Zoe Garoufalia interviews Dr Amy Lightner and Dr Emre Gorgun about their use of robotic surgery in IBD and training for new surgeons.

Zoe Garoufalia, Dr Amy Lightner and Dr Emre Gorgun

Dr Amy Lightner is an Associate Professor of Surgery in the Department of Colon and Rectal Surgery at Cleveland Clinic, OH and associate chief of surgical research, and is the Primary Investigator of the surgical inflammatory bowel disease translational laboratory. Thus, her time is split between operating, conducting research, and overseeing/directing the research fellows in colorectal surgery.

Dr Emre Gorgun joined Cleveland Clinic, Department of Colorectal Surgery as a full time faculty in 2011 and he is certified by the American Board of Colon and Rectal Surgery and American Board of Surgery. Dr. Gorgun holds the Krause-Lieberman Chair in Laparoscopic Colorectal Surgery.

Zoe Garoufalia: Dr Lightner and Dr Gorgun thank you for agreeing to give an interview on robotic surgery and IBD. Patients with inflammatory bowel disease (IBD) comprise a population of patients that have a high likelihood of both surgical treatment at a young age and repetitive operative interventions. However, due to special disease- related characteristics, such as bowel stenosis, fistulae, abscesses, malnutrition, repetitive surgeries, or immunosuppressive medications, patients with IBD represent a special cohort with specific needs for surgery.

What is the current evidence about robotic surgery in IBD?

Amy Lightner/Emre Gorgun: There is growing evidence about the feasibility of robotic surgery in IBD. There is improved evidence about robotic surgery for ileal pouches and completion proctectomy during that case.

Robotic surgery operationZG: What are the advantages and possible disadvantages of the robotic approach in IBD surgery?

AL/EG: Robotic surgery offers several enhanced features such as 3-dimensional visualization provided by a surgeon-controlled camera and motion scaling with tremor reduction that increases operative dexterity. Additionally endo-wrist technology with 7 degrees of freedom makes getting into a deep pelvis easier. The effectiveness of robotic-assisted proctectomy has been largely investigated regarding its suitability for work in the narrow confines of the pelvis for patients with rectal cancer. There is emerging data regarding the role of robotic surgery for inflammatory bowel disease (IBD).

ZG: In which cases of IBD would the robotic assistance benefit the most?

AL/EG: Pelvic cases, especially in the obese male with laparoscopy is significantly more difficult. Theoretically, this technique may prevent injury to the pelvic autonomic nerves. Because of the benign nature of IBD, the proctectomy is usually performed with intramesorectal excision. Robot may offer improved control of haemostasis and visualization and preservation of the nerves.

ZG: Why robotic and not laparoscopic approach in IBD patients that need surgery?

AL/EG: For the reasons listed above with improved visualisation etc. Additionally in complex surgical patients with significant septic results including phlegmons and fistulas such as entero-enteric or colovesical fistula, robot may allow surgeons to control the disease better with improved dexterity and maintain minimally invasive approach.

ZG: Is it common practise in your department to operate robotically on IBD patients?

AL/EG: Mostly the cases that involve the pelvis. At our institution, use of RP in IBD patients is supported by the results of our earlier studies with comparable functional outcomes between robotic and laparoscopic approaches. Furthermore, majority of patients with IBD are young and desire acceptable sexual functions. Future studies investigating sexual and functional outcomes in IBD patients undergoing RP are needed.

ZG: Has your current robotic practise changed in the new COVID era?

AL/EG: No there have been no significant changes related to COVID.

ZG: How do you envisage the future of robotics in IBD?

AL/EG: Will continue to expand as robotics becomes more widely applied, more familiar, and improved technology allows for even greater efficiency.

ZG: Do you have programs in place to provide training to new surgeons on robotics for IBD?

AL/EG: Mentorship program: Learning process related to the robotic technology is critical. Characteristics of the robotic learning curve in IBD patients is slightly more complex. We recently implemented robotic surgery educational program and evaluating the adoption to robotic technology for rectal cancer and IBD patients in 3 phases, which is defined from initial learning phase to higher expertise and mastery.

ZG: Do you have any messages/advice to convey to the young ESCP surgeons around the world, regarding robotic tutoring, education and upcoming developments?

AL/EG: Mastered proctectomy outcomes with standard laparoscopy are unlikely to be improved in the short term with robotics. The ergonomic benefits of robotic surgery may help overcome some of the limitations of laparoscopic surgery especially in pelvic operations. As surgeons’ robotic experience and technologic innovations grow, the role of robotic surgery in patients with IBD will expand and warrant further investigation.

ZG: Thank you both for your time and insights.

ESCP Affiliates