Vladimir Nikifarouk, MD
Robotic surgery for endometriosis
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 18-19, 2016
The Union Club, New York
Thank you. I am so happy to see so many young faces over here and I see one of the students, yes, I see you and one of my friends from my residency. He is much younger, from St. Barnabas. And I see the most successful surgeons in this room that we cannot see in one room at the same time.
Dr. Reich told me to take a look at a website Endo Forum Boston and do a passion presentation on robotic surgery. It is going to be at the end my passion. I will try to wake everybody up because I see people are tired, it is hot over here. A little background; I come from the Ukraine so I am not Russian but I am going to use a Russian video. I was very lucky to be trained under communism when you go in an operating room and they spank your hands and say, “Okay, your nails are too long, you have to leave the room till next time”. I was very lucky to be trained in the United States in one of the prestigious residencies that had never seen immigrants. I said I was the first immigrant ever going through that program in St. Barnabas, New Jersey under Dr. Breen. And older gentlemen and doctors probably know who he was. I was lucky enough to learn laparoscopy, that new stage, after Dr. Breen who was successful, open GYN oncologist. We had to have permission in the early 2000s to be able to perform first laparoscopic hysterectomy. It was years, years after Dr. Reich already completed one and became a new idea among young, progressive people but we had to have permission from Dr. Breen who was already retired in North Carolina playing golf that his hospital would perform the first laparoscopic surgery. And what happened?
I was lucky enough to be in my second year and nobody wanted to stay eight hours, ten hours and do supracervical hysterectomy. Who had to do that pleasure – me! After four years of struggling I said I would probably never do laparoscopic surgery but the opportunity came up and I said, “Okay, you know what? Let me make myself look better than anybody in Pennsylvania”. So I decided to go to one of the courses, refresh and I did my hysterectomy in 30 minutes.
Then, another stage of life, in my 48 something years, like I lived so many centuries of medicine because medicine develops so fast, so progressively. And here came robotics. Of course I was not the first one to do robotics in the United States. I was very skeptical to do it because I could perform the same job doing a laparoscopy and doing a very successful job without utilizing so much overtime, instruments, money, etc. But my hospital decided to recruit the first Tesseract robotic surgeon trained in the United States. What happened? They bought a $2 million machine for the guy who quit the job six months later. The hospital got stuck with a robot and to six GYN surgeons they said, “Who is going to be the first to be trained on robotics?” And of course my ego says, “No, I’m better than a robot. I will not do it”. But on the other side it says, “Okay, if I don’t do it, my colleague will do it and they will be better than me”, so I said, “Fine let me do the robotic surgery”.
A few cases were okay. You know it takes time. I was very impressed that it was not as bad as I was thinking. Then came one patient that changed my outlook on robotic surgery and she was one of the lady nurses. And actually, she came to see you in New York City after, yes. So the story showed she had, I think, a clotting disorder so she needs to be on the Coumadin, endometriosis, two babies. My partner probably did five or six surgeries on her. You know, taking one ovary, taking a resection, burning then she called me to do supracervical, then she decided to take out the cervix and then finally she left one ovary because she said, “Okay, I don’t want to put her on any Coumadin or Lovenox or anything so we have to preserve your ovaries”. So after six months of Lupron the endometriosis is back. My partner sent her to New York City. She went to New York City, sees the physician but the insurance would not cover it. She comes back crying, asking for Vicodin and I am feeding her with narcotics.
Then I said, “Let me take a look at your endometriosis and see if I can do it. If I have to open you that’s fine”. It was the beginning of my career using the robot. I brought in a young lady who already had a hysterectomy, supracervical, then she had her cervix removed, a couple of burning surgeries. I take her for robotic surgery and everybody in OR said, “What are you doing? It’s a case that you can do scope and she’ll be fine”. I said, “You know what? I need cases, I promised her, maybe it is more than a laparoscope can handle or maybe I can handle using laparoscope so I take the robot”.
As soon as I put the scope and prepped her we saw endometriosis that nobody could believe, these micro implants all over. It took a little time, it took maybe way longer than it takes me two or three hours it was almost like peritoneal stripping and I was impressed, everybody in the room was impressed with what we could do for that patient. Of course, that helped her for another year and eventually she had to have her last ovary removed. Same laparoscopic because adhesion and disease, etc., etc.
So, passion about robotic surgery, it is great. I love it. But what are the cons? It cost a lot of money. It cost $2 million to have this machine. It cost $300,000 a year to support it. Not every hospital can do it. On top of that because it is a very popular media, social media and the press make it like it is a robot who does the surgery. It is not a physician who really does the surgery using the robot and robot is not to do a surgery it is to assist to do a surgery.
Just to make it very short and probably wake you up again I have three little clips. The first clip my daughter sent me from England just a few days before. She said, “Dad, look what a robot can do”. You can laugh it is short, 40 seconds. It is a grape. My goal is in the next few weeks to do a video like that and prove to my children that I also can do like that and it is not a robot. And I challenge my colleagues to perform it. I would love to know who did that. Who operated that robot to do such a precise job? I really do not know if I can do it at this point but I will try it.
To make it very short – I have maybe seven more minutes. This is a video I found and it is in Russian. I will not translate you try to figure out what it is. It is probably two minutes and I will tell you what it is. It is the future. It is the future. It is such a fast future and we think that in America that we are the only ones who are on the top of technology but other countries try to compete with us. They try to get better and as an example, you know, Russians they went to space before the Americans. Let us see what Russians have for plans for robotic surgery.
(Turns on video – two minutes.) That is the news. Do not pay attention to the big guy, he probably drinks a lot. If I stop it, stop it here. I will translate it. Yes, that is the guy. So they are comparing the Da Vinci and the system they have and it brings us to another point that I want to say. That is Da Vinci they are comparing to Da Vinci. Almost done. Okay, so does it say? Yes, two minutes. What is says is that in my hospital right now everybody wants to be a robotic surgeon. Urologists try to get time, general surgeons try to get the time and we have one robot. So the Russians came with the idea to have a robot that you can put in a suitcase and you can go from hospital to hospital. So the price of that system that they already developed and they are going to start testing is going to cost just $100,000. They can use it in every operating room like we have towers for laparoscopic surgery. That is something that can be.
But another clip I have if I can do really, really fast is done in England. That is in English and the idea is can the patient do the surgery on themselves? It will all be done. (Turns on another video.) “Hello, my name is Frank Kolkman and I study design interactions at the Royal College of Art. The project I have been working on is called open surgery. Open surgery investigates whether designing DIY surgical tools outside the scope of regulated health care systems could plausibly provide a more accessible version of health care. On display is a DIY surgical robot that I built myself from off the shelf parts and using easily accessible technologies like 3D printing and laser cutting. The type of surgery this machine is theoretically capable of performing is called keyhole surgery. Keyhole surgery could be used to do any type of surgery in the lower abdomen. Very common ones are operations on the prostate, or also appendectomies or hysterectomies even. The machine uses ABS arms that are 3D printed. All the electronics on the machine to control the motors are basically sourced from the 3D printer community so essentially the same electronics that drive the domestic 3D printer drive this surgical robot. All the other parts are basically off the shelf and ordered online. So by bringing all of these parts together you are able to create a semi-functioning surgery machine. Right now the machine is just running through a series of semi-randomized movements that show the capability, the movements of the machine. But the idea would be that it normally would be controlled by a human. I am proposing that this surgery will in fact be controlled by a Play-Station free controller simply because it is available and has all the right degrees of freedom to be able to control such a device. Developing this machine took me about five months to do and cost me around US$5000. However that compares to $10,000 for a single appendectomy in the US right now and around $2 million for a professional surgery robot. The intentions of this machine are not to actually perform any type of operations but more to provoke alternative ways of thinking of medical innovation by taking it outside of this socio-economic framework that operates even in first world countries like the US. Health care is increasingly getting inaccessible to large numbers of people. What is happening now is that these people turn to YouTube to share DIY tutorials on how to perform medical acts on themselves. Although this is quite a controversial idea I can’t help but wonder what would happen if you would supply this to this group of people who have no alternative at this point with more capable tools outside the health care regulations. I do believe there is room for DIY surgical tools, especially in areas where there is no alternative…”
At the end, like I said three years ago I probably would be very skeptical but now I cannot say no because I was skeptical about laparoscopy and about robots but time goes so fast and people have great ideas to improve health care, to improve quality and make it easy.
Thank you very much.
