Pediatric Robotic Surgery with Timothy Lautz, MD and Bruce Lindgren, MD

A leading edge robotic surgery program at Ann & Robert H. Lurie Children’s Hospital of Chicago is helping surgeons perform intricate operations on children as young as two weeks old with unparalleled precision and control. Lurie Children's is one of the few free-standing pediatric hospitals worldwide to offer this type of minimally invasive surgical option for children. In this episode, two Lurie Children’s surgeons detail how robotic surgery is a gamechanger for the field of surgery and young patients. Timothy Lautz, MD, is an expert in pediatric general surgery and surgical oncology and Bruce Lindgren, MD, a specialist in pediatric urology.

“Any move that we make is stabilized, it's magnified, and it's done in an extremely controlled way that even the most skilled surgeon can't do with their own hands.”

Timothy Lautz, MD
Interim Division Head, Pediatric Surgery
Director, Surgical Oncology
Member, Lurie Children's Surgical Foundation
Associate Professor of Surgery, Northwestern University Feinberg School of Medicine

Bruce Lindgren, MD
Director, Minimally Invasive Urological Surgery 
Attending Physician, Urology
Member, Lurie Children's Surgical Foundation
Associate Professor of Urology, Northwestern University Feinberg School of Medicine

Show Notes

• Lurie Children’s surgeons utilize robots during surgeries for enhanced 3D imaging, magnification and surgical precision, even in babies as young as two months old. However, Lurie Children’s surgeons always remain in complete control of these robotic tools. (1:29)
• Because of the robot’s unusual dexterity, a surgeon can work around corners and in tight spaces with a level of ease that would not be possible with human hands or traditional laparoscopic instruments. (3:27)
• Many urologists began recognizing the benefit of the robots 10 to 20 years ago, but it's only been in the past five years or so that pediatric general surgeons have developed the skills and expertise to use robotics. Lurie Children’s was among the first to do so. (4:24)
• Benefits of robotic surgery include: shorter length of hospital stay, less pain postoperatively, and quicker recovery and return to normal activities. (5:56)
• Lurie Children’s investigators also conduct research on robotic surgery, not only to validate its benefits and ensure there are minimal downsides, but to verify outcomes against traditional surgical methods. (8:44)
• Recent research underway with the robot is aimed at new approaches for distinguishing between pediatric and adult-style hernia repairs in adolescents. (11:00)
• Patients are cared for by a multidisciplinary team–including anesthesia, nursing, and surgical teams–maintaining seamless communication and coordination for successful surgery. (12:16)
• Three surgical divisions–urology, ENT, and general surgery–utilize robotic platforms for a wide range of procedures across the body, from bladder and kidney operations to complex oral surgeries and various thoracic and abdominal procedures, while also focusing on building expertise among lead surgeons to mentor others in adopting robotic techniques. (15:42)
• Lindgren and Lautz believe that the future holds potential for conducting remote surgeries via robotic platforms, allowing for collaborative efforts between local and remote experts. (19:15)

Transcript

[00:00:00] Erin Spain, MS: This is Precision: Perspectives on Children's Surgery from Ann & Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they're transforming pediatric medicine. Many Lurie Children's surgeons are performing delicate procedures with greater control and ease through the hospital's comprehensive robotic surgery program. Lurie Children's is one of the only pediatric centers in the world to house this type of minimally invasive surgical program for children. Here with details on how robots are used at Lurie Children's are doctors Timothy Lautz and Bruce Lindgren. Dr. Lautz practices pediatric general surgery and surgical oncology, and Dr. Lindgren is a pediatric urologist. Welcome to the show. Could you please introduce yourselves?

[00:01:02] Tim Lautz, MD: Hi, my name is Tim Lautz. I'm the Interim Division Chief for Pediatric Surgery and the Director of Surgical Oncology and an active member of the Robotic Surgery Program.

[00:01:11] Bruce Lindgren, MD: Hi, I'm Bruce Lingren. I'm a pediatric urological surgeon, and I'm the Director of Minimally Invasive Urological Surgery at Lurie Children's Hospital.

[00:01:19] Erin Spain, MS: Robotic surgery can conjure up many different ideas in the minds of patients and parents. Explain what robotic surgery means at Lurie Children's.

[00:01:29] Tim Lautz, MD: Yeah, so that's an excellent question. So the main thing to remember is that the surgeon is always in control of everything. The robot is not independently doing any actions at all. So what the robot brings to the surgery is, first of all, there is a very enhanced 3D view that the surgeon has when they work with the robot. The robot's camera is three-dimensional, which is very different from a typical laparoscopic procedure. So the surgeon really feels like they're in the body because the view is so good. But then the other aspect is that instead of holding the instruments with our own hand, they're attached to the arms of the robot. And what that means is that we control those arms indirectly through the controls on our console, but we're able to move the arms very, very precisely. Any move that we make is stabilized, it's magnified, and it's done in an extremely controlled way that even the most skilled surgeon can't do with their own hands.

[00:02:23] Bruce Lindgren, MD: It's not that the robot's doing the operation, you know, just push a button and it fixes what the problem is. You know, what the robot does is it's connected to some instruments that are really fine and could be inserted in the right place through really tiny incisions. And then the surgeon, you know, works through the equipment that's around and over the patient by moving instruments in a different part of the room, in a different piece of equipment, which actually makes the instruments move and do the operation, and it allows us to accomplish that repair or procedure through these little tiny incisions with a lot of precision.

[00:02:57] Erin Spain, MS: How important is that when you are working with, you know, small people. These are smaller areas of the body. Do robotic surgery techniques make a difference there?

[00:03:06] Tim Lautz, MD: The newest intuitive system has the most precise controls, but it also allows you to work in the smallest spaces. With the original versions of the robot you really have a big separation between the arms of the robot, which prevented the precise work that we do in pediatrics. But with the newer versions, even doing operations on babies as small as six months is possible with the robot.

[00:03:26] Bruce Lindgren, MD: Yeah, two months.

[00:03:27] Tim Lautz, MD: Both the view and the precision enhance that surgery so much. So having that magnified three-dimensional view allows you to feel as if you're right on top of the part of the body that you're working on. And then the very detailed, precise movements that you can have allow you to not only be precise with those moves, but you can also, because of the movements that the robot allows, you can work around corners and in tight spaces and in challenging locations with a dexterity that would not be possible just with your own hands or traditional laparoscopic instruments.

[00:04:00] Erin Spain, MS: Comprehensive robotic surgery programs are still fairly rare in pediatric medical centers. Why did Lurie Children's want to offer this approach to patients?

[00:04:10] Bruce Lindgren, MD: Well, I think that allows us to offer those benefits that laparoscopic surgery provides patients to just a wider range of problems, and therefore a lot more patients can benefit from laparoscopic surgery by use of that technology.

[00:04:24] Tim Lautz, MD: Yeah, so we realize the benefits that the robot brings to our patients' recovery, and like I said, the precision of their surgery. So if you look at the field of pediatric surgery, many urologists began recognizing the benefit of the robots 10 to 20 years ago. However, the role of the robot in pediatric general surgery is newer; it's only been in the past five years or so that pediatric surgeons have developed the skills and expertise to use the robot, and we were one of the first to do that. Part of that was done because of our close collaboration with our colleagues in urology who have been using the robot for some time. And so, there are many procedures that we have overlap with them, and as we saw the benefit in their patients, we were able to imagine what the benefits could be with our patients, and then we quickly discovered that it really did help enhance our surgery for a wide variety of conditions. And so we are now doing robotic procedures in the chest, we are doing a number in the abdomen, everything from what we call the foregut, which is the esophagus in the stomach to the liver area, including the bile ducts to the kidneys, to the tumors in the adrenal gland, and then a lot of surgery for colon procedures that are just much easier and more precisely done with the robots. In addition, we can use the robot to do very precise hernia repair for those teenagers that need a mesh placement, and that's really a very unique aspect of our program.

[00:05:51] Erin Spain, MS: You mentioned benefits to patients. Tell me about some of those benefits. What are they?

[00:05:56] Bruce Lindgren, MD: Yeah, the ones that have been really shown over and over are: shorter length of stay, less pain postoperatively, quicker recovery, and return to normal activities.

[00:06:04] Tim Lautz, MD: Yeah. The main benefit is our ability to do minimally invasive procedures when we otherwise would've had to do a more traditional, open, larger incisions.

[00:06:14] Erin Spain, MS: This is still a newer technology in pediatric surgery. Are there any known drawbacks to using the robot?

[00:06:20] Tim Lautz, MD: The only known drawback is that the incisions are eight millimeters. So we deal with some very small children, and sometimes when we do traditional laparoscopy, we can do incisions that are five millimeters or even three millimeters. So to do robotic surgery, the incisions have to be slightly larger. However, the benefits gained from that couple millimeters of extra incision are immense, and so we believe that the incisions are still truly minimally invasive, and the recoveries are still extremely quick. But the benefit that we get from having the added degrees of freedom and the degrees of motion from the robot.

[00:06:55] Bruce Lindgren, MD: Well, I think that robotic surgery is great for a lot of things. It doesn't apply to all the procedures that are out there, you know, that patients may need. So basically patient selection or case selection that's necessary. I think the biggest drawback that's been described other than what Dr. Lautz mentioned is just the cost of starting a program like that. It's an expensive venture for a hospital to commit to.

[00:07:17] Erin Spain, MS: That brings us to the equipment that you're using. As you mentioned, this is state-of-the-art equipment, the latest intuitive DaVinci surgical system is what you're using at Lurie Children's. Tell me about this machinery and why it is such a good fit for pediatrics.

[00:07:31] Bruce Lindgren, MD: Well, as the equipment has evolved and the systems have evolved over the years, they have become a little bit more streamlined and allow us to have the instruments closer and closer to each other. In the older versions, when we're doing robotic surgery, even on larger children, there's a lot of instruments clashing on the outside of the patient. The arms would hit each other in order to do what we needed to do inside the body. And with the newer system, there's a whole lot less of that happening. In fact, I can't remember the last time we've had much of that. So it just allows us to offer robotic surgery to smaller and smaller patients.

[00:08:03] Tim Lautz, MD: Yeah, and the main thing to understand about the robotic instruments is that they have a wrist. And so when you think about traditional laparoscopic surgery, you can kind of move them on the outside of the body like chopsticks, and then they have some little pincer type things at the end. The robotic instruments have a whole extra degree of freedom, so they have a motion that's very analogous to the human wrist, and so that allows you to work around corners. It allows you to work at angles. That would be impossible to work on with traditional laparoscopic instruments.

[00:08:31] Erin Spain, MS: As surgeons, you are continuing to study and research robotic surgery as well. Tell me about that. Why is it important for you all to be involved in studies and publishing about your findings?

[00:08:44] Tim Lautz, MD: So we know the benefits to our patients, but we want to be sure that those outcomes are real and that there are no downsides. So as an example, we just collaborated with our colleagues at another major children's hospital. We are the only two major US children's hospitals doing pediatric general surgery cancer operations routinely on the robot. So we want to make sure that we are getting the same oncologic outcomes as we would if we did these procedures with a more traditional open approach or even a laparoscopic approach. So we are working to pool our data with the other still relatively rare sites that are doing comparable surgery, to make sure in a very systematic way that not only are the patients getting the benefits of enhanced recovery, but they're getting equivalent or even improved oncologic outcomes as an example.

[00:09:31] Bruce Lindgren, MD: I think that's very true for what we do in urology as well. And as we've gained experience with robotic technology, we've offered different types and expanded the procedures that we're able to do, that we offer to patients. And we want to look at our experience with that and be sure that we are truly offering all the benefits we think we are. The other reason for that is to share that knowledge with other surgeons and other centers so that they can gain from our experience and help them to be able to offer the same benefits to their patients as well.

[00:10:01] Tim Lautz, MD: And to Dr. Lindgren's point, a number of other institutions are coming to us now and saying, we see what you're doing with your robotic program, this is something we've always been interested in, but didn't know how to start a program. How did you do it? What can we learn from your experience? How can you help us develop a program like you have at Lurie Children's?

[00:10:20] Erin Spain, MS: You mentioned the surgical oncology procedures that you're doing. Can you point to some other findings that you've published that have really changed the field?

[00:10:28] Bruce Lindgren, MD: Some of the things we've done in urology… we published about body habitus and looking at healthy weight, overweight, and obese patients, and found that there was no difference in outcomes or complications or infections for those different categories, which is great. We recently published our experience with smaller and smaller patients, patients under a year of age, and found that there was really no difference in complications depending upon their size. We divided up into four different segments and they all did equally well. So kind of expanding the boundaries to who we offer robotic surgery to.

[00:11:00] Tim Lautz, MD: I think one other area is the field of adolescent inguinal hernias. So, the type of hernias that children and adults get are different, and for adolescents they kind of span that gap between children and adults. So, in adult surgery, when you come in with an inguinal hernia, the standard operation now is to do a robotic mesh placement to repair that hernia. That is not something that many pediatric surgeons have done or have experience in. We have created a systematic approach where we look with the camera and we're able to determine whether the patient's hernia more closely resembles a pediatric hernia that doesn't require a mesh. And if it does resemble an adult hernia where they need a mesh, we're immediately able to dock the robot and proceed with that mesh inguinal hernia placement. I think we are the only center in the US doing this approach that gives them really the state-of-the-art adult style repair when they do fall into that category, but doesn't commit them to a mesh repair if they don't need it. And so we're presenting that data and I anticipate that this will become the model for other institutions around the country.

[00:12:05] Erin Spain, MS: I want you to walk me through a common procedure. Set the scene for me. What does the room look like? How does everyone in the room interact with the robot? Paint it for me.

[00:12:16] Bruce Lindgren, MD: Our patient sizes could be anything from a three-month-old, two-month-old up until, you know, adult size. There's a whole team that cares for the patient during this. There's an anesthesia team, nursing team, and the surgical team. We all work together. So the patient is put to sleep under anesthesia, positioned appropriately for whatever procedure we're going to perform, prepped like any other surgery, and then we gain access to the abdomen. So we put these through small incisions we call ports that allow us to connect to the robot and pass the instruments through those. And then the patient's position after the ports are in, the robot is connected to those or docking, as we mentioned earlier. And then the procedure starts. And there's coordination and communication between the anesthesia team, the nursing team at the bedside, the surgeon at the surgical console who is moving the robotic instruments, and then there's always a bedside assistant who's helping pass the instruments back and forth and watching the patient and handing you sutures and things that you need inside the abdomen to perform what you need to do.

[00:13:14] Erin Spain, MS: Physically, how far away are you from the patient?

[00:13:16] Bruce Lindgren, MD: You know, at the other side of the room, maybe 10 feet or so. You could be, you know, half the way around the world really, but we're in the same room.

[00:13:23] Erin Spain, MS: What was that like the first few times when you did it after being, you know, so close and intimate in the procedure with the patient to then being, you know, on the other side of the room?

[00:13:32] Bruce Lindgren, MD: Well, it was a little bit different, but you know, like I said, I had done laparoscopic surgery, which was quite difficult for these types of procedures, and so it was easy to forget about being across the room because this was so much better and so much easier to do.

[00:13:45] Tim Lautz, MD: I'll add though that we also have looked at the benefit of a coordinated team and we published on that, you know, having a team that's experienced, and not just the surgeon, but really the whole operating room team makes a difference in the efficiency of the procedure and, I think, in the outcome for the patient. We know that there's clearly benefits for the patients. There are also benefits for the surgeons. When we do standard laparoscopy, we're contorting our bodies in all sorts of different ways and there are legitimate concerns with surgeons developing long-term shoulder injuries, neck injuries, things that can limit their career and limit their ability to take care of patients. Whereas when you are working with the robot, you are sitting in this console in a very ergonomic position, and when the surgeon's comfortable, they do better work.

[00:14:27] Erin Spain, MS: You talked about this team that you have that is experienced and comprehensive. Can you talk a little bit more about that? Describe the team that you work with.

[00:14:35] Bruce Lindgren, MD: Well, it's both the anesthesia team, they have an understanding of what we're planning to do and how to best optimize the anesthesia for a laparoscopic procedure. And a lot of it is the nursing team, so that they have the things we need available for the routine and for the less routine procedures and less routine findings. You know, if something goes wrong, you need to be able to address that efficiently to prevent a big problem. And having a team that's experienced with that, not only make sure that the procedure is safe, you know, in addition to the surgeons knowing what they're doing, but it also helps the day go efficiently and there's a lot less frustration. And procedures take less time if you're not waiting around for things.

[00:15:13] Tim Lautz, MD: And the nurses, they're preparing the robot for us to connect it. They're bringing it in. They're helping us to connect the instruments, helping us to exchange instruments, helping to load clips and sutures that need to go through those instruments. So they're doing a lot of important tasks. Just like when surgeons do things more frequently, they do it better, it's the same for the nurses.

[00:15:32] Erin Spain, MS: The program in general, all the different areas of divisions at Lurie Children's that is using robotic surgery. Can you walk me through that?

[00:15:42] Tim Lautz, MD: Currently there are three surgical divisions that make use of the robotic surgical platform. The urologists have been using it for the longest and use the robot for procedures on the bladder and the kidney and the tube that connects between the two, amongst other things. At the other end of the body, the ENT surgeons occasionally use the robot to take care of problems deep inside the mouth that would be difficult to see with traditional cameras or traditional views. So by getting that 3D magnified view, they can see some lesions at the base of the tongue, or very difficult tonsil or adenoid procedures that would be challenging without that 3D view. The general surgeons, we kind of span a larger part of the body. So we use the robot for some procedures in the chest, and so that includes things like taking out masses in the thymus, which is a gland that sits on top of the heart, or taking out tumors that sit along the spine within the chest. We also can use it to remove lesions within the lung doing a lobectomy procedure. In the abdomen, we use the robot for gut procedures, which means surgery of the esophagus or stomach. That includes things like fundoplication procedures for gastric reflux or hiatal hernia repairs. It includes things like the operation when the stomach does an empty well surgery on the bile ducts and gallbladder surgery on the adrenal gland. Surgery on the colon, both the right colon and the rectum. And particularly for the rectum where you need a view that is magnified deep down into the pelvis, the precision and magnified view that you get from the robot is really outstanding. And then as we mentioned, the hernia surgery that we do is kind of the last big area. So we really can use the robot all over the body. And different people have different expertise. Within general pediatric surgery, we took the approach of having an initial two surgeons really gain great expertise first, and then we've been able to help proctor some of our partners as they have begun becoming full fledged robotic surgeons.

[00:17:37] Erin Spain, MS: You are a teaching hospital and the next generation is coming through. How are you exposing these younger physicians and younger surgeons to the robot?

[00:17:46] Bruce Lindgren, MD: Well, just like any teaching that we do for any other procedure, the trainees come in with a wide range of prior experience. Some of our fellows in pediatric urology have never done any robotic surgery, and some are very accomplished robotic surgeons based on their residency training, but haven't done it in pediatrics. So we kind of take where they are and then gradually increase their experience and their level of responsibility and autonomy as they progress through their year under very close direct supervision until they're very skilled and comfortable doing these procedures.

[00:18:18] Tim Lautz, MD: And the really nice thing about training future surgeons on the robot is that we can see exactly what they can see and exactly what they're doing. We have the ability to annotate on the screen and show them, “I want you to go exactly here.” And we can even very easily alternate who's doing the work. So it's very easy for us to say, “Let me take control for one minute and show you what I am looking at,” and then they can take control back. And so of course, everything is with the patient's safety in mind first. And the attending surgeon is always in control of all aspects of the operation, but it is a very safe platform for giving what we call graduated autonomy to the residents.

[00:18:57] Erin Spain, MS: Dr. Lindgren, I think you joked a little bit that you could be anywhere in the world doing the surgery, even though you're just across the room, but there is a little truth to that. In the future, do you think there could be an opportunity to do surgeries remotely, maybe at other institutions or in low or middle income countries? What do you think?

[00:19:15] Bruce Lindgren, MD: Yeah, I think there's definitely potential for that. And I think it has been done. Not really at a wide scale. You need a really good internet to allow that to happen. But yeah, I think there's a lot of potential for that. Talked about use for battlegrounds and, you know, trauma surgery and things like that, all sorts of potential applications.

[00:19:33] Tim Lautz, MD: And I think there's great opportunities for collaboration, right? Like I don't think we're at all close to the point where there would not be a surgeon in the room who could be at that patient's bedside if they're needed. But what you can do is if there's a rare tumor that there's a world expert somewhere, they could join that operation along with the local surgeon and they could take control of the most critical aspects of that operation, but you would still have the local surgeon there to sort of guide the operation.

[00:20:01] Erin Spain, MS: How would you describe Lurie Children's commitment to expanding this program and really making it world class?

[00:20:09] Tim Lautz, MD: Lurie Children's has been incredibly supportive of the robotic surgery program. This has involved a lot of close collaboration between the different surgical divisions who use the robot, the nursing staff, and the hospital leadership. It starts with understanding our equipment and what equipment we need to make the program successful. It includes guaranteeing that any surgeon who uses the robot has the most robust training before they're operating on patients using this platform. And so it means sending surgeons to training courses all around the country when necessary.

[00:20:39] Erin Spain, MS: What do you want patients and families who are considering a robotic surgery at Lurie Children's to know?

[00:20:45] Tim Lautz, MD: I want them to know that it is still your surgeon doing the operation. They're just doing it better, more precisely with a better view, and a minimally invasive approach that's going to get their child in and out of the hospital as quickly as possible.

[00:20:59] Bruce Lindgren, MD: Want them to know that we're just not looking for an operation to apply the technology to. We're selecting the technology because we think it's the best way to do that procedure. And I also want them to know that they should feel free to ask us any questions they have about the procedure or the equipment or what's involved so that they're comfortable.

[00:21:17] Erin Spain, MS: Are some of the kids really curious about the robot?

[00:21:20] Bruce Lindgren, MD: Oh, some of them come in having drawn pictures of what they think it is. Some look it up online. Most of them want to see it across the room when they get in the room.

[00:21:28] Erin Spain, MS: Thank you both so much for coming on the show and telling us about the program and some of the expertise here at Lurie Children's. It was really a fascinating conversation. Thank you.

[00:21:38] Tim Lautz, MD: Thank you, Erin.

[00:21:38] Bruce Lindgren, MD: Thanks for having us.

[00:21:39] Erin Spain, MS: For more information, including how to make a referral or an appointment, visit LurieChildrens.org.