[00:00:00]Hi everyone. Welcome back to the Bariatric Surgery Team on the Behind the Knife Specialty series. I am Katie Seroni. I am a general surgery resident at the University of Southern California, and I am joined by our team of bariatric surgeons, Dr. Martin. Hi, I'm Matt Martin. I'm a trauma and bariatric surgeon at University of Southern California. And Dr. Dan? Yeah, Adrian Dan. I'm the program Director for the advanced G-I-M-I-S Bariatric and forgo fellowship at a place called Summa Health System, Northeast Ohio Medical University in Akron, Ohio. I'm a jack of all trades, but first and foremost, I'm a metabolic and bariatric surgeon. So I am Crystal Johnson Mann. I am a bariatric before gut surgeon at the University of Florida in Gainesville, Florida. Go Gators. And I guess we all should have introduced ourselves as robotic surgeons for this episode. Yes. Yes. Perfect. Today we were talking about the use of robotics in bariatric
[00:01:00]surgery. To start off our discussion, let's discuss the strengths of the use of the robot, Dr. Martin. Yeah, and I'll just say I, I've started robotics on the old da Vinci s then the si, then the si. So I'd say one of the big strengths and, and why I got interested is. The massive leaps in technology we've seen over a short period of time and even if the first system wasn't the greatest, it just keeps getting better and better. So I think it's important that people understand this technology because it is not going away. I think some of the biggest strengths are the camera view. You have a 3D view. It's an incredibly sharp and clear camera. Much better, especially than my 30 degree five millimeter scopes at LA General Medical Center that are like from 1950. So you have excellent vision. You have full control of all the working arms, especially if you are working alone without a resident or fellow or assistant. The system removes any
[00:02:00]tremors. Either natural or acquired from stress. So it's a very smooth movement and I just think you can do much better fine dissection and fine tissue handling with the robot. And probably the biggest strength, and especially for me as an older guy, had my first spine surgery during residency is the ergonomics are so much less stressful than laparoscopy. We have to remember, laparoscopy is the worst ergonomic surgery. It's worse than open. So I always say my top 24 reasons for robotics are my vertebral bodies. It is much better and much more relaxing experience than doing a long laparoscopic case. I have to agree with you on lots of your reasons for the strengths and the ergonomics of it was a big one for me. Very petite wrist have plagued me through my many years of playing sports, and it is wrist pain that drove me into the robotics. For bariatric surgery specifically. So weaknesses of robotic surgery I think are fewer than the strength, but one of the
[00:03:00]things is that loss of haptic feedback that exists on the X si, which can be a little challenging when you're trying to train residents and trying to train them specifically like how to use their eyes to determine tension because you can't feel it. Which can be a challenge at times, trying to just get them used to that. The other thing that I actually feel pretty strongly about is loss of laparoscopic exposure for trainees and such that if you have a situation where you don't have 24 7 access to the robot and you find yourself doing emergency things in the middle of the night on a weekend laparoscopically, that can be a challenge for trainees who have very limited laparoscopic exposure and then running the bowel to deal with internal hernias, you know, using laparoscopic staplers, so on and so forth. I think another sort of weakness of the robotic platform can be potentially limited autonomy for trainees. You know, the attending is gonna let them do a whole lot less as they themselves are trying to build up their robotic comfort. And this is gonna be
[00:04:00]more of a problem for systems that have limited robotic exposure. Of course there's gonna be, in the beginning of the robotic exposure, longer operative time, which means more time on a general anesthesia for patients, which can be a problem for higher risk patients. And this can be potentially just overall in general, if again, the attending surgeon has very body access to the robotic platform. And then I can't, you know, have this weakness conversation without discussing cost potentially. And the cost for starting a robotic program. Economics of better ergonomics, keep your surgeons happy and working. So the data has come out of comparing robotic and laparoscopic surgery specifically in bariatrics. A few more recent studies have published on the MBSA Quip database, which is the metabolic and bariatric surgery. Accreditation and quality improvement program. The most recent study that came out looked at over 800,000 patients over a seven year period
[00:05:00]from 2015 to 2022. Notably in this study, there were a lot more patients that had laparoscopic bypass and sleeves done, but still about 11% patients had a robotic sleeve gastrectomy, and about 4% had a robotic ruin y gastric bypass. And they compared the robotic versus laparoscopic groups. They showed that robotic sleeves actually had a higher complication rate compared to laparoscopy higher overall morbidity, leaks, and postoperative bleeds. In contrast, the robotic bypass has actually had a lower overall complication with decreased morbidity and decreased bleeding, and then other studies have also showed that robotic Bruin R gastric bypasses are actually advantageous. When surgeons are undergoing revisional surgeries. And then also a lot of studies have showed that, you know, over time we've decreased our operative time, both for both laparoscopic and robotic cases on average, but robotic cases are still taking longer. Some studies have shown that this length of time doesn't affect a patient outcome as far as DBTs
[00:06:00]or organ dysfunction, but it is something to note when discussing a patient having to undergo more time under anesthesia. So Katie, I'm gonna ask you, isn't it funny how sometimes studies that look at the same exact database will have completely. Opposite conclusions. Mm-hmm. And I can tell you over the past few years we've seen that a lot. We've seen M-B-S-A-Q-I-P administrative database studies that have shown a benefit with robotic sleeves, while the very next submission shows that there's a detriment in those patients. And sometimes just for fun, we'll put 'em in the same session. At our A-S-M-B-S national meeting, just to get a nice little debate going. But it's important for our listeners to understand all the confounding variables that exist. So first, you're gonna have a transition over time as this is pretty much new technology and learning curve for everybody doing it. And when those folks are better at it and more people adopt it, there's gonna be less of a learning curve on average.
[00:07:00]But it's important to realize that. It kind of reminds me of the data that came out in the 1990s that proclaimed that laparoscopic cholecystectomy is much more dangerous than open cholecystectomy. 'cause people weren't used to it. All right, so let's talk about setting folks up for success. I'm gonna talk about why surgeons struggle early on in their robotic experience, and I think there's. Several reasons for this. I've already hopped on one of these, on how to determine how much tension you're putting on tissue, especially as you're manipulating the bowel out of the pelvis. This is especially true if you don't have the benefit of having cable motion because we don't. So I have to eyeball the reverse trendelenberg enough so that I can actually get access to the upper abdomen, but not so much that I'm fighting gravity to brain bowel northward, but that requires lots of reps to kind of get that done and to kind of understand that. Another one with the robotic technology is learning how to assist yourself, because those of us have done a lot of this laparoscopically.
[00:08:00]You have a first assist or you have a resident over there with two arms helping expose what you need to see, or you yourself are the assistant for your trainee. But in robotic surgery you have three working arms, and so learning how to manipulate the cameras to get it to where you need to be, and then learning how to use that fourth arm effectively to set yourself up for success. I think it's a little bit of a struggle early on. Learning how to alter how you do a procedure laparoscopically to the robotic platform is another one because things that may have helped you in your efficiency laparoscopically can actually work against you robotically. And so sort of thinking about that, let me take a moment to just talk about or teams and how much it is critical to have an efficient or team and. Part of the struggle can also be your team. And them not being familiar with the setup, the take down, troubleshooting the robots and just not efficient with turnover.
[00:09:00]And then again, with spotty access. So let's say you're trying to start your robotic practice and you get access one block a month. Well, that's not great. That's not gonna help you get rep, it's not gonna help you become efficient. It can be a long time before you feel pretty comfortable. And then lastly, I can't say this enough, don't cherry pick cases. So it is super important when you're starting a robotic practice to kind of just get yourself, get your feet wet, get comfortable with the platform, get comfortable with the technology, and working on economy motion and efficiency. Just throw everything on the robot. Everything, everything that can be done minimally invasively. Just throw it on the robot because what you don't wanna do is say, okay. I've done a very small number of cases over here, and now I'm just gonna use the robot for technically challenging revision cases. Well, that's not great because you haven't done easy cases and it's super important to do the easy stuff first. Get proficient at the easy stuff so that when you tackle the revisional, redo and everything else, that's much more challenging if you feel much more comfortable
[00:10:00]and confident in being able to do that. Yeah, I completely agree. So. I've been tasked with going over some of the important factors to setting yourself up for a smooth robotic operation. I think it's important to realize that robotic surgery is not just an incremental improvement over laparoscopy. It's actually a paradigm shift that requires one to change their mindset and the way they look at it. Surgeons who successfully transition to robotics have to embrace the platform as the primary platform and fully leverage. Its advantages. One of the most important factors in setting yourself up for a smooth robotic operation is initially patient and case selection. And in my transition I made sure that I completed a sufficient number of easier cases in order to be able to get comfortable with a robot. And then as Crystal mentioned, everything that could be done robotically. I am now doing robotically. Not every case is ideal for a robotic approach,
[00:11:00]and ensuring that you are working within the strengths of the system is really crucial. No different than working within the strengths of laparoscopy or open surgery when those are the ideal choices. Proper truck art placement is another key element. It's a bit easier than laparoscopy because it's usually a straight line, but it's important to plan the distance from the target anatomy to allow for optimal instrument reach and mobility. You have to position the table, the arms maximizing visualization and using the superior dexterity of the robotic arms. All of these things contribute to a more controlled and precise operation. So by making these strategic choices and instrument selection in your workflow, you can enhance efficiency and ensure that the robotic approach is not just. Another alternative to the way that you can do things, but it's actually an advantage, and I'd be remiss if I didn't also mention the importance of your team. So I will give kudos to my team and a shout out
[00:12:00]because I could not do what I do without them. They make my day a lot easier. And I'll add one thing to that. As someone who struggled early on, like I think most of us, one, don't hesitate to add an extra trocar for an assistant trocar or especially a suction. Irrigation trocar for your bedside assistant. 'cause one of the most disruptive things when you start off is then you get into some bleeding and you're trying to switch out one of your instruments for a suction. So. Liberally, add an additional five or 10 millimeter trocar. It's not a big deal. Have somebody you know standing by with suction have a good person at the bedside. 'cause you don't want to be learning the console while someone else is learning the bedside and use all your arms, for example, I know a lot of people learn al hernias and gallbladders, and we'll do inguinal hernias with. Camera and two working arms. When I started, I would do those all with three working arms or when I'm doing a teaching case, so one extra choke car, not a big deal.
[00:13:00]Once you get more comfortable with it, then you can pair it down. Good points. Now, Dr. Martin, do you do a lot of your bariatric cases the same laparoscopically as you would robotically? Absolutely not. I do them sitting down. Adrian and, and Crystal already mentioned some of the, I think some of the main differences of one of the errors is you try to do it exactly the same robotically as you do laparoscopic. So remember, RO laparoscopic is set up for having a camera closer to the target and having straight angles with straight instruments. And robotic, you have articulating instruments. So I think the big things are realizing how it's different from laparoscopy. You want to be a little further away with your camera and instruments than you are laparoscopically. You know, 20 centimeters is the, the quoted number. You wanna be at least 15 from your main target. Generally, your trocars will go in a straight line or close to a straight line. And that that's how the robot was designed to operate. So you wanna do that. And I would say,
[00:14:00]and for most. Especially bariatric procedures. I'll usually use at least one less trocar than I do laparoscopic, which is again, one of the advantages I think of robotic. But I think those are the big things of understanding the difference between, okay, I'm doing this robotic, it's not just recreating a laparoscopic procedure. Matt, I wanna reiterate how important that point is because many times I'll mention to my fellows in residents that you're trying to do. The laparoscopic procedure robotically, and then you're not playing to the strength of the platform that you're on, right? The stability, the ability to turn the camera, your ability to get right up to the tissue and work in a more magnified field that gives you better dexterity, better precision, those are all things that you have to use that you may not necessarily have available to you in laparoscopy. And there's a few things where laparoscopy shines over robotics, but. I always mention don't try to
[00:15:00]do the laparoscopic procedure robotically. And interestingly, last year, for the first time, as one of my fellows was more comfortable with robotics, she was trying to do the laparoscopic procedure robotically. So you have to, I. Play to the strengths of the various approach. Yeah, I agree. And I think when, you know, when teaching residents and fellows as a junior resident, I'm very early on in my learning curve. I find that, you know, what I'm told is that preparing for the cases help me the most. Doing the modules on the Da Vinci, watching the YouTube videos or the SAGES videos and then just trying to get as many reps as possible helps a lot. I think, as we mentioned, the difficulties with residents, I feel like is. The obvious, the haptic feedback that was already mentioned. Learning various steps between the surgeries and how each attending does it, which can be helped by reporting the surgeries and learning from each attending preferences. And then also just getting reps like you guys mentioned, the more reps you get, the robotic sims. Don't
[00:16:00]quite emulate real tissue. So the more little tasks that the attendings can give us when suturing ventral hernia can be really, really useful. One other thing I found super useful was doing like a bilateral inguinal hernia and the attending does one side and then let's. To the resident, take a stab at the other side. I think that can be very helpful, at least from a resident perspective. But Dr. Dan, what do you think about teaching residents and fellows in my position? Yeah, so that's something that's, as you know, very near and dear to my heart when it comes to teaching residents and fellows. Robotic surgery provides an really, an unparalleled. Platform for surgical education, possibly the best tool that's ever been invented for surgical education. The ability to switch instruments seamlessly to draw and guide like a teleprompter within the surgical field, and even to stop the operation emergently when it's needed, creates a safer and a more controlled learning environment. The robots
[00:17:00]recording and in the future sequencing capabilities, which means breaking down an operation to various segments that you can watch. Allow the trainees and the faculty to review the performance and refine the skills with really good objective feedback. In addition, there are built-in tools and metrics in the newer platforms, and I for this podcast, we can mention names. Obviously, the new DV five allows you to evaluate efficiency of movements with data-driven teaching tools. There's one particular graph that shows you the tip of your instruments and how they move across the procedure. And just by looking at that little ball of movements, it allows you to compare your movements with someone who's more of a novice or somebody who's more experienced, and determine how you can get more efficient. But unlike a laparoscopy where the attending has to often physically take over to assist robotics allows a really gradual
[00:18:00]transitional responsibility of the instruments enabling the trainees to build confidence and precision in a way that's really difficult to achieve with other traditional laparoscopic techniques. So I think it's amazing and I really enjoy teaching more on the robot. And anecdotally this year I've been able to turn a greater. Percentage of the case over to my fellows. We'll see if that continues. It may just be that I have a great fellow this year, but it's easier to turn it over and be able to regain the controls as needed throughout the operation. Yeah, and I think the one thing to remember, and I do every case with a resident, and it might be an intern, it might be a chief resident. When they're learning robotics, sometimes we forget how much information. You're trying to remember, here's how I dock, what's the order? Now I'm with the console. There's a foot pedal, there's a camera pedal. There's two right sided foot pedals to activate energy. I've got my hands and it is
[00:19:00]overwhelming and I think it's important to remember that, especially when an inexperienced resident is doing it. And then we often do what the educators tell us is the absolute worst thing to do if someone who's trying to learn. A technique is then we start saying, oh, hey, what's, what's the anatomy of that? Oh, the cystic cardio. What's that come off of? So I've really had to stop myself and stop doing that, especially robotically and just focus on the technique and tips for hand movement. But that's where that immerse in yourself. It becomes so important to, to do, to Crystal's point, as many cases as possible. So it becomes like riding a bike, right? It's not something that you're just something that's second nature. Like when you drive your car, you no longer have to think of where that pedal is. Yeah, no, absolutely. I mean, and I tell them like sort of, when I was still doing laparoscopy and they're sort of like, how do you, you know, adjust the stapler so seamlessly? I'm like, I can't explain it. I just need to show you because it's like a part of my problem. Look at this point, like I don't think about it. I didn't do it,
[00:20:00]and that's exactly how robotic surgery is. I no longer think about what I'm doing, honestly. I just do it. And it's really hard to explain that. It's more of a, you have to do it a ton to start to get that. I, I think we have to mention that. Immers in yourself a lot of times sounds like a sales pitch from industry and quote unquote drinking the Kool-Aid, and it's really not. It's not until you do it that you realize that you just become one with a robot and use it all the time. I think it's important also to mention in this podcast somewhere that. Every one of our listeners is gonna talk to faculty and attendings are gonna be naysayers. They're gonna say, gosh, what do I need that for? And honestly, even in my institution, they're running out of excuses for not adopting computer assistance and technology to operations. If we think where we're at compared to other industries, we are so far behind in the middle of the night with a perforated bowel, you could still be getting the exact same
[00:21:00]operation you got 120 years ago with cold steel hot lights, right? So we have to apply these techniques to enhance what we already can do with our two hands. Now to dive into the robot on bariatric surgery and Dr. Martin, what are some tips you have for the robotic sleeve gastrectomy? I. Yeah. And we'll real quickly, I think run through some tips for the different procedures and we're planning on having a video to accompany this, showing some of these techniques. So sleeve gastrectomy, I would say, of the bariatric operations, it's the one that is gonna most be like your laparoscopic procedure. It's a straightforward stapling procedure. You're not gonna transition to, you know, hand sewing your sleeve back together. So it will be similar to your laparoscopic sleeve gastrectomy. Some of the key points, at least for me, and that I've learned, one is positioning for a lapsed sleeve. I usually end up in pretty steep reverse trendelenberg. For robotic sleeve,
[00:22:00]I find I need much less steep T trendelenberg, so usually 30 to 40 degrees of reverse trendelenberg position. I do not use a liver retractor anymore with robotics. I do a liver hammock stitch, and I have yet to find a case where that doesn't provide adequate visualization, so that eliminates one trocar and I do the procedure with four total trocars. So the stapler, 12 millimeter trocar is in the patient's right abdomen, and then my camera is just to the left of the umbilicus, and then my two other working trocars. Then on the left abdomen, although I have some colleagues who do the whole thing with only three trocar, so camera and two working robotic instruments, which I, I think is very doable, especially for lower BMI patients. I think the most important thing is getting your trocar for your stapler. Angle correct and especially not having it too close. To the sleeve. So again, this
[00:23:00]is have your trocars a little further back than you do laparoscopically 'cause that stapler can be difficult to handle if your angle is going straight down for your first firing on the stomach. I use generally a green staple load for the first firing and then the rest blues. I do not use any reinforcement strips when I do it robotic, which is different than what I do at laparoscopic. But I do oversaw the staple line at the end. I actually pia it to the, the cut edge of the gastric colic ligament one, because suturing is just so much easier robotically. I think that definitely helps with some bleeding from the staple line and anecdotally it may help straighten the sleeve out. So those are the key differences, at least for me when I do a robotic sleeve and kind of how I approach it. Actually, I'm gonna ask you, Adrian and Crystal, do you use, are you using reinforcement strips when you do a sleeve with the robot? So I am. I am not, go ahead Chris. You go ahead. I want to hear your, so, you know, this is one of those things where
[00:24:00]y'all can laugh at me all you want. So when I was training with my attendings in residency, Carl Barn and Van Pal, Safeline reinforcement was a thing for at least one of them. And then in fellowship, same thing with Bruce Sheer and Pete Hollowell. I have noticed that when I transition to the robot, when I have, not even, when I've downsized staple cartridge, when I have not used staple line reinforcement, I get bleeding. I had to take a patient back to the OR for bleeding. So for me it costs a bit more, but you know what costs more, I trip back to the or. So for me, I will continue to use them and my bleeding is basically nonexistent. Now. I've just been to myself by saying that, so I'm gonna knock on some wood right now, but I a hundred percent use it in all my sleeves. And when I have LVAD patients, I use that plus other hemos I do. Yeah. Selected patients like LVAD patients where the bleeding rates are higher because the non pulsitile nature of the blood flow and people who have bleeding AEs, like even patients with renal failure, I will use them, but
[00:25:00]routinely I do not. And I think one way that we can mitigate that is, I know Matt mentioned he starts with a green, but. If we're gonna use this technology, we have to trust the computer assistance. And if the robot tells me that I can use a blue or a white, then I'm gonna do that. It's gonna have a tighter staple line. If money and cost was no issue at all, I. I would of course use a reinforcement on every single staple load. The truth is that you do have to justify the use of the robot, and if you have increased costs with the robot and the increased costs of the reinforcements, it does add up to a lot. So our data has been pretty good so far, but yes, I would agree with you that if I could choose that in every patient, we may see a difference, although very, very rare. Points. Now, Dr. Johnson Mann, do you have any tips for the robotic gastric bypass? Yes. So just a few here. So I think the first one is there's lots of ways to do robotic
[00:26:00]gastric bypass. Some people still do, you know, the JJ first then create the gj. Some people do an omega loop. I'm a believer in the mega loop technique, but there's pearls to that to prevent thinking of the jj. So the one thing I would say is you need to watch a lot of videos from colleagues. That's easy to do, just you can watch them on various platforms. You can listen from your friends videos, but watch the videos, watch what they do, and then ask questions as to why do you do like this? Like, did you find that this is more efficient than this? This is easier than this, and so on and so forth. You wanna think about how you do these cases laparoscopically, and then again, modify that technique to fit the robotic platform. You cannot do this how you do this lab, so you have to adjust. I'm someone who gets frustrated very easily because I'm supposed to just catch on from everything very quickly. That's just how I tell my mind works. So another step is to be very patient with yourself. Frustration is part of the game early on. It's just not gonna go the way you think it's gonna go, and it's
[00:27:00]super easy to get frustrated with yourself. Positioning. So like Matt said, in how Adrian, Ken mentioned, you know, positioning is key. The mature cars are supposed to be aligned for a purpose to facilitate non collisions of the robotic arms. You have to remember in a gastric bypass for doing multi quadrant surgery. So if you do not have table motion where you can just move the table at your whim, those of us who do not have that, you have to set yourself up for success so that your arms are not fighting when you're trying to do things in different quadrant. So that's one thing. As far as trocars go, I use four trocar. I use Nathans and liver retractor. I put two twelves in, so there's a 12 on the patient's right side, there's a 12 to the left of the umbilicus and that really is used for creation, the gastric pouch. So I have better angle. The camera goes in arm two for me, just to the right of the umbilicus to the patient's, right. And then of course I have my cyst arm and arm four. And that is really key. Sometimes depending on the size of the liver, and I've had some
[00:28:00]doozies where I've had to sacrifice arm four to provide additional liver retraction so that I can actually use arms one and three to do the case, at least with the pouch creation and the GJ anastomosis. As far as what I do as far as like staple cartridges and sutures, so the blue load for primary gastric bypasses a blue load, similar how I do them laparoscopically. No issues with bleeding there. I do not do a totally hands stone gj, so I do a linear fire of the stapler for just make that back row osmosis. And then I do a two layer closure with absorbable barb. Suture. A similar technique for how I do my jj. Again, I fire the stapler, create that backrow, and then close it in two layers with absorbable barb feature. And then of course you close your mesentary defect, JJ and Peterson with non-absorbable braided feature. And then the other tip that I kind of have is when you're starting these cases, if you can have one of your partners is really adept of the robotic and doing, you know, these sort of cases robotically, have them in the room with you. It is
[00:29:00]really helpful to have someone in the room who can help give you some tips and tricks and because you get so caught up in why isn't this going the way I want this to go, that you just get very tunnel visioned and they can see the whole situation and say, Hey, why not try this? That might make this a little easier for you. So having someone there to kind of give you some real time tricks in the OR is very helpful. Great points. Thank you, Dr. Dan, do you mind giving some tips on the DAL switch and cd? Not at all, Katie. So for the more complex hypo absorptive procedures such as the DS and the single anastomosis du ileostomy, say ds, there's some specific robotic techniques that can. That can make a significant impact. So first I'm gonna start with trocar placement. This should be a little bit lower, especially when you do an ILE ileostomy like you would for a duodenal switch. And even with this conversion, Sadie, the duodenal ileostomy anastomosis tends to sit lower in the
[00:30:00]abdomen. So if you put your trocars up too high above the umbilicus, you can end up working under oneself, and that can be quite cumbersome. Early in the learning curve, you have to focus on the straightforward cases to build that proficiency, to build that confidence before tackling the more complex variations. I think that's an important point, and one of the greatest advantages of the robotic platform is the ability to easily perform hands sew anastomosis. So I do my duodenal ileostomies hand sew. It used to take me half hour, 45 minutes. It's. Cut down at least by 50% now, and it's a lot more fun now that you have it down. Once I started doing it, I started planning out exactly how I was gonna do it, how many sutures I would put posteriorly when I would move to the corners, and then that type of reproducibility is what has made it easier and more fun to do. It's important to take advantage of the stability
[00:31:00]of the robotic platform. The enhanced degrees of motion and the precision that is offered by the instruments over a laparoscopic approach. So I think it's important to embrace things like hand zone suturing of the anastomosis. It's easy to see that as a challenge, but I think it's important for robotic surgeons to embrace it and see it as a skill that actually enhances outcomes and expands our capabilities. We know that with the hand zone anastomosis, we see the least bleeding, the least stricture, and it really gives you an. Opportunity to control the size of the anastomosis without worrying about jamming a linear stapler or end-to-end anastomosis, stapler into the bowel. So it's really a nice way of doing these anastomosis when you have a smaller space and you have to have that dexterity and that careful attention to the way you handle the tissue. So that's about it for the. DS and Sadie,
[00:32:00]and I'm not gonna expand on the sleeve for the Sadie and Ds of course has to be a little bit more generous than for a primary sleeve procedure, but essentially the technique is the same as what Matt has mentioned. Hey, do you notice any difference on the duodenal dissection, laparoscopically versus robotically? So I've done it three times, laparoscopically and done. Since I did it robotically, I've never gone back. It is night and day. That stability makes it actually fun. You can just relax, sit back, get yourself the perfect retraction. The perfect visualization. I usually keep a EC in there just to make sure in case I get into a little bit of bleeding. I apply a little bit of pressure and usually stops, but it's just a night and day difference. And laparoscopically. You have to have someone hold the camera. They may not be in the right place. You may be working on the edge of the screen. You may have seconds before you lose that view to get a small little vessel rather than just taking your time.
[00:33:00]So I think the answer in a nutshell, Matt, is yes, big difference. That's where the robot shines. What about you guys? Yeah, I mean, honestly, I, there's no comparison. There's just no comparison. Laparoscopically. Like I said earlier, I was literally with one hand. Pushing the camera in adjusting me, trying to operate and moving the camera, or alternatively assisting and again, controlling the camera with the arm. I do not have, there's just something to be said about, especially like in revision cases and redo stuff. I also put a ray check in, so I expect the bleeding. You have better visualization to control things before they become a problem. Yeah, and I think especially a loop duodenal ileostomy is. Much nicer hand sew, which is much easier with the robot than, than laparoscopic. I, I just, I was never super happy with the technique laparoscopically, but robotically I think it's much easier for a loop. Yeah. I think the operation lends itself to a robotic
[00:34:00]approach and I think a lot of folks who adopted Sadie started robotics primarily with that being one of the reasons. I'm curious to see more of the data come out about Sadie robotic versus laparoscopic. A lot of the data is still percolating, being published. Yeah, and, and as we mentioned, Katie, the data is very, very confounding and confusing. Honestly, it's important to, to realize that if a medical student asks you, is there any level one evidence that one or is better than the other? The answer is, at this point. Really there isn't, but those outcomes are certain metrics and there's other metrics that you could look at, such as comfort and postoperative pain and things that, that may not show up in the, in the primary outcomes of some of these papers. Great points. I'll briefly touch on some of the exciting events going
[00:35:00]on in robotics and surgery. Some of the new involvements are the haptic improvements on the new Da Vinci robot. I think that can help at least residents learn a lot better about being able to feel real tissues while being on that Da Vinci robot. There's also talk about incorporating T scans into the robotic experience to have more of a visual overlay. So you have more of anatomical map, which would be really cool and really helpful in so many ways, including finding tumors. And then as we've seen already, the integration of AI into our everyday life. I think that could possibly help the robot help us make real time decisions in the operation or even. Potentially in the future, allowing the robot to do more simple tasks like suturing. I don't think that's happening anytime soon, but I think that could be really, really interesting in the future. One really cool project that I heard of too was telesurgery. I saw this one robot that was deployed to the Space
[00:36:00]station about a year ago, and they used this robot to cut and grab some rubber bands while it was being controlled on earth. Granted, they had about a half second delay, which I'm sure would. Drive all of you crazy, but the idea of Teles surgery is definitely, can have such a huge impact globally. Yeah. I mean, I think that's really remarkable. The telesurgery thing is pretty remarkable as we think about like just for instance, our astronaut that were in space for nine months. Mm-hmm. What if one of them had an issue? Like what if they got appendicitis? This is sort of a, an example of how that could be very helpful in those situations. And Katie, I think you said that that may be very far off and I think, I'm gonna say, you may be surprised. You know, they have robots cutting perfect circles outta napkins. It's pretty amazing what machine learning and artificial intelligence can do. It's probably not as far off as we think. One other thing to add that I think is important for this episode is robotic surgery in
[00:37:00]patients undergoing bariatric surgery, by definition, you're gonna have some patients with some pretty thick abdominal walls, and the amount of torque and cranking that you have to do on the abdominal wall is extremely. Physically demanding on the physician and the surgeon. Sometimes, especially with very high BMI patients, where you may not be able to do the operation laparoscopically, but it's also painful for the patient postoperatively. So the concept of the remote. Center of the trocar, which does not move at all. You can place that portion into the muscle, which tends to be most tender after surgery. I have anecdotally seen a lot less pain in my robotic surgery patients than in my laparoscopic surgery patients, so I'm sure data will percolate on that. It's very difficult to tease out the differences between the two techniques, but anecdotally, without a doubt, and I'd love to hear what, what Matt and Crystal have to say about that Also. Well, not only that, I've broken several
[00:38:00]laparoscopes on some of those high BMI patients from torquing them, especially if you use a five millimeter scope. And so robotic has a big advantage. I think probably the biggest, what's next for robotics is obviously it's been dominated by one company and one product. Mm-hmm. The Da Vinci, and there are now multiple new robotic platforms coming on the market or newly available. And so that's gonna be, I think the big change that we'll need to navigate too, is do these catch on? You know, do you need to get competent in multiple different platforms? I think the ones that are either available now or coming online are a little more modular, where it's, you know, four separate working arms that you can individually drive up to the table. There are some lower cost systems I think that'll help expand robotics to some places that couldn't afford it. But I, that's also a big change we're about to see is multiple competing products. Right. And with competition comes lower prices
[00:39:00]overall. So I think that'll be a win for, you know, smaller hospital systems who can't afford the current price model for various things regarding the torque. That is reason number one, like I said, why for robotics, I just could not. I would say from a, from a personal standpoint, physically on high BMI patients with very thick abdominal walls, I could not use my hands in a way that was normal for several days outta those operations just because of the force that I had to generate and how much that transferred energy to me. As far as pain goes, I would say yeah, surprisingly, I have also sort of anecdotally noticed that my patients. Especially the higher BMI patients really don't complain as much as they did previously. Yeah, and And Matt, it sounds like certain surgeons have not decided whether they're gonna go robotic or not. It sounds like industry has decided for them. All the major players are coming out with their own robot, right?
[00:40:00]Yep. And yeah, I always say the debate is over. The hospitals have them, right. Even if we didn't use 'em, you can't hire a urologist anymore unless you have a robot. So they're there. They're getting better and better. I, I think it's, you know, adapt or die. Alright, that was a great discussion. So in summary, robotics has a clear, clear place in bariatric surgery. It is different than laparoscopy though, and you wanna learn those differences and not just try to replicate your. Laparoscopic procedures and a lot of big changes coming on the horizon. Alright, any other final thoughts or comments? I'm just gonna say the future called, and it's robotic robotics is here to stay whether we like it or not. And it's, I think the, the advantages of it cannot be disputed. Yeah. And, and I'll say, and I'm, I, again, as someone who had spine surgery as a resident, I have no shame anymore of saying I
[00:41:00]don't care if this costs more. It's worth it to me for my health and our surgeon's health and longevity. Even if it has no benefit, no patient benefit. Alright, well thanks again for joining us for another episode of Behind the Knife and we will as usual sign off with 3, 2, 1, dominate the day. Dominate the day, dominate the day. You gotta just dominate the day. Just gotta dominate it. Alright. There's no other option. You gotta dominate it. Alright, I want that in the podcast.
