Guillermo Ares, MD and Mark Wulkan, MD - 2024 Pediatric Bariatric Surgery Update Course

All right, I think we're moving on now. Yep, time to move on. OK, so, uh, Tom, do you wanna introduce, uh, Guillermo, or I can introduce him for our, our session since he's, he's since he's kind of a friend of yours. I'll introduce. Guillermo was, was a senior fellow a couple of years ago and has done a beautiful job at the Central to Page Hospital following the big footsteps of Ann O'Connor, I might add, and has, uh, taken up robotic bariatric surgery as well as straight stick. Um, and, uh, really do, uh, uh, thank you for being here today, Guillermo, um, and, uh, doing a little battle with Mark because, uh, you know, we, we know this dinosaur is not a robotic guy. So, yeah, this is, this is a non-controversial topic for me. Go ahead, Guillermo. Give me your best shot. All right, here we go. Thank you all for having me and thank you for bringing me in. Um, I'm gonna present the pros and pros of robotic surgery because I think there are so many advantages to this, um, and we can debate all day about uh what other people have to say. I have no disclosures. And so, oh, I wish this was animated. OK. So my first slide is just a picture is worth 1000 words. Would you rather do laparoscopic surgery or would you rather see what you're doing as you're getting up into tiger country and finishing your dissection? Um, And so, uh, I'm, I'm choosing to start with what the refs will tell you about the benefits of robotic surgery, which is you have a markedly superior um camera with 3D uh visualization, stereoscopic vision, um, Uh, and I think that speaks for itself into, um, uh, what we, what we try, when we try to get around that curve and, and becomes difficult, um, you do want to see what you're doing over there. We have wrist instruments, uh, so that improves your dexterity and your ability, um, to do more complex, uh, intraoperative procedures including as, as what it is, uh, more, uh, integral portal suturing and more complex anastomosis. Um, and then lastly is, as we, uh, know, there is, uh, with vasive BMIs, there's an increase in, um, certain discomfort fighting the abdominal wall, or you can let the robot do that for you. And so studies show that there's increased muscle strain, uh, post-operative, uh, pain on the surgeon's side, um, and increased, uh, overuse of muscles and in laparoscopic surgery, uh, compared To robotics. Uh, and this is done using like EMG, uh, motion tracking, as well as, uh, questionnaires. Um, and so statistically significant, uh, change in surgeon irritability is also quoted, uh, after, after, uh, robotic versus laparoscopic surgery. Um, Uh, from the, from us, uh, what we say to each other is, my first point is, um, laparoscopic surgery may be great in some settings, particularly, um, when you have a PGY 9 coming to assist you in every case reliably or a second attending who will be there with you. Um, but if you're some other places like community practices or bariatric practices, uh, you may be at the mercy of the surgical assist of the day. And this person may have varying levels of experience to help you out, um, but when you're doing, uh, surgery with the robot, you are assisting yourself. Um, you're able to display what you want better. You're in control of the whole operation, you're dissecting your exposure, um, And you're not, and this essentially displaces one or staffing member, um, which will also, will also help offset cost if you're counting on uh having to pay a surgical assist or even a cold surgeon to come assist you. Um, and being able to control the operation from, you know, from all angles is especially important when you're doing a revisional bariatric surgery where retraction matters and matters significantly. Um, there are studies in all directions, but there are, I, I, I chose to put up two of here. One that showed a decreased conversion to open, uh, and robotic, uh, revisional uh bariatric surgery compared to laparoscopic, um, And all the studies show essentially no difference. Uh, but I think when you look at the studies more closely, you do tend to see a difference in patient selection or in procedure selection. So that people who are, um, more robotic, uh, uh, more advanced or complicated, uh, uh, revisional surgeries, uh, are being performed in the robotic platforms compared to laparoscopic ones. Um, and so you can see that Intuitively, we're already seeing this patient come to the door and thinking, you know what? I think I may do this one that's a little harder on the robot. Um, and, and that leads into, uh, maybe uh heterogeneity in the, in the data. Um, but certainly, we are using that benefit. And, uh, I think that gathering experience is, is key to performing more complex tasks. You don't want to have your first robotic case be that we do, we do, we do, uh, conversion. And so, Performing some of the simple robotic cases, um. Uh, upfront, it helps you gather that experience. And we can see that it's what they have shown, um, uh, over time. So this is, uh, the last study here is a, uh, retrospective, uh, look at cases now from 2015 to 2020. Uh, and we have seen that over time, we have, uh, We've been doing more robotic cases than we used to do, um, and our complication rate for those cases have gone down over time. We have been able to narrow down or decrease our, our, uh, OR time significantly to the point of having even in, in certain centers, no difference in laparoscopic versus robotic uh OR times. We see that sicker patients are being, uh, operated with the robot, uh, and we see that more More commonly, robotic, of the robot, the cases on robotically, more of them are revisional uh compared to the, the laparoscopic cases. So we have seen that over time as, as we do more, we get better at it and we have been able to narrow some of the disparities that we see from the earlier data of uh robotics is, that says robotics may be more expensive but not really beneficial. And so this is the piece that comes from the, from those at the, at the, at the frontier, these are the trailblazers, um, as we see that, um, The versatility of the robot lends itself to improve as we do. Our successes and failures make the next generation of uh robotic platforms and robotic instruments uh uh more safer and tailored to our needs. And so, I was trying to show here behind is, is the progression of the, the very uh um uh rudimentary Da Vinci console versus the XI, which is what I think we can all agree of those, those of us performing bars of robotic surgery. That is what we should, we ought to be using is, is, is the XI. I think the other platforms are pretty much outdated and don't provide the same um uh support. But we've also been able to, to say and give feedback to the industry as to what are the things that we care about, how can we tailor the instruments to our needs. Um, and as we have seen, uh, as we've given the feedback, now we have developed uh a robotic stapler, and that I think was the last piece to really equalize, uh, Laparoscopic versus robotic surgery, um, and that will be like on the later half of the, of the 20, uh, you know, of the last decade that we had that technology. Um, so, so Guillermo, you're telling me that the robot's almost as good as, uh, laparoscopic surgery. Is that what you're saying? That is what I'm saying. And in fact, depending on who's using it, it may be better. Um, and I think that I want, this is my last point is the robotic platform has opened up doors to things that would be a dream in the past. So this last one is, uh, a dream that was happening when I was in residency and training, uh, and from that same institution, they are now performing simultaneous robotic, uh, sleeves and kidney transplants, uh, on the, on the morbidly obese patients. And we have seen that, of course, there's longer. time because you're doing two procedures, uh, but no increased rates of complications, no increase in blood loss, and at 1-year follow-up, they both have good kidney function, but you have a significant weight reduction, um, in the patients that are asleep, obviously. But I think we can all agree that obesity hurts kidneys and obesity hurts transplanted kidneys. So I think that if we see, um, long-term data on this patient populations, we'll see that these people who are getting uh some of these surgeries are probably doing better overall. Um, and so with that I'm gonna, I'm surfing over to my, my opponent, um, and happy to. Well, I, I, you, you, you took 80% of the time, so I, I'm gonna do something kind of there to say, yeah, I, I, I'm sharing my screen, so like you can't have a, a talk without chat GPT now, right? Can everybody see my screen? So I'm gonna, I'm just gonna ask chat GPT, right? OK, um, I'm gonna say I'm a surgeon because it actually gives you a different. Answer, if you are a surgeon versus a patient. Um, You didn't say I'm a technically challenged surgeon. I, I know I can't, I can't. Well, I have some message here because the robot, the robots for those people, right? Yeah. You, I, I, I'll notice that, um, that we don't have any sponsorship from the robotic company. Why is my? Keyboard now. So I, I do have slides prepared, but I guess this might be more fun. OK. So, here's a comparison of the two. You know, again, I, I don't disagree that the, that the robot's gonna get there. And if we can do it faster, um, that'd be great. Uh, I, I, I don't know if we have any urologists on the, uh, call right now. You know, the urologists all want it because they don't learn how to do the laparoscopic suturing like we do. Um, again, you know, looking at comparative studies between these two, there's, there's some big studies out there, um, which I think this will bring up, uh, in a second. Uh, which basically show that there's, you know, really no difference in outcomes with either one. As a matter of fact, there's a, there's a large study that shows there may be a little, a little bit of increase. Uh, infectious complications with the robot, and I'm not sure about that. Um, well, that's patient outcomes though, Mark, and I, you know, I, I'm, I'm joking around here, but, uh, you know, I'm a believer at my, you know, senior age here that, um, this is gonna be the savior and have me operating till 80. I, I, I don't disagree with you. I don't, no, it's, it's gonna be the opposite because you can't do 4, robotic cases in a day without like stabbing a pencil in your eye because there's turnover in the setup. So like I think. I think it's true. I mean it's better, but is true at a veterans hospital. Hospital, but nowhere else. Children's hospital. Yeah, no, so, so that's the whole thing. I, I think that we need to figure out ways to improve that. OK, yeah, here's the study with out of the MBS QIP database, almost 800,000 patients, and this is the one that showed, you know, with robotic roy there was slightly lower infectious complications, but with sleeve it was higher. Uh, and then the robotic surgeries at higher thirty-day readmission and reoperative rates, these are all, I mean, you can see these scrolling across the screen here. Um, and at the end of the day, I, I think, you know, again, I'm, I'm not saying that this isn't going to be what we need to do. Um, can you stop, you can stop sharing my screen, Isa. Um, we'll just go, there we go. I, I don't think that this is necessarily, I, I think it's a technology that is still in its infancy. The good news is there's been one vendor, one vendor for the last 20 years. Now, there's gonna be 3, there's 2 other robots that are gonna be coming on the market, at least 2 this year. So hopefully, there'll be some competition and the instruments will get better cause we, you know, as pediatric surgeons, we complain that they don't make 3 millimeter instruments. There's not even listed 5 millimeter instruments. In our bariatric patients, that's not necessarily an issue. But I, I don't know what a robot can add that I can't do, you know, I can, you know, we do sleeves, it's, it's, and I do, and I don't have a PGY-9. I do them, so I've done them with a medical student. And you can do a laparoscopic sleeve with a medical student and it still doesn't take that long. Until we can decrease the cost of the robot. I, I don't think that it's gonna be, you know, I don't think that it necessarily is gonna be widely adopted. Now, future state, I'm saying you guys that are using the robot, keep going because we need to push them to make it easy and cheaper. But I think in current state, all you did, Guillermo, is tell me that you showed, there's, you showed me that the robot is almost as good as straight laparoscopic, only it's more expensive and takes longer. Yeah, and, and I think that that's something we have seen that over time we, we are going to continue to offset offset costs for the two reasons you mentioned. One is we're going to have 2 more robots in the industry, so that's gonna lead to some hopefully some competition, some better instruments and decrease costs as the, as, you know, the market changes. Um, and the second thing is, one of the things that's linked to um increased cost is longer OR times. But we have seen that in center, centers who are doing this over and over, and they have a dedicated OR robotic team, they're able to get in and go almost as fast as, if not the same as fast as laparoscopic surgery. And so, I think this is one of the things that, and I'll tell you my own experience, my first robotic case, and my second one, my OR time just cut in half. Um, and then it keeps going down from there. And so I think that's almost so, so, uh, but I'm gonna ask you, what's your laparoscopic time? Does it, did it get to your laparoscopic time? It's one thing to say that my robot time was like 2 hours and I got it down to 1 hour and 15, but if your laparoscopic time is 45 minutes and your turnover time, how is your turnover time between cases 1 and 2? So my turnover time is, yeah, is, is similar because we have a dedicated robotic team, um, in, in this particular solution at the, our, our downtown center, we don't, and the difference or, you know, our turnaround time is, is palpable, right? So I think that's what I'm trying to say about, about having a team, um. That's a pat, you wanna say something. I'd like to hear what Janie has to say about this. So Mark, you're talking like an open surgeon who's never done laparoscopic surgery. Oh, it's too long. It's blah blah blah, blah blah, blah blah. OK. That's not the point. The point is wristed instruments and, and, and 3D. Vision is better than straight instruments and 1D vision or twoD vision. It just is better. It is a better instrument. It is, you get better visualization. I have, I did laparoscopic surgery for years. I didn't have access to a robot. I started doing robotic surgery six years ago. It's amazing. You want to only do robotic surgery once you've done it because it is so much better than laparoscopic. We're, we're at time, Janie. I, I actually, I, I agree with you, wristed instruments, better visualization. I'd argue that, you know, 4K and 3D, I don't know. Um, but we need to get to our break. Yeah, we need to get to our break. Thank Rod, Rod, Rod Garrado, uh, actually threw in there that, uh, I'm using an, I'm using ancient AI technology using GPT. I should have been using doximity's generative AI that's medically oriented, and he's probably right, uh, but you know, you can't, yeah, so AI is already, you know, I'm a dinosaur with AI. I'm a dinosaur with laparoscopic surgery. I'm so sorry, that was inappropriate. forgive me. No, I love it because it's like I do. I, I say, I sit there and I say I sound like my predecessors, right? And again, I, I agree with you, wristed instruments. I don't know that a robotic wristed instrument is necessary, but a wristed instrument is. OK. Now to move on to our break and thanks to our sponsors, Medtronic and Teleflex, and stay tuned. We'll be right back in about 10 or 12 minutes.