Trust evolves a robotic technique to perform laparoscopic pelvic surgeries, eliminating the need for abdominal incision, resulting in faster recovery and reduced morbidity

Synopsis:

Our goal was the successful and safe introduction of Robotic colorectal surgery at NNUH, led by Dr Irshad Shaikh, to improve patient post-operative outcomes, achieve cancer surgery targets, and increasing capacity for theatres. Minimally invasive colorectal surgery is an integral part of enhanced recovery post- surgery. The benefits are faster recovery, no abdominal incision, no need for epidural anaesthesia, shorter LoS and reduced morbidity.

Minimal invasive surgery can be done with laparoscopy or robotic surgery. Laparoscopic surgery is provided as the standard of care in most of the colorectal surgical units across the world, however, there are several challenges associated with laparoscopic surgery. Not all patients are suitable for laparoscopic surgery, the instruments are not articulated and with a lesser degree of freedom, difficulties in laparoscopic suturing and in particular pelvic rectal dissection can be difficult.

Therefore often surgeons don’t’ attempt laparoscopic pelvic surgery or unfortunately have to convert to open surgery. Robotic surgery helps in overcoming these issues and enables completion of pelvic surgery with minimal invasive approach. The pelvic dissection is noncomparable to any other approach as this the only technique allows embryologic plane dissection, minimal tissue trauma enabling precise tissue dissection to remove cancer/disease affected colon.

Challenges:

The technological advances make Robotic assisted colorectal surgery easier, safer and with better outcomes for patients however, it is currently provided in very few units in the UK/Europe, there is a distinct learning curve, dedicated commitment is required to learn and deliver , and regularly performing this surgery is also imperative to keep with skills and improve efficiency. Our key challenges were:

• Access: Although the Trust has a robot, it’s fully utilised undertaking urology work and consequently the Colorectal team had to use the robot out of hours. However, in the evening we don’t have a scrub/anaesthetic team and consequently would be unsafe to do major 4-6 hour operation, so we negotiated Saturday usage to develop the service.

• Training: Dr Shaikh spent 40-50 hours simulation and online training module in his own time and study leave to undertake training in Belgium.

• Proctoring: To introduce this programme safely, we asked Prof A Parvaiz, a highly experienced international trainer from Portugal to attend weekends.

Due to the commitment shown at NNUH and the colorectal team, for the first time in the UK we performed 6 operations on three continuous days of operating which trained the scrub team and anaesthetic team.

Outcomes:

We are the first unit in East Anglia to perform robotic colorectal cancer surgery and have performed 41 colorectal surgery for cancer/ benign procedures. Only 1 patient had a readmission due to wound infection. Our mean hospital stay for patients after robotic high rectal surgery/left colectomy is 2.8 days, compared to trust mean length of postoperative stay was 9.4 saving 270 bed days. Cancer related outcomes:

All cancers were excised completely. Lymph node yield is one of the markers of cancer-related outcomes. We noted mean and median lymph node yield was higher than the national requirement of 12 which is requirement for better staging. Our average lymphnode yield was 20.3 and we have achieved almost more than 1.5 times more than required.

As a result of higher lymph node yield patients are better staged and able to direct for chemotherapy as required. Another marker of cancer related outcome is residual cancer left (R1 margin). We had 0% R1 margin in this cohort compared to 5-10% according to national data. Anastomotic leak is one of the significant and life-threatening complications and can happen in 8- 15% of patients whereas a clinical anastomotic leak occurred in none of our patients.

Spread:

This initiative has helped to develop the following: A multi-speciality business case for second robot, which will help Upper GI, Gynaecology, Thoracic and ENT surgery to build centre of excellence. Most important of all is the nursing staff who strongly believe in the benefits of robotic surgery.

They have developed into a highly successful and committed nursing team. Mr Shaikh is now ready to be a proctor to teach and train our surgeons across the UK and Europe. We are eligible to be a case observation centre for other surgeons across the world to come and watch and learn. We‘ll shortly publish two papers which will enable surgeons to alleviate the apprehension of robotic surgery, and could potentially increase minimal invasive colorectal surgery from current 50 to about 70-80% with the attendant benefits to NHS.

Dr Shaikh has completed 3 years Master’s Degree in clinical education training and thesis on concepts of haptic feedback and robotic surgery helping to train surgeons with varying experience. We believe our results are the best in the Europe with minimal access to the robot on weekends, single surgeon training and hope this will inspire others.

Value:

In the first year of undertaking Robotic assisted colorectal surgery, there have been significant financial savings directly and indirectly:

• No clinical post-operative anastomotic leaks (each leak prolongs hospital stay, significant cost to manage including ITU care, etc)

• Operations were performed on Saturdays improving the utilisation and cost-effectiveness of the robot. The daily cost for maintenance of robot is £500.

• Mr Shaikh’s team have developed and evolved robotic technique to perform the surgery using less instruments, saving of average £180 per operation. Unlike many other trusts Mr Shaikh’s team undertake now two operations per day reducing cancer related breaches.

• Improved patient flow and bed utilisation due to Saturday procedure and with discharge on Monday or Tuesday. Through the use of robotic surgery, we have improved the value in the surgical services:

• Reduced inpatient stay – saving around 270 bed days/year, value approximately £72.9k.

• Improved theatre capacity – saving up to 50 hours of main theatre time/year, valued at £125k.

• Reduced re-admissions – saving approx. 50 bed days/ year, value approx. £13.5k

• Reduced sterile services costs – saving approximately £6.7k

• Improved patient outcomes- faster recovery, no abdominal incision, no need for epidural anaesthesia, shorter length of stay and reduced morbidity.

Involvement:

After gaining approval from the Trust and our commissioners, we engaged with theatre’s surgical teams to seek volunteers in assisting with the robotic colorectal procedures. Although this would entail working out of hours, we emphasised the benefits to patient outcomes and the opportunity to be part of a team at the forefront of colorectal surgery in the UK.

Our Managers appreciated both the patient and financial benefits, and have been very supportive both from an operational perspective, e.g. Due to nature of operations and preoperative preparation, patients often need to be assessed in short notice and these have been arranged efficiently.