2025 Pediatric Surgery Update Course - Robotics in Pediatric Surgery: Which indications benefit the most?

We are, I told everyone this goes fast. We're going to move on to the next one now. We have Dr. Juan Guria from Cincinnati Children's, who's going to be talking to us about robotics. There you go. Thank you, thank you, Todd. I love this meeting. My goal is for you guys to convince me to draw robotic surgery. Because I'm about to ask my boss right there for a new robot. So, I'm just going to grab it, fire robotic stuff. OK. Who is a robotic surgery here in the audience? The ones who are not lifting up their hands, who has a robot available? All right. So, for the audience, four people out of like 30 or so raise their hand that they have done robot. And another 12, they have available, but they don't use it. Why not? Sizing kids. OK. Convince me. Convince me for that. OK. So, three-year-old 15-kilogram mass, who is a candidate for robot case here? Call it a total of six kilogram, baby. 11-year-old, medicinal, obese, 15-year-old, galsam-panker, tightest, horrible gold ladder. There's nothing like a leprosy. Mexican robot right here. I love this galsam-pank, perfect-ish robotic, right? You go a little bit to the right, take care of the gold ladder, forget about the pancreas, never mess with the pancreas. So, why not the other ones? All these are perfect cases for a robotic approach. Six-kilocal-local cyst, perfect-case for robotics. OK. Adrenal mass? Perfect. No elastic tumors confined to the adrenal mass. Perfect case. Dr. Andrew right here will not let me lie about that. She's using it for this. OK. Excellent. Repi-fire a lot of pros. Some cons, but convince me, if you don't agree on my pros, please let me know. Perfect three, the perfect visualization, tiny stations. So, once you see them in the clinic, they're as tiny as your five millimeter port. OK. Please close the fascia. All the other stuff. Yes. You guys know about degrees of freedom. I'm not an engineer, but the hand has six degrees of freedom for mobility. Robotics has seven. That's unimaginable angles that you can reach with a robot of learning the diaphragm back near the cave for the right adrenal. You can do it. OK. That was my attempt for AI. So, some cons listed kind of like pros, but tell me about this. Shortening the learning curve. If people think I was going to take me so long to learn this robot, open to lab massive learning curve. Lab to robot. A lot of you guys do MIS. Now you have a 3D camera and a wrist inside that moves with you. Why not use it? The 8 millimeter ports? What do you guys think? Why don't people use the right people who have access to the robot who don't use it? Why don't you use it? 8 millimeter ports. OK. 8 millimeter ports and it's not cost effective for us or. We'll talk about costing the sick. Yes, boss. I don't mean this, but I'm sure there's people in this room in the field this way. I can do it as good laparoscopically as I can do with the robot. I'm just going to rip the bandaid off and say that, because I'm pretty sure people will feel that way. I love it. Let's talk about a media and archival ligament release. Would you guys do it laparoscopically or open anymore? Going back into that angle near the Ciliac trunk. Right? We will never do it lap anymore. We will never do it open. Use ICG to look at the vessels. It's game changer. So laparoscopic versus robotic. You have three, you know, you have your wrists. Have you guys been doing 12, 14 hour cases like this? You're sitting in your console head straight, next straight life changer. Right? So why? The concern I have is in order to, you have to have cases lined up to get the training. So you have to go through the training. Yes. And I can't think of enough cases where I initially would use this that they're big enough that it makes sense at the port size. So I would have to have three cases in big kids lined up to do this. That's my, why I'm going to do it. Three gold ladders to do. Line it up. You're not lifting the weight of the patient anymore. Are there FDA indications for the robot for pediatric surgery? Great question. Great question. No. Great question. No. And by the way, no robotic system face me at all. Disclosure. I have zero. OK. Now there's no FDA approval for it for pediatrics. But it should be coming soon from different systems, different consoles. So this is, so talk about training centers and how long is going to take me to be efficient on this. If we look at laparoscopic versus robotic, not only the learning curve is better, right? Your time to efficiency and time to reduce your operative times is way faster than laparoscopic after a few cases. So you're talking about cost. After a few cases, you're decreasing your operative time. Initial cost with robotic is high. I'm going to talk about that in a sec. But all the pediatric fellowships are integrating this. We're graduating currently fellows and since our children is training robotics for a reason. These things here to stay. Remember the first laparoscopic towers, right? You're like, nah, lap colony, don't do this. This is here to stay. We're getting more and more robots available, right? So you have a perfect deaf perception. Some people say you cannot feel anything. New systems, you can feel by the way. In the current system, you can tell when the citrus is about to rupture, express it a little bit of water out of it. But you get your feedback from your eyes. You get used to it. It takes only a few cases to do that. There's no tremor for the older guys back there, right? There's no tremor anymore, right? Yes, sir. So, speaking between in color, specific cases, color rectal, gold ladder, right? Lower convention, conversion to open in the robot than laparoscopy. Call this a text to me. Slower, violent injury risk, okay? Now, it takes longer to set up. If you train your system, if you train your personnel, it will take the same amount of time to change over, turn over the room for robot than for lap, okay? We're at 30 minutes currently. So, this is key in a gold ladder case. Cases needed for basic proficiency, 20 to 30 laparoscopy. This is the current numbers, robotic 10 to 15, is the increasing the amount of cases in half to go to advance efficiency and proficiency in a case, specifically for your trainees. So, that is going to decrease your operative times. That is going to decrease the cost of the robot, that initial cost, which is around 4,000 in most institutions. So, here is, if you train your, as we talk, 30 minutes for turnover, create a lean process. Don't open all the trays of the robot. Peel packing. You don't have to waste money on those trays. If you don't open them, they're on charger. They charge you by the use, right? Again, nobody pays me for this, okay? And I hope there's more robots coming, not only the current one that we have. I don't know if I should be showing these numbers. My boss will tell me this, but 4,000 more than lap, initial cost for that case. But each additional 15 minutes is its exact same as laparoscopy. So, when you review your operative time at the end of the day, which I checked, fact checked myself against my partners in gold ladders, I'm faster in the gold ladder with a robot than laparoscopy. I didn't want to show that because my partner is there. But that will, that will decrease the cost. So, speaking for Todd's, why are the cases, I don't have cases. Gold ladders, appendix, don't do it for appendix. Don't do it for appendix. And most people don't have a ton of gold ladders either. So, it's appies, hernias, and babies. It's a very simple operation. Don't make it complicated, right? Do more badminton or badminton or badminton. It's awesome. So, next year, I mean, like it doesn't, the cases you would do every week, unless you're getting a ton of gold ladders. Most pediatric surgeons have babies, and appies, and hernias. Well, let me show you some cases. The case is different. Let me show you some cases you're saying, I don't have the patients. This is from our institution, what have we done in the last year and a half? I'm not going to read them to you, but perfect cases. Time makes to me. Go for it. Time for my diurnal repair, not the newborn. Extra-lovers orchestration, right? All the urologist stuff, all right? There's no urologist here, but they love this robot. You can do everything there, right? J pouches, we have color recal surgeons here. What about, this is a picture from miles. Would you guys go in there, laparoscopically, in that angle? Can you do it? Yeah, we can do it, right? Have the time with the robot, then laparoscopy. That's the order on the C-electron. Funded applications, perfect case for a trainee, to make those sutures. We're getting me hernias, as Dr. Kutowals mentioned, perfect for this. Polidoclocyst, I cannot stress this enough, perfect case for robotics. Have you tried to train your fellows to suture that, the pedicure, not some laparoscopically? Can we do it? Yes, and we're very efficient at it. But this game changer for that, miles. Adrenalectomy, you guys have done it really well, like there, we do it too, and Cincinnati. I think it's a no-brainer. You can see those adrenal arteries being supplied by the renal and the diaphragmatic and the aura. You can see them live right there in front of you. What about pancreas? Weeple is coming in some institutions with all the distal tanks like this, it's planectomies, without a planectomy, is a perfect case. Fios partial adrenalectomies, you can see exactly well the tumor is delineative, you use ICG, no-brainer. Who's using it for tumors here? Other endocrine aldrinque? Try neuroblastic tumors, confined to the triothl, why not, in the chest, neuroblastic, vergon gliumas? Sure, we're expanding, is this a children's tetransmitter we've done, don't don't reflect on me. We're going to expand to liver, because imagine that dissection in the veins with 3D and wrists. Yes. Is it like robotic refractomies for smaller size tumors and robotic partial adrenalectomies are great cases to do that way? Yeah, some tips, some tips, because they're like, oh, 8 millimeters, I don't have enough space to do my four day recommends 6 centimeters. Select your patients well, take over early, with your trainees, you can just shut your charge right away, take over early, don't wait until I get into bleeding. Position patient first, then dog your robot. Play with your troker positions, does not have to be a straight line that they say. Play a little bit, especially with smaller babies. Only you only need three centimeters between the four, pull it back to the thinner line, that increases your angle outside dramatically. They don't recommend this, but it works. And there's no problem with your incisions. Use three ports when able for smaller kids. Is there a question? Comment. So one comment, you're talking about robots. So every I think in this room probably knows Yuri Kuzlov and Russia, he's done like 300 plus robotic case, he was in Phoenix while I was still there. And he gave a presentation, and we have about 10 general surgery resins in the room. And I asked him, what percentage of minimally invasive surgery are you doing robotically? And to a person, they said 75 to 80%. So whether we like it or not, the people that are me coming into our field to do pediatric surgery, they are not going to be doing laparoscopy. They're going to be doing robotic surgery. And so we need to embrace this and be prepared for that. Because otherwise we're going to try and teach them a whole generation of people who have never done laparoscopy. And we think they're good now, but they won't be good. They'll be used to in the robot. So it's the reality of where the futures headed in terms of our field that are doing robotic surgery. We're going to be doing it whether we like it or not. So we may as well embrace and start doing it now. Yes. First of all, I agree with that. I want to be a believer. But let's think of a broader scope. How could we make these international standards when the initial acquisition cost for this is so much bigger when compared with other MIS? I agree. And I agree with you. And I've trained through Mexico and Mexican. So I hear you. This is not a standard of care. We're not implementing standard of care. This is a tool. It's like when you bring your literature, I'm going to give a paper that I've a literature into the room, you bring the robot. It's a tool and aid to help you with efficiency, with cost, with getting to those angles to MIS benefits. It's just an aid, a tool that you can bring. It's hard internationally, of course, yes, it is. But you know, you need your backup from your institution, for sure. With Moore's law, every year technology gets half the size and less half the expense. And it's taking longer with robots. Eventually, there will be competing companies. The technology will cost less. And the size, I mean, I do think it's going to be a lag. It's great that they're competing, right? Competition is awesome. They're bringing better and better robots. I'm going to go through some of our recent cases. Sorry. Go ahead. OK. So I think we failed to convince you to drop robotics. I'm sorry. I might be the grinch of this talk. But why does robotics avoid the trial of the clinical evidence? Like everything we do. So I see lots of arguments, pros and cons. I've seen a lot of this enthusiastic. Of course, I want those angles. Of course, I want the ICG, the good view. All the things you said, it's OK. But I have seen very few clinical articles. And robotics is not that new. And the studies have been done. And it's always equivalence, equivalence, equivalence. And with that, I do not convince my hospital management, my manager, too. And I think costs are going to drop. But we should not be doing something because it's cool or because it's cheap. We should be doing business. It's better, but clinically proven better. So where is that? I think that is a key. And let's not get confused. We're going to turn them in guidelines. This is MIS, period. It's just like having a better instrument in your hands that gives you a wrist that gives you access to those angles that might have cost a bleeding otherwise if you're super stiff. But now you can get under that vein. This is not about being cool. It's about efficiency and outcomes. Less cases to prove it now. Less cases to proficiency. Less cases for the crystalline of say. Less cases to have outcomes. It does not even per outcomes in oncologic surgeries either. That's being published also, right? For certain tumors. So I guess this is not trying to implement a guideline. It's just a tool that would not make you cool, but it's proven to cause better efficiency, better outcomes in MIS. Why don't I put that back on my most honorable and assertion then? I think that the new generation, we're not going to develop a three millimeter robot, right? And we're not going to have three millimeter listed instruments. So what I'm seeing is the people that are coming across now and training from these programs where they're doing a lot of robotics. They can't tie. They can't sew. And they can't do that with a three millimeter instrument. That's going to be a problem because it's going to make their learning curve even harder. Well, we didn't know. It might be common. We were talking about the first lab for all scoops and also the P-Towers, new robots, smaller robots are coming. We just see the tip of the iceberg for MIS. I think also with the age of social media and patient selection or patient choice, people are seeking out. It's particularly in adult centers, where can I get my robotic whip-hole done? And I'm going to go to that center. And so this isn't going away. And I understand there's not a lot of direct comparison or science that shows it's superior by far. But patients are going to be asking for it. And as the technology improves and things get faster, I think it's going to be more. Yeah, this is a quick picture of the colorical cyst with the use of ICG. You can get really far backing to the head of the pancreas to get that tapering down. OK, so that will decrease your chances of having a cancer in the future. One minute left. I'm always on. The new systems are coming. They're already here. The fog you guys have seen. And again, I don't need to pay for this. Send hands, the mirror that like consoles, different open console technique, like tiny robots, like the one you see on your right to triangulate for a thyroid, for example, without a tremor, without chance of injuring nerves. So look at this. Japanese, they have pneumatic systems. I reduce the force application of 83% and we tactile sensors. So things are coming. Things are changing. We're going to have a talk on AI. But image guide of robotic surgery, right, for vessels, for tumors, for lymph nodes, is here to say, I hope I can convince you about this. Yeah? All right. Thank you.