The Future of Ambulatory Robotics Is Now

The technology and same-day discharge protocols are being used more than ever for complex elective procedures.

Sharona Ross, MD, FACS, became a surgeon in 2007, yet didn’t sit at her first robotics console until 2012. Eleven years later, 99% of her cases, many of them complex cancer procedures, are performed robotically.

The director of minimally invasive robotic surgery, surgical endoscopy and the GERD and Esophageal Cancer Center at AdventHealth in Tampa, Fla., urges peers who weren’t trained on robots in medical school to devote the time to become proficient on them, even if they feel resistant to the change. “I encourage surgeons to take time out from their busy practices to learn how to use the robot,” says Dr. Ross. “The future is here; the educational training is available; and it’s only going to get more complicated from here if you don’t start now.”

Prime purchasing opportunity

Dr. Ross also thinks now’s the time for ASCs to invest in robotic platforms, despite the initial sticker shock, and enable their surgeons to perform minimally invasive procedures they used to do laparoscopically or by open surgery.

After all, the younger surgeons you’d like to recruit will have been trained on them during their fellowships and will expect them in your facility. Patients, too, now want to undergo increasingly complex surgeries at places that can discharge them on the same day. “Administratively, leaders might say, ‘Wait. This can be done laparoscopically. Why should we pay that much for a robot?’” says Dr. Ross. “But investing in a robot allows you to recruit new surgeons who are experienced with the platform and apply the technology to operations that used to only be done in hospitals but can now be performed on an outpatient basis.”

Another incentive: Many companies offer creative financing arrangements, including placing the robot itself in a surgery center at no cost in exchange for agreeing to purchase other money-making products exclusively from them.

Safer, more precise surgeries

A variety of surgeries, such as hernia, gallbladder and foregut procedures, can be performed robotically in ASCs. The robotic approach has several attributes that Dr. Ross says make it a preferable approach compared to laparoscopy.

“Robots revolutionized surgical outcomes, and made operations safer by providing a stable platform that offers surgeons more control,” says Dr. Ross. Robotics minimize mistakes that can result from laparoscopic imprecision. With laparoscopy, surgeons can hold an instrument in each hand but an assistant must hold the camera, which means they need to know where the surgeon wants to look. A robotic system gives the surgeon better control — the ability to move the camera and at least three other instruments.

Three-dimensional visualization in robotics systems also makes the surgeons’ work more precise, which reduces injuries, as does the ability to make wrist-like motions, which aren’t possible with the straight sticks on a laparoscope. This allows for more exact suturing rather than a reliance on stapling devices.

“Ergonomically, a robot can prolong the surgeon’s career,” says Dr. Ross. “Sitting at the console, which can be adjusted to fit the surgeon’s height, puts you in more comfortable positions compared to standing at the bedside looking down for hours.”

While some robotic procedures take longer than laparoscopic ones, patients recover significantly faster, have a lower risk of complications, their wounds heal better, they walk sooner and their pain is better controlled, says Dr. Ross.

Ambulatory colectomies have arrived

A PROCESS Dr. Laila Rashidi’s patients went from five-day inpatient stays to same-day discharges as she incrementally implemented protocols for ambulatory colectomies.

A shortage of hospital beds, OR staff and nurses exacerbated by COVID-19 essentially forced Laila Rashidi, MD, FACS, FASCRS, to accelerate her plan to perform complex colectomies on an outpatient basis in 2020. “It wasn’t simple, but I needed to get them done for my cancer patients,” says Dr. Rashidi, MD, a colon and rectal surgeon at MultiCare Health System in Tacoma, Wash. “Ambulatory colectomies require extensive planning of all phases of care and significant education of all staff, from pre-op to PACU.”

Robotics are an enhanced tool that can also play a critical role. Three robotic arms, as opposed to two laparoscopic ones, and the 360-degree rotation these platforms provide result in a reduced-touch technique, which minimizes trauma to the bowel that can cause ileus and lead to extended recovery stays. “You control everything when you use a robot,” explains Dr. Rashidi. “I don’t worry about ileus in my patients because I’ve touched the bowel in the most minimal way possible.”

Dr. Rashidi’s colectomy patients began by staying in the hospital for four or five days. By narrowing patient selection to otherwise healthy people with strong family and social support for the days after the surgery and creating same-day discharge pathways patterned after Enhanced Recovery After Surgery protocols, the stays went from two to three days, then finally to a same-day experience.

The ambulatory colectomies, while performed in hospital outpatient departments, show how very complex procedures are advancing to include same-day discharges. The biggest hurdle to their move to ASCs is likely the site-of-service reimbursement gap between HOPDs and ASCs. Currently, however, robots are used in ASCs to perform many colorectal and other minimally invasive surgeries that previously were performed at freestanding facilities with a laparoscope. “In most cases you can do better, faster, less invasive and less traumatic surgery with the robot,” says Dr. Rashidi. “You can also perform procedures that, while not impossible, are much harder to do laparoscopically.”

Patients prefer same day

Five physicians, including Dr. Rashidi, polled 41 patients who underwent same-day colectomies in 2022 and found that 35 of them said “they would do so again if given the opportunity.” The results of the poll will soon be published in an article in Surgical Endoscopy.

The findings showed the authors that same-day-discharge colon surgery, while in its infancy, is feasible and reproducible. Dr. Rashidi says it’s an example of healthcare- and patient-driven care. It’s good for hospital systems because it helps alleviate staff crunches by not having to tend to post-op patients who can be at home. It’s good for the patients because they can take their pills and go the bathroom when they want, with the help of a loved one, rather than having to wait for a nurse who’s tending to multiple patients on the floor because of personnel shortages. “If you can have these patients go home the same day with no severe complications or bad outcomes, and increase their satisfaction levels by doing so, why should we keep them in a hospital room when we don’t have to?” asks Dr. Rashidi.

This high level of patient satisfaction is part of the reason surgeons should get on board. “I tell surgeons they better jump on the train now,” says Dr. Ross. “If they don’t, they risk becoming obsolete. Surgeons who have experience but who don’t keep up with the latest technology risk not having their valuable knowledge put to use, as they will no longer be able to reach the next generation of surgeons because the two groups will be talking two different languages.”

ASC investments in robotic systems will help. “Surgeons need to feel more comfortable with the robotic approach in order to offer it in an ASC setting, and the only way to get them comfortable is to give them access to the robot,” says Dr. Ross. OSM