 It is Bill Ritt, yeah. Hello, and welcome to this episode of Quality of Life. In this episode, we're going to talk about the science of robotic surgery. To help us discuss that topic, joining us from Aurora Health Care is Dr. Bill Ritt, who's a general surgeon. Dr. Nick Drager, who's also a general surgeon. And Dr. Jeff Tomassini, who is from urology. Gentlemen, welcome to the show. Thank you for having us. Excellent. To me, this is an exciting subject to talk about because formally working in health care and in IT, and you talk about robotics and how it works, this is really exciting as far as that goes. How long has the science of robotic surgery or technology been around? It's been around for quite a long time, actually, in actual clinical practice for about 15 years or so. The centers that were using robotics at that time, very few in select. And then it started to disseminate as the technology grew and more surgical disciplines started to use the technology. Is it meant, has it been used on, let's just say, in the veterinary arena at all, or has it mostly been on people? Not to my knowledge, in the veterinary field, but certainly it is increasing across the board, across multiple disciplines in human surgery, of course. Tell us about the new technology coming into your facilities here, Aurora and Sheboygan. The newest technology we have is the DaVinci XI system, which is the pinnacle of their technology right now. It's the same machine you'll find anywhere from Harvard to Mayo to Cleveland Clinic. So the fact that we have that here is really great for the patients. It allows us access to all sorts of areas of the body that we might not have had such good access to before, along with all the other advances in terms of better camera, different lighting techniques to see different organs and such. Just to tail on a little bit more, are there any other benefits to this new technology that it brings to the table where we didn't have before? I would say the two or three of the biggest technologies advances that we've had compared to the laparoscopic or open techniques are, one, is visualization. Before it, we were doing everything, even if we were going to do a minimal invasive be laparoscopic, but it was on a 2D scale. So it was kind of like looking at a TV screen instead of looking at a 3D, like we normally view things. The way we view things now through the robot is actually in three dimensions, and we've never had access to that before. So the dissection planes, the quality of what you can see, the minutiae of what you can see is a lot better now with the robot as opposed to anything we had or had ever dreamed of before. The other thing that's the greatest advantage for us surgeons is the way the arms articulate. It's more like a wrist, as opposed to laparoscopically, you could really only open and close. You could rotate and open and close that way, but you were limited. It was basically like having fixed arms, whereas now we're able to manipulate tissue almost like our hands are inside the abdomen without our hands being inside the abdomen. So would it be about invasively the same as what you do now or would it be less invasive or just a different way of doing it? Technically, any procedure that we do laparoscopically we could do with a robot. So as far as the incisions go, a lot of them are the same size as a laparoscopic. That being said, we can often do it with a lot less incisions, smaller incisions, and it allows us to do a lot of procedures that we weren't able to do laparoscopically with a robot. So instead of somebody getting a big incision and we're talking like 10, 15 centimeter incision, we're now able to do it with smaller incisions. Okay. Who will be able to use this technology? Is it pretty much limited to, like you say, yourselves at Aurora or eventually if other physicians have practice rights or privileges, will they be able to use it as well or is it just specialized in the one thing right now? Well, right now, the surgeons using it are general surgeons and myself in urology. We do have a gynecologic surgeon who will be using it in the near future as well and potentially even an ENT surgery down the road. So we have as many as four disciplines across the board that could be using this technology to do surgery. Nice. Is there any type of training or certifications that you have to go through for special schooling to be able to use this technology or tool in your procedures? Well, first of all, there's the general pathway for the surgeon or urology surgeon, gynecologic surgeon to go through medical school, residency and all their training programs to be able to do everything safely with any technique. And then there's additional training for the robot. You have to be proctored on so many cases. You have to watch so many cases be able to work the robot not only at the bedside but at the surgeon side also. So you can troubleshoot anything that could be potentially an issue during surgery which really doesn't happen but you have to know the technology to be able to use it. So there's extra training, extra certifications that we've all gone through. There've been animal labs that we go to and also human cadaver labs before you're even able to operate on a person. Okay. And Dr. Redd, Dr. Drager and myself all had extensive training with robotic surgery in our residency program. So I'm very familiar and comfortable with that technology and had a lot of training at that point. So it translates nicely into our clinical practice now. And the greatest thing about the robot itself is whereas a lot of our colleagues were trained during residency with all open technique and then once they were out in the field they had to learn laparoscopic techniques which is completely different. We were trained open laparoscopic and with a robot but that being said the robot isn't a whole lot it's not a different modality it's not a different way of operating it actually just makes the laparoscopic stuff a lot easier. So as far as the training process there is an extensive training process that goes into it but it actually is easier to do it from a surgical standpoint robotically than it is laparoscopically. Okay. Getting into the technology of the process a little bit now. Is it basically when you're operating the robot it's obviously all set up with everything and is it you're running controls almost like a computer joystick game or whichever or is it like a machine out on the shop floor when you're making parts so to speak where you program the thing and it goes in and does the thing I guess how does it work as far as that goes? So the current there's only one FDA approved robotic platform right now which is as Dr. Red suggested what we have is the DaVinci XI has three components to it and one is called a surgeons console and that's where whoever the surgeon is sitting to operate and operate the instrumentation there's a patient side console or what we all refer to as the robot and this is an instrument that has four different arms that can approach and hold the instruments in traditional laparoscopic ports that are placed into the abdomen and then there's the third portion of it is a we call it a vision tower and it has all the devices that are necessary to help run the equipment. So the instrument the robot actually just literally holds the instruments at the bedside and the surgeon sitting at the console has some hand controls and foot pedals that we can use to control cameras and energy delivery and the various instruments in different arms of the robot in order to and that's translated over to the patient side robot and that's where the magic essentially happens. Okay. Do you see it eventually like some of the sci-fi shows or some of the medical shows you see nowadays you have the robot set up ready to go on this patient but you need a specialist for this one procedure that they could actually be doing this remotely from their office so to speak. This actually has happened quite a long time ago remote surgeries and this is part of where robotic surgery was born out of. I believe it was 2001 was the first time a transatlantic surgery was performed. It was a cholecystectomy or removing the gallbladder. The surgeon was in I believe in New York City and the patient was in Paris and procedure went very well and the idea of being that space travel things like that or even remote areas a surgeon can be in one place the patient with the robot in another and ultimately there is work being done on more autonomous type surgery but that is very far in the future at this point. Nice. Part of my IT background we had talked a little bit pre on the show part of my IT background says boy you have operating system, cyber threats, updates. I'm assuming they are working on that whatever platform it's on because the last thing you need is the little window comes up you need to reboot to apply updates during the middle of a surgery so I'm sure lots of protection and precautions have been taken on that as well. It's not only, like you said, if it's now a computer it's on the network it's also open to cyber threats. As far as that goes and viruses and everything like that as well. Well our system operates on a closed system I don't believe there's any security threat or any threat of hacking and in terms of breakdown of the actual machine we've never experienced I don't know if there's ever been one that anybody knows of even. Machine is very safe, very reliable, very consistent which is important obviously when you're operating on a person there's nothing more important than that so the consistency with which it performs is fantastic and occasionally there will be errors and the machine will alert you to an error but it's usually involved with the way an instrument is positioned or with things like that there's no software errors that we've ever encountered. And as far as worst case scenarios like city blackouts and stuff like that that's no different than if there's a city blackout now where if you're doing an open procedure and you have complete loss of power the hospital is set up for loss of power and backup generators and stuff like that so loss of power is obviously our biggest concern especially when you're working on a robot but again we have stuff in place even if you have an open abdomen that's no different in loss of power that way versus loss of power with a robot. It's just another layer to plan for for contingencies now that the network is as you want. If it's your server or whatever is here in one place the robot here in the console is another you need to make sure that the connections are always up and that's always on power generator as well just to provide assurance of the people at home that these things are all being taken into a column. They definitely are and we could always convert to a laparoscopic procedure from the robotic or even from the robotic to laparoscopic to open if we would have whatever would be safest for the patient that's what we do. And that's also a great point. You can always recover and still go back in because as you mentioned earlier the procedures are the same. It's just that the robot for detailed really that fine where you're in critical areas or sensitive areas that you're talking hairline procedures versus cutting or removing a fingernail so to speak or a toenail is a little different. So and hopefully either you guys ever end up glitches or whatever when you're... Well that's part of the benefit of the robot is it actually has tremor reduction built into it and so it does reduce that aspect of it too. Okay. As far as the patient's experience do they, do you see that is it being pretty much the same or the same amount of time being on an operating table under anesthesia? Do you see procedures being actually performed in a more quick fashion? So actually they're under anesthesia less time and better recovery times. That's where the new platform, the X-Eye, it's the newest robot and they've worked out a lot of those kinks. People would go in for a surgery and it would take four hours to do maybe a half an hour surgery with the older versions. The new version makes everything so streamlined so once you get the robot to the table things are able to move along quickly and the actual operations themselves really don't take any longer and sometimes take shorter with the aid of the arisen instruments and increased visualization. So we don't see any delay in patient care. We don't see any extended anesthesia times at this point. Like you said, if anything it's less. And in urologic surgery many of the procedures we're doing robotically these days were procedures that there was no intermediary for the most part laparoscopic version of that because they're more complex reconstruction or procedures deep in the pelvis that were just very difficult to do laparoscopically. So we really went from doing open surgery for instance for prostatectomy or partial nephrectomy for kidney tumors. We went from open surgery to robotic surgery. We kind of skipped for the most part the laparoscopic version of that because it was more challenging. And we've seen as a result, it's about comparable times in the operating room but where the real benefit of the robot comes in is that improvement in the length of stay after surgery in the hospital many patients after these procedures instead of saying one, two, even four or five days after kidney surgery are now leaving after 24 hours in the hospital. Nice, nice. Are there any risks? I mean with technology and computers once in a while you see latency. Something happens and the commands don't go through with the network or something would get bogged down. That's a general technology thing. So are there any risks that may happen or that may be prone to happening with the technology like this? Really the only difference between at least for many of the urologic surgeries as I alluded to we were doing these as open surgeries. Now doing laparoscopic surgeries we have to fill the abdomen with carbon dioxide gas in order to have a working space and that's also one of the benefits is it reduces blood loss through that mechanism. In some patients if the heart and the lungs are not up to speed if there's some problems with the heart and lungs it can be a little bit more challenging and positional things can also affect that. So that's really the biggest difference or the biggest risk with this and there's a lot of safeguards that the robot has employed so that the instruments when they're advanced through the robotic system don't just get placed haphazardly into the abdomen. They go back to the position they were at and three millimeters shorter actually so that if an instrument was close to a vital organ aorta vena cava something like that it won't go through and cause a puncture injury. It actually stops just short of where it was previously so there's a lot of safeguards built into it to prevent those. Nice, a lot of thought had to go into that so whoever designed these algorithms or whatever it was either a genius or a mad scientist wanted to throw both probably a little bit of both. In regards to the risk the robot helps us out a lot in terms of decreasing a lot of the risk especially with infection because we're able to bring down larger incisions down to small incisions about that size less incision means less risk of infection and that is obviously beneficial to the patient. Decreased pain and decreased length of stay all these things that we see from the robot are all more risky with other surgeries than the actual robot which is one of the reasons we wanted to bring it here. Nice, I'd like to go a little bit into your backgrounds obviously medical school and everything but you also have technology backgrounds or other types of backgrounds that you work in because obviously you guys are the new generation so to speak of physicians coming in so who do you see really adopting and really taking off and really running with this type of technology? It's in many disciplines, general surgery, urology, OBGYN, a number of disciplines now this is how residents are training is very strongly with robotic instrumentation and so most of the doctors that are graduating from residency programs these days and these surgical fields are being trained on robotic surgery it's essentially the new version of laparoscopy and this is becoming the newer standard. Yeah, that's what I was gonna say to Jeff it's like it's becoming the standard of care it's not quite there for general surgery but it will be for a lot of procedures as the studies come out and as the follow-up goes on stretches off five years, 10 years I believe it will be the standard care for certain procedures I believe it already is for prostatectomies from a urology standpoint OBGYN a lot of them it's becoming the standard for them as well I know it's gonna be weird is all of a sudden walking through a park and I see you sitting there with your iPad or your Android tablet what are you doing? I'm just doing a surgery right now You know that's probably the way the future works Yeah, we're a few years out from that yet But the technology, I mean we're all the younger surgeons and we've been trained on this from the get-go but the real truth of the matter is that it's a technology that's been able able to work and embrace by surgeons of all ages and where we trained even some of the older surgeons who are a little more resistant to change they would try the robot and they would like it and they'd see their patients were happier with the outcome and so these surgeons who are typically set in their ways and they do things how they've been doing and for 20 years will change because they've seen the outcomes and they prove I mean there were some that even took the step the drastic step from just doing all open procedures never adapting the laparoscopic procedures and going straight to the robot because they saw the advantage of it is kind of like from a neurologist standpoint there you guys didn't really get into the whole laparoscopic stuff just because the utility wasn't there Yeah, well the utility was there it was just really challenging Right and so it took a lot of skill to do those and it was just more challenging to do the reconstruction So to see the older surgeons that put aside laparoscopic technique and said you don't need this to say to embrace the robotic technology is pretty amazing You know I'd also think just my thought here is it would also give people who want to be surgeons you know they have the how should I say the knowledge you know they know the anatomy they know everything but they may have a little bit of a physical thing where now this may give them a chance to be actual operating surgeons because it's more technology which is you know very precise stable center where they can control it versus you know now it takes away some of the risk factor of oops you miss and cut this or cut that you know where you manually do with your hands Yeah, we still do a lot of work with our hands some and definitely getting the patient to the OR table is one of the biggest things you know the history and physical and the work up it's all very hands on thing but the technology is quite exciting and it's kind of fun How about procedure prep time still about the same you know you still have to bring them in get them prepped put them under and get them all ready for that that's still pretty much the same time essentially and one of the wonderful things I think really what's making us so successful at Memorial Hospital is that we have an amazing surgical team Robotics is not just about the surgeon we're just a very small part of this team and we have a very dedicated and hands-on team at Memorial Hospital that has really made this successful we've launched this program and we've done quite a number of surgeries already we're doing very well with it and it's much to do with our team their dedication is unmatched and that's something when I worked in health care it's the same type of a thing even though I was in IT you know I still felt part of the team where I'm contributing to make this happen you know I was a technology person to make sure everything was rock solid secure you know ready to go so I understand you know the whole teamwork thing as it takes everybody you know to make a service successful as far as that goes Definitely and that's what we're lucky to be like just like Jeff said to have here in Sheboygan is a team effort from everybody from people that are cleaning the rooms afterwards to the nurses that are handing us the instruments to the people that are down in CPD cleaning the instruments everybody works very hard makes things very efficient and we've had people come in and watch our surgeries and watch the first few robotic surgeries make sure things are going well and going efficiently and they're blown out of the water by how well things go and how efficient it is for a program that's only been up for a couple weeks where these guys have been operating for years and they're going back to their places and saying you know we've got to be like Sheboygan we've got to go faster we've got to be better so that's a nice feeling to have already a couple weeks into the program and I would imagine you could use provided HIPAA and disclosure and everything you would think you could use some of the surgeries that you do is training activities for other surgeons coming in because I'm sure you can record the procedures as well and use them as training activities for other people to see and observe who want to be physicians or training as well Definitely The actual machine has a bunch of there's a training pack on it that we attach to it and there's all sorts of training maneuvers and things you go through and surgeries that are basically like a video game you know with consequences you know you hit this and it starts bleeding then you have to deal with it so that training pack comes with it and that's part of the learning process and things that training we've gone through already so So between procedures it doesn't come up with you want to install a mobile strike or something like that No, it's not like that No, Adobe updates Nice, nice How is this new wave of technology on procedures being you know accepted in the general community I mean are health care costs going to go down does this help reduce and how are insurance companies reacting to it? Overall I mean costs are going to go down you know you look at the price tag on it and it's easy to see your think that the costs are going to go they're going to skyrocket but when you look at length of stay which is always one of the biggest ones for us from a general surgery family and urology standpoint length of stay is a big cost as far as length of our time and as far as one of the bigger one is return to work and how fast can we make people back to work and back you know enjoying their activities of daily life and all those will go down as we use the robot more as far as the cost of the patient itself there is no difference as far as how we bill it you know from a laparoscopic cohesus sector me to a robotic cohesus sector me the cost to the patient is exactly the same it won't change sometimes people can get into some issues with their insurance if it gets boarded a certain way as far as them saying it's not the standard of care but from a billing standpoint it's exactly the same there's no difference in cost to the actual patient as far as what's coming out of pocket provided it's coded correctly you know that's part of the team as well and from our standpoint there is no difference in coding right now I mean down the road there may be difference but as far as the CPT coding our reimbursement isn't any different our pay or coding is exactly the same and just like Dr. Drager was saying that it is an expensive instrument and so it's easy to think that this is quite easy to think that this is going to cost the patient more but ultimately where the recovery of cost comes in with robotic surgery is not necessarily in that setting but when compared to at least traditionally in some of the robotic excuse me laparoscopic neurologic surgeries some of the instruments we use were one time disposable instruments that were very costly and a lot of the instruments for robotics are reusable to a degree and they're cheaper because of that and then looking at length of stay and a lot of the other factors that go into this it's a little sooner and that's where that recovery of cost comes in and so ultimately in many studies looking at robotic versus laparoscopic nephrectomy removing the entire kidney they essentially break even on cost and this is now a safer procedure and we can do more complex procedures because of it sure complex or you know shrinks the you know length of stay down like you were saying before or would this ever be used in like one day type surgery does it have applications I guess that probably the applications are unlimited it's just a matter of what do you want to do next and come up with your plan as far as how to progress with it I mean some of the cases we do our outpatient procedures from a general surgery standpoint like I said before anything you can do laparoscopically you can do with a robot and so I know Dr. Red has already done some hernias and some different stuff where people come in that morning and go home in the afternoon granted a lot of them do that we do that with laparoscopic stuff now but the capabilities are pretty much endless like you said yeah I know we've been talking quite a bit about this but you know just kind of pick your brains as far as what's on the scope for future technologies that you guys will be bringing in you know for into the discipline well right now one of the pitfalls you might say about robotic surgery is it's all by wire so we don't actually for instance in traditional laparoscopic surgery you're at the bedside with the patient and when you grasp tissue you can actually feel that through the instrument when you're tying a suture you can feel the tension on the knot and that is lost with robotic surgery it's all by wire so you have to rely on visual cues how the tissues deform to know how tight suture is being tied and from what I understand that some of the technology is coming down the road with newer robotic platforms involve haptic technology so being able to feel this tension the pressure how much pressure is being applied to tissues and suture material and those types of things so the current instrumentation also has different cameras inside of it so it allows for visualization through fluorescence so I know Dr. Ritt and I have both been using it's called ICG it's a dye that's administered intravenously and this can highlight vascular structures and show us if something is getting good blood supply or not and useful in gallbladder removal and a variety of things and it's all through fluorescence so there's really interesting technologies that are even baked into this current iteration of the platform nice anything you guys can add as far as new things coming in that you're aware of or the projects that you're working on basically the two main things that are coming down the pipes eventually the one we already have is which is the Firefly Fluorescence Fluorescence which is great like Dr. Homestini said is not only four ureters or further gallbladders we'll use it for if we're putting a colon back together we can see actually visualize the blood supply you know even five years ago four or three years ago you just have to wait and see if the tissue looks good say okay yeah it looks good there's some blood coming from it we'll hook it together and hope it works you know you can't actually see the blood flowing through it now this allows us to visualize the blood flowing through it and if it's once we flip that switch if that part of the colon isn't green you know lighting up green that means blood's not getting to it and when we put it together it could potentially fall apart we want to avoid that we want to avoid any you know hiccup in the recovery definitely and that allows us to have a safer surgery and a better recovery for these patients okay well gentlemen we're just about out of time so I'd like to thank you guys for coming on the show and really talking about this exciting new technology I think it's really great as far as you know advancements making things you know safer for the people you know and make them comfortable as well because you know technology can be quite intimidating as far as that goes safety's obviously our number one concern as well as getting people back to working getting people feeling better faster but the greatest thing is that it's here in Sheboygan and that we were working I don't know Jeff was working through Grafton and other areas that had the technology available but just to have it in our local communities is really great that's one thing nice to say about Sheboygan it's kind of a little jewel along the lake shore where we are quite advanced in some areas that we're bringing to the field which is nice to go for today as far as a robotic surgery on behalf of Dr. Witt Dr. Drager Dr. Tomasini from Aurora Health Care thank you for coming on the show thank you if you have any questions about this procedure or other show ideas you can contact us at www.wscssheboygan.com for Quality of Life and WSCS I'm Dave Augusty thanks for watching