neither the el paso medical society its members nor pbs el paso shall be responsible for the views opinions or facts expressed by the panelists on this television program please consult your doctor [Music] in easy terms it's basically a doctor-controlled robot performing your surgeries it's become the standard of multitude of surgeries and operations around the world and we're going to talk about it tonight some specific questions how did it first start where are we now and when there's there never going to be a doctor in the operation room i don't think that's ever going to happen but these are questions that people are asking during this next hour we have questions that you can ask us live at 881-0013 if you have to leave your television you can also stream us live this is streaming live on youtube.com and just search for el paso physician live and it will be going on live and you can ask questions there again too eight eight one zero zero one three this evening's program is underwritten by the hospitals of providence and we also want to thank texas tech paulo foster for providing students to answer our phones and i want to say very much a welcome to you this is our 25th anniversary of the el paso position and a big kudos to the el paso county medical society for hanging in there that long i'm katherine berg and you're watching the el paso interesting cause i'll have some of these doctors on the show and yeah they're doctors but i've known them for 20 years we've been doing this show for 20 years you know he talks about farts and he talks about diarrhea and he talks about all kinds of things that nobody wants to talk about and that's what's great about the show because you get to hear those things on the show and go i'm not the only one it's great see el paso physician [Music] the docs in the studio did not get to hear what that audio was all about but uh i think it's always fun if you can say on live tv you can talk about farts and diarrhea and people think oh that's okay i had two giggles here earlier so um with me we have two veterans and a newbie but i think this is going to be great dr richard farnham is uh gynecology he's with us this evening and i remember you just doing all kinds of stuff with da vinci system for many years then we have dr chiba who is abdominal surgery which includes all kinds of things and then we have dr antonio de la rosa ob gyn and the first show that we did about robotic surgery you were on that show in 2007 so i just kind of went back and did some of our research so it's kind of interesting to see what is going on now compared to what was going on at nine years ago and ten years ago so we're going to have a lot of discussion this evening and what i'd like to do is start off with each one of you and since dr dela rosa you're right next to me if we can just tell the audience what your discipline is uh what you do all day every day that's kind of my way of introducing it and that way people at home know which doctor to ask which question of that makes sense so dr dela rosa you get to start you can even go back to the show in 2007 what you remember from it was it good was it a good experience yes it was thank god because it only took you nine years to come back yes yes um well i'm an obstetrician gynecologist so we deal with women's health as far as the da vinci robot goes we do gynecologic surgery including things like hysterectomies ovarian cystectomies pelvic support surgeries as such okay and then uh dr chiba as an abdominal surgeon um i know that includes a lot of things but you were saying earlier that you specialize in weight loss surgery and uh what was it weight loss surgery and just general abdominal surgery but what does that mean to the audience yeah so so my training is in general surgery but there is extra fellowship to train for weight loss surgery we call it bariatric surgery uh also including in the fellowship is robotic surgery as well so abdominal surgery would be a gall bladder hernias incisional hernias appendectomy those some of them are emergencies as well which can be treated with robotics as well and then you have bariatric surgery which is weight loss surgery the most common surgeries uh sleeve gastrectomy and gastric bypass and i perform those in robotics as well okay and i'd like to get into that a little bit too because i know that there's there's still questions on the sleeve and bypass and which is better what's being used more it's a little bit shifted throughout the year so that's going to be interesting and dr farnham uh you do anything gynecological um and you're knowledgeable that's not a word but uh in that in that in that whole realm we're going to make it a word tonight but if you can explain to the audience at home what you do including all your conferences that you go to goodness wow yeah so um like dr de la russa obgyn trained in that specialty and did a fellowship in specifically minimally invasive surgery so doing things through small incisions which is what we're talking about tonight with robotics and and board certified in female pelvic reconstructive surgery so uh the you're no collogic yeah so it's uh basically urology that's our made up word for the night it's basically urology neurology for women so prolapse incontinence conditions that are frankly epidemic authority of women have it but no one wants to talk about it bingo and that's why we're here and that was kind of what that promo is about this program is about stuff that people aren't you know uncomfortable speaking about and so especially the female form once we get a little bit older literally one of the big questions is every time i go and it's like are you leaking when you cough and i'm thinking what does that mean then you start realizing what they mean so these are questions and that's why we have a live program here dr um de la rosa i'd like to start with you and um going back to 19 or 2007 fine but explain to the audience what robotic surgery is i remember back then we were talking about it and it freaked people out it's like is there not a doctor in the room what's going on if you can kind of explain what it is and then we've got a video that we're going to cue up in a few minutes too so people can kind of see how the the hands work okay well things have changed a lot since we were last year um robotic surgery lets us do mentally invasive surgery a lot easier you could think of it as a tool a lot of people know what laparoscopic surgery is and we do surgeries through little small incisions instead of a big abdominal incision so what the robot lets us do is do more complicated procedures in that way we get specialized instruments we get better visualization there's a lot of safety mechanisms involved that help help us get better outcomes going through small incisions let's just do surgery with less pain less bleeding less chances of infections too just on the bigger incision the more it's going to bleed the more it's exposed to the outside elements so there's also a higher rate of infection um when we first started robotic surgery i mean it was fairly new not a lot of people knew about it but now it's pretty much become the standard of care and um and also i mean there's a lot more when i first started we were pretty much just doing hysterectomies simple cystectomies and now we're doing a lot more complicated procedures like the pelvic organ prolapse surgeries which are a lot more complicated now this allows us to do it and get patients home sometimes the same day and instead of being in recovery for two months they're getting back to work in about two weeks or so dear lord two months it used to be with a big incision yes yeah that makes sense and i remember just visually i remember uh i don't know if it was you but one of the doctor's hands back in 2007 they were showing the cameras like do you see how thick my fingers are and then immediately they came in with a little tiny tweezers when you're looking at trying to tie stitches inside the body and i thought that's brilliant you know so again we were trying to talk people into the idea that this is good this is an awesome thing again it was freaking people out but now it's it's so great and so many things that have come into play dr farnham there is a video and gracie if you don't mind uh running this video in the back there's a video and if you don't mind just kind of talking over it of kind of what the surgical room looks like when uh you're in there and and performing a robotic surgery and there we go [Music] the robot since it came out as the standard s s i now the x i so these are my hands they're working on these joysticks basically that are in this robotic console that i'm peering into and i'm operating in a corner 15 feet away from the patient bedside and essentially this these arms hold the camera and it the robot is a giant marionette and it holds all of the instruments and all of the movements that i make in space in this little console area are miniaturized inside so a movement of 10 centimeters in space here is a movement of one centimeter space on the inside making it much more um precise and this is actually a case observation we did we had a surgeon proctor come from maryland i believe on this one and so she's trying to advance her skill sets she's trying to learn more procedures and so we at trans mountain are the only epicenter training site in all of tenet um all of the providence health networks but actually in the country and all of tenant and so this is this is the destination site where surgeons will come to learn the robot in general and then also as they you know move along in their learning curve uh take on more complicated procedures well i'd love to transition that into to me that one of the most obvious questions is training training training um i did not know that about el paso just one more high five to el paso on that one um and dr chiba i'd like for you to kind of take it too because we have two ob gyns here and then we have general surgeon you're concentrating on abdominal surgery surgery but dr farnham if you can start off on these trainings because again you go to conferences because you are helping train other people um and then you also go to get trained in other conferences as well explain what kind of training everybody needs so i know that every there's four hospitals of providence robots so each each campus has a robotic system like you said there's generations of them now but how how often do you go to trainings how often do things change uh when do you bring the dr chibas in et cetera i mean how does that all work and that's a good point there's a lot of collaboration for what we do um on tuesday i collaborated with dr javier arenas from urology to do a case where patient had a ureter that was obstructed and from endometriosis so that falls under the gyn category but then it had to be you know transected removed and then re-implanted into the bladder which goes to urology and as we saw there not only for teaching purposes right but with that dual console both surgeons can sit and just hand instruments back and forth to one another to have a completely integrated uh correlated you know surgery and so you have an ob gyn that specializes this and then a urologist and or somebody else that specializes in a you know whatever and you can all do surgery at the same time when i say all two of you can do surgery at the same time exactly right um and i haven't worked with dr chiba yet i've worked with your partner dr eng where we've done cases together that may involve bowel disease so we can talk about endometriosis all night but it's a it's a condition that women have that causes painful periods many times debilitating painful periods and um it's a disease that originates in the uterus but it implants into the pelvis and it can go anywhere it can go on the ureter as the case we mentioned you can go on the bowel and sometimes we would have to have a combined case where we remove some of the disease and then reconstruct it comes in and you know so sews up the bowel or sometimes even removes the portion of the bowel goodness and dr chiba as far as your training goes when did you first get into this i mean was it you you look like you're 12 years old which means i think it's always been there since you're around uh but but seriously when was this something again 2007 is the first time i really got involved in any knowledge granted it started before then um but just in general how was your training and was it ever a question that this is what you would do surgeries with yeah when i was meaning uh residency is where i trained to become a general surgeon it was you know robotics was still new we only had the first si system the first robotic system so my bosses were actually learning so i was bedside learning with them now come fellowship that had changed a lot now at that point a lot of surgeons general surgeons bariatric surgeons are already capable of doing uh robotic surgery so at that point you know i learned a lot of uh robotic surgery and that's where i got you get a certificate certain number of cases and uh with that certificate you're able to operate uh using the robotic gotcha platform and dr dela rosa i know that dr farnam said uh earlier before the show that you were the first person that did i forgot what you said abc surgery what was that um and do you remember doing that you're training before that because were you for the first one doing uh ob gyn surgeries in town do i remember that correctly the first gynecologist that utilized the robot okay and back then the training's gotten a lot more sophisticated as we've gone back then i did laparoscopic surgery so it was it was um i was transitioning from using my own hands to direct the instrument to using the robot and the the robot's like a tool you could kind of compare like kind of like an electric screwdriver you could do it manually or you could just right use the power it's supposed to make it and it's supposed to make it easier back then i had to go to a training site well first we did case observations we went to a training site um there was a lab an animal lab where we learned how to use a robot how to use the instruments just how to work the robot without doing surgery then there was an animal lab where we actually did um surgery on specimens um after that um we had to get preceptor for our first cases so they would get more experienced physicians to come in and and guide us through the surgeries and you had to get a certain number of cases and after that a certain number of cases that they would review make sure you were doing well and you were progressing fine and then from there you'd get your full privileges now a few things have changed the the labs and all that they do are more more um i guess now they have cadaver labs and stuff where you actually do surgery on human cadavers um there is um there is some simulators where you could do like virtual surgeries i'm a pilot and all this associates with the same thing you have so many hours and you go over here and then you get this certification and that certification there's yeah there's the simulators the dual consoles now in residencies now a lot of the residents are coming out trained and your faculty sits next to you and just guides you the whole way so that is part of medical school training at this point for the most part the robotic system is if you're going to go into the surgical field yeah now it is okay now it is said that yeah okay um what i'd like to do too i was just looking at dr farnam what was i going to ask you um so let's talk about you were talking earlier about pelvic reconstruction so i'd like to go ob gyn then go to abdominal for a while but when you're looking at and this is females obviously but there's a lot going on inside the female body lots of we can start with babies and really go to someone who's 45 50 years old what has happened to the different organs now the reproductive organs let's talk about urology let's talk about just different things that you do and maybe if you need to pass it on to urologist too but things that you're specializing in with with this system well i think uh as antonio mentioned earlier um the breadth of what we do now with robotics is unrecognizable from what it was in 2007.

[Music] in fact when it came on there was a lot of pushback that oh no you know this is this new technology how do we know it's safe how do we know it's effective and there actually is a lot of literature now that specifically shows that robots are actually better uh there's level one evidence that shows it's you get fewer conversion meaning that you are starting out with little holes little incisions you're less likely to do an open incision by the end of the case if you use a robot as opposed to doing laparoscopic or straight stick right or laser surgery um so there are and endometrial cancer node counts are higher with robotics um there's it specifically has better outcomes for morbidly obese patients so as we get further and further they're out we're collecting i mean besides the obvious you know you look into a console you can see 3d you can't do that laparoscopically you have to look at a screen that's a two-dimensional screen and try to create a 3d perception in your mind i mean you guys all have done this i mean you went through that experience where as a surgeon you have to kind of um create the 3d image in your mind from a 2d screen you don't have to do that with robotics that's given to you right it's more precise there's the motion scaling there's the trimmer reduction so there's a lot of just obvious advantages and at its simplest level i would say robotics is computer-assisted surgery right we all we all live computer computer assisted lives right right i mean what would we do if we didn't have our iphone and our calendar so it's just taking the surgery that we would do laparoscopically and just making it more uh precise so um and i'll say one other thing is that uh it got a lot of pushback when it came into obgyn and what we did see though is we saw the number of open cases meaning that someone get an open incision that we talked about here where you have a long recovery for the first time in history dropped below 50 percent with the introduction of robotics right which makes sense right right of course uh and now it's not the plurality it's actually the majority of all hysterectomies 51 are now done on the robotic platform so some some surgeons think oh you know i'm too good for the robot i don't need that it's a fad well guess what it's here to stay right so three on a abdominal or pelvic organ so you know appendix is hernias hysterectomy tube ligation ovarian system smoking heavy lifting um the the connective tissue that supports the pelvic organs the bladder the rectum the vagina becomes weak and these organs can actually start to descend and you know as you shared in your anecdote why are people asking me if i leak well this is where we talk about it let's let's make people uncomfortable you know they're sitting at home or wherever they are but explain why the organs do that you know that would be part of the show well and again the biggest risk factors are going to be obstetrical risk factors vaginal deliveries particularly instrumented deliveries those are going to have a statistically significantly higher risk for the future development of prolapse no prolapse no one comes to my office and says hey doc i have a grade three prolapse how can you help me how does one know so it's i feel a bulge i feel like i'm sitting in an egg i was in the shower and i felt something these are the common uh things that will come up um things that will resonate with patients if you if you ask and then just as part of annual uh women's health care we're going to do a clinical exam and maybe they don't want to talk about it but you're embarrassed about it right right and and then you know you have to have that conversation you know does this bother you and it's okay i mean this affects a lot of people and and they're very effective treatments now it doesn't have to be surgery right um they're pelvic floor exercises there's pessary devices but for those patients that have suffered with it and particularly for for urinary symptoms incontinence coughing and leaking urgency running to the bathroom not being able to empty their bladder some some patients never leave their house oh gosh because they're afraid they won't be able to find the next bathroom right and you know not necessarily robotic but there are treatments uh for this you know so what are you doing physiologically in the body then so you're talking about the ligaments that are that are holding these organs there so during the surgery not hysterectomy but say a bladder are you lifting the bladder are you what are you doing inside the body that's helping in that situation yeah so i mean there's three levels of support there's the upper support which is the unicycle ligaments um there's the level two support which is the architecture fascia pelvis but it's they're just different layers of connective tissue they become weak and sometimes even break away there you go yeah okay and that there's no more support and so they then fall and gravity pulls them out through the opening in the vagina and usually it takes years and years but if you feel something just definitely ask i mean for the most part we're hoping for the most part everybody has an annual exam anyway uh women especially in that well but just ask the questions that brings up a very good point because so many uh people but women uh kind of missed out for years because the pandemic right now they're coming in with more severe and you probably see this in general surgery too right the patients have waited too long and things that may not have been as critical or severe we're seeing more acute uh problems now coming out of the pandemic and that's that's a great point and going to dr chiba when we're looking at weight loss surgery i'm just trying to think of some of the things that you specialize in that is an elective surgery so to speak you know um and coming out of the pandemic i'm i'm assuming that there's more and more that happening but when you are doing robotic surgery what so you were talking about the bypass and you talk about the sleeve both of those you do robotically yes is that correct if you can just explain to the audience what you're doing i think sometimes they're just curious as to well what does the sleeve bypass do and what does the uh or the sleeve or bypass do i know i'm talking about the same thing with two different words but yeah so sleeve gastrectomy is one of the most common procedures for uh bariatric surgery now and is that the one that has been for a long time like which one came first so bypass is a little bit more open okay gotcha i kind of had uh have the tested the times and it is a great operation a little bit newer operation is called sleeve gastrectomy okay and it's one of the most common procedures bariatric surgery performed in the u.s now about maybe more than 80 percent of bariatric surgery is sleep gastrectomy now more than 80 percent is goodness okay depends on the area but majority okay i know that usually when we have that show we've got a great video that kind of describes what's happening there but if you can describe just verbally to the audience what is bi what are you bypassing when you talk about the bypass surgery and then what do you mean by the sleeve right if you just kind of describe it for the mind right so sleeve gastrectomy is basically creating a banana out of your stomach your stomach is basically a bag that you store food for digestion uh you resect about 80 to 90 percent of your stomach so it becomes more tubular for one you can't eat as much number two there's actually a metabolic effect that happens and your metabolism actually stays high even though you're losing the weight typically when you lose a weight your metabolism goes down so it's much easier for you to gain weight again right but with bariatric surgery your metabolism stays high to keep on losing that weight uh over the first year year and a half now gastric bypass is is a little bit more complicated operation uh initially you create a small pouch so you basically your stomach becomes the size of your your your thumb uh you connect a piece of intestine to that so now the food goes into your small pouch we call it the gastric pouch and then goes into directly into the small intestine gotcha and then um you bypass about 125 centimeter of small intestine so and then there's another connection a little bit later i know it's a little bit complicated but uh another connection where the digestive enzymes come in and the food and the digestion enzymes meet there and the absorption starts there so one you can't eat as much because your stomach is extremely small now and number two you're there's a malabsorptive component where you don't absorb food in portions of the small intestine and then there's that metabolic component as well where your metabolism stays high interesting and then i know after that there are uh just different uh nutrient situations that you need to pay attention to going forward what i'd love to ask at this point is because this show is really about the robotic system is using when you're talking about connecting this disconnecting this connecting this uh which which makes sense i mean i get it but this is where i feel like it's so cool to have the system that has these little tiny tweezers that are doing the stitches because when you're disconnecting and then reconnecting i feel like that's something that we can you know give a high five to the robotic system for like how many stitches are there that are connecting and how is that stitch done is it one continuous stitch or just how does that work when you're reconnecting things yeah so different surgeons do it a little bit differently but i typically use a stapler to make the connections okay but you still have to close that uh that hole that you put the stapler in and when you're using laparoscopy you technically only you don't have a wrist so with robotic surgery you have an ex extra uh axis where you can turn so your suturing becomes much more smoother and more controlled okay so imagine trying to suture with like a like a crab versus having that wrist like a human being right so it kind of imitates open surgery actually as the laparoscopy with the benefit of open surgery which is resting would you okay and i'm sorry i just got a question from the audience so um and when you were saying that too and and gracie uh gracie taurus is in the back eventually what i'd like to do gracie if you don't mind is show that video again because we showed at the beginning of the program but it does really describe and show when you're when you're doing your wrist movement so we'll we'll definitely show that a little bit but a question here from the audience and it's perfect that we have dr dela rosa who's next is uh the question what is the removal process for a hysterectomy and so this is a great question because there's a lot going on there too and then there are organs that are moved out of the way because another organ is now gone and then now the organs come back that you know find the room again if you can kind of explain all of that because people hear the word hysterectomy but don't really know what that means they just know it's something that old ladies have you know um and i'm one of the old ladies so i don't have any hysterectomy but in general i think that's uh just a a question well a hysterectomy is the removal of the uterus that's the womb where the baby lives when it's growing right okay so it takes up a lot of room it does and there's different there's different sizes of their they have fibroids they get enlarged they could be some hysterectomy do we remove uterus the size of a five-month pregnancy sometimes oh my goodness and okay i get that patient a lot i get that question a lot from patients like you're doing the surgery through small holes how do you get it out so there's two ways there's two ways that we usually go about it one is a lot of times um once we detach the uterus and the organs right we're able to pull it out vaginally i mean that's how you have a baby it's right simple yeah once it's out we close the opening that was left in the vagina that's and sometimes when we get those big huge uteri i mean it's even those are impossible to get out in that route so there's different techniques but a lot of times um what most of us do is these small incisions we might have to extend them just a little more i typically use four incisions less than one centimeter and i'm going to stop you there because i think it's interesting to know where those incisions are placed so if you're thinking about the abdomen explain to people at home where i use one at the belly button two lateral to that on one side and one lateral on the other side okay they're all one centimeter which is amazing yeah i mean really just a little now with a larger my technique like i said there's different techniques but i usually extend the umbilical incision to about four centimeters and there's a variety of endoscopic bags we could put into the into the pelvis so we basically put the specimen in the back get the top portion of the back pull it out through that incision that we extend out a little and then we pretty much just pull out the specimen chunk by chunk we cut it up reasonably quick and the reason we put in the bag is so we won't lose any part of it there's no nothing left behind i remember when lapis scopic surgery was first a thing that chunked by chunk i mean granted it that in and of itself in the day again this is the 25th anniversary of the show right so back 25 years really you're just doing little scopes on doing this um but the idea of removing a larger organ from the body from the body in these small incisions is to me absolutely amazing um we have a question another question here from the oh that's nice we have a call actually from riverside california so youtube is working yay so we're streaming live i'll give another plug on uh pbs el paso show of el paso physician live if you go to youtube.com just go to el paso physician live and you'll get the show and you can ask questions which is great the training we were talking about training earlier and if there is specific trainings for pgyn for bariatric surgery for and and maybe i don't know this but can you do robotic surgery on let's say joints or what other what other areas maybe that's more the question what are other areas aside from the abdomen and gynecological reasons what other areas are the da vinci system being used on and i'm just throwing that out to anyone who wants to take it well it's i mean intuitive surgical is the maker of the surgical robot that we all use that platform is for abdominopelvic surgery okay um it's also been used and being used currently for thoracic surgery it is okay pre pulmonary tumors lung tumors even cardiac surgery in fact uh the the ceo gary guthrie for the company um originally their goal was to have this platform for thoracic surgery because if you're talking about a reduction from uh two months down to two weeks for abdominal surgery imagine not breaking the sternum bingo yeah you're talking about six months ribcage right for recovery and interestingly uh and again the hospitals of providence brought the robot to el paso and it was a urology robot at that time and so gary says you know we aim for the heart but we hit the prostate ah so um but that was that was what the robot was used for uh but but yeah any abdominal pelvic even thoracic now for the for the intuitive robot um they have a new robot called ion which is for pulmonary biopsy so without actually going through uh incisions on the abdominal wall just down the throat you can biopsy tissue that way and there is a platform called single site and it's can be done all the robot arms through one incision in the belly button or through another natural orifice there's trans anal trans oral surgery um the ents have found a role for that as well and uh then there are other platforms and the i think most recognizable one is the mako robot and this is for joints uh maplo m-a-k-o okay orthopedics okay now that being said that's interesting there are seven other companies that have robots coming to the market in the next 24 months goodness uh to compete directly with uh the intuitive robot um but uh you know it's it's a process and they're 20 years ahead and so uh we'll we'll see you know what who the win winners and losers are in in that process but for the foreseeable future it'll be intuitive um and i would say that um the training pro process that we're talking about so you have to do didactics online learning you have to go and do a lab then you have to get a case observation then you have to have somebody observe you if you think about any other instrument any other technology in the or what's the training pathway for the surgeon i want that that's it that's all they have to do so to have a company that has created this longitudinal relationship where um you have access to these learning opportunities so i mean the next 12 days i'm teaching courses in houston la tampa bay and uh maryland i think so you know there's a lot of demand for advancing you get to a plateau and you're like what else can we do with this technology and i would say however good you are laparoscopically i can make you better with a robot right you know just like i said it's these these little tiny precision and i think that's probably one of the best words uh dr chiba i'm going to ask you as a general surgeon we've been talking a lot about the abdominal area yes and that's what you concentrate on but as a general surgeon when you were training when you were learning how to do this uh because we did talk about other systems as you had said were there other systems that you were interested in at what time um you know whether it was joints uh thoracically i can see that makes perfect sense if there's if there's a way not to open up that ribcage um in general no the only robot that i've been uh able to use is intuitive so okay even from the the first robot that i i got on was intuitive and so when you describe into it and i know dr farmy said that a couple of times too describe the word like what's the definition of an intuitive robot robotic situation uh versus when we were talking about joints when you're saying intuitive that it kind of it kind of not that it reads your mind but it it uh to win i think intuitive it's like well it's just a natural thing that your mind knows how to do so describe what the word intuitive robotic system would be versus another robotic system in surgery is that it's a hard question right is it just marketing good marketing yeah the robot is it's called intuitive surgical that's okay yeah that's the robot right because i'm just thinking it's like sure though well how can it be intuitive on its own because either way you guys are operating it on the outside so um but you you said the only robotic system that you have is abdominal and intuitive so to speak would you ever because again i'm looking at you like like you're 12. you've got 100 years still to go um are you interested because i'd like to talk about the future and i want to ask you some questions about the future too would you be interested in other surgeries as a general surgeon of different systems that aren't abdominal and and how do you foresee that coming about like a knee replacement for example yeah not laparoscopic but right those are used by orthopedic surgeons so i would not be using those joints but yeah as as even the uh orthopedic surgeon robot gets better maybe that technology can be used in in abdominal robotic surgery as well so i think just in the future you just have more technology and you can apply that onto the the current robot system and just make it better and smaller and improve the the robotic platform and the whole laparoscopic platform basically you know i still picture for those of us that are old uh star trek and there is was it bones the guy that is the doctor you would just go over somebody's body and fix things you know sometimes i feel like that's a place that we will be 50 years from now and i think just the robotic system starting us off with that is where we're going to be eventually dr de la rosa just because i look at you and remembering your face being one of the people that i interviewed regarding this where do you see with your practice with ob gyn where do you see robotic surgery being five years from now we can look at 10 or 20 years from now but just five years from now i think that's realistic to see with you you know the trainings that you're doing right now well my specialty i mean like i said it's pretty much becoming the the gold standard i mean there's still people that are it takes it takes dedication to get trained and become proficient some people haven't gotten to that point and um you always heard you can't teach an old dog new tricks right there's some people that more has um are hesitant but even our college acog american college philosophers obstetrician gynecologist they're saying that they released a statement that if you can't do a minimum invasive surgery you maybe should refer to another physician that could so i mean that coming from our own college is a big statement so i think um and now that we have it in residency programs it's pretty much becoming standard pretty much everybody's going to be doing it in our specialty now we all have different areas of expertise and even within ob gyn we have fellowships and people specialize even in greater so everybody will have their place but um it's just going to grow and grow and another thing that sometimes we don't mention is as a surgeon i know a lot of people that were kind of slow to adapt it are now coming along because you don't realize how much of a tall surgery puts on our body a lot of us have back problems neck problems right yeah bending over for hours on end during surgery so two benefits it protects our back and neck it eliminates fatigue and sometimes you think that's just a benefit to us but even for patients it becomes a benefit because first question i get asked a lot of times in the morning when i go to the patients is did you get a good night's sleep you know so when you have five five six points when you have five six kids last night when you have five six cases in a day right your last case you want to be as fresh as you were your first case absolutely that even eliminates some the chance of complications just just um good old fashioned human error yeah right so here here's a question uh and it may be a marketing question and i don't mean it to be that way at all but when patients know that they have a certain surgery they need to have do they where where is the coaching and or the discussion conversation with that patient of are we going to do this robotically are we going to do it the old-fashioned way i don't even know what the old-fashioned way is anymore but and i'm throwing that out to anyone who wants to take it so when you're having a discussion with a patient and let's say gallbladder because i feel like you haven't had a lot of time so i was thinking about that where are you okay so someone has to have their gallbladder out and um they're and maybe this is perfect timing for you what are the different ways to do that yeah and what's your preference and do you suggest a preference to the patient like how how is it that they come up with that decision yeah so there's two ways of doing it one is the old way which is open which is you make a very large incision basically from your sternum to you know the bottom of your rib cage and no one really does that anymore unless you really have to uh and the standard is to do laparoscopic surgery at this point and i let them know that robotic surgery is kind of an extension of laparoscopic surgery uh so similar number of holes uh they're all typically about eight millimeters except one um incision is a little bit bigger again to take the specimen out literally the incision that we create is much larger than these stones that these patients have so to the patient it doesn't really make too much of a difference because the incisions are extremely small and i just let them know that it's a type of laparoscopy and that it's using the robotic platform and patients don't really have any any issues with that and with recovery time might that be something i'd imagine everyone's interested in recovery time you know how how how much is it going to hurt how much am i going to bleed how much recovery is there what is that discussion yeah before before open versus laparoscopy you know open surgery with with the gallbladder taking out the gallbladder they have to be admitted a lot of narcotics uh but with uh robotic surgery and laparoscopic surgery i typically only give them very minimal like five tubs of narcotic and the rest is motrin wow and i hardly ever get a call saying hey can i have more it's extremely rare very nice so there you know with all these narcotic reducing protocols it's extremely important to do laparoscopic as well excellent uh question here from the audience the uh person on the line is 79 years old had a hysterectomy at the age of 27. so very young don't know what the circumstances were uh had endometriosis so dr farnham you get this question um so the way it's described hysterectomy at 27 with indo endometriosis indro oh my goodness gracious endometriosis ii it says here uh to the rectum so i don't know if that's how the surgery and then ever since she has had issues with constipation is there a surgery to address this again there's a lot going on there and this is a disclaimer that i didn't do but i usually do there's a lot going on here that we don't know so we do the best that we can to answer um just respect your question and answer that so what might your suggestion be to that question there's a lot going on so there's a lot going on yeah and um you know the severity of the disease would have to be pretty bad to have a hysterectomy to have that type of definitive surgery at that age at that age at 27. yeah i will say that endometriosis is mostly a reproductive disease now there are certain case reports i guess you could say where there's active disease after menopause but really endometriosis thrives and grows in the presence of the normal cyclical hormone production so during reproductive years that's right okay so after menopause there's a great amount of symptomatic relief if not symptomatic resolution on its own now again there are case reports a few cases where it's still active after uh menopause and actually it can uh be stimulated by hormone replacement as well um we also have to keep in mind there are other organs in the pelvis so this could be primarily a bowel condition um bowel cancer irritable bowel syndrome diverticulosis diverticulitis um it could be just the scarring that occurred from the original surgery could be causing some bowel symptoms so that's a good question there if there is scarring there is a way to remove scarring surgically or if they're not again those are again this was done a long time ago so yeah bottom line is she needs to go and check out we need to have a workup and it all likely had a multi-disciplinary workup um but based on the likelihood of someone having active endometriosis disease like years and years remote from that decades removed from menopause it's unlikely that that's the culprit but um you know there's going to be exams studies imaging probably colonoscopy different tests that can be done and unfortunately for just scar and adhesive disease when you take the adhesions down lysis of adhesions many times they just grow back so usually an intervention's not done for adhesion unless it's causing like a obstruction or an illus of the bowel like it's actively affecting uh someone and in those circumstances they should become acutely ill quickly that fever throwing up and would necessitate a hospital visit so okay another question here from the audience this kind of goes to uh urinary issues you can have it again or i'm going to give it to dr dela rosa or dr chiba whichever one of you would like it 67 year old person uh female prolapse bladder again after having a surgery 10 years ago for prolapse bladder her question is again we don't we don't know a lot but her question is is this something that you can redo again i don't know what her age was when she so 10 years ago she was probably so 57 that's pretty young too um is this something that again ligaments or ligaments right they're going to stretch even more so is that a common thing that you have uh the surgery once again i'm just throwing that out to anybody too dr dela rosie haven't talked in a while so that's kind of the way i do the ping pong table yes who hasn't talked in a bit well there's a there's always a chance of recurrence after a pelvic support surgery okay if you think about it public support surgery that's how i should have worded it yeah if you think about it um [Music] we're working with weakened tissue right okay right so sometimes um there's a lot of procedures we could do a lot of different ways to fix things and sometimes most of the time we're working on weak tissue so there's always that chance it's right it could deal with genetics lifestyle the mode of surgery we did some are more successful than others sometimes we have to we have to help strengthen their tissues with the uses of meshes and stuff like that but that's kind of there's some other issues involved with that but um it is fairly common for for ladies to come back for and that doesn't make sense to me it's just wear and tear and stretching and dr farnham i mean i think he's exactly right i mean you look at the each type of procedure um success rates like a bladder lift by itself 50 a bladder lift with apical support with native tissues about 86 percent and a bladder lift with meshes and tony was saying probably 92 but you know i would also say i mean it's hard to study anything for more than five years we have a couple trials that went out to 10 years and success rates were still you know 80s something like that but there are going to be recurrences and it's like you know you you don't take your car and you get an oil change and you're good for life or maybe in this in this case a timing belt right eventually there's going to be wear and tear and prolapse can occur around the repair that we already did right that's an excellent point so and i'm thinking too because there's mesh and so i'm thinking is there a prosthetic ligament but i guess that's what would be acting the mesh would be acting as something that's actually lifting and then here's my question attaching where where do you attach what too does that make sense so if you've got the mesh are you attaching it to the ligaments are you i'm just trying to picture it this is where i wish we had graphics and and pictures to see it um but describe physiologically what's being attached to what inside the body um so we'll talk about probably the the primary repair is called a sacrocopalpexy which is a mouthful so it's called really slow okay so it was three words so sacro sacrum culpo which is vagina and pexi means tie together so sacro culpopexy so we introduce a safe mesh type 1 polypropylene mesh extremely low risk of erosion infection pain we'll take a quick aside so there was something called vaginal mesh and had a lot of complications 11 approximately need for re-operation whereas the normal operation rate is about one percent so a lot higher right right and that there was a stop sales and manufacture order from the fda in 2019 so that's not available so anybody who's wondering you couldn't have it if you wanted to have it okay this surgery sacro culpopexy has been around for six decades so this oh my goodness very proven therapy um with erosion rates one to three percent very low um and then recurrence rates like i said about eight percent uh but what happens is we introduce a it's kind of a y shape uh one arm of the y goes to the anterior aspect of the vagina in front of the bladder the other end goes um poster or back side of the vagina uh in front of the rectum and then the third arm of the y is attached to something called the anterior longitudinal ligament so it's just a well it's the strongest ligament in the pelvis that's why we use interesting okay that's um kind of on the you think about your spine and then um there's bone and then there's ligament on top of that so the transition between your lumbar and sacral spine uh l5 s1 uh there's a very strong ligament there and anatomically that pulls it in the exact direction it needs to be in and so the next time we do this show you guys have to bring pictures yeah i was hoping yeah this is yeah just because it does make all the sense in the world you're thinking or at least i'm thinking there's all the organs are in there and they all have their special place and on that note too there is a individual in my office that had a hysterectomy and the idea was and she visualizes it like this because her doctor described well now that the uterus is gone now the organs that were kind of pushed aside by the uterus need to find their space and dr dela rosa we talked a little bit about that earlier how does hmm how do i ask that that's not a recovery period but how long does it take for your abdomen or dr chiba maybe you can talk about that to find its new normal with the space that that that is now missing it's pretty much immediate yeah okay now there's going to be different sensations right after this like that the the compression belt though that she was wearing for a while and like i mean i think a lot of that comes from the surgery itself we're cutting we're cauterizing tissue there's going to be inflammation there's going to be pain involved a lot of the sensations they feel are due to the surgery the bladder lies on top of the uterus so when you remove the uterus the bladder kind of is hanging out there a little bit and you have changes in your urinary stream sometimes changes in how you how you defecate um some a lot of ladies think that they're going to feel hollow because an organ that was there wasn't gone but if you think about it your intestines are shifting all the time if you lie on your side they're gonna lie one way you turn around the way they come so you just kind of fill in there yeah okay and then they think we're just little a little bit less there to deal with um they're we're kind of at the point where i'd like to just not ask questions from the audience anymore but see what each one of you want to talk about before we get off the eggs we've got about seven or eight minutes or so so dr shiva i'm going to start with you because i feel like i haven't i haven't asked enough questions of you um and we did focus a lot on ob gyn stuff but in general is there anything that maybe as you're driving over here maybe i shouldn't because he's not the veteran that's not fair you know what you don't have to go first because i hate that in the school doctor you get to go first um is there anything that we haven't talked about yet that you'd like to get across uh before the end of the program um we could talk about like where we see ourselves going in the future with robotics and um is there gonna be a time where there's no doctor don't say that that freaks me out i think that's going to freak everybody out yeah stop um but no i think it's a process of automation creep if you think about with a car you had like uh adaptive cruise control and then rain sensing headlights and and you can sense the lanes that you're driving in and all of a sudden we have a self-driving car but was it really all of a sudden it wasn't there were all these little adaptive things that occurred over time and that's kind of what we'll see with robotic surgery and at the heart of it you know even with ai machine learning deep thought it's going to be really hard to replace a surgeon's intuition um and so that's where the intuitive question goes what does he mean by that i'm not sure intuitive robotic surgery but it'll become uh more and more things that we do in the surgery will be automated but it will be to make what we do better just as the robot makes surgery better compared to laparoscopic okay makes sense now dr chiba now you're on the spot okay i know we're talking about robotics here but i really think that you know not all surgeries should should not be done robotic there are some cases where they come to me and say hey i want robotics for this but i say no you know for for this specific case um you know open surgery would be the best best choice so i wouldn't say that you know if if they go to a doctor and they say they don't offer laparoscopic surgery or they don't offer robotic surgery i don't think they're it's not in the wrong for them to to say that i think i don't think i don't want everyone to say oh i only want robotic surgery because that's an excellent point right so on that note as an abdominal guy what surgeries would be best not to do robotically well that really depends there's a lot in there having said that i do do a majority of my surgery robotically you just think the abdomen there's like everything in the world in there for example you've got livers you've got you know the duodenum you've got all kinds of stuff in there yeah i think i think the easiest uh example is is hernias you know right okay good majority of the inguinal hernias i do laparoscopic but there are uh you know we have this umc and trauma center and they have a large incision they've had five incisions uh in the past you know that patient is not a candidate for robotic surgery in fact robot robotic surgery may be a little bit more dangerous for the patient so it's it's case by case okay nicely put dr dela rosa you anything before we wrap up well one way of dealing with that the the complicated things i think a lot of us will do uh laparoscopy insert a scope and see if it's something that could be done most of well at least i'm talking in my specially the gyn surgeons i know most of the more the ones i've i've gone to a lot of conferences seen seeing the experts and most of the those experts are all in meaning they'll do anything i mean it's worth the try of course you're not going to do anything dangerous we're going to put the patient but let's say the big giant uterus a lot of times i love how you say that the big giant uterus you look at it you think it can't be done but sometimes you're able to be me personally some of the cases i've converted even though i've had to convert they still got to benefit from the robotic surgery because instead of having to make a big incision from the from your pelvis up to above your belly button right i could detach the uter part of the uterus and it lets me use a smaller incision even though i still open right it's a smaller incision that that i would that that i needed to use compared to if i would have just done the whole case open so even in those cases there's somewhat of a benefit and every time i hear a smaller incision to me that's less recovery time less i don't know idea for infection we've got a whopping 45 seconds let's talk about infection rates really quick and dr farnam you're on for that regarding how small the incisions are and recovery time uh so we published the largest retrospective study on hysterectomy in 2016 and in our seven case observation centers we showed that the surgical site infections were less with robotic compared to any doing any other way laparosco hysterectomy laparoscopic vaginal um or open okay and that again it just makes sense the smaller the incision is and the cleanliness of it too i mean we're looking at less stuff in the way so we have less than a minute so i don't have enough questions or enough time to ask another question but i do want to say thank you very much what i do want to uh do again is you can watch this program again sometimes things go so fast you may have tuned in late uh pbselpaso.org you can go to that site and just look for a watch and i'll pass a physician you can also go to the el paso county medical society website just think of that acronym epcms.com and watch this program again and you can also watch it again via youtube and usually you can find that under el paso physician and honestly there are quite a few pbs stations around the country that air this show which is great because the words el paso in there but thank you very much to dr farnham dr chiba and dr dela rosa and a big thank you also to gracie and valeria who have been helping out with phones this evening as well you've been watching the el paso position i'm katherine berg and have a great evening good night so [Music] [Music] you