Robotic Surgery – A Facebook Live Discussion with Dr. Bahareh Nejad

[MUSIC] Welcome to another Facebook
Live from UC Davis Health. I’m Rick Kushman. And today, we are
talking robots. I’m with Dr. Bahareh Nejad. She is an associate professor
of obstetrics and gynecology and the medical director of
robotic surgery at UC Davis Health. And she oversees the whole
robotic surgery program, although not every tiny
little thing about it. But we are here with a whole
lot of new, exciting news today. Dr. Nejad, thanks
for being here. Great to talk to you. Thanks for having me. So I am actually a former
robotic surgery patient, and I do have a complaint. Uh-oh. Let’s hear it. I can’t find my scars. [LAUGHS] Exactly. I thought I was going to look
cool, but I got no scars. Yup. That’s our favorite complaint. Very small incisions. Yeah. Yeah, it went away
almost within a year. That’s amazing. Yeah. So there’s one
thing about those. So these are pretty exciting
times here, but before we get to that– and when we talk
about surgical robots, we don’t really know
what we’re talking about. I mean, a lot of
people probably think Megatron from Transformers. [LAUGHS] So what do these
things look like, and how robotic are the robots? Well, the robots actually are
quite large, so it actually– visually, they are– luckily, here, we have
very large operating rooms at UC Davis also. It’s really nice because
our ORs are large. But what they look like is a
tall structure with, literally, arms that can reach out
and attach to ports, which are little tunnels that
we place in the patient for the instruments,
and then they’re able to move those instruments. And so it makes it really
great because the robot allows us to have 360 degree
range of motion, which are better than our own wrists. And then it completely
reduces the tremor. So explain a little bit
about how they work. So what happens? What does the surgical robot
do in terms of– let’s start with in the surgery itself. How is it different
from making a slice and going in and cutting around? Yeah, so if we
make a big incision in the patient and then we
have our hands in the patient and then all these different
instruments versus we put these trocars
cards or these ports– these tiny tunnels,
which are– the incisions are about 5 to 8
millimeters in size. So we make a few of those little
holes, put the little tunnels in so the instruments
can go in and out and the camera can go in and
out, which is really nice. And then we attach
the robot to that. And then we actually
unscrub from surgery– we do that all ourselves
as the surgeon– and we sit next to the
patient in a 3D console. And when we’re sitting
in that 3D console, I can see everything in
3D because the camera’s inside the patient and I
can move the instruments, but I’m sitting right
next to the patient. And how do they move? Are they joysticks? Are your hands in with hands? Yeah, so they’re these
tiny little things and they just take two fingers,
and we just move them around. And then we have foot
pedals for our energy. Oh, wow. Yeah. It’s really cool. So after my surgery, I
was actually at a clinic where they were sort of
saying, you know, get tested. Go do this. And I was playing with one
version of these things, and one little, tiny movement– I mean, they had both
great dexterity, and just– it was like the first
time you’ve ever learned how to use a mouse. Many people, that was
when they were born, but for some of us older folk– [LAUGHTER] Or video gaming. Yes, or video gaming. Yeah. So how hard is it to learn,
and how much training do folks get to learn that dexterity? Well, we actually do
a lot of training. So what we do is usually do
on-site training and sometimes off-site training. And so luckily we here have
a simulator program also. So we have what’s called
a backpack simulator. So you can sit on the
robot without a patient and do all kinds of movements
and game-like strategies that mimic surgery. And you can do that to
warm up for surgery, and you can do that
to train for surgery. And then we do,
twice a year, full, robust training programs
that are week long– we have one next week– where we train our
nurses, our surgeons, our resident surgeons, and
everybody so that before anyone is actually operating
on a patient, they’ve done extensive
multi-week training sessions. So it gives them the ability–
your ability to move the hand. You have a screen. Is it magnified? Yeah. So when we’re in
the 3D console, it’s 10 times magnification
on the camera. And then we also see in 3D. So we can see tiny
little blood vessels to use energy on them
before they start bleeding. We can dissect in
really finite spaces that we wouldn’t actually be
able to do with our own hands. What do you mean
by “use energy”? So when we see a blood vessel
that we don’t want to be there and we want to separate
an organ from the body, we use energy or
literally electricity to grasp it and burn
it and then cut it. Oh, wow. And so how we
minimize blood loss. And we can do that with
other types of surgery also, but the nice thing with robotics
is that our human hands are actually too big to fit in
some of these small spaces, so we can do more nerve sparing
and have less blood loss because we can see
much tinier things. And you know, some old-school
person who doesn’t know how to use a mouse [CHUCKLES] might
say so, but what about that surgeon– the classic– you know, the
surgeon with the steady hand, and that’s what we always relied
on– how does this compare to that classic surgeon? Well, we still need those. So we still need those big
incision surgeries sometimes. But ideally, if we
can do the surgeries through the small
incisions, then our patients can oftentimes go home the
same day or the next day. They get back to
their lives faster. They get back to their families,
to their job, their hobbies, their activities faster. We decrease their
infection rates. We decrease their blood loss. We decrease the
amount of time people need to stay in hospitals,
which nobody really wants to be here for a long
time if you can get back to your life faster. So ideally, by making
all these tiny incisions, we’re giving them less pain. They’re taking much less pain
medicine, which is very nice. And so all of those things– ideally, our robotics
program is trying to help our patients
get back to their lives faster and have the
safest outcomes. Yeah, but they don’t get a scar. It’s really nice. Eh, well. Yeah. [LAUGHTER] And that steadiness– I imagine the robot is
probably even more steady than that steady surgical hand? Absolutely. So the robot helps us
with tremor reduction. And luckily, most of us don’t
necessarily have a tremor, but if you’re in a very long
surgical case, in theory you could have one. Robots don’t get tired, do they? They don’t get tired. So it’s a machine. It’s not a human. And so it doesn’t get tired. It reduces the tremor. So it’s very nice for us. OK. So do you deal with patients
differently when somebody is approaching a surgery
or at post surgery, how do you deal with a
patient that may or may not get a robotic surgery? Well, when we counsel
patients about surgery, we talk to them
about all the options of the ways they
could have surgery. And we say, you know, I
could do this robotically. I could do this open. These are the pros and cons. And the patient is involved in
that shared decision-making, which is really important. But usually, we
say, you know, we want to your surgery
in the most minimally invasive way possible, whatever
some type of surgery that may be. May it be for a colon cancer
surgery, a throat cancer. For me, it’s large
fibroid surgery, so women with endometriosis or large
fibroids in their uterus. Whatever the surgery
may be, we say, what’s the most
minimally invasive way we can do this to get
you back to your life faster and decrease
your complication rates? OK, so for the patient, they
have probably the same walk-up to a surgery, right? The pre-op? Yeah. Mhm. So none of that
would be different, but their recovery is the part
that’s– and plus what’s going on in there. For the OR team,
what’s different there? It’s completely different once
you enter the operating room. So our OR teams when
we do robotic surgery are specifically trained to
work the robotic systems. We have three robotic systems
that are exactly the same, and then we have our
new, Single-Port, or SP, robotic system, which we
just had delivered last week. But we have all of
those robotic systems in the same surgical pod. So all of our nurses,
equipment specialists, clinical engineers, are
all trained on the systems. The surgeons are
trained on the systems. Our residents are trained. And so ideally, we have
everyone on the same page so that we have a team
approach to the operation. Because we feel that that’s
the safest way for the patient. And what looks different? I mean, we sort of all
have an image of it. I’ve been in a couple
operating rooms, but you know, I’ve watched a
lot of television. [LAUGHS] But this
image of, you know, the doctor’s over the patient. The nurse is right behind
them, with all the assistants. Is it similar in
a robotic surgery? It’s similar to start. So we’re all scrubbed
into surgery. We’re all wearing those blue
gowns like you always see, with the hats and
masks and everything, and we’re all standing
over the patient. The patient is lying
in the bed, right in the middle of the room. And we’re all scrubbed
in in a sterile field, just like we always are. And then instead of
making one large incision, we make a bunch
of tiny incisions, anywhere from one to
five tiny incisions. And then we put those ports in. So instead of our hands
being in a big incision, we put those ports
I was talking about, which are those tunnels
that go through the skin. And then we attach the
robot to the patient. Then the assistant stays
scrubbed in at the bedside. And then the surgeon
scrubs out, and then we go sit in our 3D console. And then we move
those instruments alongside the patient. So what are the assistants
doing, or keeping an eye on, while they stay scrubbed in? Sometimes they’re doing
suction, and sometimes they’re changing instruments in and out. Oh, I see. So we say, oh, I’m going
to change this instrument. And now, it’s
attached to the robot, but it takes a
special person who’s trained to exchange
those instruments for us and to give us what we need
in the operating field. Got it. Got it. If you are just
joining us, by the way, I’m with Dr. Bahareh Nejad. She’s the medical director of
robotic surgery at UC Davis Health. We are talking about robots,
particularly robotic surgery. And we just got a new one. We did. Yeah. So tell us about that. We are very excited
here at UC Davis Health about having our new SP system. It is the first
one in California. It is the second one on the
West Coast, and one of only 20 released in the world right now. Wow. And so it’s called the SP robot,
which stands for Single Port. And so– Wow. That’s sophisticated. It is. Yeah. [LAUGHS] It’s really fancy. And so it’s a 2.5
centimeter incision. So it’s very small. And you do the entire surgery
through 2.5 centimeters. And actually, for tonsillar
cancer or throat cancer, it’s done just
through the mouth– Wow. Transorally with no incision. And so we would love
to proceed in doing more natural orifice surgery,
meaning a hole that you already have. Right. And then if we can’t, then
doing single-port surgery, which is a 2.5
centimeter incision for your whole surgery. And then the next step
would be multi-port. So how would the
single-port surgery work? I mean, why can you get
away with doing that? How do they just
make one incision? Since we need the camera,
we need the cutting pieces, we need to get
stuff out of there. Yeah. So amazingly, in
that single port, it’s one instrument that
comes into the patient through one port– goes through the skin. And then the instruments and the
camera all come out through it. So they’re in,
like, this tunnel. You can see behind us– That’s right. –that’s what that is, right.? So it actually has
three instruments and a camera all coming out
through a 2.5 centimeter instrument. Yes. This is slightly magnified. Yeah. [LAUGHTER] Yeah. So 2.5 centimeters, and
then three instruments can go and converge
on the target organ that we’re operating on. So we’ll be starting
with urology surgery– so prostate surgery–
and/or throat cancer. That’s me. So I was a prostate
surgery patient, and obviously I had
my prostate removed. So I think I remember– it was, you know, disconnected. [CHUCKLES] Once again, I just
watched a lot of television. [LAUGHS] It was disconnected, chopped
up into smaller pieces, and taken out through the hole. So if you’ve only
got this one port, how do you get it out of there? Well, there are different ways. Sometimes you would put
a different tiny hole, like a 5 millimeter hole,
to put a separate camera in. And then you can take a bag and
put it in that 2.5 centimeter hole, and then bring out
the specimen that way. Wow. Wow. All right. [INAUDIBLE] Yeah. We have a lot of
tricks up our sleeve. [LAUGHS] Oh, that’s pretty cool. So we’ve got four– rather than me guess,
what’s our inventory around robotic surgeries? We actually currently
have six robotic systems. One will be traded
in, and we will end with five robotic systems. We have a brand new robotic
system for spine surgery, for some spinal
surgery procedures– spinal fusion procedures. And then in addition to that,
we have three [? XI ?] robots, and now the new SP robot. And that makes us leaders. You talked about the single
port as only the second on the West Coast. I happen to know that
the spinal surgery, we’re the first academic
health system on the West Coast to have one of those. And then those are also the
most advanced multi-port systems as well. Absolutely. So they’re the fourth
generation product. Got it. So they’re the latest products
that have ever been released. So let’s talk about our role
as– we’re an academic health system. So is this our responsibility? I mean, is that how you folks
see it, that we are leaders, that we help train folk? Absolutely. I think– for my job– so I help train the residents
and do the teaching programs. We have a University of
California Collaborative, where across all of the
UCs we work together to design training programs. Because we truly feel
it’s our responsibility to all of the community to train
our surgeons at the highest level possible with
the best equipment and put them out into the world. Because they’re going to leave
us and go get jobs elsewhere, and we want to make sure
that they’re well trained. And then we also want the
safest care for our patients, and we feel that as
long as we’re teaching, we’re on the forefront
of technology. And at UC Davis
Health, we definitely are on the forefront with all
of our new robotic systems and our very, very
deep robotic program. How many surgeons do we
have that are trained? We currently have over
20 robotic surgeons in six different specialties. Our areas of growth
right now– we’re doing liver and
pancreatic surgery. We’re doing hernia
surgery robotically. We’re doing thoracic or
chest surgery robotically. We’re growing in
many different areas. And then of course,
as you mentioned, prostate surgery, gynecology
surgery is what I do, for hysterectomies. We do gynecologic
cancer surgery, urology cancer surgery, throat
cancer, I mentioned before. So we are very broad in our
range of robotic surgeries. And they all work together. So obviously, as you said,
there are some surgeries that you can’t do with robotics. So what– you just
listed at a whole bunch. Are their guidelines? Are there some that sort
of could go either way? Well, some of them are
already standardized across the country. So prostate surgery,
hysterectomy surgery, those have been done for
over 10 years robotically at many different institutions. And we were on the
forefront of that, but that’s something that you
see in other academic centers also. But then at UC Davis
Health, we want to be on the forefront on
a lot of the procedures. So the SP, the Single-Port
robotic systems, we are on the
cutting edge of that. So our hepatobiliary, or the
liver and pancreas surgery programs, and our chest
surgery programs, those are ones where we’re kind
of pioneering the way. And definitely with the
throat cancer surgery also. So there are certain areas
where our surgeons are really taking the lead, and that’s
what’s really exciting here. We talk a lot, at
UC Davis Health, about it is our job as an
academic medical center to lead the way into the future. And here we are, doing what
amounts to a television show off of a cell phone– That’s right. –that people will be
able to watch forever. I mean clearly, the technology
changes daily around here, around everywhere. So how do you stay up with it? You know, this is something
that we’re supposed to be– we feel it’s our mission,
in essence, to be helping people figure it out. But this is the
future of medicine. The use of technology is
the future of medicine. How do you guys, with
something so sophisticated as this, sort of stay up
on what the changes are and the adaptations
that is necessary throughout the system? That’s a really good
question, and it’s not easy. And so what I would say,
it’s a two-way street. So a lot of times,
technology comes to us. And they say, look, we
want you to pioneer this. We want UC Davis Health to
be the first in doing this, because we want it to be
in an academic center. We know you guys know
what you’re doing. We know you’ll vet
out what’s safe. And then we have to decide,
is that the right choice right now or not? And we have to
look at the studies and look at the research
and the safety profiles and decide how we
want to move forward. In addition to the fact
that we are the leaders– so we are the speakers. We are the ones who
go to the meetings. We’re the ones who
conduct the research. And so we go to
national meetings, international meetings. We see what’s out there. And then we bring it back
here at UC Davis Health, and then we teach it
to the community also. So our surgeons are
out there, everywhere. And this is you’re the
doctors who teach the doctors. That’s right. We are the doctors
who teach the doctors, so we have to know what’s
going on and what’s coming. OK. So for something like
this, how much support does the academic system– does UC Davis Health give you
guys for this sort of thing? Well, we’re really lucky
because we really find here that it’s a team approach. And so from our administrators
all the way down to our staff and in between– our OR leaders, all of our
surgeons, our nursing teams– we find that we have
a lot of support because everyone
wants to be ahead. And everyone says, you know,
if we’re going to do robotics, let’s do it big. Let’s make sure that
we do it all the way. We don’t want to do it halfway. We want to make sure we have
the best systems available. We don’t want to go
get the older systems. We want to get the newest
and best available data. We want to get the
best equipment. And we want do what’s
best for our patients. So once again, we are talking
robots, or more specifically robotic surgery, with
Dr. Bahareh Nejad. She’s the medical director of
robotic surgery at UC Davis Health. If you have any questions,
please ask them. I promise I won’t answer them– [LAUGHTER] –so you’ll get real answers. But I do have a few
more questions myself. So how are robots
received by patients? Is their first– you know, whoa. I don’t want a robot. Sometimes, but very rarely. I think that sometimes
people come in and say, you know, well,
that makes me nervous. I don’t want the robot
doing my surgery. And I say, well, the robot’s
not doing your surgery. That might be
something, you know, 10, 20, 30 years from now,
but currently the surgeon is doing your surgery. The robot just allows us to
see better and to move better and to have the tremor
reduction and have the 3D and to decrease surgeon fatigue. Things like that. That’s what the
robot helps us do. But we just try to explain
to our patients– sometimes we show them videos. Sometimes we show them pictures. And we go over it it. And usually once we
explain, the patients are completely on board
when we tell them, oh, but you could have
these tiny incisions. You can go home the same day and
take very little pain medicine. And they’re like, oh. I love robots now. And so usually we get them
on board just with education. Do you warn them they
won’t get to keep a scar? [LAUGHTER] Tell them, sorry. Your scar is a little minimal. [LAUGHS] And how about
in the medical community? Is there general acceptance? Is there resistance
in any quarters? I think that there is resistance
in some areas with laparoscopy. And so very advanced
laparoscopic surgeons– and laparoscopy means you
also make very small holes and also put in those ports
or trocars like the tunnels for the instruments, but
instead of the robot attaching to those trocars or
instruments you use your hands. And you don’t have that
360-degree range of motion, and you don’t have
the tremor reduction. And they say, well, why do you
need a robot when you can just do it all laparoscopically? And my answer is
that there are lots of things we can do
laparoscopically, and there are some things
that are just too difficult. And the robot allows us to
minimize those big incisions and to do them robotically
and where laparoscopy still has its place. So I have to imagine,
down the road somewhere– because we
talk a lot about that here too, is that AI will
start to play a role. Which is, in simple terms,
not like it’s going to think for itself, although
that may be coming too– right with the flying
cars, by the way– Maybe. –but that in essence,
a geometric progression of analysis I guess is
a way to think about it. Which is that AI will be able
to look at that situation that the robot sees and
that you see and compare it to all these other
incidents, and then help you with decisions
that you would make. Is that is that something
that’s coming in surgery? When I think of
what could be next, I think, well, that’s
got to be what’s next. But I don’t think it’s
coming anytime soon. Because I do think
that you’d have to enter millions of data points
into a computer system to say– as a surgeon, you know,
are very humbled every day. Because no two
surgeries are alike. And so when patients ask me,
you know, how is it going to go? I say, well, based
on my experience, I’m going to navigate
it so that it goes well, but there are always things
that I can’t anticipate. And so with AI that
would be the concern. So we have to figure out,
artificial intelligence-wise, how can we anticipate
the unknown? Right. This is the
driverless car thing. Right? That’s right. It’s taking all that
experience, but it didn’t have the time where
the guy on the motorcycle jumped the curve and
went over the tree and– Yeah. You can’t replace
experience with everything. Right. Yeah. Right, right, right. So would it be possible– guy who knows nothing
about technology asks– for these to be recorded and
in essence analyzed with AI? Absolutely. And actually, having
surgery recorded in general is a thing, to look
at safety of surgeons. And so sometimes we
do recordings and say, how could we do better? And I myself watch videos
all the time, surgical videos of other surgeons doing
things, and that’s how we learn and that’s how we progress. And I videotape
my own cases and I review them and see, how could
I do better, what could I do differently? And so we absolutely do that. So it would be recording that
camera image– the 3D image that you’re seeing? Yeah. We deidentify the patients,
and we do it for education. Got it. Got it. And because we also have
a medical school attached to all this– so when you’re
doing these surgeries, are medical students able
to have to watch along? Yeah. Our rooms are super high
tech, and so not only can I see in the screen
that’s in my 3D console, but we have about five other
screens up all over the room. So there’s a really
big screen on the wall, there are screens coming
down from the ceiling, we have booms coming down so
that everyone in the room– the anesthesiologist, our
nursing staff, our students, our equipment
specialists can see. From any angle that you’re
sitting at in the room, you can see screens. Oh, wow. So the nursing staff,
even though that may be somebody
there for suction, can also look around and see the
same thing that you’re seeing. Absolutely. As long as nobody
brings Junior Mints. No Junior– [LAUGHTER] Yes. Right. [LAUGHS] OK. I’m just kidding. There’s no food in
operating rooms. See? Somebody else who
watches television. [LAUGHTER] Yeah. All right. Do we have any questions? No questions. All right. Well, I got a couple more. So if you are
evaluating a patient and you’re in–
what would be some of those surgeries
that may or may not be a robotic kind of surgery? So for me, I do
benign gynecology. So I do hysterectomies
or any adnexal surgery, gynecologic surgery
where there’s no cancer. My colleagues do the cancer
surgeries for the pelvis. And so that’s my
colleagues in GYN oncology. So for me, it would be patients
with very large fibroid tumors. So sometimes their uterus
has grown to about this big– so the size of a watermelon
or the size of a cantaloupe. And so I tell them, look, I can
attempt the surgery robotically and 95% of the time
I’m successful, but there are times where we’re
going to have to open and make a big incision. And so we talk
about that upfront. Does that happen
during the surgery, where you’re working on it
robotically and you realize, no, we can’t do this. We have to go back and– Yeah. Very rarely, because we
try to judge ahead of time what can we do and
what can’t we do. And with experience,
I would extremely rarely open a patient. But we always
counsel the patient so they’re educated that
that is a possibility. And do patients actually
get to see the robot? I know I didn’t. Do they get to see the
robot before the surgery? Well, you did, but
you don’t remember it. Oh, I was– yeah. There’s a lot I didn’t remember. Thank goodness. And so the patient
rolls into the room and the robot is there. And they often say,
oh, that’s the robot. And then they have medication
on board that makes them forget, and that’s part
of the anesthetic. So most of them see it. You just don’t remember. I think in hindsight, I’d
like to have met my robot. [LAUGHS] I think his name was Rolph. I had one patient
tell me, please don’t give me any medicine. I want to see the robot. I want to remember. Yeah. Yeah, in hindsight I really
wish I would have see it. Yeah. Yeah. [LAUGHS] Yeah. That’s very cool. OK. So as your surgeons– our 20-plus surgeons
that are trained, I imagine they have to
continue training for a while. Mhm. Yeah, so at UC Davis
Health, we have proctoring and privileging. So we make sure that you’re
maintaining the adequate number of cases per year. And if you– let’s say
you were gone for a while or you didn’t have enough
patients for a period of time to do robotic surgery
and you trail off, then we have you
reproctored and retrained. And then in addition to
that, every six months we do training for everybody
every six months over and over again, for not just the
surgeons but our staff, our engineers, our
equipment specialists, and our nurses and residents. OK. So looking in your
crystal ball, what’s the next step in
robotic surgery? Well, I think that
we want to proceed more with single-port
surgery, so ideally pioneer some more areas of
single-port surgery. Some colon and rectal
surgeries with single port. Maybe gallbladder or some
gastrointestinal procedures with single port. In the future, we’d
like to pioneer some of those at UC Davis Health. In addition to generally
natural orifice surgery, which would be very
nice for patients– so no-incision surgery. Right. Right. And then way down
the road, maybe AI. Oh. OK. Yeah. I say and build
in cosmetic scars just so they can keep them. So you can have– Yes. –bragging rights
for your scars. OK. Well, that’s the basics
for robotic surgery. There will be much more to come. I’m sure we’ll be back
with you, Dr. Nejad– That would be great. –sometime soon. Thank you for joining us. Thank you.

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