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The Sim Cafe~
The Sim Cafe~
Revolutionizing the OR: A Dive into Surgical Robotics and Future Innovations with Dr. Roger Smith
Step into the operating room of the future with Dr. Roger Smith, a visionary in surgical robotics, as we explore his journey from the precision of military simulations to the innovation-laden realm of medical robotics. Dr. Smith, once a mathematician and computer scientist, now stands at the vanguard of a revolutionary shift in healthcare - a transition that is not only fascinating but also a testament to the fluidity of expertise and the power of cross-disciplinary influence. As we chat, you'll be privy to the transformative impact of the Da Vinci robot, the standard-bearer of telesurgery, and the exciting challenges it faces from cutting-edge newcomers like Medtronic Hugo. This is a glimpse into a world where precision and innovation are redefining patient outcomes and surgical excellence.
Our conversation with Dr. Smith doesn't just stop at robotic arms and cameras - it soars into the future, where AI could become a second pair of eyes in the operating room, and spherical cameras might offer surgeons a panoramic view of their surgical landscape. We consider the ethical quandaries posed by an increasingly intelligent surgical suite, the role of tele-surgery in remote applications, and the evolving design of surgical instruments propelled by software advancements. For anyone intrigued by the intersection of technology and healthcare, or pondering a career at this crossroads, our discussion is an invitation to discover the simulation technology training the surgeons of tomorrow and the remarkable potential robotic surgery holds for changing lives today.
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The views and opinions expressed in this program are those of the speakers and do not necessarily reflect the opinions or positions of anyone at Innovative Sim Solutions or our sponsors.
Deb Tauber:We want to thank our sponsor, healthy Simulation. Healthysimulationcom is the world's leading healthcare simulation resource website, providing daily news, ces, cme, webinars, expert guides, conference and job listings, product demos, research highlights and more. Take advantage of their thousands of free articles and hundreds of webinars to improve your utilization of clinical simulation technologies and methodologies and improve your education, training and patient safety goals. Today, healthysimulationcom, thank you.
Ferooz Sekandarpoor:Welcome to the Sim Cafe, a podcast produced by the team at Innovative Sim Solutions. So pour yourself a cup of relaxation, sit back, tune in and learn something new from the Sim Cafe.
Deb Tauber:Welcome to another episode of the Sim Cafe. Today we're co-hosting with Ferooz Sekandarpoor, and thank you, Ferooz, for being here.
Ferooz Sekandarpoor:Thank you very much, Deb, for inviting me to co-host this episode.
Deb Tauber:We have a very interesting guest today. We have Dr Roger Smith, and using surgical robots seems like future science fiction to many people, but you might be surprised to know that they have been in use for over 20 years and are used for over one million procedures every year. Today we're going to talk to Dr Smith about the state of the art and these devices and what might be on the horizon in future decades. Dr Smith, would you like us to call you Dr Smith or Roger?
Roger Smith:I think Roger would make a great conversation Perfect.
Deb Tauber:Thank you. Why don't you go ahead and tell our listeners a little bit about yourself and how you got started in robotics?
Roger Smith:Okay, yeah, so I've been working in surgical robotics for a little over a decade now, so that's the most current part of my career. But I didn't start there. I was a mathematician and computer scientist in college and at that time the place that mathematicians and computer scientists got jobs was as defense contractors or in the government. So I found myself building simulators and simulations for different military projects the Air Force, the Army, places like that and I thought that's what I would be doing for my whole career. But I moved from company to company to company and I finally ended up with a short appointment at an Army command that builds simulators and in the process of helping the Army start to adopt medical simulation. I met all of these doctors that were doing medical simulation in the civilian sector and they were fascinating people and they were doing things that were quite different than everything happening on the battlefield somebody getting shot, blood being spilled everywhere, a much more controlled environment. So when my appointment was coming to an end, one of those surgeons came to me and he said Roger, I know of a hospital that's building a fantastic new simulation and training center and I think they need someone like you. I'd like you to meet them and have a talk with them. And so I was. I scratched my head like I don't see that in my future, but I wouldn't talk to them.
Roger Smith:And they turned out to be fantastic people. I just really I resonated with what they were doing and their mission and the way they worked. And they told me. They said we have an opportunity to bring in a congressional grant. Our congressman has arranged for us to get several million dollars in grant money and we have no clue how that system works. We don't know how to get the money, we don't know how to manage the money, we don't know the legal implications. And then, once we have it, we don't have anybody that knows how to guide that kind of research.
Roger Smith:And I said I know how to do all of those things. So that convinced me. So I jumped from the military to civilian medical and the grants were specifically to work with surgical robots, specifically the Da Vinci robot, and try to measure how the Da Vinci robot would do if it was trying to do telosurgery across a city, across a state or across the country. That was the main focus of the grant and all of the pieces of hardware didn't exist so that you could actually just do it and answer the question directly. There was a lot of work that had to go into estimation and simulation to make that happen, and so I jumped to the hospital and started putting that grant research program together, and I ended up there for 10 years.
Ferooz Sekandarpoor:That's fantastic story of how your career morphed into some things to become special Basically reminds me of my career Just being a computer network engineer to now being a simulation expert. So it's just again similar. But now you mentioned about Da Vinci robot. The reason that is very familiar with me, my institutions and installed two of them. One was for research, one was for real surgery and I was involved sort of getting into implementation of that, integration of that robot into our AV system so that we are able to broadcast from it life into our lecture rooms and distance, and that's why telosurgery was one of the options as well At the time. Of course it wasn't controlling it, but it was able to broadcasting what Da Vinci was doing. That and obviously now, what other robots? Because I know Da Vinci is the dominated force in the robotic world. But what other robots you have worked with and can you name some of them and what are the differences in those?
Roger Smith:Yeah, I could do that. So, as you said, the Da Vinci is really the dominant machine. Of the more than a million procedures every year, easily 95% of them are Da Vinci surgeries and the other 5% are everything else. It's like back in the old days when IBM built all computers except for three. It was kind of like that. But there's still a lot of companies that are coming out of the woodwork that VCs are putting money into because they're like that 5% is still very valuable and there's no reason one company should have 95%. I think we can get some of that too.
Roger Smith:So we worked with, I think you and I talked before about the Medtronic Hugo robot. So, medtronic being the large dominant company they are, they're like we should be in this business too. So they've created a robot that they call Hugo which is very similar to the Da Vinci. Now, the two companies, of course, would beg to differ. They're very different, but in truth they do a lot of the same kind of things. It's a little bit different angle. So we worked with that. Medtronic also bought an Israeli company called Mazor Robotics and Mazor had created a robot that assist with spinal surgery, and they just had that one niche on spinal surgery and Medtronic came along and bought them. So both of those devices were things that we either contributed ideas to or we actually had them in our facility to research with. I think we didn't mention before I didn't mention before the facility where I was at is Advent Health Nicholson Center in Orlando, florida, and the Nicholson Center is like 100,000 square foot space. That's all about education and training. So because we have that dedicated focus, a lot of the robotics companies come to us either to teach courses on how to use their robots or else to proof them out and give exposure to them to some surgeons who haven't seen them before.
Roger Smith:Okay, so we did. We worked with Metrona Hugo. We worked with the CMR Bersias out of England when it was still kind of a secret. All the rumor mills knew it existed, but exactly how far along they were and things like that were secret. And so they came and worked in our facility and with us for a year and a half collecting data, having surgeons use the device on canvary tissue and various synthetic tissues and then collecting data on them on that performance that they could submit to the FDA.
Roger Smith:And then we worked with Striker Mako. Again, mako was an independent company. They're focused on hip and knee surgery, so the device is very different from Da Vinci, but they were bought by Striker, which is a big company, and then two of the smaller companies that are still rather small. The Asensis Enhance is a robot to assist laparoscopic surgeons, so they're not seeking to convert a laparoscopic surgeon to a robotic surgeon, they're letting the laparoscopic surgeon stay in their special way of operating, just giving them some assistance. And then finally the Titan Medical Enos robot. So a little over half a dozen of them came through and we would either do research with them or else they would ask us to use it and give us their feedback as compared to the other robots we'd used.
Deb Tauber:That's good, Roger. Can I ask a question? If a surgeon starts on the Da Vinci, is it hard for them to transition to a different type of surgical robot?
Roger Smith:So, as long as a surgical robot could be built for hips and knees, or it could be built for spine, or, like the Da Vinci, it's built for the abdominal and thoracic cavities, the soft tissue that's in there. So, as long as you're talking about transition from Da Vinci to CMR Vercias or to Medtrona Hugo, no, it's not very hard to transition at all. The big ideas are still the same. The things that you really have to switch in your brain is the little switches that are on the hand controls and the way the foot pedals work. But except for that, the big pieces do the same kind of thing.
Ferooz Sekandarpoor:So basically, fundamentally, they're the same, it's just need some quite twist. Now I know some of our audience may just think listening to this and say, well, robotic surgery. Can you just quickly tell us what are the advantages of even having robots for someone to have been operated, like I just recently have experienced? My dad got a kidney surgery and they use Da Vinci robot, and so can you just give us the benefits of why robotics is different or helpful for patients?
Roger Smith:Yeah, yeah, and let's do that in three steps. So usually surgery surgeries are classified as one of three different categories. The first is open surgery and when we were younger, if you had your appendix removed or any kind of internal surgery, open surgeries when they cut you open on the surface, use graspers to pull it open a little wider and get their instruments and hands and eyes directly into the tissue. And that's been the way surgery has been done for hundreds and hundreds of years. But then in the late 60s they started to experiment with laparoscopic surgery or they called it keyhole surgery back then and they would cut little slits and slide these instruments in on long shafts and one of the instruments would be a camera so you could see what was in there. So your hands didn't go in, but these tiny instruments and the camera went in and that was much less destructive of the tissue.
Roger Smith:Well, that's a benefit. But doing the surgery at like a 12 inch removed from the instrument tips, it makes it more clumsy, a little more difficult to master. Some of the subtlety is lost and so surgeons studied a lot and practiced a lot, like hundreds of surgeries, until they could regain that mastery that they had with open surgery. The other difference is something called the fulcrum effect, which is hard to explain without visuals. But when the instrument shaft goes into the abdomen and you're holding the scissor grip on the outside, when you move your hand down, the tip of the instrument down in the inside of the abdomen tips upwards just like a seesaw. So every movement is like a seesaw up down, left, right. It's always backwards.
Roger Smith:And so you have to train your brain to do that backwards.
Ferooz Sekandarpoor:Eyes and coordination.
Roger Smith:Yes, I honestly can't do it After 10 years of practicing. I am terrible at laparoscopic and I don't do people, I only do synthetic tissue when I'm doing it. Well, robotic surgery tries to take the best of both of those worlds and put them together. So you still, you have these small instruments that slide in, very small incisions, very low blood loss, but that reverse fulcrum effect is taken out by the computer that's helping you do the surgery, by the robotic pieces helping you do the surgery, and so your movements are completely natural again, like they used to be in open surgery.
Roger Smith:Also, the camera that's inside can magnify everything up to 10 times what you're seeing. So you see everything much larger. And the robot and the computers in the robot they know that what magnification setting you're on, so they scale your hand movements. So if you see a piece of tissue that looks like it's three centimeters across, it's really a third of a centimeter across. But you are going to move your hand three centimeters to move from point A to point B, and the computer knows that you're about to do that with your hand, so it only moves the instrument tip one third of a centimeter.
Roger Smith:Interesting, so even though you're magnified, to you it's like perfectly scaled, no matter what your magnification is.
Roger Smith:So, that's the advantages to the surgeon and their technique, but the small incisions. They reduce blood loss, they reduce trauma to the body. It takes several days after a surgery for your body to kind of recover from the blood force trauma of a surgery and they reduces the number of nerve endings that have to be cut and the patient usually can recover quickly. And so now when a patient goes in for an elective surgery, it's not unusual for them to check in on Tuesday, have the surgery Tuesday morning and check out and go home on Wednesday. And that used to be unheard of. They would stay for a week or longer, and now going home the next day or two days later is kind of standard because you're not inflicting so much damage on the body when you do that. That is correct.
Ferooz Sekandarpoor:And that's my dad. After surgery. The next day we went back home and he did all of his recovery at home. So he's healthy, back and just back to his routine. So it's amazing what it can do for us. Now. Speaking of all this technologies now, because we are coming from a simulation world and we immediately think how surgeons could get trained on this, because these are expensive machines for someone to go on every day. Use this, and how is there any simulators on the market that are created? And, if they are, what are those look like? And you can tell us a little bit about that, right, yeah?
Roger Smith:So the DaVinci robot. It costs about a million and a half dollars for one of those, so you can't just buy one to practice on. It's not like driving school, where the instructor has a car that they can teach you with. Very few people have a million and a half dollar robot they can teach you with, but the education happens primarily with. There's two modalities or two support systems. The first one was before. There were simulators intuitive, surgical and CMR and Medtronic, and all of them they recognize that it's too expensive to buy these for training, and so they cooperate with training centers like the Nicholson Center and they either lease or lend the machine at a very low cost so that the education can be done there, and then their instructors or our instructors will run a surgeon through a course with the real robot. But they can only lease or land. You know one of those robots, two of those robots, and you have 10 students standing around waiting their turn on the robot.
Roger Smith:Well, recognizing that that was a limitation, several companies jumped up and built simulators that you could buy, many of them put in the simulation centers. So there was Mimic Simulation, which targeted specifically their whole company was just against DaVinci surgeries. And then there was Symbionics, who has a whole line or had a whole line of simulators. They just added a robotics simulator to their product line. And then there was another small company called Surgical Science Incorporated or something, who built a simulator, and so these training centers could buy a simulator for around $100,000. That was the typical going price.
Roger Smith:At the Nicholson Center we had six of them, I think. So now we have two robots on loan and six simulators. Now we've got enough devices that we can rotate people around and keep them busy. And the nice thing about these simulators is you, since they're computer based, you can program them to collect metrics on the performance of the student while they're doing an exercise. So they might be cutting computer generated tissue or suturing with a computer generated needle and suture, and so they're doing all of that, and everything that they're doing is being measured by the software and at the end you can give them a score on their performance and you can track their improvement over time.
Roger Smith:That makes it in many ways a better assessment tool than the robot itself, because the robot doesn't collect, it's not a training device, so they don't think about it in that way. It's not programmed to collect those kind of metrics, and so the simulators collect all these metrics and help you teach a course and progress people until they get better. Now some of what I said about the companies that make those simulators has changed. A company called Surgical Science recognized that this was. They love those two companies and they bought both symbiotics and Mimic, brought all their products in-house, and so now those products are owned by Surgical Science.
Ferooz Sekandarpoor:Oh, I didn't know about the MIMIC that was purchased, because MIMIC was one of those companies based in Seattle. They were located in Seattle and I actually our center was one of the first center to beta test and purchase their first version metal. I still have the pictures of them just doing that. I will send it to you now that you're familiar with that. So there's the first prototype and we purchased that and it was all these ropes. And then you have put these and and so we were one of those to beta test for them. So interesting, I didn't know that they were purchased by surgical science.
Roger Smith:So surgical science is definitely getting big in this industry.
Roger Smith:Yeah, so that's fantastic. That's something else that's happened in the recently. Recently is the last five years. The FDA has encouraged device companies when they're making advanced devices like robots. They said you need to have a training plan that we can see when we're assessing and giving you approval. And so you see these robotics companies building a simulator that's embedded in the robot, so the hardware and software in there, and it's just a mode you put the robot into to do the training instead of having a separate outside device.
Ferooz Sekandarpoor:Very creative yeah.
Deb Tauber:Yeah, so, um, how are you using science fiction to explore the future of robotic assisted surgery and simulation, and tell us a little bit about your?
Roger Smith:books. I'd love to do that. So I spent 10 years doing research and teaching people how to use surgical robots, learning to be a robotic surgeon if I'm operating on silicone synthetic tissue, I'm good at that or in the simulator. So I thought, well, what are these systems going to be like in the future? And a few times I was invited to talk about the future of robotic surgery at surgical conferences and it was a lot of fun. Everybody's speculating where it's going to go, but when you do that at a conference, you have to be a little prescribed. You have to be careful not to think too far out of the box, otherwise it's not reputable, anyway. So with I started writing science fiction novels about where robotic surgery would be in 2050, and there I could speculate on a new instrument or something new and just make it true. So, for example, in the first novel, I have this surgical robot and it has these advanced instruments that are the kind of instruments that you dream of having right now A laparoscopic surgical camera and a robotic surgical camera.
Roger Smith:They're like a soda straw going into the body, and so when you look into the body, you look through this straw and you see in front of the straw a beautiful, vibrant HD image of the tissue. It's perfect. But you can't see left or right or up or down. You have to steer the straw around and look around to see what's around the area. Well, that means that if tissue is bleeding off to the left of the camera, you won't know it unless you pan over there and look. Well, how about this? How about a spherical camera that goes into the body? The camera looks in all directions, 360 degrees, all at the same time, and so that camera can see everything that's happening in the abdominal space. And if something starts to bleed, the surgeon. You could say well, the surgeon still has to look over there. He does. But if you have intelligent software helping with the surgery, it's not difficult to program it to identify blood flow and to raise an alert. So if you have a software assistant, that assistant could process data in 360 degrees and make you aware at all times.
Roger Smith:Or you could create surgical instruments that aren't just scissors and graspers. Since the beginning of surgery, instruments have always been built like graspers and scissors, two fingers. But if you can program software to help you, those instruments could have multiple joints and multiple fingers. You could have three, four, five, six, seven, eight, and they could have eight joints on a finger. It frees you up to think about what is the instrument I need for this job, not what is the instrument that a human's fingers can control.
Roger Smith:So, anyway, those are the kind of things that started appearing in the novels and, of course, given the day and time we're in right now, of course there was an intelligent AI in the robot, and the intelligent AI is helping and it becomes a little smarter than we thought, may become self-aware and it really wants to be a good citizen. So when it really sees that the history of a patient on the table and realizes this patient is a very bad person, this patient has escaped justice from the judicial system for years, a drug dealer and the robot contrives a way to arrange for the patient to die, to cause something to happen, without the AI being detected that causes the patient to die. And then the story unfolds and the world is trying to figure out how did this happen? Was it an accident? And they start to realize that maybe this AI is a live awake sentient doing things, and then the story unfolds from there. I look forward to reading them.
Ferooz Sekandarpoor:And, by the way, the website. We will make a link to your books as well. On the podcast. That would be great and I think you're talking to the last book is the surgeon's gene. Is that right? The one that was?
Roger Smith:the first book, the surgeon in the mirror. In the mirror. Okay, that's the surgeon in the mirror.
Ferooz Sekandarpoor:One of your book is going to be published on March of this year.
Roger Smith:Yeah, March of this year. Actually, we're a little ahead of schedule. We released it this week, oh fantastic. So the newest book is called Savior of the Warthorne and the hero surgeon. Throughout the series of three books, she becomes involved in telesurgery across the country and in the separate from her, russia is involved in an invasion of Finland, trying to take over Finland. That's familiar right.
Ferooz Sekandarpoor:So you're just the embedding real world scenarios as well in these fictions. That's fantastic, and tele-surgery is something that there's.
Roger Smith:tele-surgery is an important technology to save the lives of soldiers on the battlefield. So she gets drawn into the action and kidnapped by the Russian intelligence agency.
Ferooz Sekandarpoor:Okay, so, with all these visionary, you know writing about books, about being full front of a lot of surgical and simulation technologies over the years and decades. So where are we headed in surgical simulation, based on your experience and being attached to a lot of researchers, and where you see we are heading to Right?
Roger Smith:So the first one I mentioned earlier, I think, advanced surgical devices. We call most of them robots now, but some of them are not quite robots. I think they're going to have simulators embedded in them because when they become advanced they have computer power and graphics power built in and there's no reason that the simulator couldn't be part of the system itself. And right now that's rare, as in two, three, four different devices do that. But I think in the future, as the computer power becomes a more native part of a medical device, the simulator will be in there.
Roger Smith:Then, if we talk about AI today, ai is a wonderful tutor to live inside of a simulator, so that you, the student, are faced with an exercise and you're doing your best to do it. But there's no reason. It's not supposed to make you fail, it's supposed to make you succeed. So having an AI in there that could literally coach you step by step, that could show you on the screen that you're not going to be able to do it, you could coach you step by step, that could show you on the screen what the best maneuver is, or that could even move your hands to the best position, that, that kind of intelligent feedback during training would be very, very viable, very realistic. So I think AI is going to live in these simulators and make them much more tutors than assessment tools.
Ferooz Sekandarpoor:I think that's great. I think those are all doable. The technology is there, it's just about implementation and adaptation of that. Thank, you. Yeah.
Deb Tauber:Do you have any advice for someone who wants to get into health care simulation and training in robotics specifically?
Roger Smith:Oh, in robotics specifically. So yeah, if you're, if you're robotic specific, probably you're going to be dealing with surgery. It's not that there are robots in nursing and things like that, but the way they're used. You don't train to use them as much. It's in surgery and a little bit in anesthesia, where training and education with simulators and robots meet together. So I think you could go to work for one of these companies that makes the simulator, like I mentioned, surgical science. They're very active and there are several other companies just like them competing with selling these devices. But I think a much more exciting career would be going to work for the device companies like Medtronic and Intuitive and Johnson and Johnson that are making the robot itself, because they're the ones that would also be working on a simulator to match their robot or at the minimum they'd be partnering with an external simulator company and that external simulator company would need guidance on what the real device would do. So I think going into one of those device companies would be a really fascinating career.
Roger Smith:And then, as you're, a couple of your previous guests were government employees. The government is doing, always has been doing lots of really interesting things in simulation. Now they tend not to work in robotics, because robotic surgery happens in the civilian space much, much more than in the government space. They tend to work for simulations of things that happen uniquely in a government or slash military space. So what needs to be taught and learned on the battlefield? But I know Jude Tomicello explained his career on this podcast and I think if you listen to his, his episode, he kind of painted a great career, a great picture of what a career in government would be like that was primarily centered around simulation.
Deb Tauber:Yeah, he did, he did do that. Yeah, do you have any like final thoughts for our guests, anything that you want them to remember? This episode by?
Roger Smith:The biggest thing, I think, is you're going to be living in the future Like tomorrow is the short future than a year for now. So when somebody talks about how either robots or simulators or AI are just barely a new idea, that's true about the past, but five years from now, they're going to be the thing that you wish you had learned or invested in or put your career in five years previously, and so you shouldn't look at where those technologies are today and say, you know, they're kind of weak, or there's only three simulators companies, or there's only three robotics companies in the future, which is where you'll be running your career, earning your money and getting your satisfaction, those are all going to be much bigger than they are now. So believe in that kind of future, not a future that looks exactly like today. Very interesting.
Ferooz Sekandarpoor:Very interesting point of view. Thank you very much.
Deb Tauber:Yeah, thank you for sharing that. You're welcome. Well, we really appreciated having you, roger, today on the SimCafe and thank you so much for being a guest.
Roger Smith:Thank you for inviting me. I really enjoyed it.
Ferooz Sekandarpoor:Thank you very much indeed. Look forward to talk to you more in future.
Roger Smith:Yes, thank you, farooz and Deb.
Ferooz Sekandarpoor:Happy simulating. Thanks to Innovative Sim Solutions for sponsoring this week's podcast. Innovative Sim Solutions will make your plans for your next Sim Center a reality. Contact Deb Tauber and her team today. Thanks for joining us here at the SimCafe. We hope you enjoyed. Visit us at wwwinnovativesimsolutionscom and be sure to hit that like and subscribe button so you never miss an episode. Innovative Sim Solutions is your one stop shop for your simulation needs. A turnkey solution.
