the robot even more important when I am operating on someone and anticipate that it's going to be a difficult operation, either because of those factors that I mentioned before, or if they've had a lot of previous surgery.

Melanie: And, what are some of the benefits of robotic surgery versus the traditional methods that had been used previously?

Dr. Cannon: Well, I would say that the benefits to the patient are actually very similar to what we see with laparoscopic surgery. We've known for a long time in the colorectal world that a minimally invasive approach helps the patients get out of the hospital faster, is associated with decreased ileus and decreased narcotic use and those benefits are true whether you're talking about laparoscopic surgery versus robotic surgery. The real difference that I see between robotics and laparoscopy is that because the technology associated with the robot allows you to do a more difficult operation, that there is a greater likelihood that you're able to complete the operation via a minimally invasive approach. Laparoscopic colorectal surgery is difficult and particularly for rectal cancers associated with very high conversion rates, meaning conversions to open surgery. So, unfortunately, a number of patients that undergo a laparoscopic operation may end up with an open incision which prolongs their recovery. There's also some newer data out there that suggests that perhaps the oncologic outcomes associated with laparoscopic rectal cancer surgery might not be as good as they traditionally have been via an open approach and the thought is that's because it's very difficult to access the deep pelvis when you perform this operation laparoscopically. So, there are newer techniques that are being developed now to try and help overcome some of those challenges. One is doing a laparoscopic approach, not only from the abdomen, but also from the perineum and one of the others is using robotic surgery. I think the robotic platform makes it much easier for me to get very deep in the pelvis and do a good dissection for a low rectal cancer that would be really difficult to do laparoscopically.

Melanie: What are the main procedures that you're using the robots for?

Dr. Cannon: The most common one certainly is for rectal cancer. So, that would be a low, anterior resection where you remove the rectum and the patient will have a coloanal anastomosis where the colon is mobilized and the colon is anastomosed to the remaining anal canal. So, that would certainly be the most common one that we do. For patients that have a more advanced cancer that's growing into the sphincter mechanism, or into the muscles of the pelvic floor, then that reconstruction is not possible. So, those patients would have an abdominal perineal resection which results in a permanent encolostomy and the robot does very well for that operation, too. Outside of cancer, the sigmoid colectomy for diverticulitis is an excellent operation to do on the robot. Those patients frequently have large phlegmons. Some of these patients will have developed a fistula going to either to the bladder or the vagina, and that can really make those surgeries challenging. So, again, I've found the robot very useful there. Other operations that may not be as complex, I have found the robot to be useful for as well, and in some ways, using a robotic platform has changed the ways that we do this operation. For example, a right colectomy which, in general, is considered not to be as complex or as difficult of an operation as, say, a low, anterior resection for a rectal cancer. So, those have traditionally been done laparoscopically; however, with the robot, we're able to create the actual anastomosis where, after we remove the right colon and put the small intestine to the transverse colon, we can create that anastomosis intracorporeally, or inside the patient. And, there are some studies out there that show this may be associated with a decreased ileus as well decreased hernia rates, and allows us to make our extraction incision, which is the incision we make on the abdomen to remove the colon, smaller. So, that's an example of an operation or a circumstance where the robot has actually changed the way that we do the operation in order to improve it because the technology, again, makes the operation easier to do.

Melanie: Are there any contraindications for robot-assisted colorectal surgery such as severe coagulation disorder or pelvic metastases? Are there certain things that you cite as parameters to not use it?

Dr. Cannon: So, as with any surgery, obviously, they have to be a candidate for the operation in general. So, we're not going to offer an operation on somebody that has incurable disease. But, specific to robotic surgery, I would say that if a patient has a large pelvic tumor that's invading other organs, or if it's invading the pelvic sidewalls, an operation that might require a more extensive surgery, such as removing part of the sacrum, or having to remove the blood vessels, or ureters in the sidewalls of the pelvis, that that person would probably be better suited with an open operation.

Melanie: Tell us about surgical precision. Are there some specific things that you would like to tell other doctors about positioning when you're using the robot for colorectal cancer?

Dr. Cannon: There are a couple of different robotic systems that are out there. The older system, but still an excellent system and it works very well for rectal cancer surgery is SI robot. The newer robot is the XI robot. I would say that patient positioning is very important when you're operating on the SI robot. One of the things that's different about robotic surgery is that after the robot is docked onto the patient. So, once the robot is holding on to the trocars that are in the patient, you can't change the patient's positioning during the rest of the operation. So, you have to decide at the beginning of the operation how the patient is best positioned. In a colorectal surgery, we frequently will tilt the bed either to the left or to the right or place the patient in some head down position or head up position, because we use the effects of gravity in order to move the small bowel around the abdomen so that we can see what it is that we're interested in seeing. However, with the SI system, once the robot is docked onto the patient, you're not able to do that, so I think it's very important that a surgeon look into the abdomen laparoscopically and make a determination of how the patient's going to be best positioned in order to get the small bowel out of the way so that you can see what your target anatomy is, because you're going to be committed to that position for the rest of the operation. Now, there's newer technology available that's present on the newer robot, the XI robot, which is called “table motion” and this, if you have a robot that's equipped with table motion, through Bluetooth technology, the robot actually talks to the bed that the patient is laying on so that if you want to tilt the bed and change a patient's positioning, the robot will move along with the bed so that you are able to make those adjustments during an operation. So, in those circumstances, the initial patient positioning is not as crucial and we're fortunate enough to have that technology at UAB.

Melanie: And, tell us about some educational opportunities or conferences for community doctors to learn how to use the robot.

Dr. Cannon: Well, so currently the training for the robot is provided by the company that sells the surgical robot. So, if someone is interested in learning robotics, the first step would be to reach out to that company and they usually, generally, begin by taking a surgeon to watch a surgeon that is an expert in robotic surgery, essentially to just kind of see what it's all about and figure out how they can incorporate that into their practice. And then, if a surgeon decides to make that commitment in order to get trained in robotic surgery, they would initially work on a simulator, and they would actually go to a training lab at one of the company's facilities in order to get experience with the robot.

Melanie: And, in the last few minutes, Dr. Cannon, how can a community physician refer a patient to UAB medicine?

Dr. Cannon: Sure. There are a couple of different ways. We have the MIST line, which any physician can call and the MIST operator will get them in touch with the appropriate physician, or if they're interested in referring to GI surgery, they can always call our office directly. So, our office at GI Surgery is 205-975-3000. The MIST line, in order to contact them there is 205-934-6494.

Melanie: And, tell us about your team. Why is UAB so great to work with?

Dr. Cannon: UAB is very unique. I think UAB does an excellent job of recruiting and attracting excellent physicians and surgeons. I think we really excel at utilizing a multidisciplinary approach, particularly when you look at rectal cancer surgery. I mean, I have a great relationship with our medical oncologist, as well as our radiation oncologist and we all work together as a team to make sure that the patients are getting the right treatment plan and the most advanced treatment, whether that means robotic surgery versus being enrolled in a new clinical trial.

Melanie: Thank you so much for being with us today, Dr. Cannon. You're listening to UAB MedCast and for more information on resources available at UAB medicine, you can go to www.uabmedicine.org/physician. That's www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.