Robotic surgery’s impact on training the next generation of surgeons [PODCAST]

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“Technology continues to evolve every day. In the near-term future, portable and easily deployable robots will allow surgeons all over the world to perform minimally invasive surgery in an increasing number of procedure types and become even more effective surgeons. To achieve our goal of having a future surgeon workforce that meets the demands of an aging population and delivers good patient outcomes, we need training and knowledge-sharing at scale. Surgical robotics is poised to be an important part of the solution.”

Barry Greene is a general and bariatric surgeon.

He shares his story and discusses his KevinMD article, “Robotic surgery’s impact on training the next generation of surgeons.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Barry Greene. He’s a general, laparoscopic, and bariatric surgeon, and he wrote the KevinMD article “Robotic surgery’s impact on training the next generation of surgeons.” Barry, welcome to the show.

Barry Greene: It’s great to be with you. Thank you for having me.

Kevin Pho: We’ll get into the article a little bit, but first off, can you share your story and journey to where you are today?

Barry Greene: I started doing laparoscopic surgery in 1990 in the United States Air Force. I trained myself and went to courses, and then I started a program of teaching laparoscopic surgery within the military. I realized during the 1990s that there were some great open surgeons that struggled with laparoscopic surgery, because the hand-eye coordination is backwards as a result of the fulcrum of the abdominal wall, and it made the advances in surgery and innovation in surgery sort of slow down.

With the advent of the legacy robots that came out in the late ’90s and early 2000s, we saw an improvement in the hand-eye coordination that was laparoscopic, minimally invasive surgery. Over the years, we’ve seen a marked improvement in patient outcomes with minimally invasive surgery. But the entire society of surgery, and gynecologists, and in some cases urologists as well, struggle to take their patients to minimally invasive surgery because of the availability of robots and the difficulty of laparoscopic surgery.

So I had this idea that we could take a robot that was much smaller and insert it into the abdomen. I gave this idea to two MIT students. At the time we started talking about it, they were freshmen at MIT, and they decided to think about it and begin the building. So this is a 12-year-old story, and these guys, these amazing engineers, have brought in their friends. Really, the story continues with all the engineers utilizing current technology to improve outcomes of surgery and make the next generation of robotic surgery.

Kevin Pho: Now, when you talk about robotic surgery, what specific outcomes are we talking about, and how much are they improved?

Barry Greene: The outcomes of all abdominal operations can be improved if we decrease the injury on the abdominal wall. There are multiple societies that have promoted the use of robots through surgery to improve outcomes, such as with removing a gallbladder, or performing a hernia, or doing a prostatectomy. In these particular operations, the outcomes have been markedly improved: lower complication rates, lower death rates, and even decreased recurrences in a laparoscopic hernia repair.

However, with legacy robots, it’s a very large, very expensive proposition to have that robot, and so you can’t really use that robot at night. I do laparoscopic and robotic surgery with the current technology, and if I see someone with a hernia that’s incarcerated on a Saturday, I can’t use the robot to fix that hernia. I have to do it either as an open operation or struggle laparoscopically.

So what we’ve built at Vicarious Surgical is this robot that is much smaller and can be wheeled into any operating room, started up, and used for minimally invasive surgery to fix hernias or take out a gallbladder, and utilize this next generation of technology in hospitals that can’t afford the larger robot, the more expensive robot. Or hospitals, think of hospitals across the world: If they had an immersive technology that was easy for people to get used to and start setting up and rolling into the operating room, many more people would have minimally invasive surgery and have better outcomes.

Kevin Pho: So you mentioned three procedures that would lend themselves to robotic-assisted surgery: cholecystectomy, hernia repair, and prostatectomy. Are there any type of specific patients or cases that would lend themselves specifically to a robotic-assisted surgery versus a traditional laparoscopic approach?

Barry Greene: That’s a really great question, because it really focuses on the advantage of minimally invasive surgery. Someone who’s really thin, they do really well with open surgeries, but they also do better with laparoscopic surgeries. But a minimally invasive approach is fantastic and really beneficial for someone who’s heavier, which unfortunately is a larger part of our society.

If you take all the operations on the abdomen, there is work being done, everything from the most complex pancreatic resection, liver resection. Lung resections are also being done with minimally invasive surgery, with better outcomes than an open approach. I do a lot of bariatric surgery, and bariatric surgery, prior to the ability to do it minimally invasively, was only a few tens of thousands a year. Now we’re up to 250,000 patients a year having surgery just in the United States, because the minimally invasive approach is much better.

Kevin Pho: All right, let’s transition now into the KevinMD article that you wrote. It’s titled “Robotic surgery’s impact on training the next generation of surgeons.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Barry Greene: Thank you. I see a great advantage in using technology to help with what’s really going to be a shortage of surgeons in this country, and already exists around the world, so that we can use this immersive technology to help surgeons better prepare and do better surgery.

One of the important parts of this technology is that the vision of utilizing a three-dimensional view and differential camera wavelengths can allow a computer to aid a surgeon. The analogy would be our phones, which we call an iPhone or a smartphone, are very different than when you and I were kids and we used a phone. This is really a computer that’s allowing us to enhance our life, with the ability to make a phone call. The same is true for an electric car that has not just the ability to drive, but the ability to use sensors and to integrate that into the performance of the driver. I think that’s the great advantage of a robotic surgical platform like the Vicarious platform, which will allow the computer behind it to help make the surgeon aware of key important structures.

The specific, most amazing advantage of the Vicarious robot is that it can look to the right, it can look to the left, it can look up and down, and it all happens inside the abdomen. Just like you would move your arms, if you wanted to work upward, you’d just lift your head and work up here. The legacy robots have all the movement outside the abdomen, and they can’t look all the way around. The Vicarious robot actually can look even behind a person. Adding sensors to the arms allows for the computer to know where all the arms are. So it’s really the vision of the designers of the robot that is the most amazing advantage, and I think utilizing that ability is going to help surgeons everywhere.

One other important point is that as we make the robot’s vision transmitted over the internet, a surgeon in a smaller hospital, or someone who does a lot of general surgery but has a complex hernia or complex surgery, right now they’re pretty much on their own when they get into that situation. But as we go to this electronic digital format, then they could call a friend at a university or someone in another city and say, “Hey, can you log on and look at what I’m looking at now and give me some coaching? Help me out.” Four eyes are better than two, especially in complex surgery. So I think that’s another amazing advantage of this platform.

Kevin Pho: How much additional training is needed before a surgeon would be able to use your platform?

Barry Greene: That’s a great advantage of a platform like this that’s been purpose-designed for surgery. It’s being designed in order to make very little training in order to use the technology. We’re designing the technology so that it disappears into the background. The surgeon sits in front of a television, and we want the surgeon to feel as though they’ve been transmitted into the abdomen, beamed into the abdomen, and they’re operating with their hands.

So the idea is that of telepresence, where once the surgeon looks at the screen and sees the robot move exactly as they move their hands, very quickly they feel as though the robot is them. And so their training goes back to the training of the operation, and what they would do if they were open, except they’re doing it minimally invasively. So that’s really the beauty: Very little training has to go into the use of the technology.

Kevin Pho: And to kind of drill down further, approximately how many cases would they need supervision on before they’re able to independently operate with your platform?

Barry Greene: That I really wouldn’t be able to answer at this point. I don’t think it’s been determined. I can give you some guesses as to what’s happened before, but in most hospitals, a surgeon does only a few operations in order to use a new technology, because the technology also comes with training that’s done on simulators and in inanimate labs.

Kevin Pho: Whenever I read about robotic surgery in the lay press, and this probably refers to legacy robots, there’s always a little bit of pushback, because these systems increase costs, and the purported benefits, according to some studies, are relatively negligible. What’s your response to these types of articles that I read sometimes in the lay media criticizing robotic surgery?

Barry Greene: Right, that’s a really great point, because if we look back at the history of all surgery, even laparoscopically, when I started in 1990, I graduated my residency and laparoscopic surgery started in 1990. There was a huge criticism that laparoscopic gallbladders were much harder to do and it was going to kill people. But over time, we’ve gotten more comfortable with the technology, and we show a clear advantage.

I think that’s what happened to legacy robots: The technology was not mature, and the surgeons really started out doing the surgery and didn’t really show a marked advance very quickly. This history has been repeated many times, and I think the future, as we get advances in the technology, will show clearly that there is a great advantage.

Kevin Pho: We’re talking to Barry Greene. He’s a general, laparoscopic, and bariatric surgeon, and he wrote the KevinMD article “Robotic surgery’s impact on training the next generation of surgeons.” Barry, I’m going to ask you to look into your crystal ball and predict what you think the future is when it comes to that intersection between robotics and surgery in the next one to two years.

Barry Greene: Oh, one to two years. I think we’re going to see additional robots be added to the market, and I think we’re going to see a greater adoption of robotic surgery in the market. I think that in the next five years, we’re going to see greater utilization of telementoring, where surgeons help each other out.

I would ask everyone to keep an open mind about the benefits of this technology, because I think the penetration of the technology is going to be greater and greater as the next generation of surgeons comes up that feels very comfortable with all technology. It’s going to be a great enhancement of what physicians can do.

Kevin Pho: And my final question, what’s your take-home message that you want to leave with the KevinMD audience?

Barry Greene: Keep your mind open. Keep trying to innovate, advance surgery. It’s an amazing endeavor to help people, and this technology will help to get better outcomes, eventually at a lower cost, and to operate and to help people that have significant problems but are worried about the difficulties that they’ll have with open surgery and the recovery.

Kevin Pho: Barry, thank you so much for sharing your time and insight, and thanks again for being on the show.

Barry Greene: Thank you for having me.

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