AKU alumnus, Dr Adeel Khan (MBBS Class of 2002) and his team from the Washington University School of Medicine in St. Louis, USA performed the first successful robotic liver transplant in the US. The transplant was done at the Barnes-Jewish Hospital.
One of the fellows in this transplant team, Dr Roheena Panni is also an AKU alumna from the MBBS Class of 2011.
We asked Dr Khan about the procedure and what this means for healthcare around the world.
What were the specific challenges that your surgical team faced when performing the robotic liver transplant? And how did the team address these challenges to ensure a successful outcome?
Robotic transplant is a complex operation with many different steps. It requires, more so than other surgeries, a very qualified and skilled team. We are very lucky that we have been able to build a team that is dedicated to robotic transplants in which the members have expertise in all aspects of transplants and robotic surgery. We have been preparing for this for the last five years in general, and the last year in particular. There are many challenges when doing something that hasn't been done before as one has to think of every step of the operation and anticipate issues that may come up. We strategized beforehand, and over a span of four to six months explored every possible issue that could emerge and how to best deal with them. We also practiced the different steps in cadavers, practiced anastomotic techniques, but when you do something in real time, issues do arise. Thankfully, the team we had assembled was equipped to deal with any minor issues that arose during the transplant.
Could you explain how robotic surgery differs from traditional surgery in terms of the patient's experience, recovery process etc.? Are there any potential benefits in terms of healthcare costs or resource utilization?
Robotic surgery is a type of minimally invasive surgery; we consider it to be the next generation of laparoscopic surgery. The instruments are more user-friendly, the visualization is much better and considerably magnified, and the console allows you to see in a three-dimensional frame which maximizes visibility. The advantage is that a smaller incision is made so recovery times are considerably shorter, and the patient can get back to normal daily activities comparatively sooner. Robotic platforms allow us to do surgeries that we couldn't imagine doing laparoscopically so it really expands possibilities. There is an increased upfront cost due to the equipment required and the surgery itself costs more but if you look at the bigger picture, people with minimally invasive surgery tend to stay in the hospital for a shorter period of time which saves cost, and data from various surgeries, for instance gall bladder surgery, shows that such surgeries result in lesser conversions into open surgery and fewer rates of readmission, which impacts cost.
With the success of this robotic liver transplant, are there other complex surgeries that could potentially benefit from a similar approach?
Robotic surgery like any other surgery takes time to gain skills, and as you operate more the acquired skills grow and improve. Robotic liver transplant itself requires a high level of skill for both the dissection (the liver needs to be dissected free from the surrounding structures) and for vascular reconstruction. Once you have those skills you can apply them to any complex operation in the abdomen. More importantly, it changes the mindset; a liver transplant is one of the most difficult transplants and once you can do it with a robot you feel that you can tackle pretty much anything.
Are there any regulatory or ethical considerations that arise with the increasing use of robotic surgery, especially in complex procedures like liver transplantation?
With any new technology there are always things that need to be considered. Robotic platforms are approved by the relevant authorizing agencies; their safety has been assessed but there is a personal responsibility when it comes to this. At medical school when we take the oath, we promise to do no harm and that holds true here as well. Our first obligation to patients is to safely and effectively take care of the problem they are facing; how we do it comes second to that. You should only do robotic surgery once you have the skills and know the limits of what you can do. Experience comes with time, and it should not come at the expense of patient outcomes. Patient safety comes first and that is the surgeon's responsibility.
The team should perform the surgery when they have acquired considerable skill, not just at robotic surgery but also at live dissection as well as vascular anastomosis. If you look at our team, we have done over 500 robotic cases together prior to attempting this case; we gained experience in liver resections, pancreatic resections, gastric resections, living donor nephrectomies, kidney transplant and each of these provide a different skill set. Over time, the comfort level and confidence in ability goes up. This experience was necessary before going ahead with a complex operation such as a liver transplant.
Please share more about your personal and professional journey. What motivated you to specialize in this surgical specialty and consequently explore this groundbreaking approach towards transplants?
I am from AKU's MBBS Class of 2002. I was interested in surgery from the start, so I pursued that for residency; I got into a preliminary position at Brown University after which I went to Washington University for my HPB fellowship. During this time, I got exposed to transplant surgery, but that journey got interrupted for four years when I had to do general surgery in an under-served area in Wisconsin as per the requirements of my visa. I eventually came back to St louis to finish my transplant training, staying on as faculty. I knew this is what I wanted to do so I kept at it and things slowly fell into place.
I had incredible mentors and was surrounded by greats in the field, which meant that in order to stand out I had to develop a niche. That is where minimally invasive surgery came in. Robotics was not very common at the time, so I invested my time in learning the basics of robotics and did small cases like gallbladder surgery slowly building up to more complex things like liver resections and pancreatic resections. Couple of years ago we started doing kidney transplants, and over time these diverse surgeries taught me a wide variety of skills; for instance, with living donor cases you learn how to work around important vessels carefully. Simultaneously, we invested heavily in putting together a highly specialized robotics transplant team, allowing us to take our craft to the next level.
People only see the end result but they don't realise the years of hard work, challenges, team building and practice that goes into it. There is no such thing as a gifted surgeon; it is all due to hard work.
