Surgical oncology is a prime beneficiary of the innovative technology that is revolutionizing medicine. A perfect example is the robotic surgery program at Moffitt Cancer Center that started in 2008. Our colleagues treating genitourinary and gynecologic malignancies were the first to incorporate technological advances into the realm of robotics at our institution, and many other programs in surgical oncology have since followed suit. Over the past years, Moffitt has transitioned into a high-volume robotic surgery center. In fact, from June 2008 through May 2012, we performed 1,822 robotic operations. The da Vinci robot is used daily in Moffitt’s operating rooms for patients with prostate, bladder, gynecologic, endocrine, head and neck, thoracic and gastrointestinal cancers.
Dr. Julio Pow-Sang, department chair of Urology and program leader of Genitourinary Oncology, notes that in the past few years, robotic surgery has been incorporated into the surgical armamentarium with tangible benefits.
“Patients recover faster and stay in the hospital fewer days,” he says. “Moreover, with the robot, our surgeons have an increased range of motion in the patient, which translates to better operability compared to traditional laparoscopy. Our surgeons find that this approach enhances their ability to create ‘neo’ bladders and perform retroperitoneal lymph node dissections. This has become a crucial component of our genitourinary practice, and now all of our residents must become proficient with this technology.”
Our surgeons in the Center for Women’s Oncology also report improved quality of life for their patients with the integration of minimally invasive techniques. Dr. Patricia Judson, associate member of the Gynecologic Oncology Program, notes, “Robotic-assisted laparoscopy has enabled gynecologic oncologists to perform radical surgeries through tiny incisions. This allows patients to recover faster and have fewer complications and infections.”
One surgical specialty where the incorporation of the da Vinci robot into daily practice is particularly challenging is in the treatment of gastrointestinal malignancies. The variety of malignancies, multiple areas of operation and complexity of reconstructions have traditionally led to limited use of minimally invasive techniques. However, the improvement in technology offered by the robotic system has led some surgeons to move beyond these limitations and delve into robotics. The momentum in better outcomes reported with other specialties is crucial in the treatment of gastrointestinal cancers, where patients often receive preoperative chemotherapy and radiation therapy.
“The patients we see at our cancer center have complex problems and are sometimes heavily pretreated before we go to the OR. Minimally invasive techniques are instrumental in reducing morbidity,” says Dr. Mokenge Malafa, department chair and program leader for Gastrointestinal Oncology. “We have performed robotic surgery for patients with esophageal, pancreatic, gastric, colon and rectal tumors and have been impressed that our patients are doing better, with less toxicity.”
One particular area where results have been improving quality of life is in the treatment of esophageal cancer. These patients often present with locally advanced primary tumors and involved lymph nodes. At Moffitt, the esophageal multidisciplinary team sees the patient together in the GI clinic. Staging studies, including a 4D PET/CT scan, are often done to confirm the extent of disease. Our endoscopic oncology colleagues place fiducial markers into the submucosa above and below the primary tumor to delineate the gross tumor volume. We then proceed with neoadjuvant chemotherapy and radiotherapy concomitantly prior to consideration of resection.
Traditional surgery involves large incisions on the abdomen, chest and/or neck. With advances in robotic surgery, smaller incisions with less postoperative pain and shortened hospital stays are now possible. It should be noted that esophagectomy is a very complex operation and should be performed at high-volume centers by high-volume surgeons in order to improve outcomes. There is certainly convincing data of better outcomes with a minimally invasive approach. Recent data from The Lancet by Biere et al demonstrated a statistical reduction in postoperative pulmonary complications in those who underwent a minimally invasive approach to esophagectomy.
We have seen this in our esophageal patients who have undergone the robotic approach. Started in 2009, the robotic gastrointestinal program has seen complications reduced, less postoperative pain, shorter intensive care unit stays and shorter length of hospitalization. We perform more than 100 esophagectomies per year, among the highest in the country. Because of this high volume, we have accumulated one of the largest experiences in the world with robotic transthoracic esophagectomy for cancer. Minimally invasive techniques including the robot are the future and that they are changing how we practice surgical oncology.
It is crucial to have extensive knowledge of open operations before embarking on the application of robotics into a surgical oncology practice. A surgeon must commit to the technique and accept slightly longer operative times in the beginning of their practice. There is a steep learning curve. However, after the curve is reached, operative times will significantly decrease, and the true benefits of the robot will be seen. At Moffitt, we are enthusiastic about the continued evolution of our robotic surgical practice. With our aging population, we anticipate that these advances will offer more hope for our patients, with a goal of improved long-term outcomes.
Adapted from Florida MD, July 2012