Medically Speaking #20

Welcome to today’s episode of Medically Speaking. We are certainly glad you joined us today. I have two very special guests from our general surgery department today. I have Dr. Ryan Bolt and Dr. Alex Wang, both with general surgery, both trained robotic surgeons, and I’m super excited about our conversation today. So let’s just start a little bit with introductions. We’ll start with Dr. Bolt. Dr. Bolt, maybe tell me a little bit about your background, where you’re from, and how did you find yourself to Greenwood? Sure, no problem. Thanks for having me. Yes, I’m Ryan Bolt. I’m one of the general surgeons at Self Regional. I did my undergraduate in Buffalo, New York, a chemistry undergrad major, then found my way down to Virginia for medical school, Michigan for residency, which is a five-year program, and then after finishing up the five years, I was looking for a job and had postdocs. So I did all those things on a job board, and the recruiters here at Self Regional reached out and kind of went down that path, and there were several things about Self Regional, including the presence of robotics and that sort of thing that kind of drew me here. Awesome, awesome. Thanks. Alex? Thanks for having me. I really appreciate it. Yeah, so I’m originally from Atlanta, Georgia, and I did most of my schooling in Georgia. So I did college at University of Georgia in Athens, and then I went to MCG in Augusta for medical school, and I did my residency at Morehouse School of Medicine in Atlanta. And when I finished my residency, I knew pretty early on that I spent most of my life growing up in cities. From a very young age, I grew up in Paris and lived in city life, and I knew that as much as I love the city, I want to be somewhere a little more to my pace and my liking, Yeah. and I had to look for somewhere where I’m close enough to family still but not too far away. I can’t see them on a regular basis, so that’s how I ended up in Greenwood. This was like perfect. It’s about two hours from where the rest of my family lives in Atlanta, and the other thing I looked for that brought me here to Greenwood was exactly the robotics program, the availability, the ability for us to grow that part of our practice. Awesome, awesome. Have you guys found the community to be pretty welcoming to you and kind of hit the ground running, or has it been a little slow start? No, it’s been great. It’s been a very busy practice, and it’s just continued to grow, and we’ve continued to kind of increase the utilization of the robots and try and get more and more types of patients and types of cases on the robot. Exactly what I expected, you know. In medical school, I specifically did all my surgery rotations in smaller towns. I was in Columbus, Georgia. I guess you shouldn’t say those are small towns, but kind of what we were considered outside rotations, and so I was in Columbus and Albany and all these other places, and I just loved the small-town feel. I think people are extremely welcoming, and it’s been a great transition. I couldn’t be happier. Awesome. Alex, maybe I’ll start with you. Let’s dive into robotic surgery just a little bit, maybe just give an overview to our audience. What is robotic surgery? What makes it special, and why is it important that we have that service here? Yeah, I think it’s interesting when you look at the evolution of surgery, because for a long time, everything was open surgery, and with the advent of laparoscopic surgery, it started off in the field of GYN in the late 1980s. In 1987, we did our first colostectomy. That was actually done over in Atlanta. And so, that idea of, “Can we do the same surgery with smaller incisions?” was the whole goal, because as people who had large incisions for, say, a gallbladder surgery, they know it’s much more painful. You stay in the hospital for a longer time, and so the evolution to minimally invasive surgery starts with laparoscopic surgery, and kind of now we’re at a new frontier where robotic surgery over the past 10 years has really taken a hold in a lot of training and a lot of hospitals, and robotic surgery itself is specifically different than laparoscopic surgery, because the technology itself allows surgeons extremely minute control of the surgical field with great magnification and high visualization. And to us, it offers us more abilities to offer a surgery for a patient with better outcomes, is really the goal here. Okay. Just one thing. One thing that came to mind. Can you describe the difference between traditional laparoscopic surgery versus using a robot for surgery, and maybe some of the benefits and differences between the two? Yeah. So, one big advantage with the robotic platform is the wristed instruments that we have control of, and it basically mimics having wrists inside a patient’s abdomen. And the advantage to that is that when we’re talking about colon surgery and talking about connection of bowels, like Dr. Bolt mentioned, traditional laparoscopic surgery, it slightly limits you when you have to talk about suturing bowel together laparoscopically, just because you’re limited on the wristed portion of that. And the robotic platform offers us the ability to do the entire surgery within the abdomen. And to me, that makes a big difference because in the end, when you have to take out the portion of the colon that you’ve cut out, that makes a difference in terms of outcomes. The colorectal field has done extensive research on this and found that depending on laparoscopic surgery extraction sites versus robotic surgery selected extraction sites, people can come back with higher risk of incisional hernias in the future. And so, I think that is one advantage is that if we’re able to do everything inside the abdomen, we’re not limited in terms of where we want to take out the resected colon, and it offers patients less risk of future complications from that standpoint. There was another study that was done very recently in 2022. They looked at conversion rates to open. And so, when we talk about a potential risk of minimally invasive surgery is that there’s always a small chance you end up with an open incision. And that study showed pretty convincingly that for left-sided colons, there’s a pretty much third less risk of open surgery. So, it was about 6% with laparoscopic surgery and about 2% with robotic surgery. And I think that’s a big difference. And again, it just shows the advantages of having the robotic platform in terms of the visualization, the manipulation of the instruments, and finer dissection, especially for patients who have more difficult anatomy, more inflammation, things like that, where normally you would have to resort to open. The robotic platform allows us to continue minimally invasive. Yeah, I would say it even provides an advantage in more obese patients as well to enable completion of the surgery without having to convert to open. And I would definitely echo what Dr. Wang was saying with the wristed motions. I think that’s kind of the game changer with the robotic platform is the fine, delicate ability for dissection and for suturing is just, it’s not even really a comparison as compared to laparoscopic surgery. Awesome. Thank you. Good. So, certainly better outcomes is certainly one of the important results that we hope to see. Brian, maybe talk to me about recovery time for things like a robotic surgery versus an open surgery for something like… Sure. …a colectomy, which is colon removal for cancer or whatever reason may need to be done, versus the, again, robotic versus traditional open. Yeah. I mean, the comparison between the two is pretty stark. I think a minimally invasive robotic surgery is going to have a post-operative stay of two days sometimes. That same type of surgery performed open can last five days for various factors. By doing it with the small incisions in a small, smaller extraction site to remove the specimen, you’re able to minimize pain, get people up ambulating earlier, and you can essentially advance their diet faster, have quicker return of bowel function, and meet all the milestones to discharge in a much quicker way than if it’s done open. And just to add to that, the other thing we don’t think about is, a lot of times we look at the immediate effects like, “Oh, you’re in the hospital for a shorter time. You have less pain.” But you also got to think long-term that with a bigger incision, you’re going to have less pain. But you also got to think long-term that with a bigger incision, you’re going to have less pain. But you also got to think long-term that with a bigger incision, you’re going to have less pain. But you also got to think long-term that with a bigger incision, what we see a lot are hernias, incisional hernias, down the line, whether it’s five, 10 years and things like that. And so the smaller incisions you have, the further away they are from the middle or your belly button, which is the natural weak point for hernias, the less likely you’re going to have people come back down the line with a hernia, which could be associated with so many other complications itself. Any other benefits? Just one thing that comes to mind. You all know I’m an ER doctor, and one thing that we would see a lot are someone with a hernia years after surgery with adhesions, and they get bowel obstructions. Do you see less incidence of those type complications with a robotic approach versus traditional approach? Yeah, I would say definitely. Yeah, I mean, a big midline incision to perform an open surgery more commonly is going to have significant abdominal adhesions, which, as some people may know, your small bowel is mobile and can get caught in those adhesions. And then if it just twists off in the wrong way, it can cause an obstruction, which may need repeat surgery to alleviate. And if it can’t be managed conservatively. Yeah, so I think of adhesions like scar tissue basically from surgery. So less scar tissue, less likely to have a complication like that. That’s good. When you compare the equipment that we have at Self Regional, so far as the robotic platforms that we have here versus just compare us to the most advanced hospital in the world, is our technology comparable or are there some opportunities that we have or maybe we could do a little bit different? I know we’ve certainly invested a lot in trying to make sure we have great technology. I’m just curious from your perspective, what you think. I mean, I would say, you know, we just, I mean, the hospital just purchased three brand new state of the art DaVinci Five robots. That’s the newest and best technology that, you know, Intuitive Surgical offers. And there’s many advantageous aspects of that platform. And, you know, that’s the that’s the same type of robot that any hospital has. That’s the best, the newest and best toy, so to speak. So we’re all really excited about that, having that access to that platform and the availability. Good. Yeah, I think, you know, I came from a training program that was very busy in Atlanta. And my entire training, we were between two programs, Morehouse and Emory, sharing one robotic platform at the main tertiary hospital in Atlanta. And it just goes to show that how committed Self has been to advancement in technology and providing, you know, the best care for patients, you know, that our hospital system didn’t get a second robot until I left, you know, and so when I came here already having two robots, and now investing in a third one, let alone the newest robot really shows the commitment that Self is putting towards technology and patients. Awesome. Thank you for that perspective. Okay, well, let’s transition a little bit and think about colon cancer. Okay, well, let’s transition a little bit and think about colon cancer. Okay, well, let’s transition a little bit and think about colon cancer. Just for a few minutes. And, you know, that’s a pretty common problem. What might you want any of our listeners to know about colon cancer, the importance of screening, maybe first steps after initial diagnosis, and when does a surgeon get involved versus just your gastroenterologist? So I think as a general baseline, I’ll just start with saying that anyone above the age of 45 has new recommendation. Now, they recently changed it from 50 to 45 since the incidence of colon cancer has gone up so much in the recent years, should at least have had a colonoscopy. I know there are alternatives that your primary care physician or GI doctor may recommend, you know, there’s fecal blood tests you can do, there’s fit tests you can do, you know, there’s the yearly tests you can do, but they’re not truly alternatives to a formal colonoscopy. And if any of those tests are positive, anyway, you still need a colonoscopy. So I think that should be everyone’s baseline. If you’re above the age of 45, highly, consider at least a colonoscopy and then follow the recommended schedule by your GI team. Good. So if someone is diagnosed with colon cancer, when does a surgeon need to get involved in, like, how’s that decision made? Yeah, it kind of just depends on what’s found. I mean, when a biopsy comes back, proven cancer, then we typically have to obtain kind of staging CT scans where we take a scan of the chest, abdomen, pelvis, we obtain some blood work. Specific tumor markers. And then based on those results, we kind of determine what the next best step in your care is going to be. Most of the time, if there’s no evidence of distant disease or spread of disease outside of where the tumor is, we can perform a resection, remove that segment of the colon and then make a new connection. And many times that can be curative and they can proceed with surveillance in the future. Awesome. And a multidisciplinary team with the oncologists and radiation oncology and all the folks looking at care. Yeah, I was going to mention that. I don’t think there’s ever a wrong time for a surgeon to really get involved because even if it is found at a later time that, you know, unfortunately if the cancer had spread, you know, somewhere else and may need chemotherapy, we’re still involved in that process. We can help with that, you know, putting a port for them to administer the chemotherapy and things like that. So our involvement through any process, I think, hopefully could only be beneficial. I think it’s beneficial for the multidisciplinary process of all this, you know? Yeah. Yeah. And sometimes, you know, it’s just good to have, you know, if we’re able to catch something early, we get the work started early, you know, before they see the oncologist. And if the oncologist sees them early, they start to work early. So really just benefits all around for the patients to get either the tests or the imaging or whatever they need sooner. Yeah. Yeah. Good call out there. So just one other thing, maybe the audience might be curious. So just in general, general surgery, certainly take care of things like colon cancers and things like that, but what are some other common conditions that you treat as a general surgeon? Lots of, I mean, all types of gallbladder problems from acute cholecystitis where you’re in severe pain in the emergency department or where you’re just having intermittent flare-ups after you eat certain foods like fatty foods, fried foods, appendicitis, all sorts of soft tissue lesions, melanoma, for example, cancers, elsewhere. What else do you think? Yeah. And our other big one is other hernias. We mentioned earlier, definitely, you know, we do a lot of belly button hernias, ventral hernias, which is any hernia along your abdominal wall falls in that category. We do a lot of inguinal hernias, inguinal scrotal hernias. They’re kind of their separate category because these are kind of more advanced hernias that have kind of grown into someone’s scrotum to say inguinal scrotal. Diverticulitis is another big pathology that we see quite a bit of in terms of whether it’s just uncomplicated diverticulitis where it’s an infection of the colon, infection of the outpouching is called diverticulosis, or it can have complications such as abscess, perforation, fistula between other organs like the bladder, the vagina. Stricture is another complication, narrowing of the colon, and some of these things require surgery as well. Yeah, so it’s a pretty broad specialty in my view. One of the things you haven’t mentioned, but is, you know, we’re a level three trauma center and you guys end up seeing a lot of trauma patients as well when you’re on call for the emergency department. And I know we certainly are glad you guys are here to help with those situations, whether it be a car accident with someone with an internal organ injury or, you know, heaven forbid, a stabbing or whatever, some other penetrating injury. Maybe talk about that a little bit in our trauma center and kind of your involvement. Yeah, you know, like you said, we cover any, when we’re on call and any activations that are more emergent, typically like level one activations, these are typically patients that are more sick or meet certain criteria to be labeled as a level one. You know, we respond and we’re available. We are immediately involved in all the care for those patients and we’re there, you know, pretty much if if there’s a blunt injury to an organ or bowel or liver or any anything kind of like emergent, we’re there and available to be able to take care of that for folks as well. Yeah, yeah. And you guys both trained in places where like big trauma services and very familiar with caring for some critically ill trauma patients as well, which is awesome for our community to have you guys here. Yeah, yeah, yeah. We did in our training, at least, you know, we both came from heavy trauma center training. I would train at a level one, one center in Grady in Atlanta, which was, was very busy. Ours was a level two with quite a high volume of even penetrating and, and motor vehicle accidents, that sort of thing. So how do patients get to you? Do, can you self-refer? Can you call the surgery office? Say, I think I’ve got a hernia or someone told me my gallbladder may be bothering me, or do you have to go through your primary care doctor first? Or how does someone make an appointment with one of you guys? To my understanding, I believe, I mean, we see people who self-refer and from referrals with, uh, primary care physicians, you know, I’ve, I’ve seen people who, you know, an older gentleman who said, you know, I noticed a bulge in my groin and, uh, you know, I wanted to have it checked out. Um, so I’ve seen people that way, but a lot of times it comes from primary care referrals. It comes from emergency visit referrals. Uh, and that sort of thing is primarily how we see people. Yeah. Yeah. I think we’re pretty open to any scenario, but I agree the bulk of our referrals to get to us typically comes from a primary care, primary care physician, because you at least typically want. Some provider to confirm that, yeah, there’s probably something wrong here or there’s an hernia. There’s some sort of pathology that we can see. Uh, not that there’s anything wrong that if someone wants to self-refer and, and come in and see us, you know, I think that we are, uh, well staffed enough to accommodate that. And we’re more happy to see anyone who thinks they may have something wrong. That’s specifically surgery related. We’re always happy and open to, you know, uh, confirm that with them or do more workup if need be for them to, to, to get them through that. Yeah. Great. Great. If you could think of one or two things that you would like for the community to know, whether it be about, about your practice or about, uh, preventative care or really anything you can think of, what would you like to share with, uh, our service areas community? Well, I mean, one thing that comes to mind, I mean, uh, we just passed, I believe colorectal cancer awareness month. I think a lot of people, they dread and they put off the colonoscopy. And really, I think it’s something that just has to be undertaken as you know, the rite of passage. Once you pass forward. I think, you know, as, uh, Dr. Wang mentioned, the, the incident seems to be on the rise for whatever reason. And I think the last thing that we want some want to see for anybody is to have something that could have been removed endoscopically with a camera grow and become something that’s much worse and potentially, you know, could be the end of the line, sort of speak. So I would just say, um, get your colonoscopy and I would also recommend, you know, proceeding with a colonoscopy as opposed to these other tests that are available. I think, you know, the colonoscopy is the gold standard for a reason, and it allows them to see small growths or polyps and remove them entirely that sometimes these blood tests or stool sample kits aren’t going to detect. Yeah. Yeah. I wholeheartedly agree. I think that when it comes to colon cancer for on that topic is if you have any doubts, anything abnormal, any, any pain, anything that just seems off, it’s just always safe. Or just to get it checked out. Cause you never know. Dr. Bolton and I have seen all sorts of varying symptoms, sometimes almost non-existent symptoms, just a mild change and say their bowel movements and they ended up having some sort of colon mass or it just can vary so much. Um, but to the, to a side point to that, since you’re mentioning what else we want the community to know, you know, and I’m glad you asked the question about, uh, what else we offer, you know, it’s funny. I, I took care of a patient today who, um, drove all the way to Anderson for hemorrhoid surgery. And, you know, it came to my mind that maybe, I don’t know if, if some people just don’t know that we offer these types of surgeries here locally, you know, uh, uh, anal rectal disease, hemorrhoids, anything, you know, we are general surgeons. So, you know, maybe getting the message to them that, Hey, sometimes you don’t have to drive all the way out there and maybe check locally. We’re happy if you want to just call the office and just ask, ask the front desk that all of them are great. You know, we, uh, they’re all great folks that work at the front and, um, they’re, they’d be happy to answer any questions on, Oh, does Dr. Bolt do this surgery? Dr. Thomas do this or Dr. Wang, any of us could, could they relay the message to us and, and saves them maybe a trip, uh, you know, elsewhere if they don’t want to drive an hour for that, you know? Yeah, absolutely. You know, just some other things that come to mind that might be kind of common. Some people may get like acid reflux surgery. That was, maybe we hadn’t talked about that much yet, but I know that’s something that’s certainly within the purview of what you guys do and y’all do a great job of it. Yeah. Um, so I would definitely encourage the community to reach out, um, you know, either talk to your primary care doctor or just give the office a call and say, Hey, is this something that we take care of here? So yeah, totally a hundred percent agree. All right. Well, gosh, guys, thank you all so much for joining me today and to everyone in the audience. Uh, thank you for joining for today’s episode of medically speaking and we’ll see you next time.