Robotic surgery is a part of many colorectal cancer cases

There was a time not very long ago when robotic surgery was considered a sci-fi notion. But not anymore. More than 76,000 surgeons around the world, including here on Cape Cod, have been trained to used the da Vinci robotic surgical systems. Those surgeons have successfully completed more than 14 million surgical procedures.

Surgeon Ryan Carlson, MD, who specializes in colorectal surgery at Cape Cod Hospital (CCH), has been using the robot since 2013. He finished his fellowship in 2012 and then went on to receive training in robotic surgery about nine months later.

Dr. Carlson uses the da Vinci robotic system at CCH for many of his colorectal surgeries, including the removal of some cancerous tumors. He assures patients that he controls the robot every step of the way.

“Basically, it’s laparoscopic surgery where the surgeon is sitting in the corner looking through a 3D viewer and holding on to these two little pincers they can manipulate in 3D space, and they can twist their wrist just like if they were holding an instrument,” he said.

The robot has four arms that go into the patient. The nice thing about the robot, he said, is that it basically gives him four hands instead of two so he doesn’t need a human to be those other two hands.

“These arms have lots of different devices you can put into them,” he said. “Instead of scissors, you can put in a stapler, or you can put a needle driver, or suction tubing, and we can really manipulate nicely.

“The biggest difference is the fact that it gives you wrists (with surgical instruments), because otherwise it’s pretty much operating like working with a partner laparoscopically. These wrists are so nice. You can twist your wrist, you can bend your wrist, and that lets you suture and manipulate the tissue really naturally.”

The biggest advantages of the da Vinci surgical robot, according to a meta-analysis published in the Annals of Surgery, that is cited by its manufacturer, Intuitive, on their website, are smaller incisions, less blood loss, reduced pain and scarring, fewer readmissions and a shorter hospital stay. For surgeons, it offers enhanced precision and control. It also allows them to see things they previously couldn’t see.

For example, in the past, during surgical rectal cases, surgeons couldn’t see where the autonomous nerves that support various functions in the body were. They had to make a best-guess estimate. With the robot, Dr. Carlson can actually see the nerves and make sure to spare them.

Supports Many Surgeries

Dr. Carlson finds the robot works well for many of the things he does.

“In my field, I can do almost everything on the robot,” he said. “We can do right colectomy, left colectomy, the pelvic cases. We do a lot of robotic ventral rectopexies (repairs for rectal prolapse in women where the rectum falls outside the body), and I do almost all of my rectal cases robotically.”

He also utilizes the robot for select inguinal hernia repairs. Although he fixes 90 percent of this hernia type laparoscopically, he’ll leverage the da Vinci system for his hardest 10 percent, which are mostly the large hernias. Those do better with the increased strength, arms and versatility of the robot.

“For some cases, the robot adds some time to the procedure,” Dr. Carlson said. “Say someone has a right-sided colon cancer. The literature, and also in my experience, it’s pretty clear that I could probably do that job very safely in 90 minutes laparoscopically and the robot may add 30 or 45 minutes to that.”

Each surgical field that uses robots has different rates of adoption, Dr. Carlson said. Urologists adopted it quickly and have been doing about 90 – 95 percent of their prostate removal surgeries robotically for 15 to 20 years. The numbers are increasing for hiatal hernia surgery, which Dr. Carlson also performs.

“Then when we look at colorectal, you’ll see the adoption is a lot slower,” he said. “With colorectal, we have found 60 percent of colorectal cases are done minimally invasively which includes laparoscopic or robotic, and 40 percent are still done open.”

Both Approaches are Safe

As with any new technology, there wasn’t much data in the beginning, but robotic surgery has now been around long enough to make comparisons between minimally invasive surgeries, like robotic, and laparoscopy and open surgery. Rocco Ricciardi, MD, who was one of Dr. Carlson’s surgical mentors while he was at the Lahey Clinic, was one of the lead researchers on the largest meta-analysis study on the subject. It found that both robotic and laparoscopic surgeries were safe and had advantages over open surgery, with the one caveat that robotics sometimes took more time.

“That was reassuring for a lot of us who are using it because we all wondered if it was going to be as good as what we’ve always done. And the data is coming back that it is,” he said.

More and more colorectal surgeons are excited about robotic surgery, Dr. Carlson said.

“The residents who come through, they want robotic time and we have robotic simulators, so they can practice when there are no patients in the room,” Dr. Carlson said.