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Medical Intel

Jan 22, 2019

Thoracic surgery has come a long way in the last century. Dr. John Lazar discusses how patients in Washington, D.C., can benefit from safer, more precise surgeries with faster recovery through minimally invasive robotic technology.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. We’re discussing robotic surgery, a minimally invasive technique, which increasingly is being used for esophageal, lung, and other thoracic conditions. Dr. Lazar, what do you mean when you say robotic thoracic surgery?

Dr. John Lazar: So, basically, we mean we’re doing minimally invasive surgery and it’s robotically assisted, meaning the surgeon is in total control of the robot. Nothing is automated, and yet we’re taking advantage of robotic technology, which would be 3-D visualization, uh, removal of any tremor, and basically being able to manipulate the robot in small, hard to reach areas.

Host: When you say removal of tremor, is that from the physician’s hand?

Dr. Lazar: not necessarily the way you would think about a tremor, but for every three motions I make, the robot will make one. So, it sort of stabilizes the hand - there’s no big lunging motions - so we call it stabilization.

Host: What are some of the more common thoracic procedures that are performed with robotic surgery?

Dr. Lazar: So, when we think about robotic surgery, we think about three main areas, one of which is the lung. Uh, the other one is called the mediastinum, which is the central part of the chest - the soft tissue’s there, which includes the thymus. And the other part is the esophagus as well as the stomach.

Host: Are you treating conditions that are just cancer or what sort of conditions are you looking for?

Dr. Lazar: So, we treat conditions that are both cancerous or malignant as well as benign, meaning non-cancerous. Um, non-cancerous conditions are especially prominent in the esophagus - such things as paraesophageal hernias, where the stomach actually over time goes up into the chest. Uh, we also treat things like lung cancer. There are some benign diseases of the mediastinum which we also treat, but they have to be treated with excision. And, that’s pretty much it when it comes to the robot.

Host: So, what are some of the patient benefits that people can expect when they get a robotic surgery as opposed to a traditional surgery?

Dr. Lazar: So, traditional surgery we’re talking about usually a large incision, something anywhere from six inches to twelve inches. Uh, when we talk about robotic surgery, we call it port-based surgery. It’s minimally invasive and instead of the instruments kind of grinding back and forth, they go through a port and so there’s only one small area where the port is touching the skin, and so generally we find that there’s less pain afterwards. People are able to get back to their daily lives quicker. So, in terms of comparison in after-care for robotic surgery versus open surgery, uh, most people who have open surgery are in the ICU anywhere from one to three days, maybe sometimes five days, whereas most patients who get robotic surgery do not need to go to the ICU and therefore, they’re up and out of bed and walking around the floors much quicker and the tubes - there’s usually a tube after surgery - that can come out. And I tell most of my patients that they’re in the hospital three to five days. Everybody’s a little bit different, but that’s about it. Um, most people are walking - they’re walking up the stairs - they’re eating, they’re drinking. Uh, they’re usually...their biggest complaint is they’re a little bit sore, but nothing compared to open surgery. There’s less narcotic use, uh, for minimally invasive and robotic surgery and they’re usually 90 percent better by ten to fourteen days after surgery. That’s not out of the hospital - that’s after surgery itself.

Host: How do patient outcomes with robotic surgery compare to those of traditional surgery?

Dr. Lazar: So, robotic patients are minimally invasive patients. So, generally speaking, if you’re able to get a minimally invasive procedure, meaning smaller incisions, patients usually do better quicker. Over the long term, they do just about the same. But the idea that robotic surgery is just another type of minimally invasive surgery, the advantages being more for the surgeon and less from the patient when we talk about things like VATs or laparoscopic surgery which are other types of minimally invasive surgery. For the surgeon, we’re able to get into smaller places, we’re able to visualize things in 3-D as opposed to just on a flat screen TV, which is the way we do it in traditional minimally invasive. And this allows us to do more highly technical procedures in a smaller space. So, in comparison to open surgery, I think where robotics has really helped the patient is getting them a better...technically a better operation, whether it’s cancer operation or whether it’s for something like paraesophageal hernia, and I think that’s because the surgeons can see better. They are not constrained by stiff instruments like you have in VATs and laparoscopic surgery. In robotic surgery there’s...the wrists are able to flex just like your own wrists and we’re able to see things that we normally couldn’t see and therefore we’re able to do better operations. You’re better to see the margins, and I think that that plays a big role in the post-operative care.

Host: Why is MedStar Washington Hospital Center the best place to seek thoracic surgery from a robotic or a minimally invasive standpoint?

Dr. Lazar: I would say that the group of surgeons across multiple disciplines are outstanding here - and that’s one of the major reasons why I came to join the thoracic team. They have a great deal of experience. They’ve been doing this for many years. They have gone through their learning curves already, and they’re able to offer patients an advanced level of robotic care at the cutting edge. Robotics is being employed by a lot of different specialties, not just thoracic. So, ENT is doing some cancer operations, uh, for tonsils and tongue-based cancers. Gynecology, urology are using it a lot as well for both malignant and non-cancerous procedures.

Host: Thinking about those patients as you were talking, have you had any outstanding or really interesting patients that you could talk about in generalities?

Dr. Lazar: There was an example of a young man who was, uh, working at home, felt his, uh, back sort of twinge, didn’t think anything of it. And then a week later went to his primary care physician who got a chest x-ray and saw that there was a mass along the left side of his chest. It led to a cat scan and showed a mass. His other surgeon was gonna do a large open procedure. Uh, luckily for him, they didn’t accept his insurance and so he came to me as a second referral. And, uh, we were able to do it minimally invasively. It turned out to be a benign cyst that was growing along his major artery called the aorta. We were able to do the surgery safely and he went home the next day and so far has not had any other issues and went back to work within two weeks.

Host: You mentioned that your patient had had back problems, and that’s what prompted him to see his doctor. What are some of the other symptoms that patients often notice before they get to you?

Dr. Lazar: I would say that pain is usually the number one, um, issue that patients have when it comes to the esophagus or the stomach. There’s usually things like nausea, bloating, indigestion, reflux - those types of things. Also, weight loss can be a big part of it. Fatigue.

Host: Tell me a little bit about your patient population. Are you seeing mostly older folks or what does that look like?

Dr. Lazar: So, I think, you know, being in the D.C. area, you see a lot of different people that you normally wouldn’t see. It’s’s a much different population, probably because so many people move here from different parts of the country. So, we see people from 16-years-old to, you know, people in their 90s. And they have a variety of different issues. Um, some are cancerous and some are not. Um, so there’s... it’s really hard to pinpoint it on one thing, which is one of the nice things about practicing here at the...the hospital center you do see a large variety of people.

Host: Who’s at risk for these types of conditions?

Dr. Lazar: So, I would say that the youngest people that we usually see are in their 30s but it goes all the way up in to the 90s, especially for the benign esophageal. This can happen to anybody at any age because it’s just a weakening of the muscle lining.

Host: Is surgery the first line of defense, or the first treatment for these types of conditions or do you typically try another therapy first?

Dr. Lazar: So, when you’re talking about non-cancerous things, obviously people try to avoid surgery at all costs. But usually once the symptoms become impinging on their quality of life, they generally seek surgical opinion. They’re not necessarily sold on surgery at that point but they at least want to keep their options open, especially if medical therapy tends to get more and more expensive, such as anti-acid medications and things like that.

Host: Do your patients typically have to see their primary care doctor first or can they refer right to you?

Dr. Lazar: It depends. Some people come right in to the emergency room, and if that happens, then it kind of bypasses the primary care but I think if they have a primary care, they should see their primary care first and get properly worked up. Most conditions are not surgical.

Host: Are you or your colleagues participating or conducting any research right now on thoracic surgery field that you’d want people to know about?

Dr. Lazar: Um, we are looking to become one of the first centers to robotically repair something called tracheobronchial malacia, which is a weakening of the trachea which is the windpipe that connects your mouth to your lungs. And basically, if it loses its integrity and it just starts to collapse, it can be very difficult and easily winded. In the old days we didn’t really have a lot for this, but now we can buttress it and sort of reinforce that integrity of the trachea and allows them to have a much better quality of life and not feel continuously short of breath.

Host: Thanks for joining us today, Dr. Lazar.

Dr. Lazar: Thank you.

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