In addition to being professor and founding chair of the Kirk Kerkorian School of Medicine at 51ԹϺ Department of Plastic and Reconstructive Surgery, Dr. Richard Baynosa has become internationally recognized as a pioneer in robotic surgery. He is director of the school’s robotic reconstructive surgery fellowship program as well as president of the Mountain West Society of Plastic Surgeons.
Earlier this year, we spoke to Baynosa about advances in robotic surgery.
What are the advantages of robotic surgery?
Robots are being used in surgery for things like making smaller incisions, improved visualization, particularly in areas where it’s hard to see and get your hands and arms in. They also offer increased precision, eliminate any hand tremor, and offer magnification in regards to the operative site and be able to see things even closer.
What specialties effectively use robotics?
Typically, specialties that are working deep in the pelvis. So urologists, colorectal surgeons, and gynecologic oncologists, all of whom operate deep in the pelvis like the bladder, prostate, rectum, those structures. In the past, you’d have to have multiple retractors and multiple hands, and it would still be very hard to see and navigate through those areas. Now, the robot can have multiple arms doing exactly what you want them to do, and the scope can zoom into those areas that you need to see.
What prompted your group to begin using robotics?
Many of the things we do in plastic and reconstructive surgery are based on a need. And essentially, the need came from a challenge from our colorectal surgeons who were incorporating more robotic techniques and asking why our reconstruction required large incisions and why patients were complaining more about the reconstruction incision than about the colorectal surgery incisions. They were able to remove a big cancer and the entirety of the rectum, but because they did everything through small incisions, with the robot, the patient really didn’t have a lot of pain from those areas.
It sounds like you’re using robotics more in your reconstructive work?
Well, one of the things I’m becoming known for nationally and internationally is using the robot to perform reconstruction after abdominal perineal resection for low-lying rectal cancer. The colorectal surgeon has to remove the entirety of the rectum and the patient ends up with a colostomy, as the colon is coming out from the abdomen. Historically, we would use flaps from the abdomen, including skin, and drop that muscle from the abdomen, down into the pelvis to fill the space where the rectum used to be. But that was when we had the luxury of using the big open incision that the colorectal surgeons used. Now, these days, the majority of colorectal surgeons are using robotic techniques. Those big incisions are a thing of the past.
Robotic surgery has become an area of great interest among reconstructive surgeons who do these surgeries after the colorectal surgeons finish. Because the colorectal surgeons are already utilizing the robot, they have the crew, nurses, techs, and everyone else already trained for the robot. You’re not adding any additional expense or additional training to the staff. You’re actually decreasing the morbidity and improving the outcomes for the patient.
You obtained your certification to use the Da Vinci Robotic System in 2014. How many robotic surgeries have you performed since then?
We’re probably approaching about 30. Right now, I’m one of the founding members of our American Society of Plastic Surgeons Robotics Task Force. We are putting together the best practices, different routes for credentialing, getting together all the initial data on not just the surgeries that I do with robots, but with other surgeries that can be done with robots.
How is Southern Nevada doing when it comes to robotic surgery?
I think we stand up pretty well with all the specialties across the country that are typically incorporating more and more robotics. Overall, the majority of the colorectal surgeons, gynecologic oncologists, urologists, and general surgeons have incorporated robotic techniques. Thoracic surgeons, otolaryngologists (ENT), and orthopaedic surgeons are increasingly utilizing robotic techniques, so I would say we aren’t too far behind. In general, it’s not the quality of the doctors here but, rather, the volume of doctors. We just don’t have enough people that can actually do these techniques. But in plastic and reconstructive surgery, I would say that we are really ahead and at the forefront. I base that opinion after having been brought in to lecture at places like the University of California, San Francisco (UCSF), Stanford, and Beth Israel (Harvard).
Are we teaching the next generation how to perform robotic surgery?
Yes. Inside our new medical education building, we have a simulation center where we have a robot that is the exact same console as the one that is used in the operating room. I’ve had fellows that I’ve taken through to get certifications in microsurgery. After they do the simulations and then they do it on a patient, they tell me, “This is almost exactly like the simulations I was doing.”
Also, one of the nice things about University Medical Center of Southern Nevada (UMC), where I perform some of my surgeries, is they have dual consoles where you can actually train residents and fellows. It’s almost like driver’s training, when you have a secondary steering wheel in the passenger seat. There are dual consoles where you can hand off control of the robot, so new surgeons can become familiar performing the techniques. When you’re on the console, it’s almost like you’re playing a video game … So for trainees, especially the younger trainees that are very in-tune with video games and seeing things in stereoscopic view, as opposed to actually having tactile feedback and having to feel structures, they just see it on the screen, and their depth perception is there based on what they see, not necessarily what they feel.
Are new technologies on the forefront?
Yes, several. For breast surgery, there is a clinical trial going on where they are using the robot to perform robotic mastectomies, and breast reconstruction. Additionally, there’s a newer robot that’s coming to the states that is already being used in Europe. It’s up for FDA approval in the next couple months. This robot is more for microsurgical utilization and, because of the fine movement of the robot, the elimination of tremor, not only can it help do microsurgical dissection and anastomosis — hooking up of the blood vessels in small areas like in a transplant or a free flap in vessels that are one millimeter or under. So areas where this would help facilitate improved reconstructions with less morbidity would be head and neck reconstruction.
