So it is with great pleasure that I introduce my dear friend and mentor, Doctor Mark Mikalsky, as our visiting professor today. Doctor Mikowski hails from New York City and grew up in New Jersey, and then left to go to just across the street here to Brandeis University where he obtained his undergraduate degree in biology and psychology. He then completed both his medical school and general surgery residency at Rutgers University, New Jersey School of Medicine, before going to Nationwide Children's, where he completed his pediatric surgery fellowship in 2002. After his fellowship, he actually spent his first two years at UVA where he was essentially gently nudged by Doctor Brad Rogers to pursue a career in metabolic and bariatric surgery. Little did he know at the time that his newfound interest would blossom into such an illustrious career in bariatric and robotic surgery. Doctor Mikowski is a professor of clinical professor of surgery, um, and pediatrics at the Ohio State University College of Medicine. He's also the vice chairman of strategic Operations. Um, he's the chief of adolescent bariatric Surgery Program there and holds, holds, um, multiple directorships for the Center for Healthy Weight and Nutrition, the Center for Robotic Surgery, and he's also the Program director for the Adolescent Bariatric Surgery Fellowship. Um, without further ado, please help me welcome Doctor Mark McCosky. OK. Well, thanks, Marky. Thanks for that great introduction. I sound pretty good. Um, and, um, it is, uh, it's a real pleasure to be here. Uh, thanks to you and uh thanks to Doctor Fishman for, um, the, uh, the great invitation to come, uh, come to Boston, which is always, uh, which is always a treat. Um. These are my disclosures. Um, I'm also gonna make a disclaimer, uh, just to set the tone for this, uh, presentation. I am not a robot zealot. Um, you know, I think robotic surgery, uh, uh, merits the acknowledgement that this is an area that I think is still, uh, the focus of some controversy. So I hope to kind of take you to, take you through our story, how we developed robotic surgery, uh, a robotic surgery practice at Nationwide and Um, you know, with a healthy dose of, um, um, uh, skepticism and, um, a drive to, uh, analyze our results and, um, you know, I'll leave you to decide whether or not, um, building a robotics program, uh, makes sense. Um, as many of you know, uh, uh, it's contractually, I have a contractual obligation to make some sort of sports analogy, uh, which is part of Ohio State University's bylaws. Um, so this talk today, um, I think is the return serve, uh, for a, uh, recent talk given by this young man. Um, who, uh, Ben, uh, was in Columbus just a week ago, I think, um, and, uh, really gave a great, uh, uh, a great talk and, um, initiated some great conversation about complex airway for patients with, uh, tracheoesophageal fistula and esophageal resia. So Ben, thanks so much for coming. Um, it was really well received. Um, And the other thing that obviously I need to do is pay homage to Boston and Boston Children's Hospital. This is the home of pediatric surgery, so I think for any pediatric surgeon to, to come here, uh, from, uh, from another spot, um, is, is certainly an honor and, uh, for, uh, some of the younger folks that are in the room, um, I think it's important to understand what the legacy is from, uh, this particular institution. You all know this man. Uh, Doctor Ladd, um, who was Boston's first surgeon in chief, um, and really, um, you know, just set the mold for pediatric surgery, you know, here in the United States and obviously had a global influence as well. Um, I had the pleasure of presenting the LAD Award, the LAD Medal, uh, at the most recent, uh, Academy, uh, American Academy of Pediatric conference on behalf of our section on surgery. Um, and that award is, uh, presented, um, in recognition of pediatric surgeons. that have made a lasting and transformative contribution and the list of recipients for, for that award is, um, is, is really, um, just a, uh, quite an impressive, uh, list of folks. Um, Doctor Ladd, thank you for the picture, Marques of Doctor Gross. Uh, Doctor Ladd trained Doctor Gross, um, and, um, Uh, both of these gentlemen trained the first pediatric surgeon in the state of Ohio, which is Doctor Clatworthy. Uh, Doctor Clatworthy, uh, I, I think like any good trainee, uh, followed his boss's strong recommendation to go to Ohio, uh, uh, to join the Department of Surgery, um, uh, under Doctor Zollinger, uh, which is a name that probably rings a bell, uh, also in this room. Um, and he became the first surgeon in chief of what was then the Columbus Children's Hospital now is Nationwide Children's Hospital. And among many, many people that, uh, Doctor Clatworthy trained, uh, he also trained, uh, my, my mentor, Doctor Kaneano, um, who was also the surgeon in Chief at Nationwide and, um, you know, went on to, uh, herself have an illustrious career and, um, I get the honor of calling her my mentor. So there's obviously a great, uh, lineage. And so it really is an honor to be here. So, uh, thank you again. In terms of what I want to cover in the next 40, 45 minutes or so, I, I'll start where, you know, we should all start, uh, it, to, to understand where you're going, it's, it's, it's important to understand, uh, where you've been. Um, and so I, I do wanna touch a little, uh, touch base a little bit on The history of robotic surgery. And again, ask the question, uh, you know, why develop a robotics program per se. I'll review some of the key organizational elements. We talked a little bit about some of this last night at, uh, at dinner, uh, which was, uh, so wonderful. Um, that will include, uh, just touching on some stakeholder engagement, service line development. Some of the training and credentialing mechanisms that we've put in place to try to support this clinical paradigm, how to get started, uh, with the program, uh, first case and beyond, um, some of the access issues related to block time, which we were talking about last night as well, um, and then, uh, you know, reputation, uh, building, marketing outreach, and, uh, you know, a, a glimpse of what I think is gonna happen in the future. Um, and hopefully, we'll have time for, uh, some questions. So, You know, the history of robotics is really actually interesting and it goes back a little bit further, at least further than what I thought. This is all really um the robots that we see today, the technology platforms that are currently available. This all goes back to the 1960s uh with some very, very experimental paradigm, uh, model building that was going on at DARRPA um and NASA, uh, you know, which was new in the 1960s, as well as the Stanford Research Institute. And there are a bunch of different, um, Uh, labs, literally that were, you know, playing around with this technology and trying to figure out what, whether or not there would actually be a clinical application for any of this stuff. And it wasn't really until the 1980s where, um, uh, you know, I think a foundation was really set in terms of could you Uh, translate, uh, this stuff out of the lab to clinical care. Um, this picture here is the integrated surgical systems called Robodoc. This is an orthopedic robot, uh, that performed the first hip replacement, uh, in, um, uh, in the early 1990s after, uh, FDA approval. The green telepresence system was also a system that came out of the Stanford Research Institute and really is the progenitor of the types of robot, general purpose robot that general surgeons, adult and pediatric general surgeons use today. And I think what was most striking to me when I did, you know, some of the research looking into the history of all of this, this was an open surgical platform. This was not conceptualized as being part of minimally invasive surgery, which was really a surprise to me. I kind of assumed that robotics was the next step, the most logical evolution of laparoscopy, but in fact it was not. It was designed. Uh, to address, uh, some of the technical, you know, potential technical advantages of, uh, robotic surgery, but in an open space. And Like much of what happens in science and surgery, there was an aha moment. And so, among the folks that were working on that system, seen here on the right side of the slide was a guy by the name of Rick Satava. Colonel Satava was an Army surgeon, Army general surgeon who was one of the three key principal, you know, principal investigators that were building this thing, and he had the pleasure or good fortune, I guess, of seeing a video recorded. Laparoscopic cholecystectomy by uh Jacques Marisco, who many of you know, was the founder of IRCAD. This was an aha moment, uh, because again, robotics at that time was an open concept. So he went back to the Stanford Research Institute and really made a push to try and marry these two technological advances that were Developing in parallel but not together. And his, his argument was that the telepresence system, this green system, was offered solutions through robotic instrumentation that solved the problem of fulcrum effect, you know, where you have stress on the abdominal or thoracic wall based on the fulcrum of the ports that we put in. Um, and we see typically even today in, in most laparoscopic approaches to anything or thoracoscopic approaches for that matter. And What he said then really stands true now that the thought process was that there would be high definition stereoscopic vision, enhanced dexterity, tremor reduction, uh, motion scaling, and all of, you know, kind of the variables that we'll touch on a couple of times and, and, um, you know, you hear about some of the ergonomic advantages of robotic surgery. So, um, this was, this was a marriage of two parallel but independent approaches to minimally invasive or, well, surgery. One was not so minimally invasive. Um. Flash forward a couple of years later, um, uh, there was, um, a company, a newly formed company by, uh, Yam Wang called Computer Motion. Some of the older folks in the room, uh, will remember this. This was really the first attempt at a commercially available robot, and this was the company that developed ASOP. Um, if anybody remembers it, I remember ASOP. Um, I think I was an intern. Uh, we had an ASOP. Uh, unit and ASOP basically held the camera, you had a, uh, uh, a headphone on and you could say zoom in, zoom out. Half the time, ASOP could not understand you. Um, you know, and in those days, I had a, a thicker New York accent, um, than Then I may or may not have now. Um, but, um, it, it wasn't, it wasn't a very practical device, and I think, uh, you know, after a couple of years, or maybe not even a couple of years, maybe after a couple of months, it probably got consigned to being a coat rack and, you know, shoved off to the side. And I think that that was the experience of many people that played with ASOP. The only thing that I think is, well, not the only thing, but I think one of the things that's very interesting about computer motion was that they had 5 millimeter instruments. So, at the time, this seemed, you know, quite revolutionary and it was, and certainly because of the small size of those instruments had some, at least theoretic applicability to pediatric surgery. Um, flash forward again a couple of years and Intuitive came onto the scene, um, you know, which is the behemoth, uh, you know, to become the behemoth that it is now. Um, and that was under the guidance of Fred Moh, who's pictured here. And you can start to see, um, a pretty regular cadence of R&D that was happening here. Um, and, uh, up until, uh, the most recent iteration of the robotic platform, which is called the DV5. Um, which is, um, sort of a souped up version of the XI, which is I think what you guys have. I think the big pivotal moment here, uh, is, is right here between 2009 and 2014. 2009 was the da Vinci SI. That was the first robotic system that we had, and that really actually became a usable system that was widely disseminated. I think, um, at the time when we had ours, there were already about 3000 deployed across the US. So, It had pretty significant um uh penetrance in terms of the marketplace, but the move from the SI to the XI was really transformational. Um, it, it, it created an ability where range of motion, uh, became, uh, uh, much more flexible and, um, you know, yeah, I'll give you some examples of how that works. There have been some other platforms. The SP is a single-site platform and then, uh, again, the, the SI is, or rather the DB-5 is sort of the XI on steroids. Um. You know, back to pediatric surgery, again, I, I, I mentioned that computer motion had these 5 millimeter instruments. Well, computer motion was acquired by Intuitive. Intuitive promptly sunsetted those instruments and stopped it. I think there were a number of reasons for that, um, including, um, some of the research and development or development. Um, challenges, uh, based on intuitive's, uh, engineering design, uh, uh, to make a full suite of 5 millimeter instruments, and they basically decided to shelve that effort. Um, and so, that really, uh, you know, I think organizationally and fundamentally leaves a little bit of a, uh, a blind spot for pediatric surgery, obviously, and it's one of the biggest criticisms of robotics in pediatrics is size considerations and, you know, can we use larger instruments to do pediatric type things and Uh, you know, again, we'll talk about that. Uh, this was just a very informal search, uh, on PubMed, uh, uh, you know, with all of what I've just said, there, there have been early, there were early adopters, um, as early as 2001. Um, there was a report of the first. Um, at, at, you know, at least it's attributed to be the first known published experience for robotic surgery was a Nissan fundal ligation. And you can see that the number of, uh, published peer-reviewed articles looking at robotic experience in the pediatric surgical space, um, have increased, um, uh, exponentially over time. Um. You know, to that end, um, some of the trending, um, that we looked at when we were getting, um, our, uh, uh, you know, thinking about expanding our program and mostly, uh, expanding, uh, to go from a SI to an XI, uh, which organizationally, um, is not an easy thing to do. These are expensive robots and I, I really was challenged, I think by Doctor Moss at the time, um, to make a good informed argument for why the hospital should write another check for another $2.5 million. Uh, to, uh, to acquire this robot. And so we looked at, um, who was using the robot and it, uh, to what prevalence the robot was being used across the PIS database. And so this was just a snapshot of what was happening at about 19 children's hospitals across the country that had robotic technology. And what we found was that the prevalence of utilization of robotic technology was increasing across, uh, both pediatric surgery and urology. Urology was certainly using it more. Um, for gut and renal pelvis ureter surgery, you know, the urologist, uh, was responsible for the area of the highest growth. And, um, you know, it, it, it was the argument that, uh, that won the day, at least uh in Columbus and, um, among other things, allowed us to, um, double down, if you will, on, uh, robotics. Again, back to the question, why consider developing a robotics program? You, you all have a robot, so I, I, you know, I am, um, I'm speaking, singing to the choir a little bit here. The most obvious reason is the technical advantages that are associated with it. And so again, back to what Dr. Satava said, um, high fidelity imaging, enhanced ergonomics, tremor correction. Enhanced range of motion, uh, which I mentioned was a, a, a big, uh, transitionary, uh, uh, foundation, uh, between, uh, the development of the SI and the delivery of the XI system, wristed instruments. Um, you know, we all know that, uh, laparoscopy and thoracoscopy done traditionally is kind of operating with chopsticks. Robotic technology allows you to, um, use wristed instruments which allows you to get into tight spaces. I'll show you some examples of that. And Improved outcomes, maybe, uh, you know, the, the, the robot people will absolutely tell you that, um, you know, their robot will improve outcomes, reduce pain. This is where some of the healthy skepticism comes in and, um, you know, uh, certainly, we, we, um, have tried. To look at that. I, I think the jury is still out as to whether or not any of that's true. There's a lot of moving parts, uh, literally and figuratively to all of this. There are disadvantages of robotic technology. There's limited haptic feedback, although that is being addressed both by Intuitive as well as other companies that are, uh, you know, in, in the, um, you know, in the wings waiting to come online. So I think that technically that's something that will probably be overcome with time. Increased reliance on visual cues because of the diminished haptic feedback, size limitations which I've already, or size limitations which I've already mentioned, you know, these are big instruments. Again, there are some companies in the wings. Uh, that have the promise of smaller instruments. So stay tuned for that institutional cost, which I've already alluded to. These are not inexpensive capital budget requests, you know, they're certainly in the seven figures. One might assume that that that's going to change over time. Increased staffing requirements. Um, you need to have a staff that is able to help you do robotic cases. We'll touch base on that. And then, as I've mentioned already, there's limited evidence in the pediatric space. There's a limited evidence in the adult space as well, but, um, nonetheless, this, um, this horse is way out of the barn. Uh, across the, uh, across the adult world, uh, and gaining, gaining speed in the pediatric world. Uh, back to a little bit of history, just to kind of, you know, uh, walk you through our experience, um, to make a couple of points. We got into the robot business. I think we, we acquired our robot in late 2012. Again, that was an SI. Um, and, um, that, that's, uh, that's my work wife, Karen Dieffenbach there. It's good to have a partner in crime, um, when you're doing anything new, um, or uncertain about anything, and, uh, Karen, uh, I can't thank her enough for, uh, partnering up with me on this and a, and a number of things, but, um, it really Set the stage because when we decided to pursue robotics, um, uh, at least in the general surgery realm, uh, which was new, the robot was not acquired for us. It was acquired for the urologists, so we sort of nudged our way in, uh, into the robot after we, um, you know, distracted the urologists and Uh, managed to get on the console. Um, but what we decided to do was to start very slow and just have a couple of people, Karen and I, uh, just get a, literally get a feel for it and then decide if it was something that we could help to support and disseminate across, uh, across our, uh, practice group. Um, and indeed we did. Uh, again, we started with two, by the following year, uh, I think Benwame, uh, uh, we lassoed him in. Uh, to do some stuff. And by 2014, we were formally training our fellows in pediatric surgery. So our fellows leave, uh, their fellowship training, uh, with, um, you know, the, uh, proper training certificates, credentialing, um, and letters of support, uh, when they go on, uh, to, uh, to take a job. I've mentioned already, we upgraded to the SI to the XI in 2020, um, after a number of, uh, a couple of years of, of trying to uh convince the Capital Budget Committee that that was a good idea. And today, um, I think we have about 12 or 13 robotic, robotically trained surgeons, um, at our institution, um, doing operations across the whole gamut of, uh, surgical subspecialty. Uh, service lines which you, uh, can see here. So, uh, it's been great. Just a, a, a, a quick snapshot of our volume and, and how that's happened. Uh, 2013 was our first clinical year, so it was a high year there. Again, the urologists, there was sort of a backlog of pyeloplasties that needed to be done. Um, so they Sat on these patients for a little while. I probably shouldn't say that, but, um, uh, waiting for the robot to get plugged in and turned on. Um, we, uh, you know, quickly followed suit, but we were doing about half the volume. Again, this is just Karen and I. Um, and we, we look at 2014 as kind of our steady state when, when the backlog was worked through. Um, and you can see in 2016, we kind of, uh, sped up and matched the urology volume. And then ever since then, we've, we've probably been, you know, edging a little higher in terms of volume. I mean, there are a number of reasons, you know, uh, we obviously, we're a larger group than the urology, uh, folks, um, but also I think the, the, the The types of cases, the spectrum of cases that we do is broader. So we're, we're running about 130, 140 cases a year. Um, we're delving into acute care surgery a little bit now, uh, which, uh, we could certainly talk about. So I think our, our volume, uh, is, uh, is about to, uh, is about to go up. We'll see, we'll see how that happens. You know, the other aspect of why develop a program or how to develop a program, I think I want to address in the next couple of slides. And here's what I'll tell you. I think that for, for institutions that invest in robotic technology, it really is an important idea to try to have some kind of programmatic framework around this. Um. I, I, you know, I have the pleasure of, uh, uh, visiting a bunch of, um, uh, both adult and pediatric hospitals. One of my, one of the hats that I wear, um, is I do, uh, bariatric site visits for the American College of Surgeons for MBSA QIP. You guys are an MBSA QIP accredited program. Um, and, um, so I, I, I, I see how robotic technology is, is, uh, operating, uh, both, uh, clinically and organizationally in a lot of places and, um, Uh, one story that comes to mind, uh, that I think is the exact test case for how not to start a robotics program is a large children's hospital in this country. I, I don't wanna, you know, name, name names, but they acquired a robot without any of what I'm about to tell you, any thought process in it. So they acquired a robot. It was a, it was a, you know, uh some type of a donor-directed grant, which was great. So I don't know that it costs them that much, but it does cost money to have a robot. Um, it's not just a one-time purchase. There's a maintenance fee which runs about like $25,000 a month or something like that. It's, it's a lot. Um, and this children's hospital, uh, literally one day, this robot showed up on, on the loading dock and, and was brought up to, uh, the operating room and nobody knew anything about it in terms of how to integrate it for SPD, um, or nursing or any of that. That robot sat there for about 18 months unused with a cover over it, um, costing them $25,000 a month. Um, so it was not a really smart way to do any of this, and I think that, you know, having a plan doesn't, you know, doesn't, uh, Doesn't apply just to robotics. That's a good idea for any kind of clinical programmatic enterprise. So, we did what you should do, I think. Uh, we formed a steering committee. Um, the steering committee consisted of folks from pediatric surgery, urology, anesthesia, nursing, and per-op administration. Um, and set some strategic goals, including the desire to Um, develop an integrated multidisciplinary program. And so what that means was we really tried to dispel the, this is our robot versus this is your robot. Again, this was, our robot was acquired for urology. There was some Um, uh, sense that it was their, uh, their machine, um, and it wasn't. Uh, but, uh, it, it, it took a little, uh, nuancing and creating some strategic architecture around, um, all of that to understand that it's everybody's robot. And by the way, let's all work together and we do that on a regular basis. So it's not uncommon to see a general surgeon, um, in the Urology room or a urologist in the general surgery room if there's a robot case. Um, it just depends upon what's happening. And again, uh, that, uh, we wanted to do that because like this place where there's broad case variability and sub-specialization, we had the ability to, um, address, um, and deploy the robotic across a robotic system across a number of, um, a number of things. This is all done in the background of understanding, again, I've already alluded to resources, financing, uh, planning, and, um, and needs assessment. So, This is, you know, this is a big elusive question, the financial model. I get asked a lot, uh, what, what is our formula for, you know, a return on investment? And boy, it's, that's such a complicated question. Um, uh, there's a lot that goes into that, local and regional market analysis, what's your competition doing? What are your intangible reasons for doing that? That's another way of saying brand building. Um, there are a lot of reasons to have a robot, but to actually be able to hone it down to, um, financial dollars and cents or traditional ROI, Intuitive, um, says they can help you do that, but Um, it's, it's a hard question, uh, to do. So, um, there are nuances on how facility charges are addressed. Um, you know, uh, folks, and, and you may be well versed in this, I assume, I assume you are, but, you know, robotic cases, um, garner a higher facility charge in the operating room. How does that incorporate in the bottom line? Uh, it, you could spend a lot of time talking about this and, and probably not really come up. With, um, a, uh, a one size fits all answer to all of this. And then there's a um equipment depreciation. I was saying last night that, you know, when we got our first robot, part of the problem transitioning from an XI to an S or from an SI to an XI was that the people that approved it on the capital budget, um, you know, committee just assumed, well, we have a robot, why do we need a new one? And, you know, the argument was this is like every other large Capital expenditure in the hospital. You don't have the same CAT scan machine you had 5 years ago. Uh, you don't have the same MRI, um, and it took a minute for, uh, the folks at my place to understand that, yeah, you actually have to, um, you have to upgrade to the next model, um, at some point because literally what happens in this realm is the model that you're using, um, industry, um, if they decide to sunset some of the. Technology and they do, you're out of luck. So if you want to continue doing robotics, you have to continue uh to consider uh upgrading. So, some of the practical issues, uh, that I've run into, um, surprisingly is having the right size room and the equipment that's required in the room. I visited, uh, another children's hospital, um, wasn't there for robotics, but I was again there for, for bariatric accreditation. Um, and the anesthesiologist tapped me on the shoulder and, and, and, um, told me that he thinks the robot's very dangerous. Because the way the room was set up, um, they actually had to flip the patient 180 degrees so that the anesthesia machine and setup was at the opposite end and the patient was at the foot of the bed instead of the head of the bed. And when I asked why that happened, it was simply because the plug. Literally, the plug, to plug the robot in was too far away to do it the right way, and nobody had thought to call engineering and spend the, I don't know, $20,000 to run a new line. I mean, think about the liability. So, it, it, it is a very good idea for places that are thinking about acquiring a robot or expanding. a robot to make sure that you have the right room with the right technology, uh, because if you don't, it can definitely create some problems. Other considerations including staffing, you can't, again, you can't just have a robot, even if you have trained surgeons, you have to have trained nursing and support staff. There are a number of different models for that. At our place, we, we use the, um, um, uh, the, uh, nurse first assist, uh, who are, you know, uh, model of credentialing for uh OR nursing, um, and some additional robotic training. That's not mandatory, uh, but that's the way we built it in our system, and that creates some limitations. And then credentialing, how do we credential for faculty? Uh, we set up a, as I mentioned, we set up a staggered, uh, timeline. Um, uh, you know, we don't, we don't, uh, credential, uh, hordes of people at any given time, but there are some industry markers that are, um, uh, uh, required by, uh, places like Intuitive, including doing online modules. Um, we require folks to do some case observation of other surgeons in the institution. Um, skills and drills that are done, uh, with a robot simulator if you have a dual count, count, uh, dual, uh, console system, and then an off-site lab accreditation and so typically for intuitive anyway, which is the dominant force, uh, that means you fly to either Atlanta or, um, or a Mountain View, uh, to, uh, to do a pig lab. Um, and, and that usually is what gets you going. But I think it's also important to consider who is um pursuing robotics in your institution. It really should be someone who is going to do more than the occasional case. If you're only gonna do one or two cases with the robot, the robot's not for you. Um, like everything, you know, repetitive use, um, and muscle memory, like everything else we do is important in robotics. I can even tell you, if it's been a month since I've sat down on the robot, it takes me a minute to, um, uh, to reacquaint myself with everything and, um, and that's, uh, that's important. We have a system again for credentialing that includes some initial proctoring. Uh, one of the senior robotic surgeons, uh, when we are on boarding a more junior faculty or, or it doesn't even have to be a junior faculty, someone who hasn't. Um, yet established a robotic, um, uh, skill set or practice yet, uh, we do some very close monitoring. From a credentialing standpoint, we have a couple of different models for that. Again, for faculty, many, many junior faculty who are coming on board now have had robotics. Experience in their general surgery training. We require a letter, a copy of their training certificate, um, you know, you can see the parameters here. And again, for faculty that have, you know, for older folks or, or, you know, people that have come from programs where the robot has not been part of their experience, um, again, we have developed a, um, uh, uh, sort of a case use for credentialing that folks need to go through. It's not meant to be overly burdensome, but it's, it's designed to address some safety. And with regards to safety and the comment I just made about Um, uh, you know, needing to keep your skills up, we do require, uh, maintenance of certification. Again, we were talking about this last night. You're, you're required to do at least 10 cases over a 2-year credentialing cycle. Um, and, um, this goes without saying, obviously, meet the established quality standards defined, uh, by the surgical service. at your institution. We actually do also mandatory quarterly, uh, maintenance and certification. Um, this is a, a digital, uh, simulation, uh, again, that, um, Intuitive pushes out, uh, where you can go through skills and drills, ring drop, things like that, that just keep your skills going, keep your motor memory. Uh, uh, uh, it going and, uh, we require that, uh, 4 times a year. When we first did it, um, I, I set it so that you had to have, you know, uh, you had to have a score of 80% or better and people freaked out because it was hard, uh, to get 80%. So now, if, if you just do it, you passed. Um. Um, and, uh, after, you know, there was almost a revolt about that, um, and we do look at case logs. Scheduling challenges, access to the robot, we, we had a little chat about this last night as well, and, um, it's hard. You have to align, a lot of things need to align to get, to, to get a case, you know, from A to B, uh, with the robot, you have to have the patient, they have to have uh availability on the day that you have availability and block time. And by the way, the robot has to be available. And when we first started our robotic program for several years, Um, we, we did what a lot of places do. Um, if I had blocked time and I had the patient, then I had to go hunting for the robot, and it was a rarity if all of those things aligned perfectly. And by the way, you know, when your scheduler tells a patient that you're gonna have, you know, an operation on November 3rd, and then all of a sudden, the next day you find out that, oops, the robot's not available or somebody grabbed it. Um, and, you know, it's, it's no longer available to you, and you got to call the family and tell them, sorry, we made a mistake, and it just, it doesn't go well. Um, so we, we played around with that nonsense for a while. Um, and then this became an issue, uh, if for no other reason that we were getting more and more people starting to use the robots. So we needed to fix that problem and What we essentially did was we created a, uh, a, a block overlay. So at our institution, and which I'm sure is similar here, block time is assigned by um service line. It's not really assigned to a specific surgeon, but from a practical standpoint, you know, I have my block time, you have your block time. And so what we did was we decided to um Uh, overlay automated availability for the robot on top of people's already established block time. So I know that, um, uh, you know, 2 Mondays a month and 1 Wednesday a month, I have access to the robot. It's mine. I'm free to schedule in it. I don't have to go hunting for the robot. Um, and then, you know, we include in that a release mechanism so that 14 days before, if I haven't, um, scheduled a robot in case, I don't lose my block. I just Potentially at that point, um, somebody else can come in and, uh, schedule on the robot. So, um, and then we have the 5th, you know, the 5th day of the month, which happens, I think 4 times a year. It's open time. Anybody can schedule a robot. Um, you know, it's, it's, it's basically first come, first served. So that works out well. This is just a snapshot of how it works. Um, and on this list, uh, you know, you may know some of these people, uh, you know, half of this list is general surgeons, the other half is urologists, um, And, uh, and that's worked out quite nicely. So let's, you know, spend the rest of the time talking about a little clinical, um, examples here. Uh, this is my son, Ben, um, over the years, and like everything we do in pediatric surgery, especially in pediatric minimally invasive surgery, it's important to integrate size consideration. I said at the beginning that obviously the robot is not for every patient, it's not for every case, and it certainly depends upon the size of the patient and some of the other nuances. So, We do what we do in, in, in minimally invasive surgery anyway, you know, we try to take advantage of um some of the positioning tricks um that are available, including elevating the patient on an altar. Um, you know, you are dealing with a machine that has some potential for external equipment collision. Um, and for, you know, for those of you, uh, that, um, have, have worked on the robot, you know what I'm talking about. We also try to take advantage of positioning Trendelenberg, reverse Trendelenberg. Uh, we actually have a, a robotic bed that's integrated with the system itself, so you can actually move the bed without having to actually undock the robot. Um, that's been, uh, that's been quite nice. And then one of the things, uh, that we do is, uh, we use long instruments for everything. And, uh, we Call them the bariatric instruments. That's, you know, that's my, that's my fault. Um, but we wind up using them even on smaller children because exactly what happens is if you use longer instruments, it basically spreads out the robot above the patient and reduces the, uh, likelihood of creating external collisions between the arms. Um, and, you know, we have a, a, uh, once in a while, you know, we'll get a new intuitive rep that comes in to support us and Um, they look at, look at us like we're crazy, but then by the end of the case, um, uh, you know, they, they see the light. Um, and that's worked out really, uh, nicely for us. We've, I mentioned that, you know, we have, again, this healthy dose, dose of skepticism. There's a lot about, there's a lot out there. Um, what's the minimal size? What's the maximal size? We've tried to look at that. Uh, we looked at our own experience of patients arbitrarily above and below 15 kg. Um, and, you know, uh doing our aggregate series, uh, this is a few, uh, well, you know, the, the data is already a couple of years old. This came out last year, but looking at about 1000 patients, um, it turns out that, um, uh, you know, we do have about a 12, uh, 12% experience, uh, overall. Using the robot on patients less than 15 kg, and you might expect or not be surprised by the fact that the people that are really driving that are the urologists. Um, and again, um, there are some, there are some technical reasons for that. Um, they're operating in a very defined, um, uh, limited range of motion, so it may be amenable to them, but it can be done. And again, um, I think that this is technology and evolution as we start to see systems become available that have smaller instrumentation, they are coming. Um, uh, you know, uh, that, that limit may get pushed. On the other end of the spectrum, again, I apologize, bariatric surgeon, so I'm, I'm, I'm much more comfortable on the, on the severe end of, uh, of BMI. Um, again, there's, there's, there's sort of this lure out there where there has been that you really shouldn't use the robot for anybody above a BMI of 50. Um, I, I tracked that down, by the way. It, it was published in some abstract somewhere with no data. It was just an opinion. Um, and so, you know, we looked at our own experience. Um, this was just looking at, uh, sleeve gastrectomy. We saw no difference in operating time above and below BMI 50. No, no difference in 30-day complications, no difference in hospital readmissions, just no difference. Um, so we don't let, um, uh, you know, the upper end of BMI really influence anything. Um, start simple. Start with an operation that you know, uh, and, um, um, get comfortable with it. Consider double scrubbing. Uh, we scrub a lot of these cases together. There's a lot of advantage to doing that. It's great to be in the consult, but it's also, I think, vitally important to have Experience as faculty, um, or trainees for that matter, to be at the bedside. There's, uh, there's Karen, that's, uh, Jenny Aldrich, uh, who, uh, is our, uh, uh, surgical oncology lead. Um, and, um, you know, it really helps lead to, um, some troubleshooting. Um, again, this is uh kind of a reiterative slide, but I think it just, um, it, um, It makes the point and you, you know, our, our organizations are, are similar in many ways including uh the fact that um like here, uh, we are incentivized to help each other, um, uh, you know, or rather, we're not disincentivized to not help each other. Um, so having a partner, an experienced partner with you in the operating room is really a, a great thing. It does not diminish our trainee's experience, you know, we have a dual console system. So the, the primary pediatric surgeon is on console one, the trainee is on console two. And somebody is at the bedside, somebody with a lot of experience is at the bedside just in case. We record everything. We have the book. Um, we record, um, some of the nuances for every setup, um, and I would definitely encourage you to do that if you're not doing it already. I mean, it really helps, uh, again, especially if you haven't done a case in a while or you have staff that's in the room that maybe is less familiar, um, or hasn't done a particular case with you because there are a lot of literally and figuratively moving parts on how you get a case done, uh, safely. OK, bariatric surgery. I, I can't leave without um just mentioning a little bit about bariatric surgery cause that's really what I do. Um, this is, uh, just a quick snapshot of the teen lab's data, um, you know, which is a large multi-institutional prospective observational study. Um, Uh, that was chaired by Tom Inge, um, many, many years ago. Um, and, um, suffice it to say, I'm, I'm not gonna give you a whole bariatric lecture here, but suffice it to say outcomes have been, uh, very, very, um, uh, significant in terms of weight reduction and, um, cardio metabolic improvement over time. Uh, this is just a snapshot of, um, results, uh, out at 10 years showing effectively no difference between Rou and Y gastric by. Pass and sleeve gastrectomy. Why am I showing you this other than the fact that I can't really leave here without talking about bariatric surgery? Well, do an operation that you know well. I know bariatric surgery really well, and this was our sentinel operation, our sentinel procedure for adoption of the robot. And so, this is an example of a sleeve gastrectomy, um, done. Uh, with the robot and, um, you know, a couple of nuances here, uh, that are, uh, worth showing. As I mentioned, when we started, uh, this enterprise in Columbus, we had the SI. The SI was great for operating in one direction. A sleeve gastrectomy is basically a one-directional operation. You kind of go from the right lower to the left upper quadrant, um, to create a gastric sleeve. Um, So, uh, you know, here we are, uh, doing that. This is really where the robot shines, you know, getting up, um, uh, you know, to the hiatus and really being able to move with that extended range of motion. Yeah, of course, you can do this laparoscopically, and I've done, you know, lots of these cases laparoscopically. Um, but doing it with a robot is, is really a pleasure, um, and, um, easy to do. The other nuance here, you can see I'm using a standard. Um, stapler. I'm not using the robotic stapler, although, um, uh, you know, the, the robot has a couple of different stapler platforms. Many people do use it. I just, you know, never really adopted that for this operation. And so, again, getting up at the angle hiss, um, this is where the, really the robot helps you and certainly as a, as a bariatric surgeon, um, you know, my fear is that I'm gonna nick the spleen and, um, um, you know, create some bleeding and, um, be unhappy with myself. Um, the, there's a learning curve, obviously. Um, again, trying to do our own, um, analysis and, um, and be thoughtful about our own experience. Uh, our initial experience, we tried to look at robotic, uh, sleeve gastrectomy versus laparoscopic sleeve gastrectomy at the time. This was the sleeve, uh, this was the SI versus laparoscopy. So, it took significantly longer to do this with the robot in the early days, about 30 minutes more. And You know, that's, that's, um, there are some downsides, there's a lot of downsides to that including, you know, having a patient spend an extra 30 minutes under general anesthesia, the, the facility charges that go along with that. Um, interestingly enough though, in that early experience, we saw patients with, uh, undergoing robotic, uh, bariatric surgery being sent home earlier, um, but, um, it was, uh, costing more money. When we did a comparison of our, our aggregate experience, the learning curve went down to about 50 minutes. Uh, it was Uh, a little bit above with the SI and then when we converted to the XI rather from the SI to the XI, you could see a significant drop. So we went from 132 minutes down to 36 minutes, and I think when I made this slide, I've done a 21 minute case. Um, so that's pretty, that's pretty remarkable. Um, and you can track all of this, by the way, on your phone. Um, so that's been a great experience. Um, single-site technology for anyone who's, um, you know, struggled with single-site laparoscopy, I've tried that a few times in my career. It's, it's awful because, you know, you have to, you know, work opposite. The robot solves all of that. It's, you know, Wizzy Wig, what you see is what you get, which means the computer is Switching your arm motions so your right hand is doing what your right hand should be doing, your left hand is doing what your left hand has uh been doing. So we almost exclusively use the single-site port to do gallbladders, um, which, which is nice because it shows, it winds up with a, uh, uh, an often hidden incision, um, um, not that that's specifically the reason to do it. And again, um, just a quick snapshot of what that looks like here. Um, It does take a little bit used to, uh, getting used to because these are not wristed instruments, believe it or not. I've just told you how great the wristed instruments are. Um, the robot also lends itself nicely, although I, I, I, I didn't bother bringing um a video showing you um into sign in green. Um, you can really see the architecture very well. You hit a button on the robot and everything lights up green, um, so you know uh what to cut and what not to cut. Um, so that's been, um, that's been great. Uh, we did compare our, again, robotic cholecystectomy experience to our laparoscopic, uh, you know, experience. And again, um, uh, in this early, uh, phase, uh, the robot took longer, it cost more. So there's that, you know, there's that dose of skepticism, no difference in complications. So, um, is this necessarily the right thing to do? Um, you know, uh, that's an open question. More recently, we've been using The robot for acute cholecystitis, so acute care surgery, and is there any difference? Is it safe to use a robot for someone with an acute surgical uh paradigm going on? And certainly that's something that has happened, um, is happening broadly in the adult world. We saw no difference of acute cholecystitis. Uh, uh, versus, uh, non-acute cholecystitis or elective, you know, elective cholecystectomy is no difference in time. Um, now, uh, you know, It's a very common criticism that the robot takes longer. We're really seeing no difference in time and I think that's, uh, that's a, a byproduct of just the experience, um, at the institution. Uh, no difference in length of stay, no difference in pain, uh, uh, follow-up. So again, uh, very, very similar outcomes. It's safe. You, you can do an, an acute cholecystectomy. Other advantages here, um, in terms of uh operating, uh, you know, I was saying last night at dinner that I feel, I feel, um, like robotic, my robotic surgery. Experience has made me a better laparoscopic surgeon. Um, I didn't train in general surgery on the robot there, you know, again, it was ASOP back in those days, so there was no, no advantage for me to do that. But, um, I think intracopoural knot tying, things like that, it's, it's a breeze with a robot. Um, and, and if you do, and we do, I do still do a lot of laparoscopy, non-robotic MIS, and, and it's really, um, you know, it's really helped my experience. Just a quick snapshot, uh, this is, I think this is Jenny Aldrin, uh, doing a spleen. Um, again, it's really, really helpful to, to get up in those tight spaces, uh, address the anatomy, um, uh, with, you know, relative ease, uh, which is, uh, which is really great. Um, again, going up to the hiatus, uh, really, uh, really, really, um, excellent. And then, um, this is an example of a perduodenal hernia. Thank you. Um, Repair. Um, uh, you know, again, I think that this is where this technology really, really shines in the ability to identify the space, have amazing visualization, and be able to, um, sew, uh, with relative ease, uh, to closed spaces. You can see also here, I think you'll see some lines pop up here. Let's just give it a second. Um. And um the, the robot allows for uh the person at the console, or rather I see this lines that, that's Karen Diefenbach uh. Who's very bossy, uh, telling me what to do. Um, so, um, that's, that's great. So, even at, even if you're at the consult, you have the ability to have some input, uh, that can show up on the screen or show up on the uh visual panel that the actual operating surgeon is doing. That's great. Moving on to more complex things. I said start simple. Everything I've just shown you is relatively simple. Moving on to some more complex things, median archiate ligament release. Um, this has really been, again, a great, great, um, uh, uh, tool for us. Um, you know, the median archiate ligament is compressing, uh, the, uh, celiac, uh, axis and causing intermittent episodes of intestinal ischemia. You can see here on this CAT scan, uh, where this compression is happening. Um, And this has really helped us, uh, uh, approach a multidisciplinary again, um, uh, approach to all of this, um, uh, you know, obviously, uh, gives you the ability to use intraoperative ultrasound. Here you can see, uh, the takeoff of, uh, the celiac here with, um, uh, uh, elevated flow velocity. Um, and, uh, being able to visualize at this level, um, and take down or release this ligament is really an incredible, incredible thing. This can be, you know, this operation admittedly can be a little stressful. Um, you know, you don't want to poke a hole, uh, here, obviously, and again, a good reason to have somebody experience at the bedside should you have a surgical misadventure. Um, but you can really see that the robot really lends itself to dissecting out, um, all of these muscle fibers to release this artery. Um, and, uh, allow, uh, uh, some, uh, better flow and pain relief for these patients here. We're down to the trifurcation. And again, this is after the release, um, you know, using intraoperative, uh, ultrasonography again, um, and flow velocities, you can see, uh, diminished, uh, uh, flow velocity peaks here, so. Uh, that's an indication that we've done, you know, at least an acceptable job in terms of when to stop. Um, again, more complex stuff. Here's a gastric bypass. Um, so this really makes the argument for how to do in, not more than just intracorporeal knot tying, you're doing intracoporeal, uh, anastomosis. Um, uh, you know, here's an example for those of you who have, have had the pleasure of, of, uh, doing gastric bypass. Um, robotically, you bring up a loop. Um, it's a little bit different than doing a laparoscopic and certainly an open where you kind of take the opposite approach and start down at the, uh, at the jejuno jejunostomy. Uh, robotically, you start at the top side, you do your gastroginostomy. This is using a V-lock suture, which is also a real-time saver and, um, and excellent for a two-layer anastomosis and Once you get this omega loop, uh, sewn up, uh, you then divide what, which is now, uh, uh, you know, the r limb here, and this is the bilio pancreatic limb. We've just done a leak test here and now, you know, marching forward about 150 centimeters in anticipation of, uh, doing a linear junior digitostomy. Again, you can do all of this with the robot, uh, with the robotic, um, stapler platform for this particular one. we didn't. Um, but, um, um, you know, and again, that's just dealer's choice as to whether or not you, uh, you want to do that. Uh, you know, just a snapshot of our growing list of things that have been done with the robot at our institution, um, And, uh, you know, expanding, uh, all the time. And finally, in the last, you know, couple of wrap up slides here. Uh, you know, marketing and professional education, you know, uh, for external or family facing, um, you know, this is a business and, and, and if you do something and you feel like you're doing it well, um, it's important to let people know what you're doing. And so, um, we've tried to highlight this with some patient stories that are available on our website. Um, also, Obviously, uh, peer facing, um, and thought leadership to, uh, you know, to kind of spread the, spread the word, uh, that, uh, we do this. Um, we also share our experience, we've had, um, we just finished our third year in a row of, um, a, um, a nice, uh, 3-day conference, uh, that we host. Uh, in Columbus, uh, including a pig lab, uh, which is great, really designed for folks that are thinking about, um, acquiring a robot or at an institution that have a robot, but maybe haven't themselves, um, uh, delved into it, um, but want to get an experience, you know, kind of a, um, uh, a no fault experience, uh, on a pig, uh, which is, uh, which has really been, uh, great and well attended. So, in the last, uh, two or three slides here, uh, what does the future hold? Um, Emergency procedures initiated. Please verbally state the nature of your injury. I mean cesarean error. This med pod is calibrated for male patients only and does not offer the procedure. I don't know. Maybe this is gonna help with field surgery. Anyway, um, you know, this is a snapshot of the future. I don't know that we're ever gonna get to such a level of autonomy, um, uh, uh, you know, where robots really can, you can just dial up the operation and it's gonna do it itself, maybe. Um, what I can tell you is that I think there are some fundamental design changes that are already in the works with big companies like J&J and Medtronic. Um, and some smaller companies as well, actually including Storts, um, now has a robot system, um, that, uh, that, that they own. Um, this, uh, sort of central patient cart model that is the basis of Intuitive is changing, um, not with Intuitive per se, although maybe, uh, to really what's considered more modular systems. So, uh, this is, uh, this is Hugo, which is, uh, the The system that Medtronic is working on and it has been, you know, every year, it's been, um, it's coming out next year, but that's been going on for about 10 years now. So, um, uh, this is a census, uh, which was a company in, uh, is still a company in North Carolina that was last year acquired by Carl Stortz. Um, so there's, uh, there's the promise of smaller instrumentation. Um, so we'll see how that goes and miniaturization, I mean, there are designs for Very, very small, um, uh, robotic platforms. Uh, will this have a place, uh, certainly in microsurgery, in fetal surgery, uh, maybe. Um, you know, we have yet to see. So, what can we expect? I think we'll expect enhancements in vision, precision control, um, error avoidance, data integration, artificial intelligence, you know, all of these things, I, I, I think are coming. Maybe some point of care diagnostic imaging like, uh, like that clip, um, um, alluded to. Remote control, uh, some level of autonomy. I mean, I think, uh, you know, that, that, uh, that, uh, video, um, snippet is, is a far cry. I mean, I think that obviously surgery is, um, you know, the, the, the, the science of surgery happens way before the operating room. I think human, uh, integration will continue uh to be the foundation for any surgery, even robotic surgery. So not to worry, uh, I think we all have job security, which is good news. So to wrap up, Um, from a programmatic standpoint, um, it's important to identify clinical, operational, administrative stakeholders to really, I think, put, um, thoughtful architecture around how to engage in this technology, understand personnel and staffing requirements and logistical challenges, create some kind of scheduling and faculty. Support so that access can be had um and uh will increase the likelihood of, of robotic uh uh cases being done if they're, if that's the desire. Understand the budget process and, uh, you know, clinical and financial benchmarks. Again, that's a big, big, uh, very complicated question that I don't have an easy answer to. To find the right operations for the right patients. Again, not every patient, um, should be getting a robotic operation. It's got to be the right operation for the right patient. Um. Buddy up. Find, find, find somebody uh that you, that you like, hopefully, uh, to help you in the operating room and be available to help others in the operating room because, um, uh, I, I, I think the more the merrier, it, it, it, it drives, uh, safety and quality. Service line development, leverage resources, you know, reach out, uh, let people know what you're doing and keep an eye on the future. It's moving fast. And with that, thank you very much. Happy to answer any questions. Mm Mark, thank you so much for, um, for joining us and, uh, honoring us with your, your, uh, presence and your expertise. Um, I happen to know that he expected that he's gonna come and talk about bariatric surgery, uh, and Doctor Fleming said, no, we actually want to talk about your robotic programming, uh, and, and so he, uh, well, mixed the two pretty pivoted, pretty pivoted, very nicely, uh, and, and, uh, and so you have obviously, uh, uh, experienced the two, program developments that, that merge together. Um, and, um, I'm gonna, uh, toss open for questions a second. I, I just wanna, um, you talked about the history and where it all came from, and two companies, one acquired monopoly, now it's turning into a competition again, which is absolutely necessary for innovation, um, and then you sort of hinted that surgeons will always be necessary. But the recent report with videos out of Hopkins showing laparoscopic cystectomies with no human except in the room talking and saying go left, uh, like Karen drawing lines for you, are you really sure that the people in this room, maybe, maybe, uh, uh, uh older generation retired. Yeah, but are you really sure that we're the human's gonna be there? Yeah, I, it, it's a really good question. And, and, um, it, for those that don't know, I think it was earlier this summer at, at Hopkins, uh, they did in a, uh, in a, I think a pig cadaver model, uh, there was a robotic cholecystectomy that was done effectively with no human input, which is, um, both amazing and a little alarming. I very much appreciate your talk. Um, I, uh, uh, it brings back memories. I like you trained, um, by my own accord, uh, when I became faculty, uh, on the robot, um, having not really done any in general surgery residency, and I recall being wined and dined and fed the Kool-Aid, uh, from Intuitive. It was great. Um, and then I've been very underwhelmed by how much support we've gotten from the company, uh, since then. I think it's a real tragedy for our, uh, institution and our nurses, uh, and, and the surgeons, frankly, that we don't have that ongoing support. And I gather some of that is medico-legal concerns from the company. Uh, and I gather in the pediatric world, we are a bit of an ugly stepchild to them, given that we do unindicated operations, uh, and given that our volume, even folks like you and the highest volume people, really pales in comparison to the, really have drank the Kool-Aid adult surgeons, uh, out there. So I'm just curious what kind of support you've been able to get at Nationwide and how you've uh worked through that. It is amazing. We get really good support from our intuitive reps, uh, which is, I, I assumed was the case at every place until I learned that it, it, it is not. Um, uh, you know, I, I get a call once every few weeks from one of our colleagues somewhere in the country. You know, um, uh, saying exactly what you just said, uh, the intuitive reps won't show up. Uh, they say they can't help us. Um, and, um, so, I mean, obviously, I don't work for Intuitive, but, um, you know, I know the people there, and, um, part of it is, uh, a, a problem of their own making in terms of the way that they engaged or were required to engage with FDA, kind of like credentialing. Um, you know, the FDA required case-specific clearance. So, cholecystectomy is adult cholecystectomy, not pediatric cholecystectomy. So therein lies the problem. What I will tell you, um, well, a couple of things. I mean, when, when, when folks run into that and they call me, um, I tell them to, uh, you know, Put their rep in touch with my rep. Um, and, and sometimes that has actually helped smooth things out. Um, I'm not sure why we had no issue at all, um, and we still continue to get, uh, excellent support. I mean, there's almost a, there's a rep in my room almost every time I'm in there. Um, you know, that's, that's, um, that's a practical, uh, solution and happy to talk to you about that, uh, offline. Um, I, I think more organizationally, Intuitive does recognize that, um, and they are working, they are in the midst, um, uh, you know, it's interesting. Intuitive has 4 pediatric surgeons working for it, uh, including James Wall. Um, you know, it's all the Stanford connection, it's all this Palo Alto connection, um, and they are, they are working with FDA to try and Um, reconfigure how clearance is done, uh, to be done in categories rather than specific case indications, and that's going to include pediatrics. So, you know, I, I think that the future for that kind of support, um, you know, uh, has the potential to get better. And then, you know, moving away from, uh, intuitive, there are other companies like Carl Stortz, uh, that, you know, clearly have a very, very strong interest in pedia in the pediatric world. Um, and, uh, their platform, without divulging too much, um, you know, has 5 millimeter instrumentation. So I think you're gonna see other platforms coming online that are going to be more willing. Do I think Intuitive is gonna build a, uh, a pediatric robot? No. It's not, it's not part of their, it's not part of their ROI, um, to, to put the billion dollars that it would require to really develop a, a system that's specifically meant for folks like us, but other companies will, so. Uh, thanks for that talk. It's really cool to see what Nationwide has been able to do with this. My main question is how modifiable is the increased cost? Do you have granularity on what drives that cost? Because interestingly, a lot of the cases, you know, we do robotically, the disposables are actually less. We, we use fewer disposables with a robotic case than we do laparoscopically, so. Is it OR time? Is it something we can change that can bring the cost down? Yeah, well, you know, it's interesting. It's cost and it's also, you know, it's, it's also a matter of, uh, of contracting, you know, what, what, um, contracting the hospital has or what insurance company the, the patient has. I mean, you know, insurance companies more or less are going to pay what they pay for a gallbladder, no matter how you do it. Um, and so then it becomes an issue of what your internal costs are. Um, I, I, I, I, I showed a slide there, uh, looking at facility charge. I mean, just to, to measure that out, you know, most hospitals across the country use a 5 scale, uh, facility charge. So an average laparoscopic case, say a gallbladder is a facility charge of level 3. And, and that literally means it's something like, um, You know, uh, $2200 every 15 minutes to run that room. A robotic case, um, uh, is a level five case. No matter what you're doing, it's a level five case. That's about $4000 every 15 minutes. Um, and, and so, you know, can you manipulate that? Can you change that? We've talked about that, um, internally, um, about, you know, not running these cases at that charge level. But again, what you get paid is what you get, you know, what the hospital gets reimbursed at is a, is an external issue. Um, I don't know, it, we haven't seen, um, a responsiveness to that in terms of Uh, payments. We also have not, I'm happy to say, we've not seen two things. We've not seen any insurance denial, uh, for robotic, uh, you know, uh, pre-certification, and we've also, uh, I mean, in, in the, in the, in all the years that we've been doing this, I haven't heard of one case of a patient saying that they got some astronomical bill or a surcharge that was attributed to the use of the robot. So, these are all great questions. I don't, I don't really have a great answer for you. Doctor Mikowski, um, thank you for such a great talk. Obviously this is a, a very big interest of mine as well, and I can't wait to bother you even more than I do now in less than a year, um, uh, related to robotic cases in my career. So, as, as, as it relates to the credentialing of your fellows, can you touch a little bit more on that? Is this related to fellows who haven't been credentialed in residency? Or is this a more pediatric surgery fellowship specific? Yeah, most of our fellows, uh, come in with some robotic experience, um, and, and they may have a training, um, certificate from their general surgery program. What we do, uh, for, uh, you know, to, in order to generate a letter of support that says, you know, Doctor Fleming is. you know, good to go, uh, that, that you could turn into your, uh, medical staff office at your new job, uh, for your, uh, uh delineation of privileges. We have our fellows need to, um, bedside assist unless they have a training certificate that and a case log. They bedside assist. Uh, for 10 cases and then they have to do 20 cases, uh, on the consult as the primary surgeon. And so, and, and then again, do all of, you know, the skills and drills and, and, uh, and certificate garnering. And so, um, you know, when we first started that, you know, we got some, uh, tepid, uh, interest, but, but now, uh, I mean, I mean, I think almost every fellow that's come through in the last 10 years has, has taken advantage of. It's not mandatory cause it's not part of pediatric surgery, you know, it's not part of your pediatric surgical training curriculum that you do that. So, um, obviously, you know, uh, if somebody's, uh, doing an index pediatric case, um, and there's a, you know, a robotic gallbladder, um, um, you know, I expect them to be doing the, the, you know, the, the important index case that they need to be doing and, and not be running into my room, so. Uh, Mark, uh, thank you very much for a wonderful talk, and, uh, uh, I think you've clearly shown that these computer assisted surgical devices are the way of the future. However, I'm wondering whether us calling them robots does it a disservice intellectually and conceptually, because maybe it's my MIT training, but the robotics lab they're always stressed autonomous function and to that end, I'm wondering. In addition to the uh truly autonomous uh uh or semi-autonomous uh thing that was done at uh. Uh, uh, Johns Hopkins, are there other, uh, truly autonomous systems that are being developed where you just say take out the sarcoma on the back and it integrates, uh, uh, uh, all of the imaging and just does it? Yeah, so, um, I, I'll answer the last part of that question first, uh, which is the imaging. You know, I think there are companies that are, uh, really, really putting resources into what's called digital overlay. So, um, you know, J and J has a partnership with Google. Why? Uh, it's, it's metadata, uh, power. And so what, what they're working on are systems that can incorporate axial imaging, so that when you put your head in the box, you're, you're, you know, it's, it's basically like, you know, uh, uh, uh. Yeah, you get the stereoscopic view of the CAT scan that was done, you know, kinda like the neurosurgeons. Um, so the robot shows you the tumor in the liver, um, and, and, you know, then layer on top of that, some AI, uh, where the robot is saying, no, don't cut there, cut here, or, or to your point, the robot just does it. I don't know of any, um, um. Uh, truly autonomous systems that are, you know, close to market, but I, you know, I would be surprised if somebody isn't working on some level of that. Just a matter of time. Well, uh, we're way over time. We, um, we, we usually cut off, but for, for you, the longer I wanna really thank you. Um, I, we have very similar institutions and similar ethos, and, uh, we really enjoyed dinner last night and learning, and, uh, we're gonna, uh, share some, some learnings, and, um, to have you only, uh, uh, literally days after Ben, Ben was visiting your place, uh, uh, uh, shows the, the, the collegial exchange, um, we do wanna take you up an exchange of the rep because looking at your numbers. Like If they're getting special treatment because it's a number of cases we do almost exactly the same number of robotic cases in this hospital as, as you're doing a little bit more than yeah we might be. I wanna say that, but you said that, but, but, um, uh, and so we should figure out how to get the same kind of service, uh, um, uh, from, you really should from the company because it's been, it's been quite frustrating. So, so, um, we'll, we'll partner with you in that and, uh, really thrilled to have you, really appreciative your collegiality, um, and, and the education, uh, and, and, um. Um, and we hope that the rest of the day, uh, in our sort of academic experience, uh, that you'll, uh, participate actively and, uh, our team can show you what they're, what they're made of. So thank you very much, very much. Uh, well, upstairs with Professor Ronson.
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