Point-Counterpoint: Will Robotic Colectomies Become the Norm in ASCs?

Two surgeons — who are colleagues, friends and robotics champions — face off about where the procedures should be performed.

The robotic platforms these two colorectal surgeons use almost exclusively allow them to work with greater precision, achieve superior outcomes and better reproduce those stellar results for the next patient. Each doctor has evolved from performing open surgeries to three-port laparoscopy to single-incision laparoscopy to robotics, which they now champion.

Common ground, but...

These two surgeons are alike in that they’re riding the wave of technology to offer patients the least invasive approach to their surgeries. They even perform natural orifice robotic surgery, during which specimens are removed from the patient through the rectum, without needing to make virtually any incisions at all.

The ongoing text conversations between these colleagues is about more than the virtues of surgical robotics. They also discuss the most appropriate sites for these procedures, as well as when the patients should be allowed to go home. Their back-and-forth offers a sneak peek into the banter that many surgeons are having as they continue to push the envelope of technology in the best interests of their patients.

POINT: Colectomies should be performed as ambulatory procedures and patients should be allowed to go home the same day when it’s deemed safe for them to do so.

Laila Rashidi, MD, FACS, FASCRS, director of surgical oncology, director of colorectal minimally invasive surgery program with MultiCare Health System in Tacoma, Wash., and assistant professor of colon and rectal surgery at Washington State University: Of course they should. Ambulatory colectomy is perfectly appropriate in selective patients who don’t have major comorbidities and have family and friend support to help them when they get home. With good patient selection and patient education, you can set their expectations and have success. The norm for people who had undergone gallbladder removals used to include a two- or three-day hospital stay. Then we questioned what we really offer, what we’re actually doing for these patients when they stay overnight with us. Now these gallbladder procedures are ambulatory. They used to be outpatient-only on a selective basis, but now they’re routine, even in patients with comorbidities. Today, most gallbladder patients have the expectation that they will be going home that day. You can’t even admit a gallbladder patient today unless they are super-sick or something disastrous happened during their procedure.

If gallbladder, hernia, general surgery and hip replacement patients go home the same day, why can’t a colectomy patient? All of these used to include overnight or multiday stays, and now they’re same-day procedures. A colectomy is much more complex than a laparoscopic cholecystectomy, but the biggest risk for each the first night for patients is bleeding. And the biggest concern for colectomy patients is a problem with anastomosis, the connection between the bowel. Any issues with that generally occur five to seven days after the surgery. Even patients who underwent inpatient surgery are home by then. Are we going to keep everyone in the hospital for seven to 10 days?

In a few years, ambulatory colectomy might become routine, and patients will expect to go home. It might even get to the point where patient selection criteria can be relaxed, as it has with the other types of surgeries I mentioned. Safety is always the primary concern. A lot of this comes down to the surgeon’s comfort level. We have to overcome the fear of performing colectomies on an ambulatory basis.

COUNTERPOINT: Categorizing a colectomy as ambulatory before the procedure begins predetermines its outcome. It’s better to classify them as inpatient procedures and discharge them early if they’re doing really well afterward.

Dr. Eric Haas, MD, FACS, FASCRS, president and founder of Houston Colon: I never have, and still don’t, think of a colectomy patient in the realm of early discharge or use catch phrases such as “outpatient,” “ambulatory” or “same day” when it comes to when they’ll go home. They’re not in my vocabulary because they’re somewhat irrelevant. The patients have criteria for discharge and when they meet it, they’re going to be safe, in my judgement, to go home. I’m still very resistant to using a word like outpatient colectomy. It’s almost an oxymoron because the postoperative care the patient needs isn’t like traditional outpatient pathways we have followed.

Ambulatory colectomy might be technically safe if you have amazing patient selection. We sometimes discharge patients within 24 hours because we round on them. Sometimes they’re doing very well, but that’s still not ambulatory surgery. It’s an inpatient surgery with an early discharge when indicated. While it has the same result, it’s a different concept than ambulatory colectomy, which I’m still not comfortable with. I would never want to predetermine the one thing you cannot, which is how the patient will recover. My patients will likely always have an inpatient surgery and when the clinical criteria are met, we will do everything we can to discharge them in a safe and expeditious fashion.

I also have concerns that ambulatory patients may not have the same nursing care resources at home. And from a business standpoint, I’d need to shift my resources. If any physician, even those employed by a hospital, began doing outpatient surgeries, they wouldn’t be given an additional full-time employee to manage calls from recently discharged patients with questions. If a patient had a bloody stool in the hospital, a nurse would handle it and reassure the patient. My staff would have to take that call in an outpatient case, and in today’s modern healthcare climate, I simply don’t have the infrastructure to handle it.

What about the potential rare instance in which a young healthy patient gets discharged, then has a pulmonary embolism overnight? Yes, that would be rare, but I think a lot of doctors are in my camp. You can show me a study that says it’s safe, but when I sleep at night after that surgery, I want my patients sleeping in a hospital.

PUMPING THE BRAKES Dr. Eric Haas, a robotics advocate, still believes patients should stay in hospitals overnight after their colectomies.

POINT: Patient monitoring hasn’t reached the point to make surgeons comfortable with ambulatory colectomy.
Dr. Haas: The next steps are the monitoring stuff, which isn’t far away. If there is a device that the patient can’t take off that monitors heart rate, blood pressure, respiratory rate and temperature, that would make me more comfortable. There would also have to be a monitoring service to accompany this that was parallel to my practice, but not practice-dependent. A nurse who would monitor all these things and be available to take patients’ calls around the clock would also increase my comfort level. And then, of course, there has to be a pathway to get that patient to an ER if there’s a critical situation. Under those conditions, the concept of ambulatory colectomy would be very reasonable.

COUNTERPOINT: These patients are better off at home than in the hospital.
Dr. Rashidi: I argue there’s no better nurse than your family member. There is one nurse for every five to seven patients in a hospital — it’s not one to one. Staff shortages don’t seem like they’ll be getting better any time soon. The most complaints I get are from patients in the hospital who had to wait two hours to get their pain medication. At home, a husband, wife, daughter, son would bring it to you in the next minute and can help you if you’re thirsty or want to get up. Getting patients to ambulate is hard in hospitals because there isn’t the staff to do it. Ambulation is one of the most important things after colorectal surgery. If you educate a family member and patient that they need to get up and do so many laps per hour, that will improve their outcome. We don’t have any major complications with our ambulatory colectomies.

POINT: Patient satisfaction for ambulatory colectomy is high and demand will only grow.
Dr. Rashidi: A vendor representative who is in the OR during colorectal cases all the time recently came to me when he needed surgery himself. He saw four colorectal surgeons, including me, all of whom did robotics, but I was the only one who did them on an outpatient basis. He absolutely didn’t want to stay in the hospital. He asked if he was a candidate and I said, “Of course!” He was young, healthy, had a wife and good family support and he educated himself on his case and followed my post-op instructions. The other three surgeons used the same technique as I do, but he chose me because I offer ambulatory surgery.

The reason more patients don’t ask about it is because they don’t know it exists. They didn’t used to ask for laparoscopic surgery either, but they do now because they’re educated about the shorter lengths of stay and better outcomes it provides. The more that gets written about ambulatory colectomies and the more patients start getting them, more requests for them and referrals from other patients will start to come in. Five surgeons, including myself, 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.

COUNTERPOINT: Ambulatory colectomy isn’t a bridge worth crossing until consumers demand it.
Dr. Haas: If my clinical concerns were addressed, is there anything else that would change my mind about the concept of expedited inpatient surgery versus outpatient colectomy? The only thing, which hasn’t happened yet, would be consumer demand. I’m the chief of a 10-person practice, and we’ve had zero people ask for an ambulatory colectomy.

In the laparoscopic surgery era, patients absolutely sought out surgeons for laparoscopic robotics. Today, almost every patient that comes to us is because of our reputation for robotic surgery. When I see a hint — even one patient — that asks if we do same-day discharge, my interest level will start to climb very quickly. So, with no consumer demand, no benefits from an economic point of view and considerations about the best overall use of my finite hospital resources currently, all have me sitting on the sidelines. I’ll come into play as the future demands.

Parting thoughts

“Laila and I are very similar in that we believe in expedited care that is made possible from very solid robotic work and that it’s safe to discharge patients very early in many cases,” says Dr. Haas. “I think what makes good surgeons great is being flexible. I think that sending patients home after complex cases like this, however, is a paradigm shift like no other, much more than the evolution from open to minimally invasive surgery, because the effects of asking patients to self-monitor in a critical period after surgery are unproven.”

“These are important conversations to have,” adds Dr. Rashidi. “Increased ambulatory colectomies will be surgeon-driven as their comfort with them increases. Robotics offer the least invasive way to perform the surgery and allow the patient to get better the fastest. I believe recovering at home is best for selective patients after educating them and having done extensive planning of all phases of their care.” OSM