Abstract
It was when I finished my fellowship and I came to the University of Iowa as a new attending pediatric surgeon. When I arrived, I was asked by our Surgeon-in-Chief to train on the robot. It's a little bit of “right place at right time” story. I was actually at the American College of Surgeons meeting in San Francisco, in 2002. I received a phone call from my Surgeon-in-Chief, and he said to me, “Listen, one of the faculty was supposed to participate in a training session on the robot. Can you go and do it instead?” I said, “Sure. What is the robot?” I had never seen one.
So, I get on a plane from San Francisco to Baltimore and grab a cab to the Johns Hopkins Hospital for the training. The first time, I see it I am thinking, “Wow, my training must have had a huge hole in it. Everybody has been using this thing all around the country, and I've never even seen it before.” And, as a former engineer, I was thinking, “This is brilliant; this is where we are going to go.”
So, at that time I was excited about all of the opportunities it could present, and when I went back to Iowa, late fall of 2002, I talked it over with my partners. We all agreed that it was something we needed to incorporate into our practice, and we started doing robotic cases. What we did not know at the time was that we were one of the first pediatric surgery groups to be doing it. So, as we did cases and word traveled, we would get people telling us, “That is the first time this has been done!” It was the same response with papers we published. All of the sudden, you find out you are in new territory. It was very exciting.
It was both; even the adult robotics was in its infancy. At that time, nothing of any significance had been done in pediatric surgery. I was very lucky early in my career when I was at the University of Iowa. I was given as much operating room time on the robot as the adult surgeons. I was able to use it one full day a week, and then oftentimes I was able to add on cases if needed. Over time, because of the number of cases we were doing, we got preferential access to get it, and ultimately we established ourselves a robotic center for pediatric surgery at the University of Iowa.
With our first few cases we made the same mistakes that I think a lot of people do when they begin doing robotic surgery. First of all, the robot is a little bit complicated, and it is definitely not the same as laparoscopic surgery. So we approached it thinking, “We can do a lot of things laparoscopically, so let's save this for the really complex cases.” So, the first case was a child with a distal pancreatic tumor. Our thought process was, “We do not think we can do it laparoscopically. Let's try to do this with the robot.”
So, we get everything set up, and immediately after we started, we saw this mass. It didn't take long to figure out we were in over our heads. We said, “This should be an open case. Why are we trying this when we haven't even done anything simple?” So, we converted that to an open case, and, from that point onward, we decided we had better learn how to use it on simple things.
The first successful case was a cholecystectomy, which went very well. It was a lesson in where to place the trocars. We set it up like a laparoscopic case, and then we learned that it might have gone better had we moved this trocar in a slightly different location, simply because the external arm conflict was not the same thing as what you see in laparoscopic surgery. In laparoscopic surgery, we are so worried about our own position, where are we putting our arms and shoulders. In general, we want to keep the trocars somewhat close together so we don't find ourselves in a position like wings spanning an albatross while trying to do a fundoplication, for instance.
It's different when using the robot. The arms need to be out further. We had to reinvent where we put our trocar locations. I think it is important to start with familiar cases instead of trying to jump into the technically challenging cases, like choledochal cyst and mediastinal tumors.
We actually started in November, so going by the calendar year, we had three or four done by the end of the year. The next calendar year, we had about 10, and within a few more years we were doing 70 to 80 a year.
Absolutely. It was almost entirely that. Part of it was trying to discover what cases are good for robotic use, what cases are not, and what cases are kind of silly for it. For example, a robotic cholecystectomy may have minimal advantage. However, it is a great training case that provides you with the skills to advance.
We worked forward from there. For example, we started to do fundoplication, which I view as an intermediate case. Still, there are some additional skillsets you have to learn, including suturing. It is a step above a cholecystectomy, but is another good introductory case. We did a bunch of those for a while, too.
Eventually, we moved on to more complex things. But the problem with the complex cases, of course, is they are rare. If I was asked, “If you could only do one abdominal operation with the robot, what would it be?,” I would choose a choledochal cyst. However, in the United States, any given children's hospital will only see four or five choledochal cysts a year; they are rare. Yet, it is a great case for this device. It can be done laparoscopically, but the robot removes a lot of the challenges.
I believe that this is where it has a great benefit. I went to Hanoi, Vietnam, last year to help my colleagues there when they got a robot. We did many choledochal cyst resections, and by the end of the week, it was flowing very quickly, very smoothly.
Yes. I have to give a lot of credit to Dr. Anthony Sandler, now the Surgeon-in-Chief in Washington, DC, at the Children's National Medical Center. He was my Division Chief at Iowa, and he was completely supportive of me. He was always available to assist me with cases, and he was administratively behind it. Additionally, as I said before, the Surgeon-in-Chief at our hospital was also very intimately involved in it.
It really takes a combination of administration, your Division Chief and the hospital's Surgeon-in-Chief, to be behind it. Also, let's not forget the core staff, including the anesthesiologists, as well as the nursing staff. You have to get the right core behind you. It reminds me of a quote from the movie Miracle about the 1980 [U.S.] Olympic hockey team, and Kurt Russell [as Herb Brooks] says, “I am not looking for the best players; I am looking for the right ones.”
Seattle has been a bit different than the University of Iowa. It is a much larger children's hospital with an incredible infrastructure and a significant amount of research in cancer and other fields. Although it was an older version, there was a robot there when I got there. When I first arrived, I was excited, but it took some work to get people excited about it.
In reality, it is still in evolution. We have some surgeons who have completely adopted it, and others who say they do not have time for it or just don't want to learn it. That is going to always be a challenge.
The robot is not perfect. It has issues. But, I think the technology and the ideas behind the robot technology are the way we will go eventually.
Right. I was very fortunate in that I got to watch that exact scenario unfold. As you may recall, I did my general surgery training in Alabama with Keith Georgeson, who is a minimally invasive surgery pioneer. Despite his successes, there were naysayers within his department at that time, and they were pretty loud. Despite the nonbelievers, he overcame all of the hurdles and he kept pushing forward, and look where he and other great folks took laparoscopy. It is absolutely amazing.
So, I am going to keep pushing, and hoping and dreaming, to move forward. But admittedly, there is a lot of pushback.
Of course. That is just the circle of life, and that is all right. I am sure I will be pushing back on something in another 5 years; we all get that way to some extent after a while. But that is all right. We will find our way. We will get there. Without a doubt, I believe in the technology. I am not sure this machine is the answer, but I do believe in the technology.
We are actually seeing it in the adult side at the University of Washington. The residents are getting some initial experience with the robot in the adult fields. In conjunction with the hands-on experience with patients, they participate in simulator training. This progression is just like we saw and continue to see with laparoscopy.
One important advance for robotic training was the simulation trainer released several years ago. It is not perfect, and is a little bit like a videogame device of sorts. But, the visualization and how techniques mimicking the movements are pretty good. I would like to see more modules made for it because the suturing modules and all that could stand some refinement. But, it is certainly an improvement over what was available when we were trained, when none of that was available.
The credentialing for robotic surgery is a very hot topic and is very hospital dependent. A perception exists when people consider robotic surgery that it is thought of as a completely different surgical realm. Laparoscopic surgery did not quite get put under that microscope. The reality is, it is just another instrument. If you are an advanced laparoscopic surgeon, then this is just another tool for you to do the same work you were doing. We are not inventing new operations. We are doing the same operations.
But when it comes to credentialing, one of the things that has been fairly universal is an introductory course. I believe this is very important. There are several options to do this, including a course offered by the company that makes the robot. However, there are lots of other options, so you do not have to go to the company. For example, there are robotic societies that offer training courses. I think the credentialing is probably directed more by what your hospital requires of you and that would really dictate where you go.
As you know, credentialing is more than just taking a course, it also has to include proctoring. The mechanisms and requirements for proctoring are very different from one hospital to the next. I am aware of several variations, such as requiring the surgeon to have five proctored cases or to go to three observations and have five proctored cases. I am also aware of some other variations like 10 proctored cases. As of now, I am not aware of a set standard.
Again, that is hospital dependent. At Seattle Children's, where we have pediatric surgery fellows graduating with robotic experience, we confirm their robotic cases and experience to their new institution. In some instances, that is adequate for initial credentialing.
We have had four or five fellows now who have graduated with a significant robotic experience. For these fellows, I have written letters documenting their experience and case volumes to their administrators, and, as far as I know, everyone has been given the green light. But if you are fresh to it, then it is a different game.
I think that this is a great point. The expense may be the biggest detriment to wider acceptance. If you are working in an adult hospital and doing prostatectomies and other adult-oriented procedures, you are operating on an older population who likely has better insurance, or lots of funding, or maybe his or her company is able to pay for the more expensive approach in hopes of shorter stays or modestly improved outcomes. So there are methods to be able to justify the cost of this type of technology.
When you bring the pediatric patient population into the equation, you often are seeing families that have not become established yet. As you know, most children's hospitals survive on philanthropy almost exclusively to balance their budgets because the medical expenses of some of the things we deal with are so tremendous. The additional expense related to the robot is really hard for hospitals to justify it, let alone maintain it, and keep cases going.
I think one of the biggest problems in robotic surgery at the present time is the fact that there is no corporate competition. Look at what happened with the iPhone, where we are on the sixth version of the iPhone and multiple versions of the iPad, in just 7 years. If you look at the robot, yes, it has gone through four generations, but the changes have been small.
Take, for example, the 5-mm instrument line first introduced by Intuitive Surgical [Sunnyvale, CA], the company that makes this robot. The 5-mm line was introduced in 2004, and it has not changed a bit in 10 years. We, in pediatric surgery, want things smaller, and we want to make progress there.
Ideally, I think they really need to take a hard look at what they can do to make this better, and make it more accessible.
Another issue is the longevity of the instruments. One instrument has about 20 lives, and then you discard it. Why do we not make that a longer lifespan so it is overall less expensive? I think they would get a lot more business if they were able to make it more accessible.
Every few years I hear about another robot that is coming down the pike somewhere. But they have not quite made it yet. There are companies in Canada, the United States, Japan, and a few other countries that we hear rumors about, but nothing has been brought to market yet.
Hurdles that these companies face to get through the approval process get more stringent every year. It is a daunting task to bring something of this nature all the way to market. So, although it is a challenge, I hope that something else comes out because competition is everything. I believe we have the potential to make leaps and bounds in improvement if we get better competition.
Yes, I totally agree.
Well, the first thing you would want to do is include other services besides your own, such as cardiac, ear-nose-throat, and urology. In the current environment, if you do not have a robot, you are behind. Maybe not in general pediatric surgery, where it has not quite caught up to that level. But, in pediatric urology, nearly all of the pyeloplasties performed at institutions with a robot are being done robotically these days. This is also true for ureteral re-implants. Certainly in adults, the prostatectomies, it has helped there.
What I would say to new grads who want to do robotics is they do not want to be taking this on by themselves. They want to go and pull in the other services. Also, if they are at a pediatric–adult combined hospital, they have gynecology, adult urology, and many different people to band together and show how it can benefit the hospital. Going alone would be a big challenge.
The international interest is tremendous. I receive numerous calls on a monthly basis from all over the world. In Asia, for example, everyone is desperate to learn how to use the robot, learn how to adopt it, whether it is Vietnam, Singapore, China, or Japan. They are all moving forward.
I would say the most important thing we should do is keep an open mind about the robot and help industry, show them what we need. For example, look what Storz [Karl Storz GmbH & Co., Tuttlingen, Germany] did for laparoscopy. Because they got so involved in pediatrics, they have moved the field forward. They developed a great collaboration with the surgeons and the company's engineers.
Another idea that is being discussed is the development of being able to tell where malignant tissue ends and normal tissue starts. What if there is an agent that we could give to image overlay? With the current system right now, we can already do that with indocyanine green. It will show you the difference between the tumor and the normal tissue and help you with a more accurate, more precise dissection without either leaving tumor behind or taking tissue that you should not have. With the way that this system is set up, it is amazing as to what we can already do and as to what we can do next.
Finally, there is telemedicine. Currently they have a two-console system, and we can put the two consoles right next to each other, and I can sit next to a resident, and we can pass instruments back and forth. What if we were to take that console and move the second console into another room or another building or another city, or even another country, and we can operate across lines? This is all the process of telemedicine. It is so close with this particular system that I think that it is something very possible in the future.