Robotic Surgery For Obesity

Robotic surgery at MUSC Health is making life changing procedures, such as the most complex bariatric surgeries, accessible to more people than ever before. In this episode of Advance with MUSC Health, Rana Pullatt, MD, explains how these transformational surgeries are changing the lives of patients with BMIs from 35 and to as high as the 90s. Pullatt is a Professor of Surgery and serves as the Clinical Director of Bariatric and Robotic Surgery.

“Right now, we are one of the few centers in the whole Carolina region that do routine duodenal switch (surgeries) on high BMI patients. There are several centers that limit their BMI to a certain BMI, beyond which they will not offer elective bariatric surgery, certainly not to a single stage duodenal switch procedure. Our highest BMI thus far has been a 93 BMI patient whom we were able to do a single stage switch. ”
- Rana Pullatt, M.D.

Topics covered in this show

• Pullatt explains how he began training on robotic surgeries in 2010 and has now completed more than 2100 robotic surgeries ranging from gallbladder and foregut surgery (which is surgery that we do for acid reflux). He has led the charge to bring robotic surgery across MUSC Health’s general surgery.
• He focuses on robotic bariatric surgeries and his specialty is performing, robotically, duodenal switch bariatric surgery on people with very high BMIs, such as a BMI of 93.
• Most centers in the region will not perform such surgeries on people with high BMIs because Pullatt says it is too difficult without the assistance of the robot, “the amount of abdominal torque that is required that we work against if you're doing conventional, laparoscopic suturing is a lot. Being able to use the robot really helps us suture better and with greater precision.”
• Pullatt says patients can expect to see more robotic surgery at MUSC Health in the future and he would like to see it expand to the more rural areas of the healthcare system through the use of telesurgery. He says someday a MUSC surgeon in Charleston could log into a surgery in Lancaster and take over a robotic procedure via 5G network.

Read the show transcript below

Erin Spain [00:00:04] Welcome to Advance with MUSC Health, I'm your host, Erin Spain. This shows' mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Robotic surgery and U.S. health is making life changing procedures, such as the most complex bariatric surgeries, accessible to more people than ever before. Dr. Rana Pullatt is leading this transformational work MUSC Health and the areas of foregut, hernia and bariatric surgery. He is a professor of surgery and serves as the clinical director of bariatric and robotic surgery. He joins me today to talk about how robotic surgery is used at MUSC Health and how patients can benefit from these cutting-edge procedures. Thanks for joining me today.

Rana Pullatt, M.D. [00:00:54] Thank you.

Erin Spain [00:00:55] I know some colleagues here at MUSC Health affectionately call you Dr. Robot. You've completed more than 1000 robotic surgeries. Tell me how you became interested in using robotics in the surgeries that you do.

Rana Pullatt, M.D. [00:01:09] Yeah. Initially in GI surgery, the robot was seen as a gimmick. More than anything else, it was considered some kind of technology that really wouldn't stay it another little gimmick that comes and it'll go away. So, in 2008 2009, when I first was exposed to the robotic platform, even though it was a previous iteration, it blew my mind. I felt this was transformational. So, about 2010/2011 was when I started training on the robot. I attended some of the labs they had, as well as watched procedural videos and then kind of took it head on, training myself initially with simple procedures. So, I was one of the first few who started doing this for hernia surgeries kind of built a name in that field using robotics, then expanded to include all of general and GI surgery.

Erin Spain [00:02:14] Give us an idea of what the tools look like. We're talking about the robot. What does it look like? How do you use it?

Rana Pullatt, M.D. [00:02:19] There's a general perception by the public that it's an actual, you know, when in popular culture, a robot like this clunky humanoid creature that walks around almost like a tin man. This is quite completely different. This is a sophisticated machine. The robot doesn't think for itself. It's an extremely precise instrument, so it's an extension of your hands. Basically, it's the surgeon who does the entire surgery. The only difference is, instead of using laparoscopic or open instruments, the surgeon uses robotic instruments which are inserted into the patient's body, just like how he would insert laparoscopic instruments. So ultimately, the surgeon is the one who is doing the entire procedure, every step of it. The robot just refines any movements, takes away all the tremors and makes doing fine critical surgery much easier.

Erin Spain [00:03:20] So you started off with the hernia surgery. Then what and how is it being used now?

Rana Pullatt, M.D. [00:03:27] So then I expanded it to all of general surgery. We started doing gallbladder as we started doing foregut surgery, which is surgery that we do for acid reflux. Nissen procedures, then for hernias of the stomach that go into the chest. We started using it. And then finally, we started using them for bariatric surgery for a sleeve gastrectomy. Gastric bypass and a more complex procedure called the duodenal switch. Currently, we do all of our primary bariatric surgery, as well as revision of bariatric surgeries robotically because it offers greater position as well as we've gotten good enough that our robotic times now are actually lower than our laparoscopic times, which was one of the initial criticisms of the robot that it takes time, it takes longer than laparoscopy to set up a longer. But as you get more experience, it's a very for lack of better terms because a company is called intuitive, a very intuitive machine where you become an extension of that, and you work pretty harmoniously and it's a seamless progression of the surgery.

Erin Spain [00:04:43] How unusual is it to have this? Many robotic surgeries are taking place at a big academic health care center

Rana Pullatt, M.D. [00:04:50] For South Carolina, of course, we are probably the only academic center using the robot in all procedures. In all aspects. We do everything from cardiac surgery. Colorectal. Bariatric surgery. Foregut surgery, thoracic surgery. Even trauma critical care surgeons use it. So, it's pretty unusual for South Carolina and North Carolina as well. The adoption rate has been lower than the Carolinas, where the leading robotic center, so to speak. But across the nation, academic centers have woken up to the possibilities of this transformational technology and have been doing really well with it.

Erin Spain [00:05:30] I want to focus on this duodenal switch surgery. You were actually the first surgeon in South Carolina to perform this procedure. Tell me about this procedure and how you became one of the experts in doing this robotically.

Rana Pullatt, M.D. [00:05:44] The duodenal switch procedure is a procedure that's reserved for the super obese patients. So, it's a technically very challenging operation where we go in and do a lot of complex dissection of duodenal and people who are 400 500 pounds, even up to 700 pounds. And there's a lot of dissection around critical structures as well as suturing that is involved in performing this procedure. I went to see the procedure being done by one of the nation's experts, and then he was one of the few surgeons performing them microscopically in good numbers. And then I came back in 2015 and performed the first one in South Carolina. And then from there on, I started using the robotic platform to perform it. At one point of time, I was doing them equally with the laparoscopy and the robot. But right now, we use the robot exclusively for the duodenal switch procedure because especially in people whose BMI is 94 95, which these patients are almost 650 to 700 pounds, the amount of abdominal torque that is required that we work against if you're doing conventional, laparoscopic suturing is a lot. Being able to use the robot really helps us do suture better and with greater precision.

Erin Spain [00:07:13] This is a very difficult procedure to do. Before you could do this robotically, how difficult was it to do bariatric surgery on people with these very high BMIs

Rana Pullatt, M.D. [00:09:22] We as bariatric and laparoscopic surgeons get used to it, but our body takes a real beating. When we do this procedure, our wrists, our fingers. There's a lot of workplace injury and that's becoming very evident. My senior partner has an extremely bad back and knees from just leaning over and standing and doing these procedures for hours. So, I think this ultimately preserves the surgeons, joints, surgeons. The skill level has preserved, you know, the natural tremor that comes as you get older is taken away by the robot. So, you have longevity for the surgeon. All that experience that the surgeon has is still preserved because the physical faculties are now assisted by the robot, so it prolongs surgeons’ careers and that translates to better patient outcomes.

Erin Spain [00:08:19] And was there some case where some surgery centers just would not accept these patients because of how difficult it is?

Rana Pullatt, M.D. [00:08:26] Yeah, yeah, there are several. Right now, we are one of the few centers in the whole Carolina region that do routine duodenal switch on high BMI's patients. There are several centers that limit their BMI to a certain BMI, beyond which they will not offer elective bariatric surgery, certainly not to a single stage duodenal switch procedure. Our highest BMI thus far has been a 93 BMI patient whom we were able to do a single stage switch.

Erin Spain [00:09:00] Just tell me the difference between traditional bariatric surgery and this procedure, and why this procedure makes more sense for people with very high BMIs.

Rana Pullatt, M.D. [00:09:09] This procedure for lack of better terms. The sleeve gastrectomy and gastric bypass are the more common procedures, and the duodenal switch is still a very small percentage of procedures done around the country because it's a more complex operation that requires more follow up, as well as requires more technical skill. The sleeve gastrectomy is the most commonly performed operation around the country. It's a much less challenging operation, and it gives good results, but it works well up to a BMI of 45 to 50, beyond which I think the operation does not, for lack of better terms, have enough horsepower to work on high BMI patients. The gastric bypass has several advantages while compared to the sleeve as far as reflux is concerned. But in the long term, weight loss is not radically different between the sleeve and the gastric bypass, the duodenal switch procedure is a sleeve with a combination of short circuiting the small bowel, which ultimately absorbs your nutrients, so it allows the patient to eat a certain quantity and absorb much less. So, there's a component of hypo absorption, so this allows for greater weight loss as well as it allows for a cascade of hormones that are set off because the food first goes to the small bowel, which is farther away from the duodenum. And we know that the food going to the lower part of the intestine sets off a cascade of hormones, which allows for improved metabolic health and improved weight loss.

Erin Spain [00:10:59] And you have seen that you have seen success stories from your patients who've had the procedure. Tell me about some of those great success stories.

Rana Pullatt, M.D. [00:11:07] Absolutely. I mean, we see this every day. You know, every day patients come and thank us for transforming their life or saving their life. Bariatric surgery is very rewarding in that it almost completely changes the patient's life. Everyone who tries to lose weight knows how frustrating it can be beyond a certain weight and a BMI. It becomes extraordinarily difficult to lose the weight because the hormonal mechanism, as well as a metabolic phenomenon that you're fighting, works throughout all 24 hours versus your awake and your willpower and all of it. You're working against a huge set of hormones and a cascade of metabolic derangements that you're not able to overcome. So, these patients are truly suffering and then it becomes a vicious cycle. And once the weight keeps piling on, it becomes very, very difficult to get them to lose a significant amount of weight. So, we see success stories all the time. I have a number of 600 plus who are now 250, 275 pounds. That's almost not carrying 400 pounds and walking around. So, things that are very simple that we all take for granted, like personal hygiene, tying your shoelaces, you know, caring for yourself, playing with your kids. All of these are impossible tasks. They become almost prisoners in their own houses, so it becomes a very, very transformational aspect of their life. Once you give their health back, once you give their mobility back, once you give them the ability to integrate better with society, you know there's not one success story. There are several people who were completely beat down by life and they wanted this chance and they've turned their lives completely around.

Erin Spain [00:13:09] I feel like it's not well known what you were talking about with the hormones and the metabolic response that people who are super obese have. Do you feel like that's well known even in the medical community?

Rana Pullatt, M.D. [00:13:22] Everyone who has tried to lose even the extra four or five pounds? And what do we tend to do? We tend to try to eat less and exercise more. And what happens is when you try to eat less, your body starts thinking that it's in some sort of starvation mode and tries to hang on to calories, hang on to the weight even more. And it's a self-defeating process because most people give up after about three or four weeks and they're like, I've given up. I mean, I've cut down a significant amount of food. Their basal metabolic rate goes down and they start feeling terrible and their body slows down and then they hang on to the weight even more and then they get more frustrated. And this keeps happening. So, there's a bunch of people who also try a bunch of other things like yo yo dieting, and then the weight comes back faster because now you become more efficient at storing fat once you do those yo yo diets.

Erin Spain [00:14:23] We have been talking quite a bit about super obese people with BMI is above 40 or 50, but that's not the majority of the work that you're doing with surgeries at MUSC Health, Tell me about that?

Rana Pullatt, M.D. [00:14:33] Yes. So, the majority of my patients are women and they're BMIs are the 35 and above category. So even if you have a BMI of 35, you qualify for weight loss surgery. And we know that beyond a BMI of 35, it becomes very, very difficult to lose that extra weight. So, all the national criteria support weight loss surgery even in that BMI criteria.

Erin Spain [00:15:01] What are your thoughts on the obesity epidemic, will there be even a more need for this type of surgery in years to come?

Rana Pullatt, M.D. [00:15:09] Unless there's very strict food regulation as far as food scientists go, so we can look at it in an isolated fashion, we can say, you know, oh yeah, look at this obese patient. It's his responsibility. You know, he is the one who is, you know, she is the one who was eating too much. But I think of this situation where you have a single mother who is working a couple of jobs to make ends meet, and she has two kids at her house. And the only thing she can do at the end of a day while driving back is the easiest place to get it is some fast food that she knows that she can get for cheap and goes to a fast food joint, picks up fast food, feeds her kids and these fast food places work with food scientists who know how to make the food taste in a particular way to make it almost addicting because they want them to come back. So, what chance does a two-year-old who's being fed fast food all their life have? You know, and suddenly, as an adult, it becomes your own responsibility? So, I think there's a huge societal responsibility towards the obesity epidemic. There needs to be better regulation. There needs to be just like, you know, it says cigarette smoking is injurious to your health. There needs to be more warnings. There needs to be some sort of limit on salt. You know, those kinds of things. How food can be altered, emphasis on healthy eating. I think as a society, we need to change. But I don't see that happening in one generation. So, I think it'll change maybe slowly. But for sure, right now, we're just seeing the tip of the obesity epidemic.

Erin Spain [00:16:55] How do you support your patients once they've gone through this procedure? There are special diets that they have to adhere to afterwards. What happens after the procedure to make sure that these folks can be successful?

Rana Pullatt, M.D. [00:17:07] So we obviously work as a team. We have a psychologist; we have a dietitian. These patients are frequently counseled. They're obviously counseled before surgery and then after surgery. They have a rigorous follow up with that dietitians. They also have psychological support if they need it. It might be changing your diet, but it's all there is as it's healthy eating, but with lower quantities and lower calories being more conscious of food labels. So those kinds of things, you know, are dietitians even preoperatively taking patients to food markets where they are taught to really read a label. You know, there are people who have never looked at a food label and see what ingredients are in there. So, make them conscious of those kinds of small things, those changes that they can make.

Erin Spain [00:18:03] Back to robotic surgery in general at MUSC Health, how do you see robotic surgery continuing and expanding at MUSC Health?

Rana Pullatt, M.D. [00:18:14] So, ultimately, I think the robot's going to be another tool. It's going to lose some of its sexiness because it's going to become ubiquitous. I think everyone's going to use it because it becomes an extension of the surgeon and surgery is going to become less. So, the quality of surgery is going to become less different between surgeons because the robot can be a great leveling platform so it can deliver measurable quality and improve the overall quality of surgery. So, it'll be less dependent on, oh, this person's a fantastic surgeon with good hands versus another person who may not have the same hand-eye coordination versus the robot can be an equalizing tool between the two surgeons. The other way, I think would be to my long-term vision is to connect the MUSC network in different hospitals and be able to proctor surgeons or take over cases that are difficult through tele surgery. So, the robots can be connected over a 5G network. And basically, if there's a rural surgeon in the MUSC network who need some help or he needs an assistant, then we would be able to log on from say MUSC Charleston to help.

Erin Spain [00:19:35] How far away could that technology be?

Rana Pullatt, M.D. [00:19:38] So, you know, as an experiment, it's already being done as early as 2001. There was a French team of surgeons who operated on a lady in France. They took her gallbladder out from New York, and it's called Operation Lindbergh, and it was done to showcase French technology as well as French surgery. And it's been done, and there are places in the world that are doing it right now. I think in the US it's got to do a lot with medical legal aspects of those kinds of practices. So, we need to work through some hoops before we can make that into a reality.

Erin Spain [00:20:20] That's very exciting news and it's something we will be keeping our eye on. Before we wrap up today, I would love for you to answer the question that we ask everybody on this show. And what do you do to optimize your health and live well?

Rana Pullatt, M.D. [00:20:34] One of the things is to have a very balanced life. I do use a personal trainer at a because it's almost like I'm responsible with the personal trainer. You know, there's some responsibility, others as a person waiting for me. So, I try to keep at least 45 minutes or an hour a couple of times a week to work out with this person. Then I do my own training about two times a week, so at least four to five days I do some sort of physical fitness training, then spending quality time with friends as well as your family. That is what keeps me going outside of work.

Erin Spain [00:21:15] Well, thank you so much for coming on this show. We appreciate all your insights.

Rana Pullatt, M.D. [00:21:19] Thank you very much.

Erin Spain [00:21:24] For more information on this podcast, check out advance.muschealth.org