HCA Midwest Health - May 04, 2017

If the biopsy from my colonoscopy is benign, why would I need surgery?

No one wants to face surgery with questions of whether it’s actually needed. But in the case of colorectal polyps too large to be removed by colonoscopy, it absolutely is for most patients.

A colonoscopy allows doctors to inspect the inside lining of your colon, rectum and part of your small bowel. If a small polyp is found it can be removed and sent to the lab for further analysis. If a polyp is too large to be removed during a colonoscopy, a biopsy will be taken to see if it is benign, precancerous or cancerous.

The thing with polyps is, that even if it’s not cancerous now, or even precancerous, it can become so later. Or a benign polyp can grow large enough to affect bowel function. Either way, most patients are advised to have polyps removed surgically before they can lead to colon cancerother problems.

Then why do the biopsy in the first place? The results will help determine what additional treatments may be needed, such as chemotherapy or radiation therapy.

“If you don’t remove the polyps they could continue to grow and then they become cancer,” said Dr Benyamine Mizrahi, one of the Kansas City area’s leading colorectal surgeons. “A screening colonoscopy is to detect if you have existing cancer, but also if you have something that could turn into cancer.”

Colorectal Surgery Options

There are two main types of colorectal surgery, open and minimally-invasive. With an open procedure, a large incision is made and the surgeon views the organs directly. It is the traditional form of surgery with a longer and more difficult recovery than minimally-invasive options, but may be needed for some patients.

"If the tumor is large or is invading other organs, you might have to do an open procedure. But other than that we’re going to recommend a minimally-invasive procedure."
Dr. Mizrahi

Because of their shorter, easier recoveries, most patients will have one of these minimally-invasive surgeries:

  • Laparoscopic. Four small incisions (about 10 mm, half the width of a penny) are made in the abdomen and special hand-held instruments are used to perform the surgery. One instrument has a camera, which allows the surgeon to see the organs and instruments during the surgery. The technique has long been used for removal of the appendix or gallbladder, and for gynecological surgery. But, laparoscopy has only become common for more advanced surgeries like colorectal procedures in the last 10 years.
  • Robotic. A more recent advancement, robotic surgery uses small incisions (about 8 mm), specialized tools and a camera. The tools themselves are attached to robotic arms and can move much like human hands, turning and rotating precisely to get into tight areas. There are two cameras, allowing the surgeon to view the surgery in 3D. The surgeon controls the robotic arms at a specialized console that allows a view of the surgical area that compares to open surgery.

Which type of procedure your surgeon recommends is going to depend on the expertise of the surgeon as well as the placement and type of tissue to be removed.

Dr. Mizrahi and Dr Lina O’Brien were early adopters of the robotic technique for colorectal surgery and are now recognized as two of the country’s leading robotic colorectal surgeons. They operate right here in the Kansas City area, at Menorah Medical Center.

“What robotic offers is minimally invasive surgery on steroids,” said Dr. Mizrahi. “It’s better in every aspect. You’re able to do a much better surgery because it’s meticulous and you’re able to see better, plus you’re also able to get all the added patient benefits—quicker return of normal life, quicker return of bowel function, shorter hospital stay and less pain.”

The average hospital stay for an open colorectal surgery is 7 to 10 days. With robotic surgery most patients go home within 2 to 4 days.

Considering Robotic Surgery

Robotic colorectal surgery isn’t just for cancer. It is also used locally to treat patients with diverticulitis, crohn’s disease, ulcerative colitis and other conditions requiring surgery on the colon or rectum.

“We educate patients on the whole process and describe what’s involved in the surgery and what the recovery is going to be like,” said Dr. O’Brien. “They’re usually really excited to have it done robotically or minimally-invasively because they know their recovery will be a lot easier, a lot less painful—their time in the hospital will be shorter. Their ability to resume their normal activities will be faster.”

Still, there is often some extra education that comes before the decision to have surgery robotically.

“Sometimes [patients] have the misconception that it’s a robot doing the operation,” said Dr. O’Brien. “I tell them I’m actually doing the surgery and I am using the robotic tools. It’s not that you just get plugged into a robot and the operation occurs.”

Patient education is key to reducing anxiety. The surgeons welcome family members to appointments so they can address their own concerns. Patients can also take home diagrams and other materials.

“It’s hard to absorb a lot of information when you’re nervous in a doctor’s office,” said Dr. O’Brien. “I think of it as a partnership, really… I love when patients bring family members in. I tell them to write things down… I approach it as ‘What would I want to know?’”

Choosing Robotic Surgery

Since robotic surgery is a newer technique, only surgeons trained in the procedure will offer it. Like any surgery, you want to choose a surgeon who is very experienced in the procedure you need.

There are two main factors for what type of surgery will be recommended:

  1. The comfort and experience of the surgeon. Some surgeons are comfortable with laparoscopic, some may only be comfortable with open colorectal surgery. Others, like Drs. O’Brien and Mizrahi are skilled at all three, but strongly advise patients toward the procedure they believe offers the best outcomes (in this case, robotic). The expertise and opinion of your surgeon will have a big impact on the surgical treatments available to you.
  2. The placement and severity of your tumor. For a colorectal surgery to be successful, surgeons will remove the cancerous tissue and additional tissue around it (called a margin) to make sure it was all removed. The placement of your tumor could make it less reachable with a minimally invasive procedure and an open procedure would be needed. Sometimes, surgeons will begin with a minimally invasive approach and then learn once they view the area that they need to convert to an open procedure.

Converting to open surgeries are actually less common with robotic surgery than laparoscopic. Robotic surgery cameras allow a better view of the area and the surgical instruments can move much more like the human hand.

Rectal surgeries have a higher risk of conversion because the rectum sits in a tight, narrow space in the pelvis—it’s been likened to operating in the opening of a paper towel roll. That means the robotic arms can actually get into places that the surgeon’s hands couldn’t, thus preserving more of the patient’s rectum.

“The daVinci robot … does enable you to get further below the tumor, thereby avoiding a permanent colostomy in many more patients,” said Dr. O’Brien. “You are able use these really fine, precise instruments and they work like your hands do where you can have six degrees of motion at the end of the instruments. Versus laparoscopically, using instruments that are almost like chopsticks to do the operation. It’s hard to do low rectal cancers laparoscopically.”

Finding a Surgeon

If you have been told you need colorectal surgery, Drs. Mizrahi and O’Brien offer this advice:

  • Ask a lot of questions, including “How many of these procedures have you done? What’s your experience with them?”
  • Look for a surgeon who is doing large volumes of colon and rectal surgery. “I think the more you do something, the more adept you are,” said Dr. O’Brien.
  • Feel comfortable with your surgeon and the procedure they are recommending. “You can’t take away the patient/doctor relationship. The patient has to be comfortable with the surgeon,” said Dr. Mizrahi. “[If] you get the added benefit that the surgeon is comfortable with minimally-invasive or robotic surgery you have that upper edge. And for me, I think that’s the way to go.

HCA Midwest Health offers free help finding a qualified surgeon in your area. Use our online physician finder or call 1-800-386-9355. You can use the same number to talk to a registered nurse for free—24 hours per day, 7 days per week.

Expanding the Availability of Robotic Surgery

Dr. Mizrahi and Dr. O’Brien are robotic surgery pioneers and advocates who are helping other robotic surgeons learn from their experience. The facilities at Menorah Medical Center allow surgeons from all over the world to login online and view robotic procedures.

“They can see the surgery as I am seeing it (through the robotic cameras),” said Dr. Mizrahi. Out of 1,400 colorectal surgeons in the United States, only about 200 are robotically trained, so sharing the expertise he’s gained in the more than 350 robotic surgeries he’s performed is important.

Watch a video with Dr. Mizrahi about the benefits of robotic colorectal surgery and see the precise instruments in action.