David Kooby, MD, Professor of Surgery, Chief of Emory Surgery, Northern Arc, Emory Winship Cancer Institute, talks about minimally-invasive robotic surgery being used to in pancreatic cancer treatment.
Interview conducted by Ivanhoe Broadcast News in September 2017.
I want to talk to you a little bit about robotics and pancreatic cancer. Is this fairly new, cutting-edge for pancreatic cancer?
Dr. Kooby: I would say that is correct. Robotic surgery is relatively new to big GI cases, hepatobiliary surgery in general. Robotics falls under the umbrella of minimally-invasive approaches. The pancreas is an organ that sits way in the back of the belly behind most of our abdominal organs, and it sits intimately with major blood vessels in the back of the belly, and those blood vessels bring all the blood to the intestines, and back from the intestines, up to the liver. Therefore, because of that minimally-invasive technique on the pancreas itself, it has been slow to be adapted and just a little more difficult to get there. Pancreatic operations are also less frequent than certain things like prostate surgery and gallbladder surgery, so those were adapted much faster for minimally-invasive techniques. Surgical robotics, just to distinguish this from standard laparoscopy, is really about getting an improved visualization, additional control. So with laparoscopy, I can control two instruments that will rotate back and forth, open and close. With robotics, I then can control three instruments and a camera simultaneously. I can use one instrument to retract an organ and two others to work with. I can decide where the camera is going to be. It has increased stability, and it has binocular vision, so I can see in three dimensions. And then my instruments not only rotate, open and closed but they have wrists. And so I can suture much easier, I can do cases that I might not have considered doing minimally invasively with the robotic platform.
What’s the benefit for the patient for having this kind of surgical procedure?
Dr. Kooby: I was very fortunate to be asked to be a co-chair of an international conference on minimally-invasive pancreatic resection, and this happened in April of this past year in San Palo, Brazil. Also, nine manuscripts are coming out reporting on the conference. We looked at things like the use of robotics and comparison to laparoscopy and contrast to open surgery. We also just published a big paper looking at the Cadillac of operations, the pancreaticoduodenectomy, and the Whipple procedure that compared open and robotic approaches. The outcomes were quite similar, and this is from centers that have done a lot of these operations, very experienced surgeons. The first thing we’re showing is that you can do the robotic surgery probably as well as the open surgery, and the next step is going to be figuring out the metrics being improved by robotics. I think that there will be a dichotomy; there’s going to be people who do it well, and then there will be people who do it great using the robot and then figuring out what that margin is. What is the added value of these robotic platforms? I would say the short answer would be that the more operations that are done, the more experience we gather, and the better we get at usually the technology. As the technology starts to improve, we may see patients get back to chemotherapy faster after surgery. We may see shorter hospital stays. We do sense that there is less blood loss with the robotic approach than there is with an open approach and so far the hospital is saying complication rates seem to be fairly similar though.
Is there anyone for whom robotics would not make sense, any patients for whom this wouldn’t work?
Dr. Kooby: I would say that the answer is changing. In the beginning, we said that if people had tumors that were involving or encroaching on that major vascular structure, then maybe we shouldn’t use that particular procedure. But there is a cadre of surgeons out there who are gaining tremendous experience and doing it well, and they are now starting to be less selective about which patients they approach. For instance, morbidly obese patients are challenging to operate on the pancreas because of the increased fat around the blood vessels and the way the glade are very difficult to access. In the beginning, they were hesitant to approach those patients, and now there might even be a suggestion that those patients might be ideal for the robotic approach but less well suited to an open procedure. It’s a little premature to answer that question specifically, but it’s something that I think in the next couple years we’ll have a better answer for.
About what percentage of all surgeries are robotic for the pancreas?
Dr. Kooby: It’s going to vary by institution and by surgeons. Right now, I would say, in my practice, it’s going to be about thirty, forty percent.
How long have you been doing the robotic procedure? You said it’s kind of the new kid on the block.
Dr. Kooby: Robotics is interesting, you need not only the surgeon and the actual robot, but you also need a team. I moved my practice from Emory University Hospital primarily over to Emory Saint Joseph Hospital because I didn’t at the time have a team at Emory University Hospital. Currently, we were able to develop a team, and now a good portion of my cases are being done robotically.
Is there anything I didn’t ask you about the robotics that you want to make sure people know?
Dr. Kooby: At this time, there is only one provider for the surgical robot, and that’s the intuitive company that makes the da Vinci platform. It’s a very good platform, and they are continually improving on it. However, other companies are rolling out their devices as well, and I think some degree of competition might cause the price to come down for the robotic platforms. We’re also going to see meaningful innovation. I think right now the technology is good, but I think it will get considerably better. Also, we might start using this approach more frequently as our experience and comfort level increases and as the platform and robots become better.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
MaryBeth Spence
Marybeth.spence@emoryhealthcare.org
David Kooby
404-778-3805
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