Maggie McKay (Host): It may sound futuristic, but it's been around for years and it's here to stay. We're talking about robotically-assisted surgery and it's grown at Beebe Healthcare. General Surgeon, Dr. Mark Facciolo, will share the latest on this incredible option.

Host: Welcome to Beebe Healthcare, a podcast from Beebe Healthcare. I'm your host, Maggie McKay. Welcome, Dr. Facciolo. It's so great to have you here. I can't wait to hear more about this topic. Would you please introduce yourself?

Dr. Mark Facciolo: Thanks, Maggie, very much. I'm Mark Facciolo. I'm one of the general surgeons at Beebe Healthcare. I'm currently the Vice Chair of the General Surgery Department, as well as the Acting Medical Director of the Robotic Division at Beebe Healthcare.

Host: So, let's just start right off with what is robotic surgery?

Dr. Mark Facciolo: Robotic surgery, despite the allure, is actually a new tool and a transition from general laparoscopy, which we are familiar with minimally invasive instruments and techniques, which create small incisions and allow us to do major operations through those small skin incisions. Robotics takes that a step further, allowing utilization of finer instruments and machinery that controls those instruments and allows the surgeon to control additional numbers of instruments by hand, as well as to do more advanced techniques than laparoscopy has allowed us to do in the past.

Host: And what kind of training is required to be certified?

Dr. Mark Facciolo: So for most, they begin their experience in their residency training who are exposed to robotics, is it essentially has been available since 2008 and a lot of folks are exposed to it earlier in their careers. And once you come out of your training and look to pursue a career in robotic surgery or use that as a tool with which you use to practice, there is training on the device. There are educational seminars, which are required as well as a set of modules and training exercises that the machine actually has encoded within its software where the new and young surgeon takes these on, advances their skills, essentially learns the ins and outs, the nuances of the machine. That way when you begin doing actual real procedures, you're not having any of the hiccups of learning a new technology or modality.

Host: So, can you remember back when you first learned and trained on it? Was it awkward or like Jetson-like?

Dr. Mark Facciolo: It's not really fair. They use the term intuitive and I think it really does factually -- and they're not paying me to say it -- coins exactly how this thing feels. It moves exactly like you'd think it does. It really is akin to open surgery. It allows you to use your wrists and fingers in a way, which is very natural. The ability to see better and move better when using a laparoscopic viewpoint is something which is mind-blowing when you first sit down at the device, what it's able to let you see and do is the thing that's really surprising, more so than just the nuance of using the new machine.

Host: And is this accurate that the tools are maybe curved rather than the old school just straight and flat?

Dr. Mark Facciolo: Sort of. In reality, whereas in traditional laparoscopy, because the instruments are straight, they actually sort of fulcrum or hinge right on the abdominal wall. But all of the instruments within the robotic platform actually articulate much like our wrist do, and factually move a lot more than the human wrist does. So, it's actually able to turn your hand, you can clutch around, and that instrument can continue to turn. So, you can almost make two whole turns by rotating one's own wrist.

Host: That's amazing. What are the overall benefits for patients?

Dr. Mark Facciolo: For many, it's something that they'll see immediately right after surgery. Factually, robotic surgery has allowed us to perform more complex surgeries with less discomfort and less pain. And that's been certainly clear when we compare traditional robotics to open surgery. There is a lot of divisiveness when we compare laparoscopic surgery to robotics because it is very similar.

 What I would explain to patients is that the benefits are a couple fold. First, we'll start with what our patients experience. And that is not only do they get minimally invasive surgery, but the technology itself, the visualization, the articulation of those instruments allows your surgeon to do more complex things in a minimally invasive fashion. And so, it minimizes the risk of conversions to open. And for anyone who's ever had a large or open incision, they know that the pain, the secondary complications of scarring and hernias, and those things are going away, which is fantastic to be part of that transition in surgery.

Because of the abilities of the machinery to again enhance surgeon visualization and surgeon mobility, it's actually able to expedite much of the surgery that they're getting, which means they're spending less time on the operating room table. There's less risk for things like cardiovascular or pulmonary complications because of anesthesia. We tell our patients in the general surgery world that in doing hernias, we've avoided the use of urinary catheters almost in their entirety, which means no urinary retention or secondary complications from that in our patients. So, that's a win. All in all, again, there's a lot of benefits for our patients in that sense. And it really is, again, more than just dollars and cents pictures or how quickly you return to work. Fulcruming of the instruments on the abdominal wall has made a marked decrease in the amount of discomfort that patients have postoperatively. We see it every day. Folks come into the office after their operations and they've taken, but a few Tylenol. And these were procedures that we were sending folks home on a handful of oxycodone or tramadol or something, they're just not taking them.

Host: Wow. So basically, you get out of the hospital sooner and your recovery is faster for starters.

Dr. Mark Facciolo: Essentially.

Host: Wow. Doctor, do you have any specific success stories that you remember in your head?

Dr. Mark Facciolo: Absolutely. I mean, we first started the program about four years ago. And we look at this program as one that's sort of new and it's new to the area. But for those that are listening, we've been doing robotic surgery since-- it's been four years now, and completed just about 2,500 procedures. Actually, we're getting close to 3000 procedures. The list of folks we've been able to help, that list grows and grows.

Specific standout stories, I had a patient of mine who presented in the after hours who at the time when the ability to use the robotic platform wasn't always available, because certain staff needed to be trained, needed to be readily available to do those procedures. And the way that sort of course lined up, we were able to get this woman in and treat her incarcerated hernia, which is often treated with an open procedure, a big open incision and possibly a bowel resection. We were able to do the entire thing through just a few poke-hole incisions, eight millimeters wide. We were able to reduce her hernia. We were able to repair that defect within her abdominal wall. And I tell her that she essentially received an elective surgery and she came in at an emergency after hours. We like this story because it shows the growth of the program, that we're beginning to expand not only the access to the robot in forms of time and availability, but also in the procedures that we're able to do. And I think that's the thing that we really want to get the word out and expand to our patients and our fellow providers and practitioners, is that we've done enough procedures and our skill sets evolved enough that we're really beginning to expand and push what we're able to do. And again, and that means for folks who need surgery, even emergency surgery, that some traditional open surgery can now be done in a minimally invasive fashion.

Host: That's impressive. For people who maybe are a little nervous about-- you know, it sounds like a robot's doing it all, and of course that's not accurate. But would you like to tell people what should they know about robotic surgery that they may not? I mean, you've touched on a lot already, but for the people who are nervous.

Dr. Mark Facciolo: Right. Yeah. Robotic surgery, again, it has a certain like allure or panache because we think about mechanics and, R2D2 or my surgeon's at home and the robot's doing the case, and that's not the case at all. There's a lot of touch points with us. When you come into the operating room, you'll see the device and it's draped in its sterile attire. And as your surgery starts and the patients go off to sleep, your surgeon's at bedside. I or any one of my colleagues who performs robotic surgery, we place those instruments in the abdomen. And then once everything is set up and we've got the robot in position, that's when we break scrub. The surgeon console is anywhere between 10 and 12 feet from the edge of the bed. And this is where we control all the devices and do the operation. So, it's important that the surgeon's in the room the whole time. Your surgeon is doing your operation. The ergonomics are much better, which is just a nice way of saying for much of the procedure, we get to sit down. But we are there the whole time. And then once the procedure is over, your surgeon will scrub back into the field, close all the incision sites and get you off the table.

Host: Is there ever a time when a patient says, "I don't want it"? Like they're old school and they don't want it. They want the traditional kind of surgery.

Dr. Mark Facciolo: That's a good question. We don't really see that much. We get more folks who ask, "Hey, do you do this? Should I get it that way?" Or when we offer it, "Why do I want to have it?" And I think that's the way we look at it. It's important that we don't just use the robot for every single procedure that we can get our hands on. It's important that we recognize this is a tool. It's got some benefits.

There are some downsides. For example, the instruments, because of their enhanced mobility, take a little bit more distance inside the abdominal cavity to work. So if there's ever a condition where we need to sort of work in tighter quarters, the robotic platform is factually not as good, okay? But I think having this skillset and the experience on the device allows us to really give a person to person discussion and a very pointed care plan that most of the time includes robotics as opposed to an open procedure.

Host: What do you like most about the team at Beebe Healthcare?

Dr. Mark Facciolo: I'm glad we get a chance to talk about it because much of the successes of the robotic program at Beebe really does fall down on the team. Very privileged to have some experienced team members who've come together from some other institutions or some with robotic experience themselves and have joined our team. There is a complete and total buy-in. Robotic surgery is very exciting. And as we've progressed in our case volume and developed some efficiencies, there's a certain buzz in the room. And that's the best way I can describe it.

We all want to see cases run smoothly. We want to see the day run smoothly. We don't like it when things aren't working or there's hangups or there's problems. Even though the folks are working hard in the room and the turnover is tight in the room, when the cases are running well, there's a certain excitement that makes people want to work harder, want to contribute, want to get better. And that's really made for some fantastic efficiencies in the room. And we have a lot of people to thank for that. We have some behind the scenes folks who make sure that the instrumentation is always available. It's ready to go, it's cleaned. Even when we got through COVID, having delays or things on back order, we're able to keep our volume at peak numbers because those folks were working hard to get us what we needed to be able to do the operations.

Our staff at the bedside does an excellent job of really troubleshooting, making sure if there's instrument collisions, they're having a availability. They're an extra set of eyes on the case, which are really helpful. We got some experienced folks who are not only familiar with the robot, but familiar with the cases that we're doing. And again, I think that has turned into and parlayed into a very wonderful efficiency program that really is unrivaled in much of the nation. When we start looking at what we've been able to achieve, case numbers, case volumes, there's an exceptional efficiency of movement. I think that's the best way to describe that. Our thoroughfare of patients, getting them in the rooms, getting the robot dock set up, getting their surgeries completed, and then getting them off the table. And again, we've talked about some of the benefits of that. But a lot of that really comes down to the teamwork, all around folks who see the robotics program being successful.

Host: That's got to be reassuring as a patient, to know that the people in the room are so passionate about getting it right. That's awesome. So when it comes to the future of robotic surgery, what are you excited about?

Dr. Mark Facciolo: The sky's the limit. To be honest, it has given us so much. I think we even have yet to take advantage of. I'm looking forward to some of the advanced instrumentation that is going to come out with the new devices. The new staplers are extremely intelligent and that they make computational analyses, which makes sure you're using the right staple height for division of intraabdominal organs. I mean, there is just so many things that are being processed and worked on.

I look forward to having another arm. Right now, on the surgeon console, we have control of four arms. And I think there's times that an additional arm may be beneficial, some of the articulation of the arms as that changes and the mobility of the device itself. There was a previous iteration where in order to do larger operations. You actually either had to undock the robot and spin it around or spin the patient. And in this new platform, that thing can spin all the way around to do surgeries. And I look at that as also being an improvement, minimizing the impact of that big machine in the room and making it more accessible to sort of hard to reach areas, maybe obviating the cons of working in tight fields or tight areas. So, I see those are all potential areas of where this is going.

To answer your question more specifically, I'm really excited to see where robotics can take us. We, in this generation, are challenged with the transition from traditional open surgery to minimally invasive surgery. And it is oftentimes where we have to operate on folks who've had larger midline incisions for previous surgeries. And I think the robotics platform lets us do two things. Lets us successfully perform minimally invasive surgery and people who've had open surgeries, which historically would preclude safe entry or safe laparoscopic surgery. But it also lets us do those same open procedures in a minimally invasive fashion as well.

Now, we don't do all of those procedures here. But again, robotics has been fairly prolific in the nation and there are a number of extremely advanced and technical procedures which only were reserved for open procedures are now being done due to the benefits of robotics. And I think that's the next big change that especially patients will see, is really getting away from those large open incisions almost in their entirety.

Host: Dr. Facciolo, did you ever think when you were starting out in med school that this would be an option in the future?

Dr. Mark Facciolo: Factually, I'm not so old. Just that robotics was in its infancy as a whole when I was in my training. But factually, it was slow. Like it was how I imagine laparoscopic surgery was for some of those docs who were practicing in the '80s. It was new technology, it was slow, it was expensive. There were folks who just said, "Oh, that's just the new novel thing. I don't want to waste my time. I'm really good doing what I'm doing." And, you know, we've seen it explode. Patients are now aware of this. They're seeing the outcomes, they're seeing the benefits. And again, I think what it's been able to have us do, I never thought possible. I mean, I remember sitting in as a high school student watching a robotic surgery and it was a six and a half hour operation. And that same operation I saw not long ago, just as it's done more commonly, it took about 48 minutes. So again, it's not about speed, it's about how as the technology evolves and as the experience of those that are doing it evolves, how much better those things are and how awesome the outcomes are.

So, it has been awesome to be a part of that. It's really exciting. I think if that's anything, when people hear me talk about robotics and they talk about surgery, I always tell them, I say, "I'm really excited and I love what I do because it's a great time to be doing it." We really are on a paradigm shift to take what we do to a new level. And I think robotics plays a big role in that. Again, it's not the sole proprietor of surgical techniques, okay? But when it's the right tool for the right person, it does provide us a wonderful list of benefits.

Host: That sounds very exciting. In closing, is there anything else you'd like to add that we didn't cover?

Dr. Mark Facciolo: I don't think so. Part of this, again, was the allure of getting people familiar with what robotics are. Ask questions. You can see a lot of the stuff on the internet in this day and age, and much of that information's available to you. So, I encourage you to explore, ask your doctor questions and really get a chance to see for yourself. And again, talk to your friends, talk to your neighbors. A lot of them have probably had robotic surgery and they can tout its benefits. So, it's not like we're out here selling it, we see it every day. Patients are having wonderful outcomes and we say the proof is in the pudding. Word of mouth, referrals and discussions regarding its benefits are happening all over.

Host: And if someone would like to find out more or make an appointment, where would they go?

Dr. Mark Facciolo: I'd start them first at the Beebe's website at beebehealthcare.org. From there, they can jump off to the robotic center webpages. They can see us on the robotic side, but they can also see any one of the various subspecialists who are performing robotic surgery.

Host: That's so great. Thank you so much for sharing your expertise. This is such a fascinating topic. I just love hearing about it. We appreciate you.

Dr. Mark Facciolo: Absolutely. Thank you very much for the opportunity.

Host: Again, that's Dr. Mark Facciolo. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you, this has been Beebe Healthcare Podcast presented by Beebe Healthcare. Thank you for listening. I'm Maggie McKay.