My short bio: I am a surgeon who uses the DaVinci surgical robot to remove colon and rectal cancer. I perform these operations 1-4 times a week, depending on any number of factors. I am happy to answer questions you have about surgery or robotics: - what does it take to be a surgeon in modern america? - what is surgery training like? - how does the robot cut out cancer? - whatever you'd like to know

My First AMA got closed temporarily due to actually performing one of these surgeres and not be immediately available to answer questions. Well, I'm back and sitting here for next several hours. Fire away!

My Proof: http://i.imgur.com/YjWEh12.jpg

EDIT 17:00 EST = Thanks for all the great questions! I will be signing off for now. If you didn't get a chance to ask something, DM me and I'll respond. Reddit is pretty amazing!

Comments: 134 • Responses: 61  • Date: 

desiWonder11 karma

[deleted]

holyscalpel15 karma

So - that's THE question, right? The main thing I use it for is facilitating what can be a very difficult dissection of the pelvis. Operating on cancer in the pelvis has two good analogies: 1) it's like playing Jenga where someone's life is at stake 2) it's like trying to get a redbull can out of a coke can without touching the sides. Yes, just like "operation" the board game.

if you touch the sides you can cause infection, urine leakage, infection, impotence, or even make the patient bleed to death.

desiWonder5 karma

[deleted]

holyscalpel7 karma

It's always synchronous and I can abort its movement immediately in a split second. Yes, if you twitch it will mirror your movement. However, it does have a "smoothing" option like your mouse - never used it but it's there

desiWonder1 karma

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holyscalpel10 karma

how about this: - what if you had to play Jenga by feel around a corner vs. seeing it and having minute control over your motion?

better? it's very hard for me to explain the actions of surgery to someone that hasn't done it before. it is very much unlike any other tactile experience you might have

think about try to trying to clean out a disposal in your sink by feel vs. with that endoscope thing good plumbers use

desiWonder6 karma

[deleted]

holyscalpel3 karma

The cost to the patient is 1500$ - but that is almost always covered by insurance after the deductible. However, that cost is often recouped, at least partially, by not using other "disposable" surgical instruments like an energy device or stapler

The recent publication of the ROLARR trial shows some benefit to morbidity in males that are young, but otherwise no difference in major outcomes for cancer. The question is then "WHY ROBOTS?!?" The hidden concern is that surgeons make more money or get paid to use the robot - there is no difference in payment to your doctor regardless of what form of minimally invasive surgery he/she performs. Plainly, if you use laparoscopy (like a gall bladder, for instance) or the robot you get paid the same for the work you do.

Simply, the abilities that the robot gives you to perform specific maneuvers have made several surgeries possible for my patients that I couldn't have ever done without it. Recently, I was able to prevent a 35 year-old man with very rare cancer from having a permanent colostomy and having to cut out his anus COMPLETELY by using the robot in a way that no other surgery could have done.

Quantum_Burkowski1 karma

I'm sorry, you are saying the cost to the patient for an ultra-low anterior resection in an American hospital is $US1500? Doesn't sound right.

holyscalpel5 karma

no - saying that in my hospital the added cost the patient's bill by using the robot is 1500$ fee

the overall bill will be astronomical, as they always are

appreciate the tone, though - thanks for your support ;)

Efferri2 karma

My Mom passed from cancer a few years ago. She had multiple surgeries and rad/chem treatments. Near the end, they didn't feel comfortable operating anymore. #1 Are you an Oncologist? #2 Would using robotics help in the number of surgeries (overall) we can perform on a patient. Meaning, are they less intrusive? More easily recovered from?

holyscalpel2 karma

I am sorry about your mom - cancer is horrible and my heart goes out to you!

1) my primary role is a cancer surgeon for colon and rectal cancer, but I take care of benign things as people need them

2) robotic surgery is typically less invasive overall but only if the cancer is resectable to begin with. The robot takes what would have been a stem to stern (origin of term = penis to sternum) incision and make it possible to take out a resectable cancer with smaller incisions, less pain, and less "down time"

Minimozart2 karma

Does the operation have some drawbacks or advantages depending on the type/location of the cancer?

holyscalpel3 karma

Major drawback is the lack of haptic feedback - you can't feel what you're touching in there at all. Over time your brain tricks you into "feeling" what you're working on but it's nothing like hold the guts in your hands.

But - they're working on the feedback part.

Advantages: 1) VISION - you can see! The pelvis is notoriously difficult to visualize and the robot helps a ton! 2) precision - see above 3) quicker surgical recovery - smaller incisions means less down time, out of hospital probably 2-3 days quicker

OhSeven1 karma

--see in 3D with most systems

holyscalpel1 karma

yes all but the oldest allows for 3d vision

-Tim-maC-2 karma

Knowing the body's inner workings that well, don't you feel sometimes like a mechanic repairing a car engine? How has that affected your perception of what is "life"?

holyscalpel17 karma

that's a really good question - and especially pertinent when you do essentially a handful of basic operations on the same thing time and again. It's easy to feel like a mechanic, occasionally. However, that doesn't last long and you remember why you got 500,000$ in debt and spent 16 years training after high school.

And you know who snaps you out of it fastest? The little old ladies. They are so sweet and kind. And when they come back for a cancer check up in Fall and Winter - they bring pie. Oh, the PIE!

Seriously, burnout is huge among cancer doctors. I had a lady die from metastatic disease I couldn't fix on Sunday, and another lady will likely do the same today. it's depressing and every time it happens I have to call my wife and say "Someone died - I love you."

Also, I have become agnostic as time has gone on. i had a 32 year old girl develop advanced cancer that i can't fix - she will die and I can't save her. Makes you really mad at your deity of choice at times...

sdglksdgblas1 karma

it makes you mad because you dont know why it happened. neither do we know why people behead children or rape them or whatever. this world is cruel and horrible, yet amazing and beautiful at the same time, its okay to feel down sometimes, but having it affect your beliefs is not healthy i suppose. (get it, healthy ?) haha im so stupid

holyscalpel8 karma

agree - but when you have seen people die, (and believe me after almost a decade of medical training, I have seen it more than I want to) it gets harder to believe we're not just some sort of cosmic meat accident as you watch the lights go out of people. The more people I work hard to save and they die anyway, the harder it is for me to believe in a GD that would let that happen?! There is no logic, celestial, earthly, or otherwise that would let that sweet 32 year old girl with a 1 year old daughter and loving family die. Especially when she is a devout Christian. I don't blame GD for these things, I guess, but I don't know if he/she/it is real either. If I get to go to heaven (BIG supposition) then the entity will have to do some MAJOR explaining....

sdglksdgblas-4 karma

ive been there but then again, do you really think its possible we are cosmic meat accident able to create such things like the robot youre opperating, yet we dont understand our own brains. im just being patient. you should too, since youre a doctor and probably will have some big karma with the creator. no one said this world will be easy, fun and without pain & suffering. anyway best of luck and respect.

holyscalpel3 karma

i should take solace in the bolstering of self I get from random internet strangers - you made me feel really good just now

that doesn't happen often these days, you know ? ;)

Leo_the_great2 karma

I'm going to steal your example question: What does it take to be a surgeon in modern America?

I am currently in a undergraduate Biomedical Engineering program and hoping to go to medical school. I am leaning towards surgery and this AMA makes me excited for the future! Thank you!

holyscalpel4 karma

Surgery is an incredible career - but you need to understand the path.

So here's the minimum:

  • 4 years college, get great scores, ACE the MCAT

  • 4 years medical school, be in top 25% of your class, ACE the USMLE Step I/II

  • 5 years General Surgery training, be in top 30% of graduating surgeons in America (~1250 every year) to get into something like Surgical Oncology, Colorectal Surgery, Pediatric Surgery (NOTICING A THEME?)

  • 1-4 years additional subspecialty training

General Surgery and Subspecialty training are very arduous, but fun. LOTS of late nights. LOTS of hard work. LOTS OF READING. You didn't know you could ever read that much. Also, if you are doing medicine right, there is always homework. Every night. Forever - so understand that going it. Someone is always sick, someone always needs help, another chart dictated, another bill to put in. The electronic record has added on average 8-12 hours a week of work we didn't have until about 4 years ago so there's that to understand as well.

WalkToTheHills821 karma

Seeing the precision that DaVinci is capable of, what are some of its limitations?

holyscalpel3 karma

limitations are by your intention. the da Vinci isn't for emergent surgery - and they don't recommend it for that. it is for controlled, planned operations. it won't help if someone gets shot in the aorta. by the time you dock the robot and get it ready the patient would bleed to death

nevertricked1 karma

Funny how you brought up the aorta. I was observing a robotic nephroureterectomy and the resident nicked the aorta. Boy was the staff surgeon mad. With open procedures, couldn't you just place your finger on the cut to stop the bleeding?

holyscalpel3 karma

Yes indeed - but if robotic skills are there and it's not just gushing you can see it robotically and it will work. The sewing will fix that aorta better and can be done on the robot just as well...

Again, NOOOTTTT my preference but feasible

Oh_My_Car1 karma

How were you trained to use the robot? What were the lessons like?

holyscalpel1 karma

I spent about a year and a half learning with a robotic surgeon as part of a training program. This included several dedicated sessions of a few days at a time doing nothing else. I scrubbed about 50 robotic operations as a board -certified surgeon before I was able to schedule my own cases. Following this my first ~10 cases were proctored by a robotic surgeon to make sure everything went smoothly.

hurtsdonut_1 karma

How do you feel about Car-T research?

holyscalpel6 karma

Engineered T-Cells are incredible things and I hope they put me out of the cancer business so you guys can put me and my robot in a museum of medical history.

RoadToTheShow1 karma

What's been the biggest problem you've encountered so far, and how did you fix it?

holyscalpel2 karma

Biggest problem is usually patient related, honestly. This tech is game changing in many ways. And it would be most ideal in the obese patient where you can't see at all. however, in the morbidly obese and larger (BMI 35+) you cant see no matter what you do. Often times you run out of length on the instruments when the patient is fat enough that they can't reach into the pelvis.

The system can technically have "faults" and stop working but I haven't experienced that nor has any surgeon I know.

maborg121 karma

If you could start all over again, would you still decide to be a doctor. Why or why not?

maborg121 karma

How old were you when you starting practicing medicine

holyscalpel1 karma

Graduated Medical School - 26 Independent Practice - 33

maborg121 karma

So you have your own private practice or do you work for the hospital

holyscalpel1 karma

Academic Practice actually - so essentially I am part of large multi-specialty group (800+) physicians that work at a number of hospitals around our region

maborg121 karma

DO or MD

holyscalpel1 karma

MD but I have a lot of respect for DOs

holyscalpel1 karma

oooooooooooooooo boy - i think about this one everyday. I will try not to complain because people that have food on their table and wear wing tips to work shouldn't complain about much of ANYTHING in my book.

Being a modern doctor is nothing like anyone thinks. I think it has be one of the most thankless jobs, sometimes. People in modern America show up with a tumor the size of your fist from ignoring their symptoms, morbidly obese, diabetic, with previous heart attacks, and smoking like chimneys. They can barely move at all to get up on the exam table without being short of breath.

Then they blame you for a common complication like their wound getting infected. Despite warning them to stop smoking and helping fix their blood sugar, and give them antibiotics.....

Also, I easily work an 80-100 hour week. Which, to be fair, I am paid well to do. Would I have been happy working in IT and with computers in some capacity coming in at 8 and leaving by 5 every day and being able to have weekends off? Yes. Do i feel I am happier with my job as a surgeon? Unqualified, HUGE yes.

One of my med school professors said, "Medicine is a fickle mistress. It is fun and challenging. It is rewarding at times. But, if you let it, it will eat you. It will devour your time and energy. If you let it, it will take your friends, family, and all your passion and leave you 65 years old and with happy living patients but with no one left of your own."

If my sons (aged 5 and 1) tell me they want to be doctors, I'm not sure what I'll say or do. It's an incredible career - but you MUST choose wisely.

BloodPolska1 karma

Since you work primarily with Colon and Rectal are there any things that you know of that a patient should take immediate action if they notice any particular symptoms?

Do you think cancer will be 100% curable in the future?

holyscalpel3 karma

New onset bleeding - like bright red blood in the toilet or toilet paper is always concerning. As is dark stools (I mean like BLACK). Usually the bleeding is hemorrhoids - but rarely its cancer. Always get checked. I have had so many young (like 30-45) people come in too late with what was presumed hemorrhoids but was actually cancer and there was little I could do to fix it....

If your stool changes caliber?! GO YESTERDAY. If it gets pencil thin.... GO TODAY!!!!!!!! GET A SCOPE!!!!!!!!!!!!!!!!!!!

BloodPolska1 karma

Looks like i gotta get a new doctor. I'm on a run between different types of stools color and sizes with some pain and stuff. Even as a young male early 20's i should get this scopped out

holyscalpel3 karma

At 20 something almost assuredly hemorrhoid a but there needs to be an unpleasant MD visit in your near future

TheFakeJerrySeinfeld1 karma

How many attachment points are there? I saw an article on this in a popular science magazine and it had 8 or so scalpels attached at once. Also, when you're doing the procedure, how far away from the patient are you? And do they have people in the OR ready in case you make a catastrophic incision?

holyscalpel1 karma

the robot has 4 "arms" if you want to call them that - this the official term from the manufacturer

the new version has the instruments go through 4 8mm "ports" that serve as sleeves into and out of the abdomen/chest/cavity of choice

Often additional, traditional laparoscopic ports are used. In this picture the robot ports are green and the port near the belly button is for the camera - the rest are "assistant" ports.

The surgical assistant is a person at the bedside that has experience with minimally invasive surgery and assisting the surgeon in cases. They are usually either a paid assistant isn't a physician or an MD in training. If I had a seizure during surgery (NEVER HAPPENED BTW) and something went nuts, they can have the robot arms out of the patient and the belly open in less than 30 seconds. It is a situation we practice and review weekly to remind everyone what the procedure will be in case of the emergency we all fear, but have yet to experience (knock on wood).

TheFakeJerrySeinfeld1 karma

Wait, so you just "stab" right in there, one arm per point. So I'd walk out with 4-8 puncture wounds rather than a massive slice and stitches

holyscalpel2 karma

you got it - I tell patients you've leave the OR with 3 -4 holes the size of your pinky finger nail and one the size of your pinky finger

all the suture are absorbable too - no need to ever have any sutures removed in the office :)

MG871 karma

How long does the surgery take?

holyscalpel1 karma

between 2.5 - 5 hours depending on how much we have to remove. I have taken a whole colon out before, and that can take 6 hours or so. Plus the anesthesia time and what not - makes for a long day for the patient.

BBTaeKwonDo1 karma

During surgery, do you use any other imaging techniques other than the cameras that come with the system? E.g., portable X-Ray, ultrasound, etc.?

holyscalpel2 karma

often we use ultrasound preoperatively to check the tumor and definitely ct scan or mri rarely do we use those intraoperatively unless something funky happens

Sonmi-4521 karma

What is your opinion of the concept of the Autodoc in relation to the surgeries you perform every week?

Will an educated AI eventually be able to employ sensors and complex algorithms to perform the same surgeries you perform with more accuracy, given your knowledge of the tech?

holyscalpel1 karma

if the tech gets advanced enough sure - but i would never let it operate on anyone I know. Reasoning? Because so many decisions are game time.

Will the machine know that the lady I did today might have to have radiation or not based on what we found? Will it then decide to give her a loop ileostomy to protect the hook-up of her bowels? What if something goes horribly wrong?

I think my chances of being replaced are less likely than my chances of being eliminated by targeted anti-cancer therapies that just melt tumors away

Check out imatinib - it's pretty amazing stuff

coldfu1 karma

Why wouldn't the machine not have the same information available that the doctor would have?

holyscalpel2 karma

so many of the choices we make are a combination of experience and surgical instinct - it takes us at least 5 years to teach that to humans that self select as some of the hardest working and smartest of their generation. if you can program an algorithm and robot to function as well as they do - not only will i put down my scalpel, I'll help you sell the thing to anyone we can make listen!

Bobsmit1 karma

What improvements do you think can be made to surgical robotics in the near term?

holyscalpel1 karma

Main improvement would be a way to decrease cost so that more surgeons can use it

Boo_R4dley1 karma

Have you seen the articles (and the study they're reporting on) that say that there are high risks involved with robotic surgery? As someone who has actually used the equipment, how do you respond to the claims made about equipment malfunctions causing injury and death?

http://www.nbcnews.com/tech/tech-news/robotic-surgery-linked-144-deaths-2000-n395811

holyscalpel1 karma

and here too?

I have heard many of these things from different sources and have several comments:

1) If you were able to track any device used in major cancer surgery to the degree you are able to track the use of the surgical robot, you would get at least similar numbers. The thing is we don't track those other devices very well / in a way that we can report on. The numbers of robotic related "adverse events" (sigh, don't you just HATE medical terminology) is comparable to other minimally invasive techniques. The access devices for laparoscopic surgery can cause enough bleeding to kill a patient when used incorrectly, and that has been reported. A famous quote from a notable surgeon (I'll spare you my love of surgical history) says, "There is no procedure so small it can't kill someone." If you look, I would bet more people in America die each year as a result of simply undergoing General Anesthesia and being unable to secure an airway or esophageal intubation than die from a robotic surgery fault.

2) In the long run, the robot has enabled surgeries that wouldn't have been possible for many people and saved tons of lives. Anyone who says they can do a procedure for routine cancer better open than minimally invasive hasn't tried minimally invasive surgery very much. There are some tumors that aren't robot/laparoscopy candidates - it's easy to recognize when you see them. But the plus is WAY on the side of saving lives for the robot in the long term.

3) The best chance you have of living long term once diagnosed with a bad actor cancer, like rectal cancer, is to have an experienced surgeon cut that tumor out in the way they are most comfortable with. The robot is my tool of choice, partially because I believe it truly is the best thing for my patients, and partially because it is familiar to me. If you asked me to eliminate it from my practice tomorrow, I could easily, but it would take a while for me to get to the old ways of laparoscopy again.

4) There is one company that makes this machine - Intuitive Surgical. That said - I have never received any compensation from them. They don't know I'm doing this AMA. They don't reimburse me per case or per 10 cases I do on the robot. They don't take me on trips to the Bahamas. Once, they paid my course fee since I was still in surgery training. It would normally have cost me 4500$ and they paid it partially and my training program provided part of it at a time when I made very little (look up surgery resident salary on Google). That was two years ago. I have no loyalty to them as a company - if and when Google makes their robot and it's better - I'm there for sure. I don't go to meetings and preach robotics to other MDs. I don't make office calls to sign people up. I honestly believe it is the best tool for this job because it allows me to do things for my patients that I couldn't otherwise do - see the comment above about keeping the young kid from having to poop into a bag for life.

BedOfBlankets1 karma

I'ma ask your example question....How does the robot cut out cancer?

holyscalpel1 karma

So - it takes me a year to teach a trainee how to do it, meaning all the steps and what not. Best example is to watch it spedup on YouTube

The steps are the same as open surgery, just done with finer movements is a good way to describe it

EDIT: grammar

ghettokhan1 karma

What's your annual salary? How's the surgery lifestyle? I'm a second year medical student interested in general surgery, but everyone tells me it's not worth it anymore.

holyscalpel2 karma

So, you and your classmates need to look into splitting the cost of something called the MGMA dataset Last I looked it was 500$ and breaks down salary by specialty for almost all parts of medicine

The quality care era of medicine is coming and it will change EVERYTHING. NO one knows who will get paid what in the future. That said if you want to work hard and make better money, anything with a procedure is better than anything without. If you want to make a salary like that of upper middle-management then go into primary care.
Pediatricians can work 8-5 and send all emergencies to the ED - but MGMA median a few years ago was 90k$ so - plus markets vary etc.

Also, you need to learn what an RVU is and how it will impact your future.

The surgeon lifestyle can be rough or easy - it's all about what you make it. you want to make 2/3 rds normal surgeon salary and take a day off a weak? you can do that. you want to work until 8-10pm everyday and never see your family? you can do that. you have choices, but the hospital based practices are eliminating them slowly.

Hell, I have a friend in trauma surgery who only works 26 weeks a year, 7 days on 7 days off. He make almost twice what I do....

sixsidepentagon1 karma

As someone deciding specialties, how tailorable is your lifestyle? I imagine your call schedule is pretty light unless you take general surg call too?

holyscalpel1 karma

Right - Colorectal lifestyle is pretty sweet and one of the things that attracts many. Very rare to have emergent colon cancer or ulcerative colitis but it does happen. Much more common to be operating late at night than to be called back in

TrackNation1 karma

Sitting on the verge of deciding whether or not to start on the MCAT train. Im a Junior in college and really do want to go into medicine yet have a strong desire to take two years right after college and go into the peace corps, hopefully in Mozambique. Any idea if this is viable or benecifical/ do you know of anyone who has taken this path?

holyscalpel2 karma

If there is something you want to do prior to medical school - DO IT! Go to Mozambique. Learn a cool language. Join the military. Anything you can do that makes you interesting will help your application, I promise. Don't be like me - a straight through boring guy whose only life adventure is buying a house. ENJOY YOUR TIME before you get to grow up.

TrackNation1 karma

And would you suggest taking the MCAT before or after that..? Im leaning towards before, as it is valid for 3 year (I think..)!

holyscalpel1 karma

hmmm - I think taking it while fresh would be better. If you take the prep course now and do the test, that gives you time to take it over again if needed (some do and there is NO shame)

besides in a decade you won't remember your MCAT or SAT scores - i don't

Bbbenji1 karma

I'm an aspiring surgeon (22yo premed writing the dreaded new MCAT in a couple weeks). What advice would you give to aspiring surgeons? Or what was said to you that has made the hundreds of thousands in debt and years upon years of training worth while?

holyscalpel3 karma

Surgery is great for those that want to make a huge impact fast. If you want to spend your life doing the most good for a person with a given amount of time - be a surgeon. This week I have already rendered two people free of cancer for a total intraoperative time of about 5 hours. What kind of other job on the planet offers that kind of reward for time spent? You mean cancer is out of me in an afternoon? ARE YOU SERIOUS!?

I chose surgery when I learned this and figured out some other things.

Surgeons need to master a lot of Internal Medicine as well as surgery. The surgeons who have bad outcomes are: 1) not thoughtful in their choice of patient to operate on 2) forget their broad-based medical training 3) never learn how to operate well in the first place

Surgeons are often some of the smartest MDs in the hospital in terms of practical, life-saving knowledge. Most can't recite the coagulation cascade to you, but they can damn well save your bacon until morning comes and help is there.

If you choose medicine, choose surgery and specifically general surgery. It's just fun to be awesome.

Sports599891 karma

Do you have anything to say about single port robots? RASIL

holyscalpel1 karma

yes, I am excited for it. it's not ready for prime time for rectal cancer yet but MAYBE for a right colon cancer

if you use it for some other things, sure. They are currently making a single incision patient cart for the Da Vinci Xi and I think we could start using that for robotic transanal TME very soon.

kingofwukong1 karma

budding surgeon/bioengineer (junior doctor in UK), i was wondering how you found the interface and if you use single port or dual port with your surgeries?

With regards to the interface, do you know if anyone is currently working on applying either oculus or hololens with robotic surgery?

I've been planning on doing a paper on paeds single port vs conventional laproscopic techniques as there seem to be quite a recent trend in people publishing about single port operations, do you feel this would be a worthwhile paper to try and get published?

holyscalpel3 karma

with regards to interface - it's honestly clunky and needs a 21st century redesign

hololens would do the trick

holyscalpel2 karma

single port isn't new right now, will be hard to publish

I'm sure that the battling VR firms are working on surgical applications, and Google is developing another robot with VR capability but scant details are available

redmercuryvendor1 karma

The DaVinci has a completely stationary display; you lean up the the optics to receive the camera views. In the last two years, Head Mounted Displays have dropped in price dramatically and shot up in image quality.
Do you feel the ability to 'look around' inside a patient would be useful, or is the ability to have a static viewpoint - and to easily 'back out' to interact with others in the OR - preferable?

holyscalpel1 karma

well our viewpoint isn't really static - we can move the camera any way you like really. true VR displays are the next thing for robotics I bet but it will be a while before they make it into the OR

Jeffums1 karma

What's the deal with airline food?

holyscalpel1 karma

you mean the Sbarro in the food court? wouldn't touch the stuff - better to carry on a Pike's Place from SBux with an oatmeal muffin

Fidesphilio1 karma

My mom is a sterile tech, and she says a folded-up DaVinci resembles a giant spider. Confirm/deny?

Also do you need special training for the robot or just kind of pick up the controls and go to it?

holyscalpel1 karma

Confirmed! Spider is appropriate analogy. Took me about 1.5 years to feel ok another year to feel really confident. Lots of practice on dry labs and pigs

razelbagel1 karma

I am an EMT and student, changing careers to go into medicine, specifically as a PA and finishing my last few pre reqs.

My question is do you utilize any PA's during surgery and if so what are their roles typically? I have always been interested in surgery and often hear about surgical PAs but never about their role directly from a surgeon.

holyscalpel1 karma

PAs frequently work as surgical assistants and a second pair of experienced operative hands. It's a great gig but hard to find work as most MDs only hire 1 PA if they hire at all and turnover is LOW

jofo51 karma

Thanks so much for doing this AMA! I am an undergrad Biomedical Engineering student with aspirations to work on robotic surgical devices such as the DaVinci. I was wondering how big of a difference the DaVinci robot and other brand new advances have changed your experience as a surgeon.

  • Does the robot make surgery easier and give you a greater success rate?
  • Is it also better for the patient in terms of comfort and recovery?
  • How important is technology in making surgery easier for the surgeon and what does that let you do that you could not do before?

Thank you for your time and is there a way I could shadow a DaVinci robot surgeon for a day to see what it is like?

holyscalpel2 karma

Does the robot make surgery easier and give you a greater success rate? - the robot does make surgery much easier in many instances, but less so in others (see previous comment about obesity)

Does the robot make surgery easier and give you a greater success rate? - the recovery time is significantly less with the robot, average stay is less by a day or two in hospital which is significant

How important is technology in making surgery easier for the surgeon and what does that let you do that you could not do before? - it's not that we couldn't do it before, but it is more elegant for lack of a better term

humperflumper1 karma

I'm beginning college this fall as a biology major (pre-med), any tips you could give me?

Thank you, doctor.

holyscalpel2 karma

Study harder than you ever thought you could. If I could go back in time I would have studied much harder in college and gone to a more elite medical school. In medicine, pedigree is everything. If you didn't go to Hopkins or Stanford etc. You are starting from a leg down professionally - at least in terms of academics. In private practice doesn't matter where you came from as long as you are kind, work hard and know your stuff

mtocrat1 karma

A big focus of robotics research is about having robot act autonomously (this can also take the form of assisting a human user intelligently for example by inferring intentions). Naturally, this is not something that you would want to employ on a surgery robot where any mistake could cost lives and where you want complete predictability. However, as someone who has experience in working with those robots, can you think of any part of the process where you think the robot could help you out with some degree of intelligence without endangering the patient?

holyscalpel1 karma

We have some of that now - the newest robot has "automated targeting" where we point the camera at the tumor and the Dr octopus arm deploy automatically for optimal placement!

-Tim-maC-1 karma

I was wondering since you know the digestive system so well and must have seen all kind of "shit" (pardon the pun) over time, what are the food types that are mechanically harmful (specifically to the digestive organs such as colon) on the long term and which food types are the system's "maintenance oil", keeping it well running all the time?

holyscalpel2 karma

OMG FIBER FIBER FIBER FIBER FIBER WATER WATER WATER WATER

The rest of it is kind bunk

SmartAlice1 karma

Have you used the injections that makes cancers glow in the dark in conjunction with the robotic arm?

holyscalpel1 karma

No but I have heard of them and boy would that be a game changer for us!!!!!!! That would make operations so much eaiser

ghostabdi1 karma

How do you respond to this?

holyscalpel1 karma

See posts above

TL;DR it the same for every major variable in an operation and the rate of problems is very very very low

thundershawk1 karma

I'm a certified surgical tech, &have experience with the "Spanish" Davinci Si heheh how's it different from the xi model if you've worked w/ it? What's your fav procedure w/it, whether it's you or like a gyn case that you've seen/find interesting? Ps love your techs!(:

holyscalpel2 karma

Or techs are instrumental (wakka wakka) to our success. I have a few robotic total proctocolectomies with leaving trendelenberg or redocking. Thy as the difference Xi makes.

advicebad1 karma

Some older colleagues compared the advent of robotic surgery with the somewhat rapid mainstream adoption of laparoscopic procedures, despite the (at the time) lacking evidence to support the transition. Do the data support adopting this new technology?

holyscalpel2 karma

The data say it's essentially no different than laparoscopy in terms of outcome. I defend my use of the robot because it decreases length of stay for my hospital and my patients. As well, the fact that the instruments are wristed it makes a Huge difference

johnny_kickass1 karma

I was curious - we now have robots and lasers and advanced real time 3D imaging, yet the doctor still as to stick his finger in your ass to check your prostate. Why? Why is fixing this not a higher priority?

holyscalpel1 karma

The fingernails cost efficient - that other stuff costs both time and money The finger is super cheap

furyfairy1 karma

How do you see this robot technology evolve in 10-20-50 years ? How you see the cancer field in general evolve in that time period ?

holyscalpel1 karma

By the time I am 70 cancer will likely be cured I believe - targeted therapies will wipe the common diseases out but cancer will be a rare cause of death in the US

[deleted]1 karma

[deleted]

idontknowwhattoput011 karma

How did you get into robotics in surgery, my brother is training to be a surgeon (he has finished his first 2 years working as a junior doctor) and is interested in using robotics for surgery?

holyscalpel3 karma

it was about finding a mentor in robotics - once I did that it just took the time to train and learn how. however, the right mentor is a very difficult thing to find

tellmetheworld1 karma

If you needed to use that robot to kill a man in the fastest way possible - how would you do it? (Let's forget that whole hippocratic oath thing for a sec. . .)

holyscalpel2 karma

I am not sure how best to answer this. Personally, I think the robot makes it harder to inadvertently commit a fatal surgical error as there are range of motion fail-safes that aren't on the human hand.

Bleeding to death is the quickest way to die without decapitation or direct cerebral injury. I have seen in on Trauma Call many times - only had it happen to a hand full of my patients (MAYBE 3!?) and they were all gun shot wounds to the chest or belly.

champangecandy1 karma

What did you have for breakfast?

holyscalpel4 karma

Souls - delicious souls!!!! Or cereal with coffee....

ichegoya1 karma

Describe the robot - I presume it's not completely automated, meaning you don't just inject it somewhere and let it go. Can you tell me how big it is, what it does well and what it needs more guidance to do?

holyscalpel3 karma

http://olsman.esquireinteracti.netdna-cdn.com/wp-content/uploads/2013/06/Davinci-robot.jpg

This is a typical set up but not the one I use - we have the next model up from this one. The robot is actually a method of translating your gross motor movements into VERY fine motor movements inside the patient. Think "Minority Report" glove thing but with the ability to control the scale of movement like you do mouse sensitivity in an FPS.

The whole thing together is pretty big as you can see. the console is about the size of a desk. The tower is 3x3 feet and usually 8 feet tall with the hoses to run the equipment. The Dr. Octopus looking thing with the arms (the "patient cart") is what goes inside the patient and deployed it is 8 feet tall and about 5 feet wide.

It is entirely guided by the surgeon. It is really just a huge glove box essentially. It is awesome for pelvic surgery or surgery in a small space. It is TERRIBLE for anything you need to do fast. The robot is NOT a viable way to operate on someone acutely dying over long distance due to trauma (think MD on earth, patient in space) because you can't get the big things fixed fast enough.

ichegoya1 karma

So is this device solely used for colo-rectal cancer removal? Or is it a multi-use robot? I assume it must multi-use, since it'd be strange to think all that research adn money went into something like a 'one-trick pony'.

holyscalpel1 karma

we use it for everything: - colon/rectal - endometrial/ovarian/gynecologic - prostate/bladder - lung/esophagus - pancreas - thyroid

the abilities are limited only by the imagination of the surgeon and the commitment of his team

yeahthatworks1 karma

Very interesting occupation! I was wondering with the increasing level of technology becoming involved in surgery, like 3D printing, do you feel as though these advancements are intimidating, exciting, etc.?

holyscalpel3 karma

Dr. Eddie Abdalla has printed a scaffold for kidney stem cells which seems cool. The problem with non-human transplants won't be their construction. Smart bioengineers will have artificial kidneys up and working within 10 years. However, it is getting the body not to reject the foreign body that will be the real kicker.

The immunosuppresives given to transplant recipients are no small joke - they can cause cancer themselves. A patient from last month got a renal transplant 8 years ago and now has a huge skin cancer on her anal canal requiring chemo and radiation.

Interesting tech we use now: firefly

it basically shows you the blood supply of structures in the body. Don't know if the blood vessel you are looking at has a branch you can't see? Just hit a button on your camera in the belly and inject a teaspoon of inert contrast - then you see it go from grey to green in real time. Cool, no?

Hinarfed-2 karma

How about you be a real human being and do this for real cheap?

Edited for profanity, the healthcare system really pisses me off.

holyscalpel6 karma

so, yeah the healthcare system pisses me off too in many ways. For starters, I have NO CONTROL over what I bill for a procedure.

Basics of billing - MDs bill your insurance in something called RVUs (relative value units). The value of a procedure is determined in RVUs and not dollars and is set by CMS (Center for Medicare/Medicaid Services). This way, it's standardized and Surgeon A and Surgeon B don't charge different prices for the same service. Every surgeon makes the same # RVUs for same procedure. The RVUs I make then go to feed not just me but all the office staff, nurses, techs, and assistants that work in my office as well as their families. It pays their health insurance and supports them too.

Now, let's say I take a tumor out of your colon. You have no complications after surgery (most don't). I submit a bill to your insurance for ~35 RVUs. The insurance company has a set price they pay per RVU to people in my region of the US for that procedure based on specialty. That's it. I don't negotiate with the patient or their insurance unless the patient is poor and needs surgery and I can intercede to help them get it for free.

Moreover, I have little say in ANY of your hospital bills. That is set by Pharmacy and Administration among others. If you are a routine patient of mine, then you get minimal accessory costs like lab work, etc. I can't control how much pathology pays to process your tumor to determine if you need chemotherapy because it has invaded your lymph nodes. I can't control how much pharmacy charges you for the morphine you need to control post operative pain.

The main thing in my power is giving you the best damn surgery I can give you with my training - being a technically bada$$ surgeon that is the equivalent of the pilots from Top Gun. If I can do that perfectly, you'll have a better cancer outcome, a shorter hospital stay, a lower hospital bill, and better overall experience from something that can easily completely ruin your life or potentially end it.

If you want to be pissed off at health care, go ahead. I'll join you. But don't even try to say that I'm somehow to be faulted for the economics of modern surgical care. Yes surgeons make a good living. That may make you angry, that's fine. But I guarantee, you have no idea what the person operating on you has given up just to have the chance to help save your life. You don't even have the slightest idea how hard they worked, the friendships they lost, the weekends, the holidays, the lack of sleep, the stress, the CONSTANT work, the decade of their life they essentially gave up. If you want to learn - give up everything else you ever loved or wanted for over a decade of thankless hard work and then complain about healthcare and what surgeons make.

The average surgeon will see about $300 for that life saving colectomy they do for you after everything settles out that then has to feed and help everyone working for and with him/her. If that's not the best bargain going today, then I'll quote Ron Weasley "You need to sort out your priorities."