Scott Bovard, MD, discusses robotics in weight loss surgery, including how robotic-assisted surgery compares to traditional surgical approaches.
Transcription:
Bill Klaproth: Performing bariatric surgery can be technically demanding. However, robotic surgery has improved outcomes, decreased complications, and shortened recovery times and has been proven safe and effective for the surgical treatment of morbid obesity and other conditions. So let's find out more about robotics. The future of surgery with Dr. Scott Bovard, a Bariatric Surgeon at WakeMed Bariatric Surgery and Medical Weight Loss. This is WakeMed Voices, a podcast from WakeMed Health and Hospitals. I'm Bill Klaproth, Dr. Bovard. Thanks so much for your time. So can you give us kind of a rundown on the history of robotic surgery and the usage that we have today, and overall what makes it much better than traditional open surgery or even minimally invasive laparoscopic surgery?
Dr. Bovard: We've been going through many decades of improvement of our surgical capabilities. And bariatrics is a great example of that. When I started doing bariatric surgery back in the 90s, as a medical student, we were doing open gastric bypass, which means we had.
Host: Traditional open surgery.
Dr. Bovard: Right? And so when you're doing open surgery, it's very reliant upon the surgeons hands, the surgeons touch because you're doing a lot of stuff without being able to see. You don't have really very good visualization even though you're retracting everything and you get those lights that put down there. A lot of it is just what you feel. And this is the way I learned how to do surgery when we were doing an open surgery. And it was really kind of brutal as far as the patients were concerned. You know, after we finished, you know, two to three hour case for gastric bypass, they'd go to the ICU for two days and then go to the floor for two weeks and then home for two months before going back to work. And that's when we started doing bariatric surgery. And there were still people at that point in time willing to undergo that debilitating case just to get the results that they got. And they were very happy for it. And then we started doing things laparoscopically and we made a huge shift in like a surgical paradigm. We no longer are cutting people open. We're making small little incisions. We're doing what we call minimally invasive. Now what we did here is we improved visualization.
Now all of a sudden we've put a camera in there and we blew the abdomen up and you could see it, you could look at it on a screen and it's much larger and you're right down there and you get great visualization, and you're using these long instruments that kind of reach into the abdomen. So what we lost there is that manual dexterity or that feel. So the, you know, lauded surgeons hands were no longer as important as the eye, right? We could see much better, but we're using these instruments that, you know, these long instruments at the ends of our fingers to do the case. But it was superior in so many different ways that now all of a sudden we're doing a gastric bypass and half the time, the patients don't go to the, they go to the floor and they're there for a few days, and then they're home for a week or two, before they go back to work. And it was much superior to doing it open, just for as far as the surgeons were concerned. And as far as the patients were concerned outcomes. And all of a sudden a lot more people started getting bariatric surgery done because it wasn't near as debilitating. So now we've come up with this whole new modality and it is robotics.
So what it is robot assist. It is not actually a robot doing the surgery and surgeons still doing the surgery except between the patient and himself he has a robot that is basically just enhancement of the surgeon themselves. You're using more of a computer aid in the actual surgery. So now what we have is not only have we improved with the robot, we have improved visualization because now we have binocular vision. There's actually two scopes that go in there. And the reason that you and I see in 3D is because we have two eyes that are slightly offset, the brain sets it and shows that something's in 3D. Well if you can put a scope in there that has two different eyes that are slightly offset and then you're looking at it through a console, this is what the surgeon's looking at is you're looking at a console. It is in true 3D. It's not 3D like you would see in the movies or a video game. It's literally true 3D that you're actually looking at, and it's almost like you take your head off and stick it inside the body, and that is so far superior. You don't really notice it, it'd be hard to explain without showing somebody the difference between it. But it is amazing that the visualization has actually improved. But here's what also improved. Now with this robot, the robot works with these robotic arms and the instruments that we use are no longer limited in what we had before. So prior with laparoscopic surgery, we have instruments that would kind of open and close and we can kind of twist them and turn them around in our hands.
But they're basically like a pair of pliers, like a very long pair of pliers. Imagine trying to tie your shoes with pair of pliers. So that's the dexterity loss that we had. Well, with the robot, we have an increased dexterity. Now all of a sudden we have these things called wristed instruments. The instruments on the inside actually will follow and mimic the movement of my hand that is free flowing in every direction, and opens and closes and moves in every direction. And I have the exact same thing happening on the inside. So now all of a sudden I can take something and it's like when I'm sewing on the inside, it would be like I'm sewing on the outside. It's just literally I'm grabbing the needle, picking it up, pulling it through, and tying a knot with my fingers just like I would do with my, with my regular hands. But we're doing it in a minimally invasive environment. So you've got your visualization actually improved, but you also have the dexterity back, the touch of the surgeon, that dexterity, the surgeon now is become in the forefront again. So this is a wonderful thing, you think, well, you know, that's, that's good. Well that's just not quite all of it either. There's now we're taking step beyond, now we're going into something that would previously be looked at as being, you know, science fiction because now we have augmented reality. So we can actually put dyes in, you know, into the IV, into the patient, that will actually light up different structures. So now when I'm looking at something and I've got better visualization and everything, I can put a dye in there and flip a switch and all of a sudden it will glow underneath tissues hidden behind things.
So if I'm looking for stuff like bile ducts or arteries or veins or something like that, these important structures that we obviously throughout all of history have just blindly kind of started dissecting to find and to slowly isolate. Now we can just flip a light and they're just lit up and you're seeing something that is not visual to the naked eye, but you can only see it through this robotic modality. And so now we're stepping, you know, more into the future with this augmented reality. And I've also just doubled my own capabilities because I have total control of everything. I not only have my two hands that I'm working with, but I also will control the camera to move it right where I want it to be. And I will also have an accessory hand that I can just swap over and utilize that one as well, so that it's not myself and an assistant in the operating room and a camera driver, it's just myself. And so I'm the one that's controlling each and every part of this operation because now I have effectively four hands.
Host: So it sounds to me after listening to this, provides the surgeon with more precision and also provides better outcomes, less recovery time, and really is the future of surgery. Are those the basic benefits of robotic surgery?
Dr. Bovard: Absolutely. You know the benefits, especially if we're talking about bariatric surgery, there's one particular operation called a duodenal switch, a biliopancreatic diversion with a duodenal switch. Big fancy word for a big fancy operation. But there's a very delicate part of this and we're doing this, something called a duodenal dissection. We're in a very tricky area of the body doing a dissection to release part of that small bowel up, and in the area you have stuff like, you know, the portal vein and the vena cava and the bile ducts and all that just hidden behind. It's just there and doing it robotically, you're not blind. You can use some of this enhanced reality or augmented reality to show you where some of these structures are and plus you can get a lot closer or you can blow things up. And with every movement that I make, I can actually adjust on the computer to where my hand has to move like three times as far to what the instrument on the inside does. So in other words, it's much finer movements with those little instruments on the inside. And I can adjust that. So the fine, fine motor skills are actually enhanced quite significantly because we can just adjust as simple on a computer.
Another thing I didn't mention. So with surgery we do a lot of stapling, right where we're going to separate something and specifically with bariatric surgery, so I'm doing this duodenal dissection, which I now know is very, very clean and I'm getting what I want because I can see where things are and it's much safer. But then when I put that stapler across there and I bite down on that, the computer reads the tissue. It knows exactly how tight it's able to close and it'll tell you exactly how many tenths of a millimeter thick that tissue is, and it knows exactly how long that staple line is. And it will stop and wait for the fluids to flow out of there to kind of compress a little bit more, and it will lay down that staple line and you will know every single staple is perfect because there is a robot reading, there is a computer reading that. And it makes me feel like every other staple line I've ever put in prior to this in my life was just a guess because that reading. Now, I've never really had a big problem with staple lines all the time. But once you make that change, once you see, once you open up that Pandora's box and you look inside and you see what, you know, what it could have been, it kind of makes you think I want to do everyone in my cases on this robot now because it just makes you feel much more comfortable with what you're doing.
Host: Well, I'm sure the robot is in high demand and it's not to the point where you have robotic technology in every room. So tell us about what's happening at WakeMed. How often are you able to use robotic assisted surgery?
Dr. Bovard: Yeah, I have two days a week where I'm in the operating room and one of those days is usually robot day. I would like it to be both, but I'm trying to get time on the robot when I have the gynecologists and urologists, like I mentioned before, we also have thoracic surgeons that use the robot who are very, very happy with the robot. So, you know, we've got to get in there, you know, we got to get on the console. And so I get what I can usually about one day a week.
Host: Got it. Well it's good to know that that technology is being used at WakeMed Health and it sounds like more to come in the future because the robot is this, from what you're telling us, certainly superior to traditional open surgery.
Dr. Bovard: Yeah, absolutely. And I hope that, you know, that we see this improve all the way around. I think as soon as we get a lot of surgeons that are very adept at it, they're going to start seeing, you know, improvements in outcomes and OR times, and just patient driven desire because the patients just do better with it. You know, when you leave the hospital and you haven't had any problems, you haven't had any pain, no nausea. You go tell your friends, Oh, I had it with a robot and next thing you know, everybody wants it.
Host: Well, we all want an improvement in outcomes, and if robotic surgery helps us to get there, then everybody is all in on that. Dr. Bovard, thank you so much for your time today. This has been really fascinating.
Dr. Bovard: Well, I appreciate that. Thank you.
Host: That's Dr. Scott Bovard. To learn more about WakeMed’s Bariatric and Medical Weight Loss services, please visit WakeMed.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Thanks for listening.
Bill Klaproth: Performing bariatric surgery can be technically demanding. However, robotic surgery has improved outcomes, decreased complications, and shortened recovery times and has been proven safe and effective for the surgical treatment of morbid obesity and other conditions. So let's find out more about robotics. The future of surgery with Dr. Scott Bovard, a Bariatric Surgeon at WakeMed Bariatric Surgery and Medical Weight Loss. This is WakeMed Voices, a podcast from WakeMed Health and Hospitals. I'm Bill Klaproth, Dr. Bovard. Thanks so much for your time. So can you give us kind of a rundown on the history of robotic surgery and the usage that we have today, and overall what makes it much better than traditional open surgery or even minimally invasive laparoscopic surgery?
Dr. Bovard: We've been going through many decades of improvement of our surgical capabilities. And bariatrics is a great example of that. When I started doing bariatric surgery back in the 90s, as a medical student, we were doing open gastric bypass, which means we had.
Host: Traditional open surgery.
Dr. Bovard: Right? And so when you're doing open surgery, it's very reliant upon the surgeons hands, the surgeons touch because you're doing a lot of stuff without being able to see. You don't have really very good visualization even though you're retracting everything and you get those lights that put down there. A lot of it is just what you feel. And this is the way I learned how to do surgery when we were doing an open surgery. And it was really kind of brutal as far as the patients were concerned. You know, after we finished, you know, two to three hour case for gastric bypass, they'd go to the ICU for two days and then go to the floor for two weeks and then home for two months before going back to work. And that's when we started doing bariatric surgery. And there were still people at that point in time willing to undergo that debilitating case just to get the results that they got. And they were very happy for it. And then we started doing things laparoscopically and we made a huge shift in like a surgical paradigm. We no longer are cutting people open. We're making small little incisions. We're doing what we call minimally invasive. Now what we did here is we improved visualization.
Now all of a sudden we've put a camera in there and we blew the abdomen up and you could see it, you could look at it on a screen and it's much larger and you're right down there and you get great visualization, and you're using these long instruments that kind of reach into the abdomen. So what we lost there is that manual dexterity or that feel. So the, you know, lauded surgeons hands were no longer as important as the eye, right? We could see much better, but we're using these instruments that, you know, these long instruments at the ends of our fingers to do the case. But it was superior in so many different ways that now all of a sudden we're doing a gastric bypass and half the time, the patients don't go to the, they go to the floor and they're there for a few days, and then they're home for a week or two, before they go back to work. And it was much superior to doing it open, just for as far as the surgeons were concerned. And as far as the patients were concerned outcomes. And all of a sudden a lot more people started getting bariatric surgery done because it wasn't near as debilitating. So now we've come up with this whole new modality and it is robotics.
So what it is robot assist. It is not actually a robot doing the surgery and surgeons still doing the surgery except between the patient and himself he has a robot that is basically just enhancement of the surgeon themselves. You're using more of a computer aid in the actual surgery. So now what we have is not only have we improved with the robot, we have improved visualization because now we have binocular vision. There's actually two scopes that go in there. And the reason that you and I see in 3D is because we have two eyes that are slightly offset, the brain sets it and shows that something's in 3D. Well if you can put a scope in there that has two different eyes that are slightly offset and then you're looking at it through a console, this is what the surgeon's looking at is you're looking at a console. It is in true 3D. It's not 3D like you would see in the movies or a video game. It's literally true 3D that you're actually looking at, and it's almost like you take your head off and stick it inside the body, and that is so far superior. You don't really notice it, it'd be hard to explain without showing somebody the difference between it. But it is amazing that the visualization has actually improved. But here's what also improved. Now with this robot, the robot works with these robotic arms and the instruments that we use are no longer limited in what we had before. So prior with laparoscopic surgery, we have instruments that would kind of open and close and we can kind of twist them and turn them around in our hands.
But they're basically like a pair of pliers, like a very long pair of pliers. Imagine trying to tie your shoes with pair of pliers. So that's the dexterity loss that we had. Well, with the robot, we have an increased dexterity. Now all of a sudden we have these things called wristed instruments. The instruments on the inside actually will follow and mimic the movement of my hand that is free flowing in every direction, and opens and closes and moves in every direction. And I have the exact same thing happening on the inside. So now all of a sudden I can take something and it's like when I'm sewing on the inside, it would be like I'm sewing on the outside. It's just literally I'm grabbing the needle, picking it up, pulling it through, and tying a knot with my fingers just like I would do with my, with my regular hands. But we're doing it in a minimally invasive environment. So you've got your visualization actually improved, but you also have the dexterity back, the touch of the surgeon, that dexterity, the surgeon now is become in the forefront again. So this is a wonderful thing, you think, well, you know, that's, that's good. Well that's just not quite all of it either. There's now we're taking step beyond, now we're going into something that would previously be looked at as being, you know, science fiction because now we have augmented reality. So we can actually put dyes in, you know, into the IV, into the patient, that will actually light up different structures. So now when I'm looking at something and I've got better visualization and everything, I can put a dye in there and flip a switch and all of a sudden it will glow underneath tissues hidden behind things.
So if I'm looking for stuff like bile ducts or arteries or veins or something like that, these important structures that we obviously throughout all of history have just blindly kind of started dissecting to find and to slowly isolate. Now we can just flip a light and they're just lit up and you're seeing something that is not visual to the naked eye, but you can only see it through this robotic modality. And so now we're stepping, you know, more into the future with this augmented reality. And I've also just doubled my own capabilities because I have total control of everything. I not only have my two hands that I'm working with, but I also will control the camera to move it right where I want it to be. And I will also have an accessory hand that I can just swap over and utilize that one as well, so that it's not myself and an assistant in the operating room and a camera driver, it's just myself. And so I'm the one that's controlling each and every part of this operation because now I have effectively four hands.
Host: So it sounds to me after listening to this, provides the surgeon with more precision and also provides better outcomes, less recovery time, and really is the future of surgery. Are those the basic benefits of robotic surgery?
Dr. Bovard: Absolutely. You know the benefits, especially if we're talking about bariatric surgery, there's one particular operation called a duodenal switch, a biliopancreatic diversion with a duodenal switch. Big fancy word for a big fancy operation. But there's a very delicate part of this and we're doing this, something called a duodenal dissection. We're in a very tricky area of the body doing a dissection to release part of that small bowel up, and in the area you have stuff like, you know, the portal vein and the vena cava and the bile ducts and all that just hidden behind. It's just there and doing it robotically, you're not blind. You can use some of this enhanced reality or augmented reality to show you where some of these structures are and plus you can get a lot closer or you can blow things up. And with every movement that I make, I can actually adjust on the computer to where my hand has to move like three times as far to what the instrument on the inside does. So in other words, it's much finer movements with those little instruments on the inside. And I can adjust that. So the fine, fine motor skills are actually enhanced quite significantly because we can just adjust as simple on a computer.
Another thing I didn't mention. So with surgery we do a lot of stapling, right where we're going to separate something and specifically with bariatric surgery, so I'm doing this duodenal dissection, which I now know is very, very clean and I'm getting what I want because I can see where things are and it's much safer. But then when I put that stapler across there and I bite down on that, the computer reads the tissue. It knows exactly how tight it's able to close and it'll tell you exactly how many tenths of a millimeter thick that tissue is, and it knows exactly how long that staple line is. And it will stop and wait for the fluids to flow out of there to kind of compress a little bit more, and it will lay down that staple line and you will know every single staple is perfect because there is a robot reading, there is a computer reading that. And it makes me feel like every other staple line I've ever put in prior to this in my life was just a guess because that reading. Now, I've never really had a big problem with staple lines all the time. But once you make that change, once you see, once you open up that Pandora's box and you look inside and you see what, you know, what it could have been, it kind of makes you think I want to do everyone in my cases on this robot now because it just makes you feel much more comfortable with what you're doing.
Host: Well, I'm sure the robot is in high demand and it's not to the point where you have robotic technology in every room. So tell us about what's happening at WakeMed. How often are you able to use robotic assisted surgery?
Dr. Bovard: Yeah, I have two days a week where I'm in the operating room and one of those days is usually robot day. I would like it to be both, but I'm trying to get time on the robot when I have the gynecologists and urologists, like I mentioned before, we also have thoracic surgeons that use the robot who are very, very happy with the robot. So, you know, we've got to get in there, you know, we got to get on the console. And so I get what I can usually about one day a week.
Host: Got it. Well it's good to know that that technology is being used at WakeMed Health and it sounds like more to come in the future because the robot is this, from what you're telling us, certainly superior to traditional open surgery.
Dr. Bovard: Yeah, absolutely. And I hope that, you know, that we see this improve all the way around. I think as soon as we get a lot of surgeons that are very adept at it, they're going to start seeing, you know, improvements in outcomes and OR times, and just patient driven desire because the patients just do better with it. You know, when you leave the hospital and you haven't had any problems, you haven't had any pain, no nausea. You go tell your friends, Oh, I had it with a robot and next thing you know, everybody wants it.
Host: Well, we all want an improvement in outcomes, and if robotic surgery helps us to get there, then everybody is all in on that. Dr. Bovard, thank you so much for your time today. This has been really fascinating.
Dr. Bovard: Well, I appreciate that. Thank you.
Host: That's Dr. Scott Bovard. To learn more about WakeMed’s Bariatric and Medical Weight Loss services, please visit WakeMed.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Thanks for listening.
