By Mona Orady, M.D.

There is still much to learn about the benefits and potential of robotic surgery.

Great things are done by a series of small things brought together.
–Vincent Van Gogh

We are still forming opinions about robotic surgery. Although the existence and progression of robotic surgery is undeniable, the question of a proper role within the spectrum of minimally invasive surgery is constantly under debate. To many, there is no definitive answer about robotics: Some believe robotic surgery to be too complex, too costly, a choice overload. Others believe it is a necessary option that provides answers that traditional laparoscopy does not. Both opinions have their place; however, having more choices in surgery is the natural progression of learning and making progress in providing patients with better options for surgery. Staying updated collectively is critical to caring for our patients and being able to offer them the best possible option for their problem.

Robotic-assisted surgery is still considered a revolution in surgery for many reasons. Watching videos and having quick discussions about this new application of minimally invasive surgery is not enough. Both methods offer a limited understanding about how different robotic surgery is instrumentally and how to maneuver a very different device than the ones used with traditional laparoscopic surgery. Robotics, by virtue of wrist-like instrument maneuverability and three-dimensional visualization, has returned both the advantages of the human wrists and the depth perception ability of eyes to the field of minimally invasive surgery. And this advantage is evolving—especially now. Soon, the addition of the sense of touch, as well as image guidance, will take robotics to the next level. We need to understand what’s coming.

This is why at MIS Week this year I’ll be leading an event called State of the Art Lectures in Robotic Surgery. New applications, advancements and options within robotic surgery are being presented constantly, and it can be tough to stay updated, so I’ve put together, along with the Society for Laparoendoscopic Surgeons (SLS), a multidisciplinary panel of experts in gynecology, urology, general surgery, thoracic surgery, cardiac surgery and others, who will talk about the most relevant issues in robotics that we are dealing with today, such as:

• The cost and value of robotics
• Complex robotic hysterectomy
• The urologic procedure that launched robotic surgery itself
• A technique for hernia repair
• Simulation for all disciplines
• The benefits of robotic bariatric surgery
• Robotic coronary bypass surgery

This series of presentations by the experts I’ve scheduled to speak at MIS Week will outline the very latest in the application of robotics to the each specific field in surgery. These lectures will help surgeons to develop a critical eye so that they can now advance in their adoption of robotics into their practice. The multispecialty nature of the session will allow surgeons of difference specialties to benefit from the experience and different applications in other specialties. So often, the solutions to certain problems encountered in one specialty application exist in the techniques and experience of other specialties. This constant interchange of ideas, techniques and experience is what allows robotic surgeons to push the limits of minimally invasive surgery using this remarkable tool.

Why is this so necessary now? Because there are many developments on the horizon, beginning with new FDA approved robots that may have new advantages or even disadvantages, and may have different applications. There is so much to anticipate, to learn, to look forward to and even to avoid. We’ll be talking about this and other issues because a lot of innovation needs to happen, and on behalf of our patients, we need to understand this together.

As we come together, we learn from each other’s knowledge, experience and insight. New issues come up all the time. As we collect and share new data, we really learn the benefits and risks in each area of medicine. It’s important to know what another discipline is learning—as it helps in all areas of medicine. I’ve watched as one cohort after another benefits and have learned which benefits the most and why—this only increases our efficiency. Interactive learning produces this important knowledge. I’ve watched as surgeons at all levels avoid complications by learning from someone in a completely different area of medicine.

Coming together we are defining together which robotic surgeries have benefits, which have challenges, and what applications are most important for each specialty. This helps each and every surgeon, regardless of his or her level of expertise. With new robotic technologies forthcoming and older ones evolving and advancing, we are all learning, together.

We come together not just here in the United States, but also internationally. U.S. meetings are fantastic for worldwide learning, simply because there are so many surgeons from countries throughout the world who come to our meetings. Major differences exist in residency training around the world, and the structure and quality of each country’s residency program differ, between the country and between centers. It is critical that a better understanding of the similarities and differences in robotic surgery training be determined so we can initiate better and more constructive discussions and commentary among training programs worldwide.

Coming together in these type of sessions helps us learn from each other: How to train, how to keep costs down, how to improve efficiency and reduce risks, and how to assist surgeons in credentialing. In reverse, learning only in isolation presents real problems. Simulation is a helpful tool, but true learning also comes from learning together, comparing our thoughts and our techniques, discussing and sharing what we have seen work and not work, is all important. Accessing the collective competency ultimately benefits all of our patients.

After all, robotic surgery is poised to change the nature of surgery forever. Getting out of your day-to-day environment and learning through other disciplines may be the way you learn the most.

DOT MED Healthcare Business News

By Dr. Raymond Lanzafame and Dr. Richard Satava

It is surprising to see how the understanding of certain aspects of energy medicine are not stressed during traditional medical training, given their importance in daily operations and in the surgery of the future. In fact, our identity as surgeons will eventually end up depending on it. You may think you know enough about surgical energy — but ignorance about the topic and its importance is common.

The importance of learning about surgical energy and its future is the reason we are highlighting these technologies in a exciting session being presented at MIS Week in September.

Critical to Understand
As most of us know, surgical energy and energy devices are essential in the modern OR, yet the vast majority of surgeons do not understand the basic principles, applications, and patterns of complications. When Pennsylvania Congressman John Murtha died in 2010, which likely involved an electrosurgical injury, it led to a renewed interest in both research and education in the safe use of surgical energy-based devices. If we can get the surgeon to recognize the patterns of the complications, they can begin to modify how they use energy-based instruments in the OR and avoid the very real risk of surgical energy-based device−related complications.

Surgeons currently are not required to train on specific energy-based devices or to document their knowledge of safety issues related to their use. There are approximately 40,000 burns by electrosurgical devices every year.2 During laparoscopy, 70% of these burns may go undetected. Safety aside, understanding the different surgical energies and the nuances of the devices used to deliver them is critical not only to current operations, but to a surgeon’s future in medicine. The use of molecular energy to operate is not far off.

It is important that we are well versed, as opposed to just generalized, in the mechanisms of the different types and areas of energy medicine application and research in order to understand the future. Our goal is to cover what is most important to know:

• How energy causes effects in cells and tissue, as well as learning the basic function of an electrosurgical generator is important to know. Understanding the applications of electricity requires a basic understanding of the effects of temperature on the cells and tissue.
• Understanding that electro-surgery is about the control of current density, allows the surgeon to increase safety and versatility.
• Surgeons are not specifically trained on the mechanisms by which monopolar instruments produce their clinical effects nor do they know their optimal use. Knowledge gaps remain common, and injuries are not rare.
• Knowing the differences between monopolar and bipolar instruments, and the basics of their application is key information that is necessary for the surgeon to understand how to develop and refine one’s surgical skills.
• Bipolar devices contain both the “poles” in the tip of the instrument, which focuses the energy delivered and reduces the energy required. This allows for electronic monitoring of tissue, with each manufacturer having a slightly different monitoring system.
• There are key advantages of the use of advanced bipolar energy, and how these devices and their effects are monitored is also important.
• Every surgeon must recognize the critical importance of ultrasound in the current and future practice of surgery. The majority of surgeons don’t have a minimum understanding of these technologies.
• Surgery by molecular energy is in our future, and knowing what is being studied and what surgeons can expect to be available for their use is crucial.

Being able to ask questions in a live setting can help us learn the latest and the future applications.

A New Kind of Surgery and Surgical Understanding
There is a science and an art to understanding electrosurgery. This involves the control of current density, that is defined as the amount of current per unit area of the electrode in contact with or near the tissue, and this is what allows the surgeon a more safe and versatile surgery.

There is much more basic education to cover, which will be accomplished during the session, but it is also vital to talk more about the future of energy medicine. This aspect of medicine should be incorporated within the curriculum of medical schools world wide, just as minimally invasive surgery was finally included in the 1990’s .

Molecular Energy
Scientists have long known that many forms of energy such as light and ultrasound can penetrate through tissues just as x-rays do (but without harmful radiation). By choosing the precise frequency and power of directed energy, it is possible to use it to make a diagnosis or to perform a surgery. This can be done seemingly instantaneously with a single instrument, at either the tissue, cellular or molecular level.

Directed Energy for Diagnosis or Therapy (DEDAT), as we now know it, was based on a concept conceived originally by Richard Feynman, who gave a famous talk on the topic in 1959 at Cal Tech to the American Physical Society. He inspired us to look to molecular energy to heal patients. Because patients are continually demanding progress, we believe that as strategies for using energy result in leading edge technologies, non-invasive surgery will eventually become a reality providing many powerful options in our tool belt as surgeons. During the MIS week session on energy, experts will be discussing how to present energy technology to scientists and surgeons in a way that summarizes its importance to the future of medicine.

How does it work? Nanotechnology involves the control of nano-materials and nano-devices, depending on the tools and methods for manipulation at the nanoscale. There is incredible potential in the manipulation of each molecular species, though at this stage it is still very difficult. But it is not far away. We are already making progress in the research of molecular energy and brain tumors, in optical research, and other areas.

As an example of some of the newer imaging research, broadband Coherent Anti-Stokes Raman Scattering (CARS) micro-spectroscopy is beginning to make an impact after more than a decade of instrument and method development. CARS can rapidly generate high-resolution images with high quality abilities. Raman spectroscopy is a laser-based technique that can be used to nondestructively differentiate molecules based on the inelastic scattering of light. While most of the existing instruments are prototypes being used in research projects, it appears that the relevant technologies are maturing at a rate that will allow commercially available instruments in the foreseeable future, making these remarkable imaging modalities widely available to clinicians.

There are advances in the surgical management of brain tumors, that are achieving more optimal surgical results. However, there is much more work to be done in order to identify and destroy tumors. Certainly, as the science matures, it will become an important component for identifying residual tumor and improving the surgical management of brain tumors.

There are other advances in various specialties, and we are now at a tipping point where we realize that energy medicine will be making great strides in the future. We want to be aware of it and learn all we can in order to be prepared for what we can count on—exciting developments in energy medicine.

About the Authors: Both Raymond Lanzafame, M.D., M.B.A. and Richard Satava, M.D. are board members of the Society of Laparoendoscopic Surgeons (SLS). Their discussion on energy medicine will occur at MIS Week in San Francisco, on September 7th, 2017.