Super Bowl Grand Rounds (10/1/2025)

Good morning. It's right at 7 o'clock and I'm actually going to start right at 7. Apologize for those still milling in or in the coffee logging in. But these are always action packed. I don't want to waste a single minute of the opportunity. Welcome to the new academic year. Some across the street would say today's the first fiscal year. I'm in Washington would say we don't have a government today. But there is lots of excitement going on here, which we're going to share. And so for those of you who are new to the environment, we have started a few years ago. This sort of new construct that we call informally super bowl grand rounds. We become such an incredibly hyper specialized set of specialists over the decades that we like to have our own grand rounds and conferences. And we spend our time with each other and don't actually know what's going on down the hall or in the next operating room with all the world experts that we're trying to steal our time from. At least that's the part I get. And so we started this. I remember back I was in medical school like at the children's hospital that said grand rounds. And every single person in the hospital went to the same grand rounds. It was obviously an era. And but it was really amazing how much people learn from other disciplines. And of course many of us work at interdisciplinary experiences and learn from people who don't have the same or certification that we do. And so we've decided to twice a year in March and October. Preschedule these out. It's hard to get all these people together to be in town at the same time. So a reminder up front after you see these if you think of a case a patient. Or one in your department please email me or have your chief email me and we like we really do try and keep a list of things in advance. It's very difficult to schedule and they don't have to be like you're going to see today interdisciplinary cases. And that's what we tried to emphasize to show how people work together to solve problems. But it can be if you just have just something that's crazy new and we can all learn from something innovative by all means. Let me know we tried to mix it up and try and be inclusive. Unlike most kind of formal grand rounds again by the speak you like bring your CV and I didn't necessarily for CV. We don't do introductions because we will not introduce these four people. The hour would be over before they start talking. Therefore I want to stop talking. They're going to take the first hour and they're going to each say like less than 30 seconds about their background and go into the case. Take away guys. Morning everyone. Our talk is called what is it where is it and it is a. An intra cranial extra cranial low flow high flow vascular anomaly will see how much clarity we have by the end of the case. I'm Darren or back from NERN's eventual radiology to pleasure to be here with my esteemed colleagues at Smith from neurosurgery. Danny Belkin from plastic surgery, the indomitable Alfred C from neurosurgery as well. And I'm going to jump right in. So what is the problem? This was a patient who was born with an obvious subcutaneous mass in the temple that was soft and fluctuating. It was seen on ultrasound just before birth. I'm not an ultrasound right after birth and initially it was thought to likely be a lymphatic malformation. It looked like it might have some internal hemorrhage and there was no evidence of high flow at all. And the baby was born and then it the local team watched it grow essentially and then at three months they attempted aspiration and sclerotherapy and the patient coded basically. There was dramatic hemorrhage during the case that does not exclude the possibility that it was a lymphatic malformation because sometimes these have very large veins within them and the patient can bleed a lot. So that was not diagnostic itself, but it obviously stopped the procedure and they resuscitated the patient. And they then referred the patient to the local neurosurgeon in Virginia who did an angiogram and saw these disappearance here. You see there's sort of a faint. This is a frontal view of a right external carotid artery injection. This is the middle men in gel artery and this was interpreted as a middle men in gel artery pseudo aneurysm. It's a little faint and hard to see, but the surgeon went ahead and coiled it. You can see the shadow of the coils right over here. This is the unsubtracted view over here and it was thought that that might be the end of the case. But the lesion, the subcutaneous lesion just continued to get bigger. So you can see what it what it looks like now on the coronal MRI scan. It looks like it's extra cranial, but now you actually see there's an intracranial component also that's going towards the middle cranial phospho over here. And they attempted an open biopsy and again the patient coded. So dramatic bleeding. They did not get diagnostic tissue. They resuscitated the patient again and they referred the patient to us. So the patient came to us at eight months and we started out with repeating the angiogram, which was interesting. So this is the external carotid artery injection and this is after coiling and you can see there's a very faint blush over here. Unclear exactly what that is or where the contrast is pooling. But the internal carotid injection was something I had never seen before. So here it is. This is a right internal carotid artery injection. You see the arterial phase, the capillary phase and then in the venous phase. If you watch this is all normal, normal and then in the venous phase, the contrast is spilling out of the venous sinuses just into open space down here in the middle cranial fossa and then outside into the into the sub temporal fossa. And here it is on the lateral view. Again, everything's normal in the arterial phase and the venous phase, but you see the contrast sort of spilling out. And I had never seen this outside the setting of trauma and a patient who looked totally intact other than this subcutaneous mass. So really very unclear diagnosis and unclear how the extra cranial component involved the intracranial component. We thought about all kinds of things like aggressive tumors that were invading the bone and. Invading the intracranial space unclear what what we would do or what it was. So now I will hand it off to Ed Smith. Dr. Robeck, so just to be clear, I'm the wringo of this little four group here. So one of the important things that Dr. Fishman mentioned is that it's very important, I think to understand that when you have complicated problems like this, one of the strengths we have here are children's as we can put together a team. And it was very insistent from Darren that we had a good acronym for the name of the team. So we tried to make sure you had that right. So the name of the team, we had the Peno team. But I you know what I want to emphasize here is that this is a really multi disciplinary problem. And one of the big differences that they had in I think coming here compared to where they were down in Virginia is that we really put together multi disciplinary team. We had Dr. Balcones you saw here, anesthesia was incredibly helpful with Craig McLean and Mary Landrigan from IR. We had Darren and Alfred and then myself and Alfred from their surgery. And I really can't overemphasize the importance of the nursing team here. Chris Benson who recently retired really led, you know, an incredibly helpful group of folks. And I think putting that team together, you know, making that call was was really important. Now really we're really happy about this. But one of the important things I think in assembling the team is, you know, we were able to perform planning. You know, the two previous times they tackle this, they both resulted in massive blood loss and codes. And this is a little bit about sort of how we rehearsed our talk here today as well. But you know, I really think it's important to emphasize that putting together the team was absolutely critical. I think to being able to deliver what I hope was a good result for this child. I tell all of my residents, you know, I'm not the best surgeon. I'm not the smartest scientist, but I hope the one thing I bring is a plan and working with these folks here. One of the great advantages was we really were able to put together a plan. And I think that's also really critical. What we ended up on here and what we're going to talk about for the final bits of the talk here include how we decided to tackle this and that leveraged each of our specialties. So the thought was to start with embalization with Dr. Orback and Alfred. Then to tackle that inside component that Darren showed you the big basket collection inside the skull by the brain. And once that was hopefully secure and safe, then tackle the large outside component subsequently with Danny. And so we really had put together a plan and another part that was key to that plan that we had that others didn't hear at children is the resources to make this complicated case happen. And that was the hybrid OR and also having a person like Alfred that can do that along with a nursing team that can make that run. So this was a really I think important deal to put together a strategy and have that ready to go now after this. You know, I think we can lead from there in terms of what we went and executing the plan. Alright, so the the initial Angie Graham images I showed you were from last August August of 2024. We put together this plan had multiple meetings with the parents and then they came here for treatment in December. And so this is the Angie graphic appearance in December and you can see it has dramatically increased. So this is a frontal view of the external carotid artery injection and again. It doesn't look it's hard to say is this a high flow lesion it doesn't look like an AVM. It's more like contrasts spilling into anatomic spaces and it again in a patient who looks intact. And this is the micro catheter injection you can see right there. This is an accessory men and geolartery of IMAX just spilling into that space. So this is not technically so challenging to treat. This is here's a glue cast over here in frontal and lateral view. You can see circled with red and it looks great. You look at the Angie the external carotid Angie Graham after the embolization and there's no more spillage. So is the problem solved. I was actually happy at this moment and Ed was standing in the room and he said do the internal carotid artery injection. It's not going to be fixed and there was one of the rare times in my career that Ed has been right. So here we are. Here's the frontal view internal carotid artery injection and here it is. It just continues to spill out really unclear why or how this could happen and here's a lateral view. And here you see in the Venus phase the contrast just spills out and sits there. Okay, and so now we're going to pass it off to Alfred or Ed or. So again, I think it's important to emphasize that we have some opportunities for improvement here and one of the things is certainly the development of the hybrid OR which many adult hospitals have had for many years, but certainly don't use very frequently. Brigham UIC in Chicago and MGH all have these facilities and they don't really know how to use them that being said. Figuring out how to use them effectively and to solve novel problems is one area and this is one of those cases, but actually how to use this more frequently to solve some actually routine questions and routine cases where people feel like there's already a great solution, but maybe they're not taking full advantage of the available tools is something that we hope to be able to expand upon and. Getting a great collaboration with our nurses to develop that experience and our radiology technologist who right now we only have two that can run this room is important and so using this room more and more it's going to be critical in getting this as part of a normal workflow for both neuro, but all the other vascular surgical divisions. So again, we show the size of this lesion on the axial plane really expanding that cheek here on both cuts and then we started off by not doing this training, but by getting intro, intra vascular access so we'd be ready to do the angiogram at any time or to achieve additional he must at a control if during the craniotomy there was significant bleeding. I'm going to step back for one second let I talk about this for this picture. Great. Sorry about getting this before your coffee. So one of the big things here was with our strategy we had to figure out how to get access to the part inside the head without poking the bear from the outside stop that would explode and bleed before we were ready. And so I'm talking with Danny and Alfred and others what we decided is that we could sort of essentially peel part of the face away the temporalis muscle so that we couldn't hopefully puncture the big bleedy part on the outside till we had the inside part under control. And what you can see right here is the nose is sort of up there and then we can sneak down under the muscle without getting into the big bloody part on the outside open a tiny window in the skull and then using the pictures that Darren had obtained beforehand. The goal was to be able to place a number of clips or cauterize the blood vessels that were filling that big sack of blood inside the head and turn that off so that hopefully we could confirm the inside of the brain was safe and to reduce some blood flow to the lesion before then Dr. Balcon can tackle the outside part. And this is where it was really critical not just have a plan to access it from the outside to get to the inside which was you know we did from their surgery but then to be sure that this was turned off very well during the actual procedure and this is the interoperative room comes in handy. And so once we get that craniotomy stuff done we sort of call to Alfred for help and I'll let him sort of walk through the pictures here a little bit what we did. So this speaking really demonstrates that rapid back and forth transition that is necessary in certain cases but as many of you have seen sometimes if you need interoperative imaging it may be just transport issue and a safety for anesthesiology issue but really within a few minutes we can switch from the surgical mode to the end of ask the mode and be acquiring these pictures to tell us where are we now at what stage of the procedure we now we see in the red box before we did the treatment. And then now you can see during the surgery all these staples here are securing the drapes in place we see some of the retractors which we partially moved aside but we still have some hooks over here as well as ultimately in a new surgical clip in this region pointed on here relative to the location of the coils that Dr. or back at place. We were able to see this vessel injected the carotid artery and the arterial inflow there on the anterior view and the lateral view and then play this out. And so here this is you know that final view after that dissection showing the isolation and lack of continued flow. We're very much blowing past the intracranial part but I do want to say and I'm surprised you know Ed didn't go through a little bit more details about the incredible work that he did intracranially in in fact figuring out a way to to get down to where this faucet was to turn it off was quite remarkable and required a lot of intracranial dissection. So I'm working with him. Once that was turned off though we turned our attention to the extracranial component as Ed mentioned a lot of this was intramuscular but we were uncertain where the intracranial and extracranial communication was and so as we dissected and peeled back the temporalis we quickly realized that the entirety of this lesion was actually intramuscular and then it wasn't possible to actually parse out what was muscular and what was this anomaly. And so ultimately we decided to sacrifice the entire temporalis itself and so as we were peeling down the temporalis into the temporalis faucet we found an absolutely huge vessel that was you know. You know, regular size that was connecting this intracranial component to the extracranial part. Ed and I were able to control that vessel and once that vessel was controlled we we turned off the faucet largely to this mass using the you know ligusher and using other sort of techniques we were able to dissect the mass free and and honestly figure out exactly where that large connection was. So what we did is we did a cranial plastic to close that connection we use some particulate bone to close up our exchange cranial plastic and you can see this is where we're coming across the the base of the lesion with the ligusher and you can see that it was a pretty massive resection we took the entirety of the temporalis muscle because the entirety of the temporalis muscle was involved. We don't need to go through the painstaking pathology but what I do want to point out is a couple of things. Expectedly skeletal muscle and lots of dense fibers tissue but there was also organizing thrombi and lots of calcifications and as you can see there is also these large venous channels with alongside intumal proliferation and lots of men and very little musculature reflecting these enlarged venous channels. There was also clusters of dysmorphic thin wall venous channels throughout and so I'm sort of painting a picture that brings us to our diagnostic challenge. We weren't sure whether this was tumor we weren't sure whether this was a vascular anomaly we weren't sure whether we just didn't know what this was and so we turned to one of the tools that was developed by our vascular anomaly center at Boston Children's which was a panel that we called Genva. It has 35 genes with known diagnostic and prognostic and orthoeraputic significance in vascular anomalies. This was set up by Steve Fisherman and Marilyn Leang within back and it's proven to be an incredible resource. It employs next generation sequencing. It doesn't look for the through the entire genome. It doesn't even look through the entire exal. What it does do is it does a targeted survey of the genes on this panel and by by really focusing where the sequencing is going to be it allows for an incredible in depth read with great coverage over these exons. And why is that important if you're looking for a variant or a mutation that's of low frequency you need really high coverage to in order to detect it and that is exactly what occurred in this in the situation. We actually identified two mutations in the same gene probably in the exact same allele in a gene called tech. This is a cell surface receptor that plays a pretty paramount role in vascular integrity and we know that this gene is mutated in lots of forms of venous malformations both germline and somatic ones. And so it's very interesting to think about this. This is a low allele frequency so 3.4% of all the reads picked up just about each of these mutations. Really interesting to think that in a somatic way meaning not inherited this patient got two mutations probably in the same allele in the exact same gene causing this very rare phenotype. What's even more impressive or more awesome about discovering the fact that you know what gene is driving this is that there are therapies that target this. And so we now have the opportunity through the molecular diagnostics to have a medicine that is effective against this this gene mutation that we can potentially use in the future. Should this legion recur should this legion become aggressive. It's an incredible opportunity that's been made possible by identifying mutations in vascular anomalies. Right so I guess we're sort of hopefully on time here but this is the jump to conclusions part for anyone is in office space but tough crowd are totally quiet. No, no, no enthusiasm whatsoever drinks from I also similarly want to say you know in terms of before we get to the conclusions. This is one of those cases where literally both times the child had an operation previously they had coded they had essentially almost died on the table and we were obviously very nervous and uptight about doing this case here. And despite that this ended up being a very boring sort of pleasant case where we're a joint joking in the room. I know it's unusually here that I would joke in the room but you know and I think it really highlights the fact that we had a very clear plan in terms of how to execute this. Right word but you know it really I think showcases the importance of having a plan in rehearsing ahead of time and it led us to I think the nice conclusion of this case and more importantly what we sort of learned as a team from this. So I think you know for the case specifically it's super interesting to a bunch of nerds like neurosurgery folks I are folks and plastics but I think the bigger lesson for this sort of grand round setting we're here as a team. Hopefully we never see this thing again and probably none of you were able to see this again and I think the bigger issue is what are the generalizable what are the important messages we can take home for all of us as we sit here in the room as you know Dr. Fishman mentioned bringing the group together from the start and you know Mark our chair and neurosurgery is a big fan of bringing all the different members of our team together as well. So one of the things that bring it together the first is building the team you know and right in this room we see that we have Milky Disciplinary folks I think one of the great strengths of childrens you can just call from the OR and ask for help with another service and I would suggest casting a really wide net you know it's very easy just to well just need IR neurosurgery but to bring in plastic surgery to bring in anesthesia to bring in the OR nursing team who are unbelievably helpful I think really lent itself to the success of this case and get the best. I mean you know we are a great hospital here and I think we should make sure we reach out to the specialists and the best ones in the field they're right here in this building. Second thing I think is a question of resourcing right I mean Dr. Fishman and the OR team they work really hard to get us all the fancy tools and toys and sometimes we wonder is it really worth it. Well yeah if we didn't have this tool as Alfred mentioned I don't think we could have completed this case or this kid is doing great now but part of it isn't just the team part of it is having the resources and the staff that can execute that the radiology text and the other folks that make it go. So I really do think when we ask for resources and we work for them this is the reason that we do it we can do things that other people can't. The big thing that again is most important to me in many ways is the strategy I think for all of us as we tackle these complex problems is to really define the goals of surgery you know a lot to go south at any point you know Alfred mentioned how we're sort of bouncing in and out up here on stage. And I think one of the really important things is you know if that happens during the OR and something goes sideways what is your exit strategy when do you have a time where you can say this is where I have to stop and what are you going to do about it to get ourselves out of a hole. And I think a lot of people sometimes when you get as good as many of the folks are in this room it becomes routine and you just say oh I'm just going to another day at the office and I think unless you really explicitly rehearse anything from a simple appendectomy or brain biopsy up to something really complicated. There's a higher chance for failure so having a strategy to find the goals and having an exit plan if you get in trouble is important the rehearsal is really great you know practice makes perfect and I really want to compliment the OR team the nursing team the radiology staff you know we simulated this many times as a great center here at children's as well. The other thing I want to mention is assembling you know I think the physical contact be able to walk in a room see somebody talk them through it you know we do this in the morning huddle sometimes with complicated cases there's a lot of value to this and I think this case highlights the importance of us putting our heads together assembling together and saying you know this is our goal for the day. Finally is the activation right it's game day it's time to go out there and do it I did not use the word execution not really right for a little baby given the prior two cases but I think that obviously is really what you want from this is to be able to you know activate and see the plan come to fruition. And then the final part I think which again distinguishes children's here from a lot of other institutions is the education you know what happens after for all of us there was a lot of the briefing right I mean we said well what did we learn from this what can we do better next time where can we go from this but a big part of the education isn't just you know sort of the rehearsal of you know how can we make an operation better or learn the technical parts of the cases are why Ed is always right with angios darren right I mean some learning points we can do that. I think I'll take home but but the other part is the science right we are an educational institution and I can't overemphasize I was fortunate enough to give a lecture here the folkman lecture earlier in the year talking about the importance of how we as clinicians can inform the research you know I'm over in the ask of biology program. And my lab and all of us here can contribute to that and Danny did such an eloquent job explaining the incredible molecular understanding we know everything about this case not just how it looked in with our eyeballs how it looked with the X ray tests but now we understand it on molecular level which none of this the family had before they came here they got this team you know it's really good folks and me and we were able to give them not just a cure but an understanding of what's you know the cause of the problem. And a potential future treatment that may not involve any of us in the intervention world and simply hopefully appeal and while I know it's been sometimes a hard pill to listen to me talking up here I really want to emphasize how great it's been working with the team and how grateful I think all of us are you know to thank all of you that help make this case possible as well so with that I think we'll wrap up a couple minutes early and I don't know what this format is for some questions but we'll go from there yeah we do try and get two cases in so we're going to take minimal questions that's going to be a good question. That clock is four minutes ahead so we have four minutes we're definitely going to give the entire time to the next team any questions and we'll focus on people in the room rather than on zoom. I'm just wondering now that you know that the potential targeted therapies do you think a similar case like this like if there was a way to get a diagnosis ahead of time could potentially one of those therapies have been tried or do you think the lesion was just so dramatic at this point that there was no way to avoid intervention. Yes, I think if you look at what pediatric interventional radiology and the pediatric vascular centers around the country are doing more and more people are doing. Self-free DNA and a vascular biopsy or blood based biopsy and I think that's an area that we certainly need to kind of catch up with some of the other leading institutions but that would be required we would need a gene target. On the flip side some centers around the country are doing non targeted or non informed like the therapeutic which doesn't make any sense to me. One comment I would have about whether you know upfront drug therapy in this child would have been possible. I think that the cat was already out of the barn the horse was out of the art already out of the barn in terms of how this anomaly was was was was developed and malformed. But in the setting of recurrence and early recurrence now that we're monitoring this I think then we really do have an opportunity to try something that's non invasive. Yeah, that's an early insightful question and I want to take a moment editorialize because although they won't let me anywhere near the face or the brain I do have a little bit of pride and background of this and and Ed mentioned Dr. Fulkeman's background here. And sort of creating the field of understanding, blood, us development and blood loss of inhibition and many of us sat around every Friday night and switched to Wednesday night and we still do that every Wednesday night. Looking at cases around the world trying to figure out sort of what are these things and we named them here and we'd sit around a bunch of surgeons and mentalologists and we thought we were great but there was a bunch of cases we'd say we need a drug right and honestly if I'm honest did I ever believe in my career there'd be any drugs. That would be able to help these are sometimes prevent surgery. But Danny and others and Ed certainly done this in lab. This whole field actually comes full circle from Dr. Fulkeman and actually the naming of these lesions and the idea that there must be a gene and that we could find the genes come from John Mulligan who's not only be here today but if you were in the room maybe some zoom. I don't know and this gene this mutation this this tattoo this segmentation. He discovered by driving around New England because there was a family we still see some of those patients who did have an autosomal dominant variant of the very rare and he drove around New England on his address and Sundays and drew blood. And then in the early days of when you could find you know osm of dominant variant thing would take like two years as a now would be a college student afternoon project to do that. And I spent decades chopping off pounds of people's bodies and sending the tissue to smarter people. Mostly mostly in Brussels and and so we're going to find a gene and I honestly said like so what they find a gene these are malformations that happened before birth. What are the odds that like doing they're going to do gene therapy and like six weeks to like prevent some blood or some malforming well will. So the ignorance of me yeah we have found the genes for almost all these things we've got this gene panel and we had we give targeted therapy for lots of people and sometimes prevent surgery. But nurses and I was working like I don't operate patients I used to operate on in large part because some of these patients don't need surgery section anymore so so the evolution has filled happened in large part due to our four bears and and then followed by these incredibly talented smart people so it's both. June and John would be incredibly proud of you guys so thank you we're going to move on to the next. Same deal we want the full half hour for them no introduction self introductions give a sense to about yourselves and we don't have a whole ring of things just I guess this is a. Simon Garfunkel instead instead of instead of the Beatles we've got to and and and what time we probably will send out a survey we've done this a few years now about how people like this have been getting incredible. I saw a feedback on how people like that people know and ask people for collaboration about new projects whether we should is too rush we do one of these instead of two in an hour so be looking for this we could do this every month with all the talent in this institution but obviously we have. Other things that we spend our morning's doing so take a look at. Good morning my name is not a normal urologist and first of all thank you so much for your time and congrats to the neurosurgical team and positive surgery team for taking care of that patient this is my mentor and my college at Dickie chicken basically do everything so in the. The theme of today in terms of featuring technology and care for patients will go along with the same sort of theme and discuss collaboration and advances in the modern era of robotic surgery here at Children's and I'll start off by featuring the technology first and then we'll talk about our case. In 2002 Boston Children's Hospital acquired the robot under the guidance and leadership of doctor retic and correct Peters and at that time the cases that urology were performing were primarily simple in the fractomy and pilot plastic and then it's time went on we got more and more comfortable with these cases and instead of just working on the kidney we began to explore multi quadrant surgery with the same. And here in 2025 we're now performing cases at the adrenal level kidney year at a level bladder reconstruction and anything from tumor recessions all the way to very complex reconstruction. I'm a very grateful circle I'm doctor chamber actually recruited me to do vascular surgery here which you know we're sort of took a great turn. So when I got here robotic surgery here I had trained on the DaVinci XI and when I came here it was the DaVinci SI which is a generation before. And doctor fisherman may recall me telling him that i'm not going to do robotics here luckily with the help of the institution and collaboration between multiple services we're able to get the upgraded XI and prior to a lot of the surgeries even generally in pediatric surgery it was very limited in what we did. Single quadrant single systems a lot of it was sort of upper for got nissons and then of course limited colon sections we've now of course expanded where multi quadrant multi cavities there are multiple people I think within our department now who have robotic interest interest and you can see that we not only do for got colorectal approaching masses. Brandt has used it in the thorax I think the EAT is also done some thoracic type of robotic cases and there's still complete open field for further expansion and more importantly we're starting to work together with our other colleagues to do multi disciplinary type cases. As we've gotten more and more comfortable we've been pushing the edge lately in terms of treating younger and younger patients are smallest patient that we treated robotically recently was four and a half kilos with increase in complexity and of course multi disciplinary along the way as well so let's take a moment to explore the robot in room 301 this is where our robot exists you can see on the left side of your screen. The robot and in the middle screen here now this is completely docked and treating the patient so in essence the robotic surgical system replaces traditional laparoscopic instruments and highlighted in yellow in the back of that middle picture is the surgeon console where we can sit and control the robot and then. Here's a quick video of once the robot ports have been placed talking the robot and getting ready for surgery and there's doctor Richard Lee on the console controlling the robot and the 3d view that you get once you get to work. Here's the robot in action as well so please come visit 301 in like an hour I have to be there okay so advantages of robotic surgery just for a quick review very small incisions now through eight millimeter incisions but fortunately we get very large exposure. From this whether it's in the chest or the abdomen and so again despite having complexity of anatomy with this child here with the G2 and a history of gastro-schicers repair we're still able to do whatever we need to robotically less blood loss short of hospitals they decrease narcotic use certainly improve cosmetics stable 3d camera in articulation and we'll get into the details of what tile pro and ICG technology comes with this robot as well and finally improved ergonomics we've all done laparoscopic cases that are quite exhausting in the case of the robot. So it's really exhausting in the cameras moving around all over the place and this certainly solves that problem so on the note of the anatomy and our ability to see very clearly the robot system gives us an excellent view of the anatomy so here is a renal artery to section on that right side IBC tented up a orders down below we're right at the level of the cuss of the diaphragm and sister and we're able to get excellent anatomic visualization in very tight spaces for this to move a section. Similarly with the risk of articulation for suturing we're able to use a 6-0-viral suture tip with this year or back together and not tying is very very straightforward and easy. So this is just showing some of our other cases that we've done together the first case on the left is the urethral repair erectio urethral fistula repair in a 17 year old and it just demonstrates how we can use the firefly technology so Dr. McNamara is actually passing a cystoscope through the urethra to define it and with the firefight technology I can see exactly the definition of the urethra not able to leave and not leave a divertic them on the end. The one on the right is the tile pro which you can actually overlay images with ultrasound for imaging and you can sort of see here how the ultrasound probe is going over the kidney looking for the exact dimensions of the tumor and location. We have a dedicated team of surgeons now so like I said there's there's more and more interest within each of our departments and we do have certain people who are focused on using the robotic technology we have a fabulous group of nurses and scrub tags who are trained on the robot and also some of the anesthesia people are more and more comfortable with the crazy as positioning we have to put some of these people in where they're almost straight head down and and so they're able to help monitor. Yes, crazy. To help monitor you know they're the appropriate to get us through this cases without having an inadvertent complications and then there's a commitment I think from a lot of us to approach these cases robotically the case we're going to present is only one of many of types things that we do multi disciplinary interdisciplinary and it was actually sort of forced not forced but thought about because they're the urologic procedure was going to be robotically. And it didn't make sense for me to then make a big incision to do more part. Okay, so this is only like I said one of the very one of the cases that we've done together and we were actually sort of pushing each other now to do more and more cases together so 14 year old female who had a neurogenic water and balls secondary to a mile and a lot of the other cases that we're incorporating our neurosurgery colleagues here as well. She did intermittent catheterization and an MS system but as many of these kids get a older to become independent we do a metroff not an am alone so way to access the bladder and a way to access the colon from the top from the abdominal position. She had a user and she had difficulty with transferring so this have hopefully would give her independence. Part of this it would be a big laparotomy we would find the appendix we would either split the appendix for the most part because I'm nicer I just give the appendix to the urologist and instead of keeping it for myself. And then we've now been able to combine this to do this robotically. This is just the start. It's it does you know a lot of these kids who have had VPCs have significant adhesions which we have to take down the robot health system find things. This may look just like a straight forward appendectomy but we're actually preserving the entire medenteric blood supply to the appendix for all the neurosurgeons in the room please don't have a heart attack. And then I'll just close your eyes close your eyes we do try and cover the VPCs. But somehow the VPCs should always comes down. And so this is performing a SQL flap to create a Neomalone so we are able to create a new appendix because I gave the other one to the urologist. And we essentially make a new appendix where we're able to access for the. Antigrade flushes and you can see how the robot allows us to sew the entire must the SQL flap. We also do a plication so that no one wants poop leaking out of their belly from the talk so we actually do like a plication to try and prevent any poop leakage. And then part two of the same case once again done completely robotically all we have to do is shift the robot from the right lower quadrant to the pelvis. We're able to cannulate the appendix with a feeding tube here. Sorry about the VPCs and then take down the bladder. And now we're just about to start creating the metrophenoph which will allow these patients to catheterize through a stoma primarily through their umbilicus instead of peru-retro. And then we're going to start with these young women who are transferring it out of the wheelchair. This really gains them a lot of independence. Here we are creating the initial dissection into the bladder. Preserving the mucosa of the bladder and creating what we call detrusor flaps to provide a continent's mechanism from urine so that again urine is not leaking out of their belly button. And finally starting what is typically a very difficult and asthmoses between the appendix and the bladder. But once again with the robot and with the ability of having full control over everything this is overall achievable. Just putting the robot putting the appendix to the bladder here. And so the beauty of the robotic system is that instead of having that big laparotomy two out of the four incisions that these patients receive ultimately become their stomas. So they're really only having to heal from two very small incisions. And while this is a quite quite a long day for us, it is certainly much better for the patients. Just finishing up here you can see the appendix now getting pulled into the tunnel of the bladder. There goes and that achieves the metrophenoph. But this point over the past three years we have treated 23 patients with either sacral agenesis or myelomin ingestion seal with a median age of about 13 years BMI 23.5 which tends to be on the older side and elevated BMI compared to all of the other centers in the country. 66% of our patients have a VPC and operative time includes about seven and a half hours, which includes our stilmal maturation time. Our hospital stay has been about five to seven days, which is comparable to pure laparoscopic or open procedures. And we've had a very low revision rate of about 7% for snows of the metrophenoph or issues with the neo malone. But more importantly, our patients have been very satisfied. I think in the scheme of robotic surgery, comparing this to how other centers rather do these cases separately with an open incision from a urology standpoint or from a general surgery standpoint or having to put all these together open. So we can achieve this robotically is quite outstanding. And this is just highlighting the same patient here who was featured in the news through Boston Children's was very happy at Disneyland being able to capitalize all by herself. So just to end in the last few minutes, what does robotic surgery or what could robotic surgery look like at Children's in 2035. And so we have this year, Dr. Richard Lee, who seated right there treated this patient and the family was very grateful for the care they received. And so they helped to salvage what we call now the Palombo Center for robotics and the goals of this institution and the centers to educate and gain robotic experience for treating pediatric conditions and pediatric patients. And more importantly to expand the ability of robotic surgery to treat these conditions safely. And so today over the last few minutes is our ability to use multidisciplinary care in multi quadrant and multi cavity care with the robot. And so what I'd like to just end with is that if any of you out there have been inspired over the last few minutes with this technology, this is merely an invitation to think about innovation exploration and to really push the boundaries of multidisciplinary robotic surgery for how to build a really serious surgeon, thoracic surgeon, transplant surgeon, E and T any an orthopedic surgeon. And so that technology can be applied to far more than what we're doing today. And I think Dr. Dickie and I would be excited to help. Thank you very much. Terrific. And yet another example of sort of the high tech stuff. We've obviously a little further advanced in robotics. We've had it for longer than the hybrid sweets and they've demonstrated the advancement from when we're just doing. And so we've been doing this in fund applications. Well, long time ago to the incredible suite, which can expand. And you know what I'll say we need to do the same thing with the hybrid suite and one of the reasons to do this is to learn from each other. Recognize. So you just had a urologist invite you into their operating room. If you're an orthopedic surgeon, right, that doesn't happen. A lot of places. Please do it. Even a part of interest, right. If you spent 35 years of your career working on the third floor and you don't walk into that room to see these guys do this, you're missing out on on expanding your own sort of imagination capacity. Plus it's just really cool. I, it's tough as expensive and I'm off in a situation to give tours to see a administration, but it's just these big donors. You know, why is it so expensive to do what we do here at the level that we do it. And I'm pretty commonly come into the into the robotic room because it's easy to get non physicians. So I understand the technology, the cool factor. And so please, this is the point of this. If you didn't know these guys should have been work with these guys, they're welcoming. They're going to help yourself a problem. Questions. So I think that's one of the adult centers are using this more and more in cases that otherwise was seen routine and I guess it seems like there was an error when laparoscopic surgery was seen as well. Why would I do that if I can already do this open and then some people eventually made that move from laparoscopic to robotic. What are some of the barriers that exist at our institution to prevent this from being used more routinely for emergency type cases off hours overnight that we may see that maybe at adult centers would have been done robotically. So we actually don't do routine cases on it. I think the most routine thing I would do is just a straight up append a cost to me mostly we do it for size. Partly it's resource heavy. There needs to be nurses who are trained on the robots plus if you're going to do it in the middle of the night, you need somebody at bedside who knows how to use the robot as well. So your sister needs to know how to use the robot. And then like during the daytime hours, it's actually access to the robots. So there's as more people use it and it's more services use it. A lot of the adult institutions have two or three robots. We have one where we sort of share amongst all of us. We play nicely. So we Tuesdays are urology. Or this day or our day Thursday, you know, we just sort of work it out. But that's part of it. But I do think as we expand what we do. Can you do a lot coolly on a very large girl or boy with the robot probably would save a lot of our backs and a lot of arms. But it does become a resource issue. Unfortunately. There are there are people within maybe a three minute walking distance of this room who routinely take out gallbladders. And even now they're starting appendix is like routine love coies with the robot. One could say talk about resources like we may be resource limited with lots of global surgery people here would say this is not resource limited. But the argument that they would use it something else hospitals is it gives everybody experience with using the technology so that they can then use it in the most of the scated cases and sort of get over the learning curve. But it is. Yeah, it is incredible riches to be able to have that. And we might be talking about having that in not too distant future. So we'll discuss it. Yeah, there used to be this. I guess myth that using the robot cost more as well people have done studies where the cost actually isn't that much more. With the old sort of version of robots it took almost twice as long as it does now to actually dock. Just like getting the ports in and getting the robot on you can do that as quickly as you would you know start a case laparoscopically now. Full credit to our nursing teams who have really developed the specialization. Yeah, you used to be like. I don't have to sort of even think about talking in now it's in two cases in a day no problem if you go watching. This is great. Thanks. Thanks for presenting it. How close are we to two different things like one is the two of you doing surgery on someone across the world using this robot. And two is the robot doing the surgery without the two of you. So there so finally went funny when I was a med student. The in I went to you there was a case where they were using the robot to do a appendix. And I was the world. You know somebody in Toronto was trying to do it in France. But the problem was the delay in in chance for of information. I think with the technology now if someone can dock the robot you probably could be able to do it in a different location with somebody on the console here operating on someone over there. I don't know if anyone else who uses a robot want to go on a comment on that. Actually more than more than a decade and a half ago a prostitutomy was done in France with the surgeon sitting at Hopkins. But yeah, little little delay. I was in Toronto and they were in like Europe. Yeah, that's I did remember that. And then there was this whole thing. There was a colleague of mine who was working at NASA who was trying to figure out how to do robotics surgery in space. And these things have been floated around for years. And I think the technology is just catching up to us now. Rich. Thank you. First I want to say thank you to Blinden Houghton for really pushing the multi collaboration is. It's fantastic and it's just I think just budding and waiting to happen and probably in a lot of other disciplines. I know I spoke to Dan had a question a while ago about getting in retropearsial access to the spine, you know robotically so they can do multi level spine stuff. But I'll let you guys figure out how to do that. My one question would be is so what's next? I mean the DaVinci is is a dinosaur in the stomachs that because it's the only technology out there that we're using. And so yes, it's F 2.0 3.0 4.0 whatever, but it's still that type of platform and the reality is is that there's going to be something else. So in your mind and that's what I would challenge the people who are doing robotics surgery and want to do something mentally invasive and just thinking about hey, how could we do this and just think a little bit sci fi and what would make sense. I mean, we've got an email about some magnet thing and there's a bunch of different things out there and and the goal to miniaturize robots, which would be much, much more and make it make the cost better. So in your mind or what have you seen that that's part one and part two would be. I know there's a big thing out there about feedback on how do we know we're doing a really good job and this is one of those things where you actually have a lot of video. So what are your thoughts on on how to train and simulate for for the next generation as for just to do this. Regarding simulation, I think as we had seen in the first case also just spending time to plan and troubleshoot and figure out access for these patients is quite important, but it turns out that the robot actually records everything that you do in an XYZ axis. So all of this data is available and it's been studied through machine learning technology that the most elite robotic surgeons in the world have a very unique style that they operate on the robot and their efficiency of motion and their camera movements and all that sort of stuff make them elite surgeons. And so I think by studying what we're doing right now and those who are just starting up or mid to late career by comparing what the robot is actually generating in terms of your movements to make this safer and faster for all patients in terms of the technology. I think this is less about the robot itself and more about us pushing the boundaries in terms of what we're capable of doing. Just getting warmed up in terms of what's possible here, the complexity of our patients are increasing, they're getting much, much younger as well. And so we'll see how this plays out. Part of the limitation is for those who do or do not know like DaVinci had their patent for a long time. So we the development of new robotic technology and the ability for companies to come out with stuff was a little bit limited in the last sort of five years. There have been more robots that are coming that what limits us sometimes is the port size because you know when we do laparoscopic surgeries on infants, we use three millimeter ports when we do a robotic surgery, they're eight millimeter ports. So they're almost three times as big. And so I think that's partly what what does limit us for size. But we're told that technology to get it into a three millimeter size instrument, you just can't get the mechanics that you're able to. So I think as technology sort of catches up and we're able to get more and more advanced in sort of the the biomedical portion, we probably can even continue to push it even further. It's sort of just. A generic answer, but you know, and then Dr. Proxeras about could we not be there when we use the robot with machine learning and AI now maybe, but hopefully there's still some job security for all of us in the room. I mentioned that maybe two months ago, I got an email from my brother who knows nothing about medicine, but he reads about everything and he's he's like a curator for us. The sense of that read it and there was some of you probably saw there was a recent paper I think in JAMA where they fed a whole years worth of the case reports and doing in journal into AI, all the imaging and the laboratory data and history and AI was able to instantly make a diast diagnosis much more accurately than expert physicians in the multisprite conference at the mass general. He sent me that I said, yeah, well, there's no question that the incredible amount of knowledge that we have in medicine. There's none of us think of it all in our brain and then synthesize it and then sort of bring it out like it makes sense that I could do that. And I said, you know, so maybe if you're a radiologist or a non interventional just or a pathologist, you know, maybe your job is going to be a risk in your career time. But I said, but like we have robots to the surgery, but it still takes a human and I don't think a robot's going to be placing a surgeon anytime in my lifetime and certainly not in my career. And two weeks later, report came out of Hopkins. You guys should watch this YouTube video. They did eight laparoscopic osystecumes in a porcelain model and pigs. And the only intervention from a human was the same as if you were an attending surgeon supervising the senior resident without scrubbing, just using your voice and go left or that's the duck, not the artery. And they did eight successful laparoscopic osystecumes. So maybe in my lifetime, not my career, but the rest of you need to be innovating to be in the front and to that curve. To drive it rather than to be victim of it. I think we're at time and I want to appreciate all the speakers today. They've volunteered to do this. Please do send me emails. If you have ideas who want to expect their presentations.