Gabby Cinnamon (Host): Welcome back to the Well Within Reach Podcast, brought to you by Riverside Healthcare. I'm your host, Gabby Cinnamon. And today, I'm very excited to be joined by Riverside General Surgeon, Dr. Steven Groene, to talk about the role of robotics in General Surgery. Thank you for coming on the podcast today, Dr. Groene.

Dr. Steven Groene: My pleasure. Thank you.

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Host: Before we get into today's episode, can you tell us a little about yourself and your background? How long have you been at Riverside, training, specialties, that kind of thing?

Dr. Steven Groene: Sure. First, again, I just want to say thank you for having me here today. Having a great time. I've been here at Riverside a little over two years. I did my training. First, I did my med school at University of Virginia. Then, I did my General surgery training in Indianapolis, did a fellowship in Charlotte, and then I spent about five years in Kansas. That's where I was born and raised, grew up. My wife needed to be closer to family. So hence, we came here, and we're very happy, very pleased to be here. I'm a general surgeon, so I do a lot of what we would quote say bread and butter general surgery. So, I do a lot of gallbladders, hernias, colon surgery, lumps and bumps, breast surgery, those kind of things, so basic general surgery.

Host: We're grateful to have you at Riverside and grateful to have you here with us on the podcast today. So for those of us who don't know, can you explain what robotic surgery is and kind of how it's different than traditional surgical methods?

Dr. Steven Groene: Sure. I like to think of robotic surgery as the great integrator between minimally invasive and open surgery. So when we talk about surgery, I think a lot of people understand you've got your traditional, which I would consider more of your open, big incision surgery. For the last 30 to 40 years, we've also had more minimally invasive, which has generally been laparoscopic surgery, which is again where we use little incisions with instruments. And again, I think the robot really integrates those two and makes two become one.

And what do I mean by that? I mean that the robot has the capability to do surgery through small little incisions like laparoscopy, but it gives me the abilities that I would have if I had a big incision with my hands in there. So, the instruments that we use allow me to have 360 degrees of dexterity as if my hands were in there. So, there are certain things that can be somewhat challenging to do laparoscopically, such as suturing, things of that nature, that are so much, much easier with the robot. There's other things that the robot can do. It helps me visualize things better, but I think really that's the big thing, is it takes the positives of laparoscopic surgery and the positives of open surgery and really melds them well together to be able to do very complex things through small incisions.

Host: So, the robot not only helps the patient and the healing process, but also helps you guys. I think sometimes people don't realize that. What robots do you guys use in general surgery?

Dr. Steven Groene: For general surgeons and our colleagues in Urology and Gynecology, there's really one main robot. It's the da Vinci robot. It's created by a company called Intuitive Surgery. Not to go into a lot of detail, but essentially, it was actually first created as an idea to be on the battlefield, actually, to try to have a non-manned machine out there for people who needed emergent surgical interventions on the battlefield to try to avoid having any casualties. For a lot of reasons, it kind of didn't really pan out very well. But Intuitive and a couple of others, but mainly Intuitive, really realized, "Hey, we can actually take this back and put it into the civilian world and really find a new niche," which I'm very grateful and glad that they have. But essentially, ours is the da Vinci robot is the one that we use.

Host: Very cool. I did not know that. That's a very cool background. Can you talk about the surgeries that you guys use robots for? Do you use them more frequently in certain surgeries than others?

Dr. Steven Groene: In this day and age, I think we're really pushing the envelope. The robot itself, and we'll get to this in a little bit, but there's been multiple iterations of it. We're with the da Vinci XI now, kind of the second, third generation. And when it first came out, robotic surgery, really, for a lot of reasons, it was very specific to certain areas of the body. So, our Urology colleagues and our Gynecology colleagues really pushed it because they would stay in one focused area of the body. And as we've adjusted and they've made improvements, it's made it much easier for us general surgeons who can go all over the belly to use it. But I think really nowadays, anybody can be a patient for the robot. Any surgery that you can think of that you might be able to do, so again, gallbladders, hernias, bowel resections. I don't do this myself, but there are surgeons who are using it to do surgery on the lung. They've tried to do it with the heart. I don't know how far that's really gotten, but I mean, they're pushing the envelope. I've heard of minimally invasive thyroid surgery with a robot. So, they're pushing the envelope, I think. If you can see it, it can happen, and I don't see that it's going to go anywhere else.

Host: Wow, that's very cool. You kind of touched on this earlier, but kind of to go back to it, how do robots specifically benefit surgeons in the operating room?

Dr. Steven Groene: First and foremost important thing to me that it does, and it kind of goes with the patient, is safety. There are just things about the robot that make it a safer surgery. Things we can do, opportunities to avoid big incisions on the patient. That's the key for us as surgeons.

Specifically, there are a few other things ergonomics, when we're doing laparoscopic surgery, oftentimes our arms are up for a really long time, kind of at a 90-degree angle, our elbows with our shoulders. There's a lot of surgeons that I know that have gotten out of it because of that, it just hurts. And back, we're usually kind of stumped over a little bit when we're doing laparoscopic surgery. So, we sit at a console and it's just so much nicer and more comfortable. So from a very selfish personal way, that's how it helps surgeons. But I think the biggest thing is it's just what it can do for the patient.

Host: Hey, yeah, I mean, if you're able to focus on the surgery more and not in pain, I can't imagine having my arms up like that for-- I can barely do that movement for more than 10 seconds. I can't imagine having to stay like that for long periods of time. So, what are some of the advantages of robotic surgery for patients?

Dr. Steven Groene: I think safety and what we can do for them. One thing that I really, really love about the robot, beyond the ability to have 360-degree range of motion, is no matter how good our instrumentation, our visualization, our 4D images and things of that nature. Everything we do with minimally invasive surgery outside of the robot is we look at a 2D monitor. Again, it can be the most crystal clear picture, but it's still 2D. Seeing depth perception is very hard. With the robot, when I'm at the console, which is the portion that I use to control the robot, when I'm looking in there, it can redefine it in a 3D perspective, as if I was in there, if I had a big incision. And it actually magnifies the imaging too, so I can see better through the robot than I can with my naked eye.

Host: Wow.

Dr. Steven Groene: And so, it's a safety thing. And again, it helps them heal quicker, less risk of wound complications such as hernias or infection. They get back to work sooner. For some people, cosmetics is obviously something that matters a lot. So if you can make three or four little tiny incisions you can kind of hide versus one big incision, people do enjoy that too.

Host: We're going to take a quick break to talk about primary care at Riverside.

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Now, back to the episode with Dr. Groene. So, you just told us about the advantages for not only you, but also patients of robotic surgery. How do you determine if a patient is a good candidate for robotic surgery?

Dr. Steven Groene: At this point, I think we're pushing the limits. Like I said, robotic surgery has been around about 20 years. And we have just been pushing and pushing and pushing, and I'm grateful for the people that are really out there. There's people, Dr. Swope, he's a gentleman who really has pushed it; Dr. LeBlanc down in Louisiana. But when I was in training, we had a robot in my training facility, but it was almost laughed at to do robotic surgery. It really was. It was like, "Why do you need the robot? Aren't you a surgeon? Can't you do it yourself?" And we've just learned how much it can help and assist.

And so, truthfully, anybody can be a patient for robotic surgery. Certain things I look at, are there any instances where it may not be the best option? I think it comes down to, again, each individual, each individual patient. So when I go into it, for example, again, I do almost all of my gallbladders robotically now. I try to do most of my hernias robotically. I try to do most of my colon resections robotically. I do something called a hiatal hernia, where part of your stomach's up in your chest, I try to do that robotically. So, I try personally to really get people set up for robotic surgery.

But I do think there are certain situations where it's probably not the safest or the right decision. For example, if somebody has had a lot of surgery or they have a complex abdominal surgical history and you need to do something, sometimes that can be very, very, very hard. There can be a lot of scar tissue in there that is hard to do even with a big incision, but even more difficult when you have little incisions and you're trying to use the robot. So, people like that who have a very complex surgical history on their abdomen a lot of times I think, just unfortunately having to make another big open incision is probably the right, safest thing to do. Or for example, I do a lot of my inguinal or groin hernias robotically. Again, if they've had a lot of surgery on their belly and I can just make a small little incision in their groin to fix it, I'm not going to put them through any kind of risk for that.

Go with hernias. Sometimes hernias are really teeny tiny, and it's a little bit overkill to do probably a robot where I have to make three incisions as big or bigger than the little incision I have to do just to fix the hernia. Sometimes you can have a very large complex hernia, which is very challenging because you have to sometimes mobilize some of the surrounding muscles to get it back in, and that's just very hard to do robotically. So, I think surgical history plays a big role, what you're doing is a big role.

And then, patients, their other comorbidities can be a big issue. So when we do any kind of minimally invasive surgery, robotic, laparoscopic, we have to blow up the belly with carbon dioxide so we can visualize things. The issue with that is they add some pressure. And so, sometimes it can cause the amount of blood flowing back to the heart to decrease a little bit. Now, for most healthy people, they have no problem. You don't even realize it. For people who have severe cardiac history, severe heart disease, heart failure, that small amount of difference in blood flow back to the heart can be devastating, and I've unfortunately seen cardiac arrest with minimally invasive surgery. And so, some of these people with really bad cardiac or respiratory history, I think sometimes it's still safer and generally better even with a big incision as much as you don't want to do it to do it that way and minimize that extra pressure that makes their potential heart disease worse.

Host: Interesting. So, you touched on having smaller incisions with robotic surgery and that aiding with recovery. Can you talk about how recovery is different for robotic surgery versus a patient with the traditional surgery? I think sometimes, as someone who's never had a stomach surgery or anything like that, people I know, family members and stuff, the recovery is longer a lot of times than what people might realize. So, how does that vary with robotic surgery?

Dr. Steven Groene: The first and foremost thing I always try to explain to patients is that even though we're doing it with little incisions, we're still doing the big surgery. So up front, I'm not sure there's a big, big difference. I think it's more once you get through that first couple of days, first week or two. But there's absolutely subjective and objective data that shows that people heal and recover faster. How do I know that? They've done studies that show people who use pain scales, their pain is significantly less much quicker. They use less pain medicine. They use it for less frequent amount of time. They go back to work sooner. Things that we tell them, generally, it's like if we do a big incision, we say, "Hey, you can't do anything major for six weeks." With the little incisions, we're like, "Hey, give me two weeks and you're going to be back to be able to do what you want to do." So as long as they can get through that first few days and realize, "Okay, little incisions doesn't mean there's not something going on on the inside," there's no doubt that objectively they have Improved recovery in terms of pain and how quick they get back.

And then, again, as I kind of touched on a little bit earlier, I think it also decreases wound complications. So, the bigger the incision, the more area there is, the more area there is, the higher their chance is for a complication with that wound. Anytime that we're doing surgery, we have to cut through the muscle and the strength layers of the abdomen, which by doing that, in theory, could create a hernia after surgery. Now, we close up the strength layers. We try to do our best. It's not perfect. If you look at the data, probably with a big incision surgery, there's about a 15-20% chance of getting a hernia after the surgery. Most of the time, it's not a big deal. People just have a little bulge, it's not symptomatic, but that big incision has a much higher chance of having that happen versus tiny little incisions. Again, you can get hernias there, but you are talking less than 1% risk for those little ones. And the same with infection, big incision, you have a much higher area where you could get a little bacteria that could cause an infection that could cause a significant problem. Little incisions, rare. I've had a couple, but it is extraordinarily rare to get an infection with the little incisions from a robot surgery.

Host: Yeah. So, definitely a lot of benefits there that I wouldn't have even realized. So, that sounds like the benefits definitely outweigh any apprehensions or anything like that, that people might have about a robot being involved in their surgery. I think that that sometimes comes up, which we'll talk about here shortly, but that definitely can be apprehensive for some people. So, what are you most excited for in the future of robotic surgery? Any studies being done or anything like that, that you're aware of?

Dr. Steven Groene: The thing I'm most excited about are the endless possibilities. So again, when we're talking about the robot, there's really three main portions to it. There's the console. That's the part I'm involved with. That's where I actually control the robot. The second part is the robot itself, which looks basically like a spider, essentially. And then, the third part is the computer system. And the computer system, as of right now, for the most part, what it does is it integrates the portion of my part and the robot.

I see in the future, I don't know about AI per se, but I do see in the future the ability to take advantage of the computer system of the robot. And it's already starting to kind of get there. For example, there are certain dyes, there's something called an ICG green dye. It's basically something we can inject into the IV of a patient and it lights up green. There's a special little fluorescent light we can use with the robot and it lights up green wherever there's blood supply or blood flow. And so, it helps me with surgery. So if I'm trying to resect a portion of the intestine, I can put that in, see, okay, is it black or is it green? If it's black, it's not healthy. It needs to come out. If it's green, it's good. I'm okay to hook it back together. And I know they're working on other types of dyes that they can use to utilize to try to visualize blood vessels or the ureter or other things to try to help make it a little bit safer.

I think where it's really going to be amazing when it gets to that point, is again the computer system. So for example, my neurosurgery colleagues, I get a little bit jealous of them because they have a lot of this just outstanding technology where they can get preoperative imaging of the brain and then they can incorporate that with certain instruments in the operating room. And with that imaging and the technology they have, they can say exactly where the tumor is, if they need to burn it or whatever they need to do. It just blows my mind, and I know it's way beyond me, but that's what makes me most excited.

Right now, like I said, it's a great adjunct. It makes surgeons better, safer, quicker with little incision surgery. But I see when it can get to the point where we can take a preoperative imaging like a CT scan and then incorporate that into my visual field with the robot, I just can't imagine how much safer it's going to be. I'm going to be able to see all the blood vessels, all the other organs, all of the other bowel. Because right now, I know my anatomy and you can sort of see things, but some people have a little more adipose or fatty tissue. And so, sometimes the anatomy can be a little distorted or if you have a cancer, it can be a little distorted. And so, having that as another safety mechanism, that's where I see it coming and going to be going. And I know we're making progress. They're going to introduce the da Vinci 5, so the next step in the evolution of the da Vinci system. I don't know much about it yet, it's still very, very new and they're still letting out little teases of things, so we don't know a lot of detail just yet.

But one thing, for example, I know that they've done because they understand and they can use that computer system to help them. When we do robotic surgery, one of the biggest inabilities is what we call haptic feedback. So for example, if I'm doing surgery with an open surgery and I have my hands in there or even laparoscopic surgery, if I say grab a piece of intestine, I know how much tension I'm putting on that piece of intestine when I'm grabbing it with my hand. We have that feedback. I know how much it is. With the robot because of how it works and I'm at a console and I'm using literally the robot to do it, I can visualize how much tension I'm putting on it, but I don't know exactly. I don't have that feel. And they have been able to now with the computer system of the da Vinci 5, they have that. I've seen the video. So, they've shown surgeons using a rubber band with the new da Vinci system and they can legitimately feel how much tension they're putting on that rubber band. Safer, it's just again about safety, making it better, more efficient.

And again, ultimately, I think it's going to be when they can really take that computer system and make it more than just the conduit between the console and the robot and really bring it home. That's where see it coming. When? I don't know. Fifteen, ten, twenty years? I don't know. But that's where I see it going and where I think it's going to be. Just out of this world amazing.

Host: Yeah. You've done a great job just talking about the safety of it and how much safer robotic surgery is, because I think that that is one of the things when people are apprehensive about, like, "Oh my gosh, a robot. That can't be safe. What if it has a mind of its own, you know?" And I'm not trying to dismiss people's concerns. Because I totally understand. There's so much information out there and people are getting their information from all different sources. We talk about that all the time. But you've done a great job talking about explaining, kind of debunking why this kind of surgery is actually safer.

I was reading this article and someone was trying to do surgery on someone in a different state. Is that common?

Dr. Steven Groene: It's very possible. I'm not aware that it's happening a lot by any means. But in theory, by the basis of how it works, you could in theory do that, but I think that is a one-off situation that I've not heard.

I mean, again, when I'm working the console I'm using is literally right next to the patient. So, if, God forbid, something crazy happens, I'm right there. So, could it happen? It could. Do some people do it maybe in a teaching mode or something of that nature? Perhaps that's what it was. It could happen, but that is not something I've heard much of. And I can't imagine the vast majority of surgeons would be in agreement with doing something like that.

Host: Yeah. Yeah. So if a patient is listening to this and maybe apprehensive about the idea of a robot being involved in their surgery, what should they know? You've talked about safety, but is there anything else that would help put them at ease?

Dr. Steven Groene: Sure. I think the first and foremost is kind of what you brought up just a second ago. I'm still in control. I'm still the surgeon. It's not an autonomous robot. It's an adjunct to make me better, to make your surgery safer. I'm still there. I'm still in control. That's the first and foremost that I think most people get a little nervous is, oh, they hear robot, they think autonomous robot that's doing it on its own. It's not. Maybe one day. Could it happen? It could, but I don't see that happening for any time in the near future. So, that's the first and foremost.

And then secondly, again, I tell them there's so many safety protocols in there. Things that we can do to still, again, make it even safer. Make sure all the instruments are in the visualization and where I am. Any of the instruments that have the ability to use electricity. So, we do a lot of cauterizing for bleeding and things of that nature. They have little sleeves on them so that the amount of heat stays right where your action is and it doesn't allow it to move other places.

So again, I think the biggest thing is I'm in control. It's just making me a better surgeon, making your surgery safer and better. When I started doing robotic surgery more consistently about seven years ago, I think, probably half the people that came in were a little bit hesitant about me doing robotic surgery. And I think it's just become a standard. And most people nowadays, I still have those few people that are a little bit nervous about that. But more than not, I have people come in and they're like, "So, do you do the robot surgery or what?"

It's changing and I don't see it going anywhere else because I think even somebody with somewhat casual understanding of medicine, and if you're going to have surgery, you're going to look into this a little bit with the internet and everything else out there. So, I think most people realize that the robot is safe. It's going to be here. It's only going to get better. More and more and more training is going to occur. More and more and more surgeons are going to be using it. It'll never completely get rid of traditional open surgery. But I think at some point, it's probably going to get rid of laparoscopy at some point. It's about the same price now as general laparoscopic surgery. And so, at some point, laparoscopy is probably not going to be something that's even going to be offered to people.

Host: Wow. Before we go today, is there anything else you would like to add?

Dr. Steven Groene: Thank you for allowing me to be here and talk to you about something that is a passion of mine, the robot. I was a little bit slow on the uptake, but I wouldn't go back now with the surgeries that I do. It's just got such a good advantage. And I just want to say thank you for everyone listening, allowing me to be here and be a part of caring for patients in the greater Kankakee area.

Host: Well, thank you so much, Dr. Groene, for coming on the podcast today. And thank you listeners for tuning in to Well Within Reach, brought to you by Riverside Healthcare. For more information about robotic surgery at Riverside, visit riversidehealthcare.org. Make sure to rate and leave a review for Well Within Reach on Apple, Spotify, or wherever you listen to podcasts.