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>> Well, hello and welcome to HealthLine this Tuesday evening.

I'm Jennifer Blomquist.

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>> So again, we keep that phone number up at the bottom of the screen throughout the hour.

Why don't we go ahead and meet our guests tonight it is Dr. Michael Grybowski who is a surgeon we appreciate you coming on.

Thank you.

Thank you so much.

We are going to be focusing on robotic surgery tonight and I have to tell you I've been doing this show 16 years and it's been quite a few years since we've talked about robotic surgery and it was with an OBGYN and it was kind of in its infancy years ago when when the physician was discussing that.

But I know it's grown and you do general surgery so you probably have many different applications for it.

>> Yeah, I think robotic surgery definitely has really hit an inflection point over the last twenty years.

If we even look back and you go back to the history of surgery, really modern surgery is probably only 100 200 years when we started to develop anesthesia and different techniques with antisepsis and it's really been the last thirty years where we did minimally invasive surgery like what we call laparoscopic surgery, doing surgery through small incisions to access different body cavities and do different procedures.

And really the robotic surgery like you said was developed in the late 90s early twins the robot the dominant robot company talks that they were aiming for the heart they were looking to do heart surgery with the robot and they landed at the prostate because that was kind of where it took off.

But since that time, other specialties and other procedures have really flourished with the robot, one of them being gynecologic procedures such as the hysterectomy.

And in my world it's really general surgery.

It's gallbladders and hernia and stomach and bo and different types of indications mostly in the abdominal cavity.

Yeah, yeah.

So it's really and the rapid growth that has occurred in the last five or ten years as technology has caught up and then really looking at what the future holds is really where I think there are so much value the interface of technology, artificial intelligence, the robot and health care is just I think you're going to see an amazing thing in the next five, 10, 15 years patient outcome, patient care.

>> And is this something that a lot of physicians specialize in while they're in medical school?

Because obviously when it came out like in the nineties late nineties there were already so many people who wanted to use it but were you know, had been out of medical school for a long time.

So is the training difficult or lengthy and how much harder it is for you?

>> There's definitely a learning curve.

Well, I unfortunately or fortunately date back to the 90s.

>> So when I came through training minimally invasive surgery or laparoscopic surgery really was just beginning and so I was able to learn and train during my residency then and then in today's world there was kind of a gap where there was a lot of laparoscopic or minimally invasive surgery as the robot came into the forefront, people didn't want to use the robot or they needed a training or there was a big learning curve.

Where were surgeons really had to spend many hours doing the cases till they got proficient had great outcomes in today's world our trainees are students or residents and such pretty much are starting out on the robot and the technology of the robot and technology where they can go practice and do simulation in non-operative settings in lab and get proficient kind of like doing where you go to the driving range and perfect your golf swing maybe on my golf swings never gotten better but nonetheless in surgery it can measure how well you're doing and learn.

So I think the rapid ascent or the degree of learning curve that we used to see is much less today and it sounds like it makes a big difference for the patient because when we first started doing programs about it, you know, like it was like I said an OBGYN was just saying, you know, if somebody had to have a hysterectomy the incision could be almost like hip to hip that which is huge and then you know, the robotic change is all that.

So what is the impact on the patient in general?

Is it I mean what's why does it make such a big difference to have a really small incision versus a bigger one?

>> Yeah, I think the combination of the minimally invasive and robotic surgeries no one from an incision perspective so a healing perspective, a complication perspective and then even a real length of stay.

>> So many things today even though our hospitals are full are done on an outpatient basis .

>> I'm amazed.

Yeah.

Things that we wouldn't even have fathom that we could do where you can take out a section of intestine and put it back together and especially with the robot you can kind of stitch internally even extract the piece that you took out through a body organ.

The patient goes home the same day things that when I was in medical school or training nobody would ever thought of you.

You look like the Obi Joanne had mentioned to you was a giant incision.

>> So we just see so much better patient outcome, less pain.

You know the whole opioid crisis.

>> Most of our patients with robotic surgery don't require opioids.

Don't you know a lot of them get away with Tylenol and inflammatories like NSAIDs and such.

So it's really transformed how the patient and what we can do for the patient and state keeping them out of the hospital hospitals are wonderful when you're really sick but they're probably not great places to be if you don't need to be there.

>> Well, and I know our pediatrician made a joke one time about if you're looking to get some rest, don't go to the hospital because they got they have to come and check on you so much.

It's really not a very restful environment surgery.

>> You get more sleep at home.

Absolutely.

Yeah.

What about just even like you said would most of these robotic surgeries because I was just reading an article recently about how ambulatory surgery centers are such a huge trend and we're seeing that in our region a lot of places where it's just you're in and out today.

So is that where a lot of the robotic surgeries may happen or are there typically still done in the hospital setting?

>> It's a combination and depends somewhat on the region and the makeup of the surgery centers with the health system here in this region.

It's still a lot of it's being done in the hospitals.

But I think again you'll see a rapid development of where the robot one of the rate limiting steps was the robot itself or the predominant robot in today's world was very expensive unit and so to put it in a surgery center was a little cost prohibitive.

What we found over time though is the benefits that you get from, you know, being able to do things on an outpatient basis, a better outcomes, whatever by far mitigate any cost there because of the advantages you see.

So I think you will continue to see a world where complex surgeries and complex robotic surgeries will be done in the hospital.

But for a lot of the majority of surgeries that are done especially outpatient now will all continue to transform to an outpatient you know, a more positive setting for patients?

Well, I was wondering too about insurance because that's a big concern especially for some of these retired .

So are there because it's a newer thing is that an issue for people or do I mean do you still do a lot of surgeries?

You still have the option of doing it the traditional way versus robotic you?

>> I think you still have the option although these are generally covered by whether you have traditional insurance or Medicare or such and usually the cost or if there is an added cost would be absorbed by the health care company that where you go to.

>> But I think the advantages and so even the insurers and even the government is seeing the benefits that we're achieving with minimally invasive surgery and what we can do today and then with some of the newer technologies that that whatever cost is is offset.

>> OK, yeah I know that's always a cost is a big one.

>> Yes.

And health care costs are, you know, ever expanding like every cost when I go to Starbucks, you know my coffee costs more today but we are trying to mitigate that curve, that total cost of care.

How do we lessen it and decrease it as best we can and and even though the robot itself may cost a little bit more in the beginning long term it really provides a benefit to the patient and a benefit to lower costs for the total health care.

Sure.

Because you always have to look at the big picture.

Yes.

So I just want to remind folks that we have a quiet, quiet audience tonight.

We will usually get some calls by now but we have not heard from anybody so please feel free to give us a call at Doctor Grybowski could answer any questions you may have maybe something affecting you or a loved one or a friend somebody that maybe you could help them out by giving them some advice that you would learn from Dr. Grybowski.

So feel free to give us a call.

It's (969) 27 zero again if you're outside of Fort Wayne it's still a free call.

Just dial 866- in front of the phone number and if you're nervous you don't have to ask your question live no matter how you're going to ask the question, you talk to a call screener first a very nice gentleman and he will talk to you and tell you different ways you can get your information to us but we'll get your question answered one way or another and don't wait too much longer because the show goes fast.

>> It's only it only last eight o'clock.

So I was going to ask you about what things are looking like in the future.

>> You know, you had mentioned and that's kind of makes sense I guess we had the Organa because that was a lot of the abdominal type of surgeries and you had said the at the onset that it was the hope was that they could do heart surgeries with it.

>> What do you see on the horizon at this?

Yeah, I think there's just so many opportunities continue to expand what we're already doing which kind of really there's not a whole lot of limitations on the surgeries that can be done with the robot.

Still heart surgery in certain extents has lagged behind it for certain aspects of it.

>> But it's really kind of where the technology is going to go when you interface artificial intelligence and I use the analogy like you know, we always get a lot of bad press when a Tesla drives off the road and they talk about that.

>> Right.

But the reality is a Tesla a car like it that has all those sensors, it has all the that technology and it really makes driving safer.

It can stop the car.

It can recognize objects.

Yeah.

And the same things happening in robotic surgery.

That machine is getting lots of data and with artificial intelligence it can analyze and say that's a cup and I need to be over here.

I need to lift it this way and it will limit the variation.

There's a quite a bit of variation in the same surgery depending on the surgeon, depending on the patient, depending on various things and if we can narrow that variation we can lead to much better surgery, much better outcomes, lower cost and I think all those things are really converging here currently and then we're seeing for the future I think it's really, really exciting what can be done, how well it can be done and what it holds for patient care.

>> I'm glad you brought up that analogy of an electric vehicle because that does seem I was leaving church.

>> This is a couple of years ago and I thought what this car was just there was nobody riding it and I was like my family.

>> I like get on the sidewalk, you know?

And they said Mom, it's my kids who are grasping this technology much more than me and my husband.

They they were fine.

They're like it's OK.

It's you know it knows what it's doing and I think we forget about human error.

You know that these machines can they're above that.

>> Correct.

They really can limit and they're constantly being able to navigate that and really robotic surgery is truly robotic assisted surgery.

It's not like the robot or the machine is doing it.

>> Yeah, it's not like a Tesla driving autonomous.

It's really robotic assisted surgery.

The physician or surgeon is still in control but if you just like when I drive my car home that I hopefully those assist devices will keep me in the right lane and do some things that will make it safer for me.

And really we're seeing the fruits of all that coming together health care as well.

>> Yeah, they don't just stick in a room with a robot.

So I should clarify that there is still human intervention by physicians.

Yes, we do get a call from the name Leslie.

She wanted me to ask it for her so she's asking what is the difference between outpatient surgery and inpatient surgery and is robotic surgery possible for outpatient surgery?

>> Yeah, absolutely.

Robotic surgery is most commonly done as an outpatient for most procedures.

What probably determines whether or not you need to stay as an inpatient in the hospital overnight or several nights is depending on the type of surgery, the complexity of it, the size of the surgery, different things but so many things that we used to see just one or two or five or ten years ago that were things that people stayed in the hospital for three days, five days, ten days.

We found that we can mitigate all that now and I'd say that 80 percent of those surgeries are more are outpatient people come in that morning, have their surgery go home and and we can also really improve their ability to return to their normal function, normal activity, work status.

So it's most dependent on the type of procedures done and then somewhat dependent on the patient.

>> Yeah, and I'm glad you brought that up about the recovery being slower because that's a huge along with cost I think a lot of people just don't want to lose out.

Well I don't want to miss out on work that's difficult for some people and then just they want to get back in life , you know, they don't want to have the three month interruption with, you know, having to I guess get everything back to normal.

>> Yeah.

I mean I think back to when I was a kid my father had a hernia surgery.

It was old fashioned and hernia surgery.

>> They actually brought him in the hospital the night before and they kept him on bed rest for like six nights and then my gosh, couldn't lift a glass of milk for like six weeks or so we've been able to mitigate a lot of those things and get people back to work not having them lay in a hospital and so it's really continuing to revolutionize where we're headed with it.

>> Yeah, now we do orthopedic shows regularly and I know those guys are always saying like that hip surgery I mean they're in and out in a day which again yeah you would think I would think about my grandparent in bed for seven days but now they get you within our hours.

>> Yeah.

So it's really, really wonderful.

Well and obviously it works because it's been proven to be beneficial so yeah we have another individual wanted me to ask a question for them so Roger called and he wants to know is robotic surgery recommended for back surgery such as spinal stenosis perhaps a disk issue with with that?

>> Yeah, So I mean robotic surgery is really kind of manifesting itself in so many areas including spine surgery really where is the benefit in the spine surgery world is allowing those spine surgeons to use much smaller incisions.

One of the big hangups and one of the complications of spine surgery is if that wound gets infected especially if they put hardware in there no to what is being done with the robot.

>> It's much more precise as some of those screws and plates and things that are done in spine surgery or even kind of taking out the disk or where it's pressing on the nerves can be so much more precisely with the roboticists because it interfaces and takes the X-rays or MRI that you have and can put it right into the machine or imaging and then the robot arms themselves can be guided precisely.

>> Whereas again, you know, human interaction and human not so much error but variability is taken out of play.

>> Yeah, no that is anything related to the spine to is very delicate surgery.

Yeah.

So I can understand why that would be beneficial at this point.

>> Do you feel like there are any patients that if people are listening to this do you are there is there anyone across the board that you say that's just not a good fit for robotic surgery or certain fields or certain?

>> Yeah, not a whole lot.

I mean it continues to really expand probably one of the limitations would be access to that body cavity, whether it be the abdomen or the chest or whatever and people that have had maybe multiple surgeries where there's just not the space to get those smaller instruments in place but even newer things where we're doing things through the scope like when you have an endoscopy to look for an ulcer or colonoscopy, the things that can be done and what the expansion of robotic technology endoscopes that can be done voluminously.

So there's probably not going to be any limitations in the future but there are still obviously are some today.

>> You know, does it expand beyond just traditional medicine like into you know, oral surgery, you know, things like that?

I mean I just think about that because my son had his wisdom teeth taken out.

>> Yes.

And I mean it was done though she did a great job.

>> The oral surgeon did a great job but I wondered yes.

So there is robots that are being developed to do dental procedures and especially for cancers of the mouth and the other thing that's being developed and showing promise to is to do like women with cancer and have a mastectomy doing it robotically which you would be how's that possible?

But they make a small incision in the armpit and essentially are able to dissect with the robot and some of the added technology that shows where the blood vessels in the tissues and the differences in the anatomy or it can dissect it out and that is starting to show some promise as well and with some of the other technology that is tied to the robot in the imaging, it can light up where the tumor is and more precisely identify for the surgeon where to go.

So I think all those things we probably will continue to see and especially in the next couple of years.

>> Yeah.

And is it is it something that we've been talking mostly about adult surgeries but what about in the field of patients?

>> Yeah, children yeah.

So children likewise they are also amenable to doing robotic surgery in certain areas especially in the abdomen cavity in the chest cavity and so again being able to you know, take all those little incisions and not having to open up a kid and have them suffer and also being able to do something more precisely or that doesn't burn bridges that later in life when they might need another surgery that you deal a lot with the scar tissue ,adhesions and things that would preclude or cause other problems in the future.

So yeah, we're seeing it in pediatrics.

We're seeing it in almost every transplantation like kidney transplants are starting to be done that way harvesting of the kidney.

So it kind of goes across all disciplines of surgery.

I think one of the other exciting areas is like in lung cancer where they can do essentially diagnose your lung cancer while you're still under and more precisely do it take you and then use the robot to take it out that same setting those were times where we would spend weeks between that trying to figure that out that and you know, there's so many horrible every type of cancers horrible that lung cancer I had always heard was just very difficult to treat.

>> And the surgery I had always heard was just miserable.

>> And the robot technology allows them to get quite a bit deeper into the lung bronchi down to where they are into finding these lung cancers so much earlier and thus making a much more curable much more amenable to surgery of surgery's indicated.

>> Yeah, you talked about you know, that maybe doesn't shorten the time of surgery like what would it require less anesthetic because that's hard on people being under the anesthetic here early on.

>> You know how we talked early about like learning curves and things.

So one of the downsides of robotic surgery in the beginning was it did kind of take longer because the doctors had to learn the technology had to learn how to do it.

Today's world though I think it's truly speeding up the or limiting the time because I agree with you being under anesthesia is not good for any of your time.

>> So being able to to diminish that with the robotic surgery we're going to see and using some of that newer technology be able to identify structures whether it's with the imaging that's overlaying in the robot when you're looking in.

The other thing with the robot that really was a leap forward from other minimally invasive surgery was its magnification is like ten to twelve times, you know, magnification and then number two it has 3D visualization so classic things we're looking really at a 2D picture on the screen with the robot.

You're really looking at a 3D picture and it's much more magnified and allows you to kind of really be able to pinpoint the anatomy that you need to see.

>> So when you're doing the surgery from your point of view, are you looking at a computer screen in essence in today's today's robots, most of us are looking at a kind of a computer screen in the general surgery type robots.

>> Yeah, you're kind of sitting at a console, you know, a few feet from the patient and you're looking at a screen that's in 3-D visualization and quite magnified and you're able to control the camera and do some things where historically you'd have an assistant, you know, controlling a camera and kind of helping you.

You probably have a lot more autonomy which again gives you some flexibility in how you're doing the surgery.

>> Yeah, that's just just amazing to think about how and if you're saying this is just getting more and more sophisticated that it could just completely change all surgeries.

>> Yeah, yeah.

I mean it's really an exciting time and I think the other thing that we're seeing from the robotic surgery, you know, it's acquiring data all the time on the physician the surgeons motions and then tying that to the patient's outcomes and the cost of care and everything and really looking at how do we continue to refine that?

How do we make our our surgeries better more cost effective and most importantly to get the patient back to their best outcome possible.

So I was wondering, you know, when we have the orthopedic shows, you know, sometimes it's kind of a gamble.

They'll say you're not going to be if you're six years old, you're not going to go back to your back and to the same as when you were twenty five.

But I don't know if if robotic surgery increases the chances of just having better function afterward or.

>> Yeah I think sometimes depending on the actual surgery I think the precision of the robotic surgery really can increase function like in what robotic surgery really took off and in prostate surgery.

Yeah we're really probably helped transform besides the recovery part of thing was some of the urinary issues and contractility issues that men would suffer with after prostate surgery and really those things get limited again because you're seeing things so much better you're able to be so much more precise that we can kind of limit some of those complications that we used to see years ago and I think that also will get a lot better.

We see that in the orthopedic surgery world as well as the precision of how you put a knee or hip in if it continues to get better, hopefully you're going to continue to get a better outcome.

>> Sure, yeah.

And those guys are so busy they were field of orthopedics as a very busy field.

And the other thing real quickly I want to talk about was just we only have a minute left but just about you talked about a lot of people can just take over the counter pain relievers after leaving which is huge especially in light of all these addiction issues that sadly occur.

You know, people have been just fine and they have a surgery and they and they just can't get over the use of that.

So I mean even in the hospital, do you need you normally you're on like a narcotic something.

>> Yeah, through an IV but yeah, we've really diminished that.

>> You know, unfortunately early in the 2000s there was lots of things about pain was the fifth vital signs we were trying to overtreated almost and really the pendulum has swung back.

But I think we've gotten to a great place where we can really use a lot of things that don't involve narcotics, robotic surgery being an added tool in that by, you know, causing less trauma to the patient and so a lot of those surgeries and a lot of those patients even in patients were really able to diminish it.

Now patients need pain meds and depending on their condition.

But if we can limit it so that we don't see the after effects that we've seen in this country and elsewhere, it's really tremendous to be a good thing for sure.

>> So sorry we're out of time but this has been a pleasure to have you, Dr. Michael Hrabowski.

>> Really appreciate everything.

Thank thanks for joining us.

I told you if you watch tonight you'll learn something we always learn on this show so thank you again.

Thank you.

I'm Jennifer Bloomquist.

Take care.

Have a wonderful evening.

We'll see you next week right back here on HealthLine.

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