Single-Site Robotic Gallbladder Removal

Intro: We're talking wellness at MemorialCare Health System. It's time for Weekly Dose of Wellness. Here's Deborah Howell.

Deborah Howell (Host): Hello and welcome to the show. You're listening to Weekly Dose of Wellness, brought to you by MemorialCare Health System. I'm Deborah Howell. Today's guest is Dr. Tam Le, a board-certified general and colorectal surgeon at Orange Coast Memorial Medical Center. He is experienced in open, laparoscopic, and robotic-assisted surgery and is also one of the first surgeons in Orange County to perform single-site cholecystectomy. Welcome, Dr. Le.

Tam Le, MD: Hello. Thank you, appreciate being here.

Deborah Howell (Host): We're very, very happy on our side to have you. You know, most of us still have our gallbladders, but what are some of the reasons that somebody would need to have their gallbladder removed, and is this a common procedure?

Tam Le, MD: Typically, a patient needs their gallbladder removed because of abdominal pain either underneath the breastbone or underneath the rib cage on the right side, caused by gallstones. Gallstones can also cause infection of the gallbladder requiring removal. And uncommonly, gallbladder polyps, like abnormal growths in the gallbladder detected by ultrasound, would need removal to prevent gallbladder cancer. And uncommonly, pain can also be caused by a non-functioning gallbladder requiring removal. In the US, more than 500,000 patients require removal of the gallbladder every year.

Deborah Howell (Host): So it is pretty common.

Tam Le, MD: Yes, it's very common.

Deborah Howell (Host): So then, my next question would be to you, doctor, how is cholecystectomy, removal of the gallbladder and stones, performed?

Tam Le, MD: Typically nowadays, it is removed by the laparoscopic method with the video camera, called laparoscopic cholecystectomy. It's been performed in the last 20 years. Traditionally, open surgery is required, a large incision like 8 to 11 inches incision underneath the right rib cage was done, but this causes a lot of pain. So with laparoscopy, it's less painful, patient often go home the same day. Recently in the last few years, robotic surgery has been very useful, and I believe it has more benefit than laparoscopic cholecystectomy.

Deborah Howell (Host): Are you talking now about single-site robotic cholecystectomy?

Tam Le, MD: Yes. Even though you can use the robot to do gallbladder removal with multiple incisions, just like a laparoscopy, but for the robot, you can make just one incision at the umbilicus, about two and a half centimeter incision, to remove the gallbladder, instead of making four incisions in laparoscopic surgery.

Deborah Howell (Host): So that is a huge, huge benefit. Are there other benefits a patient would derive from the single-site approach?

Tam Le, MD: Yes, I believe besides the cosmetic benefit of one single incision at the umbilicus because once it's healed, the scar is virtually invisible. The pain for the patient, I believe, is less than if you have to make four incisions in laparoscopic surgery. And the robotic system affords a lot better visualization for the surgeon. You have a three-dimensional image instead of a two-dimensional image in laparoscopy. So the surgeon can see the anatomy while operating a lot clearer. My analogy is you can see the fish on the ground, you can dive in like in snorkeling, you can see the fish a lot clearer. And that's the difference in image between the laparoscopy and robotic. You can see the anatomy much clearer. So I believe the surgery can be performed safer, with less risk of injury to the patient.

Deborah Howell (Host): Yeah, what's better for the doctor is certainly always better for the patient.

Tam Le, MD: Yes. Yeah, it's more comfortable too. In robotic surgery, the surgeon actually sits down and operates, rather than standing right at the bedside.

Deborah Howell (Host): Oh, that's great.

Tam Le, MD: Yeah, let me also clarify that people think that when you do robotic surgery, the robot is on its own. Actually, the robot is just a sophisticated instrument that the surgeon controls to operate, to take care of the patient.

Deborah Howell (Host): Right, so the robot itself is not holding the instruments?

Tam Le, MD: It does hold the instrument, but the surgeon controls the robotic arms to move the instrument. The robot is not programmed to move by itself. We actually, the surgeon actually place the instrument into the patient held by the robot, and then the surgeon sit at the console to control the robot to move the instrument. The instrument is like a miniature arm that the surgeon can put inside the patient.

Deborah Howell (Host): I would imagine it's - this is a strange word to use when it comes to surgery - but it's kind of fun, right?

Tam Le, MD: Well, you know, it's actually for the surgeon it's fun and a pleasure to perform for me, you know, the robotic surgery, because you can see things so clearly, and your movement is a lot smoother. It's more ergonomic to control the robotic instrument than to control the laparoscopic instrument.

Deborah Howell (Host): Wonderful. And then what are the benefits and the reasons for the removal of the gallbladder in the first place?

Tam Le, MD: Typically, because a patient has a lot of pain, abdominal pain brought on by eating, and it prevents complication of gallstones like infection. People can get quite ill from infections like fever, abdominal pain, and affect other organs. And if the stone travel, it can cause pancreatitis, inflammation of the pancreas, or if it obstruct the main bile duct, people can have jaundice, yellowing of the skin, the eye, and infection of the liver, which can become quite life-threatening. So for patients who are affected by gallstones or gallbladder illness, it's a life-changing and saving procedure.

Deborah Howell (Host): Awesome. Well, I'm assuming there are still a few risks for single-site robotic cholecystectomy. Maybe you could go over those for us?

Tam Le, MD: Typical like any surgery, but the risk are small. The risk of bleeding and infection associated with the surgery is very small, less than 1%. There's concern about hernia, like protrusion of tissue at the site, because the incision is 2.5 centimeters or an inch, versus 1 centimeter and a few other 5-millimeter incisions in laparoscopic surgery. But the incidence of hernia is also very small. And the main thing we're concerned about, just like in open or laparoscopic surgery, is injury to the common bile duct. The incidence of injury to the common bile duct, the main duct from the liver going down to the small intestine, is very small. It's one in a few hundred thousand cases.

Deborah Howell (Host): Wow, wow, that's, yeah. Well, that leads me to my next question. You'd have to be, you know, quite careful and concerned about what surgeon that you're looking for when dealing with such a sensitive surgery. So what should somebody research when looking for a surgeon to perform single-site cholecystectomy?

Tam Le, MD: Yes, it's true with any new technique, there's a learning curve. So the surgeon typically has to be trained properly. Usually, there's a training program requirement before the surgeon can perform robotic surgery. So patients should make sure that the surgeon is properly trained. And then after that, it's the experience. You need some time to perform the procedure under supervision and then have the procedure to perfect your technique, so to speak. So typically, it would take about 25 cases or 25 patients experienced on your own before I think that the surgeon will feel comfortable. That goes with me and other surgeons who perform robotic surgery.

Deborah Howell (Host): How many have you performed yourself, single sites?

Tam Le, MD: I have done robotic surgery since 2011, and I have done more than 100 cases now.

Deborah Howell (Host): Wonderful. Well, it's a pleasure to have you on your show. Please tell everybody on your staff we were glad to borrow a few minutes from you today. And thank you so much, Dr. Le, for being with us.

Tam Le, MD: Yeah, thanks so much for the opportunity to speak with you and the patients.

Deborah Howell (Host): Our pleasure. We've been talking about the advances and options in gallbladder surgery with Dr. Le. To listen to the podcast or for more info, please visit memorialcare.org. That's memorialcare.org. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness brought to you by MemorialCare Health System. Have a fantastic day.