Nagendra Dudi-Venkata interviews Dr Ellen Van Eetvelde, who shares her experience of transition from laparoscopic colorectal surgery to robotic surgery.

In this interview, she gives us an insight into the challenges involved in introducing a newer technology into an already established clinical practice. She will also discuss the fundamentals of robotic surgery and how to set up and implement a robotic surgery program.

Ellen Van Eetvelde graduated as a surgeon in 2011 and has worked as a colorectal surgeon at the university hospital UZ Brussels in Belgium ever since. She started using the robotics in 2016 and made a complete switch from laparoscopy to robotic surgery for all colorectal procedures. She has been a proctor for robotic colorectal surgery since 2017.

Nagendra Dudi-Venkata: Firstly, we thank you for accepting this invitation for contributing to the series of content for the ESCP on the topic of the month - Robotic Colorectal Surgery.

How do you think robotic colorectal surgery has changed our clinical practice?

Ellen Van Eetvelde: The introduction of robotic surgery allowed us to offer minimally invasive surgery to virtually all of our patients regardless of their comorbidities, tumour stage and location or a history of major abdominal surgery even in the setting of emergency surgery. In the laparoscopic era, subgroups of patients such as very obese u patients, patients with previous abdominal surgery or patients with advanced tumour stage, would be at high risk of conversion during laparoscopic exploration and often were scheduled for open surgery upfront. This has now completely changed thanks to the availability of our robotic system. Open surgery or conversions are currently rare at our department without a rise in complications or morbidity or a reduction in resection specimen quality. The robot allows us to offer high-quality surgery even in difficult patients.

NDV: At what stage of your training did you start thinking of Robotic colorectal surgery, and what motivated you to pursue expertise in this field?

EVE: When a robotic system was purchased at our hospital, the head of our department decided to explore the possibility of implementing robotic surgery for oncological rectal resections. A case observation convinced us of the possible advantages of the system. At that time, I was only working five years as a staff member in our university hospital. As the youngest surgeon, I was given the opportunity to initiate robotic surgery at our department. The better visualisation of the operating field, the camera’s autonomy and stability, and the very precise dissection combined with improved surgeon ergonomics were game-changers. This, in combination with the improved postoperative outcome, made me continue this journey with robotic surgery.

NDV: What were the biggest hurdles for you in this transition process as a colorectal surgeon? Were there any training aspects that you had to work on personally to make let go of some of the older skills you had learned or modify to accommodate newer robotic skills?

EVE: When I started working with the robot, I was a relatively young surgeon. I just outgrew the 'pains and 'suffering' that come with becoming a laparoscopic surgeon. I just felt confident enough to call myself a colorectal surgeon finally. Introducing this new technology in our practice meant that I had to undergo all those things once more and get out of my comfort zone. Learning how to handle the robotic system, spending time on the simulator and listen to proctors guiding you through your surgery while you somewhat lose your reference points all over again.

But then I guess it was still relatively easy for me while it may be more strenuous for very experienced laparoscopic surgeons to let go of the known technique and submerge in the unknown. This said I am convinced that we all need to be open to learn and evolve throughout our career and never think or feel we have reached the endpoint.

NDV: Is there a learning curve involved? Can you share some tips with younger trainees to help them shorten this learning curve?

EVE: As in every new technique, one wants to learn, starting robotic surgery also has a learning curve. Before starting surgical procedures, you need to be familiar with the robotic system and get used to how it works performing easy cases. Afterwards, you can become proficient in the more complex surgical procedures using this new technology. And finally, you need to push the limits and expand the indications of robotic surgery, which will allow you to tackle those cases you 'weren't able to do via minimally invasive surgery before.

A standardised training program is key to start with robotic surgery. This will allow you to shorten your learning curve and start using this new technology without taking risks for your patients. It is important to know how the system works before performing your first surgery. This you can achieve by assisting at robotic procedures, observing an experienced surgeon in the second console if available and spending enough time on the simulator. If possible, perform some key steps of the procedure with guidance from the surgeon in the second console.

When operating your cases, start slow and easy but on a weekly basis. The better you select your cases in the beginning, the faster you will be proficient. Ask for proctoring when introducing a new step or procedure in your practice.

NDV: Coming to starting and establishing a robotic surgical programme, how did you approach initiating this new technology into your established clinical practice, and what were the main roadblocks in setting up of robotic service?

EVE: You cannot start a robotic surgery programme overnight. It takes careful planning and preparation to make sure that all the different players involved are ready. It is crucial not only to get the surgeon trained but also to bring together a dedicated team. This includes specially trained scrub nurses, assistants, and anaesthesiologists. Several departments that do not participate directly in the surgery, such as logistics, sterilisation, and OR-planning, must be involved from the beginning since initiating robotic surgery has also repercussions on their function.

Last but not least, the start of a robotic program demands a lot of resources from the hospital. Not only in terms of the money needed for the set-up, maintenance, and disposables of the system but also in OR-time and planning. I was lucky that our hospital management was interested in the robot as an emerging technology and willing to invest in it.

NDV: What are the benchmarks of an exemplary robotic surgery training program? And how can one create that while maintaining patient safety and outcomes?

EVE: A well-described training pathway with defined goals that should be accomplished before proceeding to the next level. A dedicated team willing to invest in new technology and to get out of their comfort zone. Good case selection and proctoring for the initial series and keeping track of the progress and results with continuous outcome and safety.

NDV: As we know, robotic surgery is still evolving, and some may argue whether there is any evidence that robotic surgery delivers better outcomes? What do you think of that, and how do you balance that in your clinical practice?

EVE: Robotic surgery has dramatically evolved over the last decade. The introduction of the Xi and X system was a huge step forward and, in my opinion, was the game-changer for robotic colorectal resections. Robotic surgery will prove its value, but to build up evidence takes time. While the gains for robotic surgery for standard cases will be small, especially in well trained laparoscopic hands, the advantages will be evident in more complex cases and cases not eligible for a laparoscopic approach. Furthermore, I am convinced that the robotic platform will allow more surgeons to achieve excellent surgical results when compared to laparoscopy.

NDV: In these days of pandemic restrictions and huge waiting lists and numbers, is it appropriate for trainees to spend time and scarce operating time on robotic surgery when many will struggle to reach their basic numbers in training? Does every trainee need to train in robotic surgery?

EVE: I don't think that training young surgeons should be reduced because of the pandemic, being it robotic or laparoscopic. Moreover, I feel that every trainee should have minimal exposure to robotic surgery as part of general training, which includes training on a simulator which 'doesn't interfere with planned interventions.

NDV: Finally, where do you think is the future heading with regards to robotic colorectal surgery?

EVE: I am convinced that robotic colorectal surgery is the new kid on the block and is here to stay. The better visualisation, superior dexterity and more standardised way of operating will make us all better surgeons when compared to laparoscopic surgery; it allows more minimally invasive surgery for more of our patients, and it is only a matter of time before it will replace laparoscopy for most colorectal procedures.

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