An innovator and expert in both robotic surgery and general surgical education, Kevin Roggin, MD, was recently appointed Chief of Surgical Oncology at MUSC Hollings Cancer Center. He brings more than 20 years of experience in surgical oncology to his new role. Roggin shares his vision for the division, his views on patient-centered care in surgical oncology, and how robotics may enhance many complex surgical oncology procedures.

[00:00:43] Kevin Roggin, MD: Thank you, Erin

[00:00:49] Kevin Roggin, MD: I'm really happy to be at MUSC. I'm a surgical oncologist and have practiced in this field for almost 20 years. The patients that I typically see are those with GI gastrointestinal cancers that include stomach, duodenal and intestinal cancer, and hepatopancreatobiliary malignancies such as pancreatic cancer, primary and secondary hepatic neoplasms, gallbladder cancer, and retroperitoneal sarcomas.

[00:01:33] Kevin Roggin, MD: I think of surgical oncologists as the gatekeepers of cancer care. Surgeons that are specifically trained in the multidisciplinary management of patients are surgical oncologists. And we often see patients when they're first diagnosed with a mass. Sometimes they've been given the news that they have cancer. And I think our role is to assess that patient. Do a comprehensive history and physical examination, look at studies that have been done, order additional studies to complete their staging workup, and then to appropriately triage the cancer modalities such as surgery, radiation oncology, medical oncology, and investigational treatments. We as surgical oncologists are specifically trained general surgeons that have expertise in cancer care. So we focus on making sure that we do a complete resection with the appropriate harvesting of regional lymph nodes to stage patients more appropriately. And in some circumstances, treat metastatic disease using defined modalities. In addition, we're also involved in clinical research, enrolling patients on trials and working with our colleagues in other disciplines to advance the knowledge for cancer patients.

[00:03:00] Kevin Roggin, MD: I think when people think of surgery traditionally, they think of open, what we call open surgery, and that is where the surgeon uses a scalpel and makes an incision and opens the body cavity to treat the cancer. We evaluate for spread. We remove the tumor and then sometimes reconstruct so that there's normal anatomy after we're done. This has led to long hospitalizations, a lot of pain associated with the incisions, and you know, a significant amount of morbidity. Over the last two to three decades, there has been a great revolution in minimally invasive surgical techniques. Laparoscopic surgery is the original modality, and this has been, you know, evolving over a hundred or so years, where we've started using instrumentation, long instruments, long endoscopes, to access this body cavity, such as the abdomen, and it allows surgeons to peek inside using cameras, and then using longer instruments, do the same operation, but not have to do this huge, large incision that's a source of morbidity. Robotic surgery is sort of the next iteration, the next technological advance where it's similar to laparoscopic surgery in that we use small incisions to access the abdominal cavity. We put endoscopes in or cameras in to see inside the abdominal cavity. But the instruments, instead of being held by a surgeon, are connected to a robotic machine. And in a robotic operation, the surgeon actually sits at a console, apart from the operating room table, but in the same room, and they control the instruments that are attached to this robotic machine using their hands, that are attached to these controls. And so when people talk about robotic surgery, it allows the surgeon to see inside with 10x magnification, and there are multiple ergonomic enhancements so that the surgeon is in a comfortable position. So it improves the longevity of surgeons. And then, in addition, it allows technology so that when I move my hands inside the console, it controls the instrument in a similar way, with the same degrees of freedom, with stabilization or anti tremor controls, and everything other than haptic feedback, it offers the surgeon. So, we can't feel when we push the instrument into tissue. There's no resistance. That's still an evolution, but it's an amazing technology, and if used appropriately, can help patients with cancer.

[00:05:46] Kevin Roggin, MD: Well, I think there are a lot of pros. One is that it's a system that's very precise. It has the potential to minimize pain and improve recovery so that patients have faster postoperative access to additional adjuvant type treatments like chemotherapy. I think the cons are that it's expensive. It has risk if people aren't properly trained, and there have been relatively few studies that conclusively prove, we call that level one evidence, that the technique is helpful versus either open or other forms of minimally invasive surgeries such as laparoscopy. I think most of the data is unfortunately collected through collaborative groups or single group practices like retrospective cohorts, and it gives us ideas about how it can be used, but it doesn't compare it to gold standards and prove that it is worth both the investment of time and money. And I think we have to make sure that what we're doing is not harmful to our patients.

[00:07:13] Kevin Roggin, MD: Robotic surgery has been previously established in urology, in gynecologic oncology, and even in cardiac and thoracic surgery. I think GI surgical oncology applications are relatively new. And I think the areas that we're seeing it used most frequently are in rectal cancer and recently in pancreatic cancers and gastric cancers and liver malignancies. So it's a relatively new application and there are a lot of pioneers in the field that have started to establish the utility, the outcomes and learning curves associated with adopting these techniques for surgical oncology.

[00:08:15] Kevin Roggin, MD: Yeah, I think you highlighted how extraordinarily difficult pancreatic cancer is to treat. The main problem is the disease is often diagnosed late and is metastatic at presentation in the vast majority of patients. Through combinations of neoadjuvant chemotherapy and selecting patients appropriately for surgical care, we think that surgical treatment of pancreatic cancer can extend survival and in rare circumstances when we catch it very early, we can offer a cure. I think in this field, in this treatment where you're combining surgical and medical treatments like chemo or targeted therapy, you really want to try to maximize surgical recovery. Anything that we can do to decrease the time between surgery and the receipt of additional forms of therapy like chemo can help. So that's why using minimally invasive techniques for pancreatic surgery makes sense. The problem is it's a very technically challenging operation that requires high volume surgeons in high volume institutions to have the best outcomes. I learned how to do robotic pancreatic surgery, and that includes robotic whipples and robotic distal pancreatectomies, by learning it from experts in the field. And then working through my performance and then offering it to patients once I was ready to do that. And this is after 18 years of doing these techniques in a traditional open approach. Robotic surgery is amazingly detailed. When you overcome some of the challenges of the robot, such as the loss of haptic feedback, you're actually able to do a beautiful operation with great visualization and very precise technique where we can reduce blood loss. And, you know, obviously there's a longer time and a significantly higher cost because the procedures are more involved, but if done correctly, you can really try to decrease the amount of time in the hospital and then the amount of time after the patient recovers to when they can receive additional treatments.

[00:10:25] Kevin Roggin, MD: Currently we're using robotic surgery in colorectal cancers for rectal cancer specifically under Dr. Virgilio George and Dr. Katie Morgan and Bill Lancaster have utilized the robot for pancreatic cancer treatment, and it has been used by Dr. Jeffrey Sutton for gastric cancer treatments. So my plan, what I hope to bring, is finding ways to incorporate it into our practice commonly. And I have had specific experience utilizing the robot to do gastric cancer resections that include for gastric adenocarcinoma and for a very special group of patients that have CDH1 gene mutations that are at risk for stomach cancer based on their genes and require, in some cases, a prophylactic or risk reducing total gastrectomy to remove the risk of cancer from those patients. This is a very interesting area where there are very few surgeons around the country that do robotic risk reducing total gastrectomy. And I had an opportunity to start a program at University of Chicago and treat a large number of patients with this rare disease, utilizing robotic techniques.

[00:11:54] Kevin Roggin, MD: So, this is a small group of patients that primarily have been identified with a gene mutation in the E. cadherin, or CDH1 gene. They are at risk for developing gastric cancer if they have the gene. And unlike traditional sporadic gastric cancer, which forms a mass, these individuals are at risk for submucosal deposits of cancer that cannot be detected by conventional endoscopy routinely. So if someone in their family has had gastric cancer, they're usually referred for genetic testing, and if they have mutation, we estimate that there is about a 50-70 percent penetrance, meaning that they're likely to develop gastric cancer in their lifetime. And these are young people. Often it occurs in the late 30s, and this is at a time where many of us want to be thinking about a lot of other things than having a life changing operation. I've been fortunate to work with a lot of really amazing physicians and patient support groups. And one of them has been No Stomach for Cancer. And they're an incredible group that has access to patients and they provide education and resources for those patients that have the gene so they can identify providers like me around the country and around the world that have specific expertise in this disease. And so I hope to continue the CDH1 program at MUSC and have already reached out to No Stomach for Cancer to become a site where we could have a patient care symposium that they hold annually.

[00:13:40] Kevin Roggin, MD: Yes.

[00:13:44] Kevin Roggin, MD: It's been a journey. It's doing the same operation that one would do using the traditional open techniques. And you're operating on patients that are not sick and the goal is to reduce any kind of complications or side effects of the surgery. So one, you have to appropriately counsel patients. You have to talk about how their life will be changed by the operation, which is intended to reduce risk. Not every patient wants to have the surgery. Some may want to delay it. And then we need to meet with a nutritionist, a genetic risk counselor, gastroenterologist, other people that will be involved in their care. And robotically, we remove the stomach completely. We have to confirm that we have done that to reduce the risk in the future. We then have to reconstruct so that patients can eat and drink normally again. And the initial experience is that we're able to do this with a very low conversion rate. And the one issue that we've seen post operatively is that patients can have a higher rate of getting a stricture or narrowing from the new connection that we make between their esophagus and their small intestine. And, we're working through how to reduce that, but all of the patients that we've had this sort of complication with are able to be treated by endoscopic or non surgical treatments in the future. And what's really gratifying is talking to these patients after they've had the surgery, and they're doing all the things that they did before. Their life's different, but they're able to eat and drink in a different way and have normal lives.

[00:15:37] Kevin Roggin, MD: I consider myself in addition to being a surgical oncologist, a surgical educator, and I've spent 18 years , in teaching and education and had the role of being the program director of the General Surgery Residency at the University of Chicago for 12 years. And what I like most about the robotic training experience is that I had to do exactly what I asked my residents to do. And that is to learn from the simulator to understanding the instrumentation to shadowing surgeons, watching, watching videos, then trying robotic surgery with mentored support, whether there's a proctor there at smaller cases and building towards these large operations, and then continuously monitoring my outcomes and making adjustments with my technique. So what I got to do through the great support of my team at University of Chicago was that I was able to do this the right way and learn it the way that I taught my residents and plan to teach our trainees at MUSC in the future. And I think it's very organic. It was patient centered and focused on making sure our outcomes were safe and that it benefited the patients, even though it was a learning process for me, not learning the technique in terms of the operation, but learning how to do this on the robotic platform.

[00:17:08] Kevin Roggin, MD: I think we try to empower the patients as physicians to make decisions that benefit the patient, their loved ones, their family, according to their own value system. And every person's different. They may come from different religious or ethnic perspectives due to their life experiences and their cultures. And I think, as opposed to the traditional, I'm the surgeon, here's what we're going to do, to the other extreme, where we let the patients decide everything. It's a shared model where we give the patients information. In this case, what are the risks and benefits of robotic surgery? How might it be helpful? How might it be harmful? What's the best case? What's the worst case scenarios? And then work with them and their family and being transparent to come to a consensus. And it can simply be, I think you need a Whipple procedure or a pancreatic resection for your cancer. There are two ways that I can do this, the open approach and a robotic approach. Here are the pros and cons of each. Here's why I think we should do this particular approach and then I get their perspective and I try to make sure we talk about cost and length of stay and other metrics that are important to them, and ultimately I'm providing them with a menu of options to do the same procedure the way that it should be done and I'm making sure that they're involved in that decision making process.

[00:18:41] Kevin Roggin, MD: That's a great question, Erin. I think physicians are often notorious for not practicing what they preach. And I myself could do a better job on an everyday basis to follow the same advice that I give patients, which is to live life within moderation, to try to make sure that you're getting daily amount of exercise, you're eating as well as you can in a balanced way, and then to make sure that you're addressing your emotional and mental well being by doing things to help yourself have each day better than the last.

[00:19:22] Kevin Roggin, MD: Thank you so much, Erin. I really appreciate it.