Dr. Mike Smith (Host): This is Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Mike. And today, we're discussing the innovations of pediatric robotic surgery and how it may help improve outcomes in even the most complex cases.

We're joined by Dr. Samir Pandya. He's a pediatric general and thoracic surgeon at Children's Health and Professor of Surgery at UT Southwestern, and Dr. Lauren Gillory, pediatric surgeon and Medical Director of Pediatric Trauma at Children's Health Dallas and Associate Professor of Surgery at UT Southwestern. To both of you, welcome to the show.

Dr. Samir Pandya: Thank you, Dr. Mike.

Dr. Lauren Gillory: Yeah, thanks. Happy to be here.

Host: So, let's start off how about with you, Dr. Pandya? Let's talk about the technology when somebody says pediatric robotic surgery, can you just give us a glimpse of what that actually looks like in the surgery room?

Dr. Samir Pandya: So, everybody thinks that it's these robotic individuals or these artificial humanoid people that are actually doing the surgery, but it's not. It's actually human-controlled machines that are connected and controlled by the human beings. And we have small instruments that go into the patient's body and facilitate the surgery.

Host: Now, but specifically you guys use the da Vinci surgical system. Tell us, how different is that and what kind of outcomes are you seeing with that system?

Dr. Samir Pandya: Well, for the longest time, the da Vinci system had the monopoly in the market, and so that's why it's got the large penetration within the market. It provides us three-dimensional magnified views. The instruments are able to articulate just like the human wrist. And we're able to work in very small spaces with those instruments. As of today, there's multiple other devices that have come to market, and the experience with that is also growing

Host: So Dr. Gillory, how do you determine when a child is an appropriate candidate for robotic versus traditional, you know, open surgical procedure?

Dr. Lauren Gillory: Every patient that we evaluate, we always are trying to determine what is the optimal and safest approach for that patient. So, there's no real procedure or patient that we say that would always be done robotic or with any other approach. But there are times when the robotic approach is very beneficial, and we feel that that is going to give the patient the best outcomes.

So, there's many factors like patient size, the specific procedure that's needed and definitely the location of where the operative approach is going to be taking place. And so, there's a couple areas that we think are, you know, really nice to use the robot that includes deep down in the pelvis where it's a limited view with other approaches. And the robot, definitely, with those articulating instruments as well as that 3D magnified view, it gives us a very nice approach for what can be a difficult surgery, whether it's open or laparoscopic.

And then, other locations like in the foregut, so when we're doing any procedures up in the upper abdomen on the stomach or other areas, it can be nice. And even in the chest. So, there's been a lot of move towards the robotic approach in thoracic surgery for adults, and we similarly use it in pediatrics because there are areas of the chest that are just better viewed with the robotic approach, and the instrumentation is really optimal for taking care of those surgical cases.

So, it's definitely a decision with the whole surgical team and talking to the family as well to make sure that that aligns with their goals. But it's a really patient selection that is focused on what is going to optimize the outcomes.

Host: So Dr. Gillory, when you talk to the patients and the families and you tell them you feel the robotic approach is going to be the best approach here, how do most families take that? How do they receive that, you know, knowing they're going into a robotic surgery?

Dr. Lauren Gillory: The majority of our patients seem to really want to have whatever we think is going to be the best approach. And robotics, as it's become much more widely accepted, is actually something that occasionally families even ask for or give us the option to do it that way.

And so, the majority of them really are very much willing to proceed with that approach and don't have much in the way of qualms about us doing it in that manner. So, when we think it's appropriate and when we discuss it, I've had very few patients that are not interested in the robotic approach.

Host: Dr. Pandya, when you look at the different types of surgical cases you deal with, what are some of the most challenging ones that you face, and how has robotic technology helped with those?

Dr. Samir Pandya: Well, I guess, surgery in general can be hard. We're performing surgery on little babies, small spaces, and these spaces could be as small as the size of a ping pong ball. And the tissue is delicate. As you can imagine, there's no room for error. So when we think about all of that, some of the most challenging places that we have to suture, I would say, is when we're working in the bile ducts, which is the little pipes that empty the liver into the intestine; also in the chest where the blood vessels are that supply the lungs, so the pulmonary artery and the pulmonary vein and the bronchus; and in the older child, working deep down in the pelvis when we're doing low rectal operations. Those are all challenging places to reconstruct and to sew. And the robotics platform allows us access to these difficult-to-reach locations minimally invasively with magnification and eliminates any kind of tremor or any unwanted movements. So, that's where it really helps us with it.

Host: So Dr. Gillory, these surgeries obviously involve multiple specialties, these are complex surgeries, lots of different people involved. How does your team collaborate across disciplines to ensure the best outcome for patients?

Dr. Lauren Gillory: I agree wholeheartedly with what you're saying surgery for every patient is really a team sport, we always say. And so, there are multiple people that contribute to the success for any surgery that we perform. The majority of the time, there's always another specialty or, the first wave of people that see our patients who are really evaluating them and then referring them to the surgical team for our expertise.

And so, that could be anyone from the gastroenterology doctors or the pulmonary doctors or sometimes even more specialized folks like the rheumatologist or the neurologists who have identified a patient that they feel would benefit from surgery. And then, we often have discussions with them and like I said, with the family to say, "Hey, we think a robotic approach is appropriate for this."

And then, we move on to making sure that we have all of the other specialized team members available to us. So, our pediatric anesthesiologists are obviously a part of every operation we do, and we talk through our approach with them and make sure they understand what's important for us to do a robotic surgery, which, we do have to inflate the abdomen. And so, talking about any risks with that or, if we're doing surgery in the chest, knowing that there's going to be some differences in the aeration of the lung when while we're working because we need the lung out of the way for us to see things in the chest. So, there's always a portion of that that we're discussing with them.

And then, we have the folks that are in the room that are the circulating nurse and the scrub tech, and we always make sure that those individuals are also very comfortable with the robotic approach since it's a whole different set of instruments and a different aspect to the case where there's a robot that's really covering the patient and there is specialized movements and approach that's necessary.

So, just certainly it is a team effort. And I think the patients are best served by us all keeping open lines of communication and really that strong collaboration that occurs.

Host: Dr. Pandya, can you compare the recovery time from traditional surgery to robotic surgery for some of the complex cases that you mentioned?

Dr. Samir Pandya: Absolutely, and a great point. When we look at traditional surgery, surgery that was done several decades ago that involved fairly large incisions, which led to a long length of stay with use of pretty strong pain medications, opioids. And so, when we compare that to what we can do now minimally invasively, you're looking at length of stay that are cut down dramatically, even by tenfold sometimes. Patients that used to spend a week or more in the hospital can often go home the next day or in a day or two, and they don't need as many or as strong pain medicines as they needed to before.

The difference between laparoscopy and robotic surgery from a recovery standpoint is marginal, to be honest. And that's mainly because the incision size is about the same. What the robotic platform does, it facilitates the access to those hard-to-reach areas for the surgeon.

Host: So, sticking with you, Dr. Pandya, when do community physicians, you know, when should they consider referring to Children's Health for robotic surgery?

Dr. Samir Pandya: Well, I think from a community physician standpoint when they're seeing the patient in the clinic and it appears to be something that requires a surgical treatment. Earlier referral is always better. And we will do everything we can to get that patient seen right away.

And as surgeons, we will communicate with the primary providers that this is the type of surgery that's going to be required. And in terms of what technique that will be done, that's something that we have a collaborative discussion as Dr. Gillory pointed out earlier. So, earlier is better. That's the overall trend for all of children's surgery. We do it smaller, it's much safer, and we like to do it earlier so that there's no delay.

Host: This last question is going to be for both of you. We'll start with Dr. Gillory. Where do you see robotic surgery going in the near future? What are you most excited about?

Dr. Lauren Gillory: I think that there is always talk, especially when we're working in pediatrics about how we can continue to make things even more streamlined and smaller for our very small pediatric patients. So, I anticipate there will continue to be movement toward smaller instruments and smaller port sizes, which is, as you would guess, even better for the infants and toddlers that we take care of.

And then, we have even seen in the last few years a few additional instruments that have been incorporated into the robotic cadre of instruments that we use. And each one of those has seemed to bring a new and better approach to the robotic surgery. So, I think both of those aspects will continue to benefit the robotic surgery that we perform.

And in addition, I think having more and more patients and referring doctors that understand the robotic approach will be beneficial as well, so that everyone's aware of what to expect when a patient gets that operation.

Host: Dr. Pandya, what are you excited about?

Dr. Samir Pandya: As Dr. Gillory was speaking about this, I was reflecting on it, and one of the things that came to mind is that innovation welcomes competition. So, we're in that era now in which there's multiple companies that are investing in robotic platforms. And miniaturization of these platforms is something that's going to make it much better for our smaller patients. So, I look forward to that.

We also have now entered an era of augmented reality in which our CT scans and our X-rays can be superimposed on the surgical field as we are working. And we've also entered this era of fluorescent image-guided surgery in which we're able to administer special dyes before the operation that then get highlighted during the operation and serve as a roadmap for millimeter-precision surgery. So, all of this is really exciting that we have entered that era now, and I can only see things getting safer and much more efficient as we go on.

Host: I'm sure the future is going to be pretty amazing with all this. You guys, this has been fantastic. Great information. What an exciting field that you guys are in and thank you for the great work that you are doing, and thanks for coming on today.

I also want to thank the audience for listening to Pediatric Insights: Advances and Innovations with Children's Health. You can find more information at childrens.com, including details on robotic and general surgery at childrens.com/generalsurgery. And if you found this podcast helpful, please rate it and review it or share the episode and follow Children's Health on your social channels. I'm Dr. Mike. This is Pediatric Insight: Advances and Innovations with Children's Health. Thanks for listening.