Using Robotics in Colorectal Surgery

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland clinic podcast exploring your digestive and surgical health from end to end.

Hi everybody. And welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Very pleased to have one of the newest members of our staff. Dr. Bradford Sklow who is a colorectal surgeon here in the department of colorectal surgery at Cleveland Clinic Digestive Disease and Surgery Institute. Brad, welcome to Butts & Guts.

Brad Sklow: Thank you. Glad to be here.

Scott Steele: So, for all of our guests what we'd like to start off first is tell us a little bit about yourself. Where are you born? Where are you from? Where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Brad Sklow: Well, I was born in New York, grew up in New Jersey. I trained at the University of Wisconsin and then did my fellowship at WashU Colorectal Surgery. I then spent some time in Cincinnati. My first job out at the university there, and then University of Utah and private practice at the University of Minnesota affiliated. And then now in Cleveland.

Scott Steele: I had the wonderful opportunity to be a medical student underneath you when you were a resident. Go Badgers. So Brad, today, we're going to talk a little bit about robotics in colorectal surgery. So let's start off a little bit high level. Talk about the different types of conditions that you would say colorectal surgery that robotics would have a place in.

Brad Sklow: I think robotics really shines in the pelvis. So most operations in colorectal that you would operate in the pelvis, such as rectal cancer, rectal prolapse, surgery, diverticulitis, sigmoid resection, those kinds of things since you're operating only in a single quadrant. When you start operating in multiple quadrants, it gets a little bit more difficult to using the robot.

Scott Steele: So Brad, take us behind the scenes about what actually what it means to have a robotic use in the operating room. We see maybe a couple images in TV or maybe in the movies, but what is it actually that you're doing? What's the robot doing? Where are you? How does all this occur in the operating room?

Brad Sklow: So really the robot is a tool to perform a minimally invasive procedure, such as laparoscopic surgery. The difference with the robot is you have wristed instruments. So it's kind of like having a hand in there with a wrist rather than straight chopsticks as we operate with laparoscopic surgery. It consists of two different pieces of equipment. And there is a cart that's docked to the patient where the instruments go into. And then the surgeon actually sits at a console in the corner of the room and controls the arm, the robotic arms inside the patient. And there's always somebody at the bedside assisting and helping out as well.

Scott Steele: So, let's just play that scene. How far away are you? Can you get to the patient quickly if you need to?

Brad Sklow: You're in the same room, usually maybe 10, 15 feet away. You could be in a different room, but most of the time you're in the same room. If anything happens, you can be at the patient's bedside, literally within seconds. So you're right there.

Scott Steele: So when we talk about robotic surgery and we talk about the benefits, let's break them up into benefits for the patient and then benefits potentially for the team or even from the surgeon. How do you break that out?

Brad Sklow: That's a very good question. So I think for the patient, the robot has allowed us to do a minimally invasive, say rectal cancer surgery, in patients that otherwise may have required an open operation. We do know that performing laparoscopic surgery in the pelvis for rectal cancer is technically difficult and challenging. The robot has enabled us to do some of those operations that otherwise would have been a big incision. The other advantage obviously is a much smaller incision for the patient, less pain, quicker recovery, shorter hospital stay. Just like laparoscopic surgery. Especially in male patients that might be obese, the robot really shines in the pelvis because you have robotic strength for retraction that you don't necessarily have when you're doing straight laparoscopic surgery. As far as a benefit to the surgeon, you're not standing, you're actually sitting at a console, it's more comfortable. You have better visualization because you're using a camera that almost gives you a 3D image, which I think is superior than just straight laparoscopic surgery. And you have a fixed camera platform in the pelvis that you control with the console that you're not having somebody else drive the camera, which can be somewhat frustrating if you have an inexperienced camera driver.

Scott Steele: So let's play a game that I like to call truth or myth. Truth or myth, if you have robotic surgery, you will not have any large incisions on your abdomen.

Brad Sklow: Define large.

Scott Steele: Bigger than just the trocars used in order to get the instruments in. If they're going to undergo colorectal surgery, are they going to have any incisions on their belly?

Brad Sklow: That's a myth. So you have to still make, with some exceptions, you have to make an incision to extract the specimen. You can't squeeze a colon out of a one centimeter incision like you can squeeze a gallbladder out a small incision. So you're making an incision anywhere from three to five centimeters, which equals an inch and a half to three inches

Scott Steele: Truth or myth. My stay in the hospital if I undergo robotic surgery is going to be shorter compared to either laparoscopy or open surgery.

Brad Sklow: Unclear. So there are people that will state that, but I don't think the data is there to say that's true. I think certainly compared to open surgery, robotic surgery is shorter length of stay just like laparoscopy. But to say that patients go home sooner after a robot compared to laparoscopy remains to be seen.

Scott Steele: Truth or myth. There are colorectal surgery procedures that cannot be performed with robotics.

Brad Sklow: Truth. So I would say that patients who've had previous open surgery or multiple open surgeries before who've had a lot of scar tissue or adhesion's are often not the best candidate for robotic surgery. I would say recurrent rectal cancer, where you have big vascular structures involved and potentially could lead to a lot of blood loss is not a good operation for robotic surgery.

Scott Steele: Let's look at it a little bit different way now, Brad. So are there surgeries that you would say that they must be performed robotically?

Brad Sklow: I would say no, there's no must I think in surgery. I think there are surgeries that can be performed robotically and allow you to do a minimal invasive approach as opposed to a big open incision as far as cancer goes. Now when it comes to rectal prolapse surgery, such as the ventral rectopexy, in the United States, it's very difficult to sew laparoscopically and the robot has enabled us to do that much more easily because of the wristed instruments. So when it comes to, say performing a ventral rectopexy or rectal prolapse surgery, that's one operation where you could use the word must perform robotically as we're not great at sewing laparoscopically as colorectal surgeons as they are in Europe.

Scott Steele: So I would say that everybody is encouraged to listen to some past episodes of Butts & Guts to learn a little bit more about rectal prolapse and what the ventral rectopexy involves and can give a little bit of insight there. So Brad as we're talking a little bit about this, is robotic surgery appropriate for every patient? Let's just say I'm a patient out there. Do I need to be searching for a doctor that only does robotic surgery? I know you kind of touched on this, but there's some pretty darn good surgeons here at the Cleveland Clinic and around the world that don't do robotic surgery. Are we just behind the times or is it something that is still just one tool in the armamentarium that can have a good fit for some people and maybe not for others?

Brad Sklow: I think it really depends on the operation that the patient's going to have and what they're seeking out. So if you say have a cancer in the right colon, should you seek out a robotic surgeon to have a minimally invasive right colon operation on the robot? I would say probably not. I think the laparoscopic approach to that operation is great and probably don't need the robot for that. On the other hand, if you have a rectal cancer and you want it done minimally invasive, there are surgeons who can't do that laparoscopically. And that's the scenario where you may want to seek out a robotic surgeon. But there are great surgeons at the Cleveland Clinic who do plenty of laparoscopic surgery, both in the pelvis and in the abdomen. So you don't necessarily have to have a robotic operation.

Scott Steele: Let's talk a little bit about kind of the world in which we live in today. Can you discuss a little bit about coming into the Cleveland Clinic during this time of a pandemic? Can you talk a little bit about the precautions that the clinic has taken, you are taking personally, to make sure that caregivers and patients alike are safe and do you have to come in for all of your appointments or can it be done virtually?

Brad Sklow: You certainly don't have to come in for all appointments. A lot of appointments can be done as so-called virtual or video visit. If it involves an examination then you should come in for that. If it's something that we can't see on video, then obviously an in person visit would be indicated and they've taken lots of precautions as far as that. There's social distancing in the waiting room. Everyone is required to wear a mask, both patients and providers. Everything is wiped down between patients. We keep social distancing in the clinics as well. We test every patient for the coronavirus before they undergo elective surgery. So patients should feel confident that we've done everything we possibly can to make this a safe and comfortable visit for them.

Scott Steele: So, Brad, I want you to look into the future and say, what do you feel maybe on the horizon in regards to the future use, or either research or expansion of the use of robotics for colorectal surgery?

Brad Sklow: I think that as more robotic platforms are released and approved that the cost of doing robotic surgery will decrease. So as there's more competition, hopefully the cost per procedure will go down comparable to doing laparoscopic surgery. I see using the robot in the future, but I think the big limiting factor is cost of the equipment to acquire and cost per procedure, which hopefully will decrease with time.

Scott Steele: That's fantastic. And I know that we're even experimenting with some protocols for learning to do some transanal procedures and select patients using a robotic platform. So let's take this time right now to get to know you a little bit better with some quick hitters. Number one, what's your favorite sport?

Brad Sklow: Baseball.

Scott Steele: Number two, what's your favorite meal?

Brad Sklow: Pasta Bolognese.

Scott Steele: Number three, give us a probably favorite place that you've traveled to in the last few years.

Brad Sklow: The Maldives.

Scott Steele: What is your last nonmedical book that you've read?

Brad Sklow: Shadow Divers. About a German U-boat that was found off the coast of New Jersey and two scuba divers exploring it. A U-boat that should never have been there in the first place.

Scott Steele: And the last one, you're relatively new to Cleveland, but tell us something in the short time you've been here that you enjoy about this area.

Brad Sklow: Well, prior to COVID-19, the food scene I think is excellent for a city of this size and the lack of traffic. My commute is eons better than where I came from.

Scott Steele: Fantastic. Well, let's give us a final take home message for our listeners regarding colorectal surgery and robotic use.

Brad Sklow: I think the robot is a great tool to perform minimally invasive surgery, especially in the pelvis. Anecdotally, patients seem to do fairly well with not a lot of pain. They don't take a lot of narcotics and that's true about laparoscopic surgery as well. But it gives us a great platform for operating in the pelvis. It's very comfortable for the surgeon and it's not going away, despite its increased costs. So I think it has to be in our armamentarium as colorectal surgeons.

Scott Steele: Tremendous insight and so to learn more about colorectal surgery and the various treatment options here at the Cleveland Clinic, please visit Clevelandclinic.org/colorectalsurgery. That's Clevelandclinic.org/colorectalsurgery, all one word. And to speak with a specialist in the Digestive Disease and Surgery Institute, please call (216) 444-7000. That's (216) 444-7000. And remember in times like these, it's important to keep up with your medical care and you can be rest assured that at Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and protect all of our patients. Brad, thanks so much for joining us on Butts & Guts.

Brad Sklow: Thanks for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.