Angela Chaudhari, MD (Host): Welcome to Parts and Labor, a round table discussion with our OB-GYN experts here at Northwestern Medicine. My name is Dr. Angela Chaudhari, and I'm a minimally invasive gynecologic surgeon and serves as the Chief of Gynecology and Gynecologic Surgery here at Northwestern Medicine. I will be with your host today as we talk with members of our Gynecologic-Oncology Division. We will be discussing robotic surgery, which is so cool, by the way. I love anything surgical, you know, as a surgeon. But really, talking about the way that patients are being cared for in the newest, most cutting edge ways to get their cancers out and to give them some quality of life.

So first up, I'd like to introduce Dr. Dario Roque, an associate professor in the Division of Gynecologic-Oncology here in the Department of OB-GYN. In addition to his clinical and research work, he serves as the fellowship program director of the Gynecologic-Oncology Fellowship here at Northwestern's University's Feinberg School of Medicine.

Next up, Dr. Jenna Marcus, an associate professor in the Division of Gynecologic-Oncology. She serves as the director of robotic simulation, as well as the associate program director of our fellowship. And so, I just really want to point out that these are our colleagues doing all the work. They're clinical, they're research, they're taking care of patients every day, and they're so involved in education. And some of this really cutting edge work in robotic surgery.

And finally, our esteemed leader, Dr. Emma Barber, the John and Ruth Brewer Professor of Gynecology and Cancer research, our division chief of Gynecologic-Oncology, as well as our director for Robotic Gynecologic Surgery here at Northwestern Medicine.

So, team, I'm so happy you guys are all here today. We are talking about some of my favorite things, surgery, And so, that is pretty amazing. But before we get started, we have a lot of different listeners. We may have physicians that may be wanting to refer in. We may have patients. I'd love to just hear like what sort of cancers are we caring for? What sort of patients are we seeing in the office? Dr. Roque, start us off.

Dr. Dario Roque: So yeah, we get a number of referrals for all kinds of gynecologic cancers. And as many of you know, or for patients that may not know, but endometrial cancer is the number one cancer in the United States. Gynecologic cancer is the most common one. We also see patients for ovarian cancers. Sometimes we get referrals for pelvic masses that may or may not have been diagnosed as a cancer yet, but because of the potential complexity of the surgery or the possibility that these patients may need to be staged, if a cancer is identified, we do see those patients. We also get referrals for abnormally-looking fibroids, that might be concern for this type of uterine cancers called sarcomas. And then, obviously, cervical cancer, which luckily we don't see a lot of because we have good screening test. We have a vaccine against cervical cancer, which is great. But unfortunately, we do see a number of those patients. So, a lot of our referrals are primarily for cancer. We see patients from the time of diagnosis. We do their surgery. We do their chemo and then we follow those patients. But we also do a fair number of complex gynecological surgeries for patients that may or may not have cancer.

Host: Yeah. You know, I trained a lot of years ago, I think, before all of you here in this room. And when I did my Gynecologic-Oncology rotations, we ended up having patients in the hospital for a week, two weeks at a time. Big incisions, big debulk types of surgeries to remove all the cancer that was there.

And to be honest, I'll be honest with you, guys, I thought I wanted to be a GYN-oncologist years ago. And the reason I'm a complex, benign gynecologic surgeon is because there was this new minimally invasive fellowship. You could do things laparoscopically and soon that transferred over to robotically. And I didn't know that GYN-oncology was going to go in that direction. That certainly wasn't happening when I was in my training in the early 2000s. And so, I'd love to kind of hear from you guys like what sort of procedures really are well-suited for minimally invasive for robotic surgery, and what sort of patients are good for that approach, Dr. Marcus?

Dr. Jenna Marcus: I think, you know, the robot was first introduced in the late, you know, 1990s, not in GYN, but first FDA-approved in 2005 for GYN surgery and then later adopted in, you know, the cancer space. And I really think at least at its inception or the idea of robotic surgery, it was really for endometrial cancers. You know, how do we do, you know, these hysterectomies? How do we keep it minimally invasive? What sorts of patient populations can we help? But then, also as time has evolved and with the last iteration of the robot, adding in things like lymph node evaluation, and that is something, you know, that has been really critical in terms of who we can take to the operating room and who we can perform these surgeries on. But in the last number of years, we've certainly seen an evolution of expanding the sort of access to other cancer types, you know, ovarian cancer, big pelvic masses, being able to address the diaphragm, the upper abdomen, multi-quadrant surgery. So, it's really come a long way in the last 20 years.

Host: Yeah, I mean, obviously, unfortunately, I finished my residency training in 2004 before the FDA approval of the robot. So, this makes perfect sense that this was obviously not a part of my original training.

Now, as many of you know, I did go on and do laparoscopic surgery training. I'm what people will call a straight stick surgeon. I am not a big robot user. Can you guys kind of share, like, what do you guys think are really the advantages of robotic surgery over this traditional laparoscopic surgery that I was trained to do in my fellowship?

Dr. Dario Roque: So, I may get into trouble answering this question. But no, honestly think, I don't really think of it as disadvantages versus advantages. I think it's more the skillset and the abilities of the surgeon and what they feel comfortable with. I mean, I think to me, at the end of the day, it's all about doing the surgery in a minimally invasive fashion. There is huge advantages between minimally invasive and an open procedure.

But if we're going to talk about just the specifics between robotic and laparoscopic, I think it all depends. You know, the way I think about it is a robot has three divisions. So, actually, if anybody has used any of those VR headsets, that's essentially where you're looking as you're floating in the pelvis. You also have that ability to zoom in really, really closely, which you can do laparoscopically, but then the robot gives you the extra advantage of actually having instruments that have as much range of motion as your rest. So, you can work in very, very, very tiny spaces. Dr. Marcus previously mentioned the ability to work, doing multi-quadrant surgery. So, going, you know, from the pelvis doing a hysterectomy, lymph node dissection, moving up to the upper abdomen, doing the omentum, diaphragmatic stripping, splenectomy. So, you really have a wide range of things that you can do robotically, which again, under the right hands, I'm sure there's going to be laparoscopic surgeons that say, "I could do all of that," which is great. At the end of the day, what we want is better outcomes for patients. I do think I'm a big proponent of the robot because I do think it's a little better technology. But I can't sit here and bash laparoscopic surgery because there are very skilled laparoscopic surgeons out there who can essentially achieve the same thing.

Host: Well, I mean, I hear you because, unfortunately, I'm an endometriosis surgeon, right? And so, I do a lot of things, straight stick, but I don't choose to do endometriosis, diaphragmatic stripping, you know, straight stick. I don't think we can get the same types of repair if needed. And so, those are the ones I'm going to call you for, Dr. Roque. You're going to come in and do some of my diaphragmatic stripping robotically. Thank you very much, sir, for volunteering.

Dr. Dario Roque: Very welcome. Let's kind of like talk about sort of what are some of these other advantages for robotic surgery when we think about our cancer patients, like which types of patients really benefit the most from robotic surgery?

Dr. Emma Barber: I mean, I think one of the key things with minimally invasive surgery is the ability to operate on patients that have higher BMI, right? If you have a higher BMI, you make a big incision. This is associated with, you know, really a lot of increased risk for medical complications, infectious complications and even in some patients, like survival, right? There are certain patients that, you know, may have been told, "You're not a surgical candidate," right? "Because this surgery is too dangerous for you." And so, I think endometrial cancer, there's a reason that that's where the robots started, right? Because of the association between endometrial cancer and obesity. So, I think that that's a really important patient population.

For us, at Northwestern, that is a patient population that is kind of referred from all over the city. Our institutional record here is a BMI of 92, which we got accomplished. Yep. We got done. And that was a patient that was pretty young. She was in her 40s. She was bleeding, she's getting blood transfusions, and she was told multiple places, you know, you're not going to be a candidate for surgery. We can't do this. And we didn't know if we could do it. But we said, you know, this is worth what I call a trial of surgery, right? We're going to put you in the position. We're going to see what we can do. We have lots of different tips and tricks. We have, you know, amazing anesthesiologists. And so, we were actually able to get that surgery accomplished.

But I always tell that story because when I was doing that surgery, you know, you get in with a 5 scope laparoscopically to see. I went to turn the 5 scope to look, to put the ports in, it actually bent. So, it actually bent, right? And I couldn't do straight stick because the sticks would've have all bent with the abdominal wall. The advantage of the robot is you have those long shafts and you have the wrists, and it doesn't matter how far away you are from the pelvis, right? Because of like the degree of the abdominal wall, the robot, you know, and these little instruments will take you right there. And so, the bigger the abdominal wall, the more important that becomes. And I think that's one group of patients that, you know, we really look at here. I think people with complex, you know, surgical histories, kidney transplants, you know, large pelvic masses. I know this is like a national expertise of yours, Dario, that you've spoken about. So, I don't know if you have thoughts.

Dr. Dario Roque: Yeah. I think, one of the things that Dr. Barber just said, the idea of a trial of surgery, right? So, a lot of times we get patients that either come to us for a second opinion or refer to us because of the fact that we feel comfortable, trying to remove these large pelvic masses robotically or at least give it a shot. And what I tell patients all the time is like, "Look, I'm not sure if it will be feasible, but it's worth a shot. You know, at the end of the day, the worst thing that can happen is we take a look. We feel that it's not feasible. We wasted 20 minutes, and then we go ahead and do the surgery open if that's the case." Not to sound boastful, but I have yet to convert any of those cases where we have tried.

So, I think it's just a matter of actually trying. Because at the end of the day, my goal is to have better patient outcomes. The majority of these patients are going home either the same day or the next day as opposed to just like you alluded to earlier, being in the hospital for five, six days developing ileuses or complications such as infections because of a very, very large abdominal incision. So, I do think that there's a lot of patients that will benefit from a robotic approach, even for large pelvic masses. I think my record was removing a mass, I had like 32 liters of fluid in the pelvis. So, just to say that there's a lot that we can do with the robot.

Dr. Emma Barber: Yeah. I think another population that I think about is like these older patients, right? Older patients, you know, in some of my research looking at neoadjuvant chemotherapy, these older patients with ovarian cancer, you know, and are there ways that we can get them back on chemo faster. We can do these surgeries, you know, with smaller incisions to help them.

Dr. Jenna Marcus: Probably a population people also don't think about when you think about surgery are fertility patients and patients sometimes who are actively pregnant while they are suffering, you know, a cancer diagnosis. And there are times when you know, of course, when everything is safe from a fetal and maternal perspective that we can actually do robotic surgery to evaluate, you know, lymph nodes or a pelvic mass and able to spare that patient who is going to have, you know, time recovering from a big, big incision.

Host: You know, as somebody who refers you guys a lot of patients, you know, we see a lot of patients that come into our office from outside places who think they have benign conditions. And then, once we see them, we recognize that this is, you know, very high risk for something cancerous. And so as I'm not the consultant, the referer to you guys as the people taking care of my patients, I gotta say, you know, what Dr. Roque said and what Dr. Marcus and Dr. Barber have said about how they really are willing to try to take care of the patient in the safest, least invasive way possible. It's just a real testament to both their expertise and their persistence to ensure that we really get the best patient outcomes that we can. And so, that's what I think is so sort of unique about minimally invasive surgery and robotic surgery in this case in particular.

I'd love to hear though, like what is kind of new on the scene? You know, we've known about the robot for a lot in time. We've now been starting to use it. I feel like we, every three to five years, expand our utilization of the robot in terms of what we can do with the robot when it comes to cancer care. But, you know, I'd love to hear a little bit more about what advancements are kind of newer.

Dr. Jenna Marcus: So, here at Northwestern, we are very fortunate to have a number of robots. So while we do have, you know, the previous iteration of the robot, we also have the new systems available, which are the DV5 systems. And the difference with this newer system is instead of having to upgrade like the lease on your car and get the new car with the new software, this robotic system is capable of having internal upgrades and software updates. And where that is really going to be advantageous for us, I think, from a patient perspective, but also from the educational perspective, is that we are able to offer, you know, new insights as to a number of things. So, sort of the first thing that I think when all of us trained, we were not used to this, is something called force feedback. So, how much are you pulling on the tissue? You know, does that matter in terms of patient outcomes? Someone is going to heal better if you're not putting a lot of tension and pressure on that tissue. And there are new instruments that are associated with this new robot that actually will give you some of that feedback. You know, we lose what's called haptics when we go from straight stick or traditional laparoscopy to robotics. And this is sort of an effort to give us back some of that haptic feedback.

Some of the other newer updates that I think are up and coming are looking at ways to incorporate imaging and, you know, information that we have about the patient outside of the operating room, but actually in the console while we're doing the surgery. How do we overlay some of where we anticipate, you know, those cancers to be those tumor cells to be, to really make sure that we are doing an aggressive resection, that we're actually getting clear and negative margins. And I think a lot of what's up and coming with the robot is going to help us to put those two things together to be certain, you know, that we are utilizing the system to its maximum efficiency.

Host: Yeah, I mean, what I really am loving and listening as you talk is that the robot companies are really taking — I mean, my feedback maybe from when I didn't like the robot and the first trained on it — you know, about sort of how we can continue to improve both the user experience such that we can do the surgeries to the best of our abilities, as well as taking into account sort of patient safety and quality in terms of being able to get to the disease process that we need in the safest way and then working towards a better recovery for our patients. I mean, that's really our goals here, right, when we think about robotic surgery.

Okay. So, there's some people out there — I get this a lot as a straight stick surgeon. I have a lot of patients that come to me and they say, "Dr. Chaudhari, I do not want some robot inside of me working on me." And I'm like, "Great news, I won't use the robot," right? But, obviously, the robot has a role here, guys. So, I 100% am behind that. So, I want to just have you guys share like these misconceptions of this robot's inside of me doing this work. What does this really look like for our patients and physicians who've never really seen how the robot works? How does this work?

Dr. Emma Barber: Yeah, I think that's the huge one, right? Where I was like, the robot's not doing it by itself, right? But a lot of patients too, you know, whenever they want to come in the OR, they want to look, "Where's the robot? Show me the robot." You know? And so, we say, "Oh yeah, it's over there. It's right over there.

Host: It's not what they expect. Yeah. It's not what they expect.

Dr. Emma Barber: So yeah, I think that's the biggest, you know, misconception. You know, we can show them pictures, show them, like sort of how the system attaches to the patient, the console that we sit at, all of that. But yeah, I think I've never had anyone, after talking to them about it, ever refuse like a robotic surgery once they understand what it is.

Dr. Dario Roque: Yeah. And I would say one of the things that I always tell patients, like at the end of the surgery, if I was to take a picture of their abdomen, their incisions, nobody could be able to tell me if they had a robotic surgery or laparoscopic surgery. I mean, I think someone with experience because of the placement, but the incisions are very much the same. So, there's really not a big difference in terms of the way that the surgery is actually done.

Host: Yeah. And in my defense, I do tell patients who come to me from a robotic surgeon and ask me for straight sick surgery as second opinion, I'll say, "You're going to get the same surgery, it's the same recovery. You know, whatever you feel most comfortable with." But I think people have this image of this like humanoid robot standing at their bedside doing the surgery. And that's not what this is. This is a robot where our surgeons are sitting on the console, being able to look in, as Dr. Roque described earlier, and really able to sort of see the work that they're doing. They have full control over that robot. There isn't sort of anybody doing anything without your surgeon present. So, I love that.

Dr. Jenna Marcus: I mean, I think, Angela, the other thing is the capability of the tools that have, you know, grown in robotic surgery. When we first started, you know, we think of things like coagulation devices and scissors and graspers. But, really, we've been able to expand. I mean, we can do, you know, bowel surgery robotically because we have robotic staplers. We have robotic suction devices. And obviously, we are the ones who are controlling all of those devices. But it has really given us a larger expansion of the tools that we have in our toolkit to do effective surgery.

Host: Yeah. Speaking of that, you know, Jenna, I think when we think about sort of the patients who come down to see us, especially downtown — you guys, I know, work at a number of hospitals around the state. But when we think about when people come downtown, often it's because they say, "My cardiologist is at Northwestern," or "I had a transplant. My transplant surgeon is at Northwestern," right? So, how do you guys think that this robotic surgery, this focus on minimally invasive and robotic surgery here at Northwestern really is impacted by sort of all the disciplines we have here?

Dr. Jenna Marcus: Yeah. I mean I think, you know, obviously we're really centralized down here. We're fortunate to have a lot of really big teams that can help to medically optimize patients before surgery. So, that's very helpful. We have a great team of anesthesiologists that can help with some of these challenging cases, like Dr. Barber's, you know, high BMI case to really utilize all of the tips and tricks that we have to make sure that the surgery is done safely and as efficiently as possible because we also want, you know, the surgery to go well, but the recovery to go well.

You know, in addition to that, we collaborate with a lot of other surgical subspecialties to do surgery that is not traditionally thought of as gynecologic surgery. So, we do a lot of, you know, colorectal co-cases, patients have, you know, a rectal cancer, colon cancer that is growing into their gynecologic organs after they've had treatment. You know, we go in as a co-case with the colorectal service, and we perform that resection of the, you know, part of the gynecologic organs or all of the gynecologic organs, depending on what the patient needs.

So, it's really expanded our space to be able to collaborate with other services to do the surgery that we do, but also to accomplish for whatever cancer or condition the patient might be facing.

Host: That's really amazing. I think, you know, for our patients listening and our physicians listening, the goal is to really get patients into the operating room to take care of these cancers with all the best surgeons and all the best technologies and tools that we have, and really do it in that interdisciplinary way that Northwestern Medicine's really known for. So, wonderful. You know, I would love to — just as we close out here, guys, any developments that you guys see coming up in gynecologic-oncology surgeries and robotic surgery? Anything you want to share sort of about our practice here at Northwestern?

Dr. Dario Roque: Yeah. I mean, I think the way I think about the technology, especially, you know, the new robot, the technology in general, it is moving the field forward. So, I mean, the surgeries that we're doing are not going to change because of the robot. We're just doing them in a way that the patient's outcomes are better. So, what I mean by that is we're still going to be doing the debulking surgery. We're just doing in a minimally invasive fashion. The aim is to achieve a complete cytoreduction. This might sound like a — you know, this is my opinion, I believe, but I do believe that for the majority of cases, if the surgery can be open, it can be done robotically. Like, a lot of times people think of comparing laparoscopic to robotic surgery. But in my mind, sometimes there's more of a parallel between open surgery and robotic surgery in the sense that you're doing the same procedure. You're just doing it by seeing better, you're close into the tissue. You can get into better — like, you know, find better angles to do the procedure.

So, the way I do see this technology is, again, doing the same things that we're already doing, but doing them potentially better. So, what I mean by that, for example, we do a lot of HIPEC, which is heated intraperitoneal chemotherapy for some of our ovarian cancer patients. And that is something that historically has always been done open because it requires a big incision to place the port and administer the chemo. But we have done robotic HIPEC cases here, and patients have done quite well.

There's trials going on right now because I think the field went back a little bit when we're talking about cervical cancer, for example. So, those are cancers that historically we were doing minimally invasive. There was a trial that showed that potentially those patients may not have as good outcomes with minimally invasive surgery. And there's trials looking into how to do that surgery robotically in a safer way that I anticipate and I predict, and maybe this is wishful thinking, but I predict that they're going to show, based on the way that these surgery's being done, that those patients do actually do just fine. So, I'm excited about seeing the findings of the trials.

The other way that I do think robotic surgery really has moved the field forward in general is, you know, some of the newer technology, you can actually do telepresence, where if you're teaching, some of us go around the country and teach other surgeons or help them learn robotic surgery. So, I could literally be sitting in my office and helping a surgeon in a different state as they're doing their procedures. So, people are able to, you know, in the future, potentially consult during the surgery. We get consulted many times about different findings. So, this technology will potentially allow us to just jump into the room without actually being there and giving an opinion. So, I think these are some of the things that we'll be able to do in the future.

Host: So cool, Dr. Roque. Like so many cool new things that we could maybe use this technology for in the future. I'm really so excited to see where this goes. I know Northwestern Medicine's going to be at the forefront of all of these developments.

And so for our physicians and patients listening, know that our GYN-oncology teams here in the Northwestern Medicine system across our 13 hospitals are available for you for minimally invasive robotic surgery for your gynecologic cancers. Thank you guys all so much for being here today.

Dr. Jenna Marcus: Thank you.

Dr. Dario Roque: Thank you.

Dr. Emma Barber: Thank you.