Joey Wahler (Host): It's dramatically changing how operations are performed, so we're discussing the advantages of robotic surgery with an international expert who performs the procedure about as much as anyone. Our guest, Dr. Reza Gamagami. He's a general and gastrointestinal surgeon for Silver Cross Hospital.

This is iMatter Health, a Silver Cross Hospital podcast where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks for joining us. I'm Joey Wahler.

Well, hi there, Dr. Gamagami. Thanks for being with us.

Reza Gamagami, MD: Thank you. It's a pleasure to be here and thank you for the invitation. So, I'm really excited to share what robotic surgery is all about.

Host: Excellent. Same here. And speaking of which, let's start in a logical place, simply enough, what do we mean in a nutshell, for the uninitiated, by robotic surgery?

Reza Gamagami, MD: First and foremost is there's a misconception by the public that when we talk about performing robotic surgery, they almost invariably think that it is the robot doing the surgery. So, I want to make sure that the audience understands this is nothing to do with the robot doing the surgery.

In all cases, when we talk about doing robotic surgery, they can be applied to many things that we perform here at Silver Cross Hospital. So, let me kind of start by explaining what are the types of surgeries that we currently are performing robotically at Silver Cross Hospital. So if you need your lung removed because you've got lung cancer, that's done robotically. If you've got colon cancer or diverticulitis and you need a colon resection, that's performed robotically. If you have prostate cancer and you need prostate surgery, that is done robotically. If you have abdominal wall hernia, say you have inguinal hernia, umbilical hernia, groin hernias, previous abdominal surgery that now you have an abdominal hernia as a result of previous open surgery, that is done robotically. If you have a tonsillar cancer, that's done through the mouth robotically. And as you can see, we have a full spectrum, including gynecologic surgery. So if you have a uterine problem or ovarian problem, that is done robotically. We're blessed with having many gynecologists here who perform robotic surgery. And also, we have a GYN oncologist. So if you've got ovarian cancer, uterine cancer, these surgeries are performed robotically.

So, what is robotic surgery? If we talked about 30 years ago, pretty much everything I just mentioned, the way we would treat them, we would make a cut. If you needed your lung out, we'll make a cut in your chest and get the lung out. If you needed your colon out, we'll make a big incision from your midline, from your xiphoid all the way down to the pubis.

Now, the way we do robotic surgery is basically a way to do minimally invasive surgery. So, I took the liberty of trying to explain what minimally invasive surgery is. If you remember back in the old days, people started saying, "Hey, if I need my gallbladder out, am I going to get laser surgery?" So, that was the term they used. And the way that came about was that if you needed to do a surgery, we simply insert a little trocar. So if here is your abdominal wall and you needed your gallbladder taken out or your colon, you would basically put a port in here and blow the abdominal cavity and then, essentially, insert the instruments in and do the surgery. So, the instruments we used to use are these laparoscopic instruments. So if you needed to have a literal minimally invasive surgery, you get these little ports, you get a few of these on your abdomen. You get a little instrument going down the instrument port. And you basically would do the operation by manipulating the handle and the mouth. So, this was called laparoscopic surgery, not laser surgery, but laparoscopic. So, we went from being open surgery to laparoscopic surgery.

So now, what is the difference between laparoscopic surgery and robotic surgery? Well, we still use the same ports. We still need an instrument, but the instrument is different now. The instrument is actually something that looks more like this. It doesn't have a handle and it's got a tip. Now, this tip is different. If you notice, the previous tip was rigid. This tip can go up, down, sideways, and in all the different directions, whereas the previous tip was just a straight tip with no manipulation. So, that basically allows the surgeon to do very delicate work inside. It's almost like having your hand inside and doing all the rotations. So essentially, robotic surgery is a laparoscopic minimally invasive surgery, but we're using a technology that is going down the tube, and this is connected to the robot, this arm. And I use my hands and the fingers to manipulate the tips in a three-dimensional way.

So, what are the advantages of this robotic? Well, number one, it's magnified 10 times more. Imagine seeing that view that you used to see now is 10 times bigger. When you and I are looking at each other, we're two-dimensional. But when you look inside the robot screen, the vision is three-dimensional. So, you have good depth perception. So, it's magnified. You have three-dimensional. And now, you have the angles of articulation, so you can do more complex, delicate surgery easier. So in essence, we took doing chopstick surgery with single instruments with no rotation, and we're standing all the time. This is the kind of maneuver we used to do. So if you have shoulder pain, back pain, neck pain, especially, you know, as I'm getting older, everything starts hurting, this technology allowed me to just comfortably sit there and just operate tirelessly doing the most complex operation, yet finish the case and go and do something like see patients. So, very, very comfortable type of ergonomics for the surgeon. And this increased the safety, the efficacy, and certainty by being able to offer this type of surgery.

Now, about 12 years ago, 13 years ago, Ruth Colby, our former CEO, had the vision that we need to do more minimally invasive surgery. So, when you look at our data in Silver Cross Hospital, 80% of the colon resections, the hernias, inguinals, ventrals, hysterectomies, 80%, 12 years ago at this institution were being done open, and now they've gone completely laparoscopic, do doing robotic minimally invasive surgery. So, the robotic surgery has allowed the surgeon to do more minimally invasive surgeries when otherwise it would not have been all possible. Well, Joey, you might say, "Well, how come you just weren't taking the colon out doing a standard laparoscopy?" Yes, it was possible. You need somebody to drive the camera. You need somebody to hold another instrument. You need to be able to do chopstick surgery really, really well. So, it was really technically challenging. Whereas, when you have the robot, it has four arms. I control the camera, I control two of the arms, and I control the third arm that would have been the assistant. So, I essentially have gone from just being the surgeon doing laparoscopic surgery, to the cameraman, to the assistant, and the surgeon simultaneously. So, I have full control of the whole situation, so I can basically make that surgery more safe and effective for the patients. So, that's basically in a nutshell what robotic surgery is all about.

Host: And showing us with the instruments visually certainly drives home that point. Now, as I alluded to at the top, doctor, you've performed more than 4,500 robotic procedures, which as of 2023, ranked you 10th in volume in both the U.S. and the world. So first, congrats on that amazing achievement. And it makes me wonder, what's the main way, would you say, in the time you've been doing it, that this technology has improved? And how long have you been doing it?

Reza Gamagami, MD: I saw the technology initially being introduced in one of our conferences in 2009. And when I saw the technology, I thought, "Ah, this is just a gimmick. It's just a tool for us to play around with." And I kind of ignored it until 2011 where at a conference, I saw this technology being used for more complex surgeries.

So, I'll give you an example what I consider complex: doing major colon resection, removal of the esophagus for esophageal cancer, doing liver resection, doing pancreatic surgery, what we call Whipple procedure. These are complex operations, either open or even laparoscopic, but now we are able to do them robotically. So, I realized people were doing these operations, making them look like it's technically very feasible and easy to perform. So, I became very excited, came back with that knowledge, back to Silver Cross. And at that time, Ruth Colby and a lot of the members of the administration recognized there was a need for us to push, as much as we can, minimally invasive surgeries in our community. And that's what began the impetus to purchase robots, start a robotic program for a hospital. I don't know if people know, but we're a community hospital. We're 350 beds here in New Lenox. And actually, we have the highest number of robots than any institution for the size of beds we have. We have six robots. We perform close to about 2000 cases a year. And we've done close to about 16,000 cases overall. We are and have been essentially number one and two within the Midwest in terms of volume, even though we were a little bit of a slow starter. In fact, there were other hospitals that had the robot, but we actually overtook many of the other institutions because we saw the value.

Now, you might say, what was the value of then doing minimally invasive surgery was the fact that the patients were getting smaller incisions. They had less wound complications, they were going home earlier, they had less pain, they had quicker recovery so they can go back to work. So, it has all those advantages. And plus, more importantly, we saw that we reduced our potential complications from surgeries, because we could see better and we can do that surgery better. And that essentially was a win-win for both the hospital and for the physicians who are at Silver Cross Hospital. And I became interested. And when I started, everybody was kind of like, "Oh, it's going to take so much time. This is the same as laparoscopy. It's so expensive," you know, all those arguments. But I kind of plugged away at it. And needless to say, we have now 15, actually, general surgeons here on staff. We've got numerous gynecologists. We've got urologists. We've got thoracic surgeons. We've got GYN oncologists. And I'm happy to say everybody who's on staff here, dealing with those organs now in their specialty, is actually trained in robotics, and that's why we have such a robust program.

Host: Now, you mentioned academia and training and your colleagues. And speaking of all that, switching gears just a bit here, you travel abroad as an educator and a consultant for da Vinci, the developer of robotic surgical equipment. How rewarding is it, doctor, to spend time now passing on your vast knowledge to so many others?

Reza Gamagami, MD: This has been an incredible journey for myself. You know, I started my career in academic surgery. So, I was at UCSD for a number of years when I finished my training. And then, I did some additional subspecialty trainings in general surgery, you know, colorectal and laparoscopy and oncology. And then, I actually moved to a very small rural setting where I was taking care of two small towns in Illinois. And then, I moved here about 17 years ago.

So, one of the sad things about moving to a community hospital was the fact that I no longer had the opportunity of resident and students. So when I started doing robotics about 13 years ago, after the first year I became good enough, I think, by some standards, that I was asked to start teaching, again, robotics to other surgeons who might be interested. So, that started my journey of moving from teaching high school students to college students, to residents in surgery and fellows, to now not so much teaching, but maybe showing my colleagues on ways where robotic surgery can make their surgeries more efficient. I always tell the surgeons that I meet every day I'm not here to teach them how to operate. I think all the surgeons I've met are great surgeons and really some very good people and extremely knowledgeable. But my goal has been, how do I show them to use the technology to do this operation more efficiently? So, that's been my goal.

I have been very fortunate that I've been doing this for almost 10 years of teaching. I do have people visiting me every week on a Thursday or Friday. They either come nationally or sometimes internationally. We also do webcasts where we have live surgeries for other surgeons, only surgeons, so this is not one of those shows, you can buy a ticket and kind of sign up on YouTube or TikTok. This is a very highly confidential arena where surgeons might be interested in how to do a hernia repair or a colon resection. And we have a group of surgeons getting into one room, they log on to our OR directly and there are cameras on the robot. There are cameras on me, there's cameras looking inside what I'm doing so they can see the full spectrum of the operation, start to finish, so that hopefully with their robot system, they can go and start implementing the same technology .

And also, the other aspect that's been incredibly rewarding was not only just doing things nationally but people also visiting. But I was very fortunate they actually invited me to go to India for a whole week, where I was conferencing with a lot of the other surgeons who are robotic surgeons, but they were going to be the future masters of robotic surgery for their country.

So, I don't know how it came about that Intuitive decided to pick me. I think they said, "This guy's probably got the most gray hair. So, you're probably going to be well respected." But anyway, it was a tremendous experience. So, I got to visit their hospitals. We did a lot of cadaver labs. We did a lot of lectures, a lot of teaching in those seven days. And then, last month, I was invited to go to Korea, South Korea. And we did a similar project in Korea where we showed their Korean surgeons who have actually had the robot for many, many years, and they usually applied it for gastric cancer and colon cancer, but they were now more interested in getting into robotic hernia repairs. So, I was very instrumental in kind of spearheading their program on how to start it and teach the future South Korean surgeons on how we run this system in the United States.

You know, the da Vinci robotic system as a company, certainly, you know, I've been a proctor for them. I've been an educator for them. People might say, well, you know, you're getting probably paid for doing these things. Of course, it's my time. If I'm teaching, whether it was a university setting or if it was a lecture at some other organization, it would be the same aspect. But I think the fact that, here it is, a technology that has made a radical change in how we do things for our patients, especially for the more complex problems, and it's the only company that I'm aware of that has invested so much in teaching. So, if you're a surgeon here in the U.S. and you want to learn all these little different aspects, whether it's hernia, whether it's foregut surgery, meaning hiatal hernia repair, colon resection, da Vinci has set up courses for all, from the most basic to the most advanced level. So to increase the patient's safety level, they've gone way beyond. So, this is not about a company who's come out saying, "Here's a robot, pay two million dollars. And have a nice day and use as much as you want it." They've been very selective about who they train. They've been very selective about advancing surgeons' progress, and they've taken an extremely responsible role to make sure that they provide the most efficient and the safest way for us to conduct our operations.

So, it's been a journey. I've been very excited. And I continue to be always thrilled with all the new technologies. And in fact, just recently, about a couple of weeks ago, they released their new robot. And needless to say, we're very excited that we're exploring on how we can be a partner with Intuitive with additional technology, which has some additional features. It's just like a better model. I don't think it's going to change how well we're going to do our surgeries, but I think it's got certain gadgets, just like your new fancy cars. You know, you and I used to have probably cars where you rolled the window down. And now, we got the automatic button, and it goes up and down. So needless to say, the window goes up and down, the work gets done, right? So, the question is, I think, the new robot is going to have some of those little extra gadgets to make the surgery a little bit more fun, as you might say.

Host: Amazing technology indeed, doctor. Folks, you've been hearing from one of the esteemed human surgeons behind the robots. We trust you're now more familiar with robotic surgery. Dr. Reza Gamagami, keep up your outstanding, groundbreaking work. And thanks so much again. Very educational.

Reza Gamagami, MD: Thank you. It's been a pleasure and thank you for the invitation.

Host: Same here. And for more information, please visit silvercross.org/surgery. Again, silvercross.org/surgery. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. Thanks again for being part of Silver Cross Hospital's iMatter Health Podcast.