Estela Casas:
Well, first of all, thank you for inviting me to be with you today. It’s quite an honor to be in the presence of somebody who is just so talented in the operating room.
Doctor Rich:
I appreciate it!
Estela Casas:
Congratulations on your four thousandth robotic surgery — one of which I was a part of!
Doctor Rich:
That’s right, you were in that number.
Estela Casas:
I was in that number. And so that takes a lot of time and dedication and talent and a lot of descriptives to describe what you do. So why do you do it?
Don’t have time to read this post? Watch the video here instead!
Doctor Rich:
When it started, I wasn’t thinking about milestones. The very first robotic surgery I ever did, I just knew in my heart that this technology was the future. I knew it, I believed it, and the very first patient had that trust and that faith to put her life in my hands. And I got to do something that had never been done in the city before. And every surgery after that, it’s just been about earning the next patient’s trust and the next patient’s trust. And I do it because I knew that it was a tool that would allow me to perfect my craft — to be the best that I could possibly be at doing surgery, at doing gynecologic surgery. My training was in laparoscopic surgery, and I just saw that through technology, you could take your skill level and amplify it ten, twenty times what it is.
Estela Casas:
So it’s four thousand, and I’m one of those. But we’re more than just numbers. Tell me about that.
Doctor Rich:
Absolutely! Well, again, I never started out even imagining that I would get one of the top five (I think in the world!) for robotic gynecologic surgery. And it’s an honor. I think every single one of those patients that I’ve treated is a part of my journey. I could not do what I do — I couldn’t offer what I offer except for the support of the community for this technology, the support of administration, and really the support of the patients. Every patient is a teacher. Every time I get a difficult case, I could be exhausted and depressed. But honestly, I go and I talk to the family. I say, “You know what? Your mother made me a better surgeon today. I went up against an insurmountable challenge, and we found a way through. We fought our way through, and I gave everything I had today.” And usually that’s enough.
Estela Casas:
Every day, you give your absolute best. So where do you get this energy? Where do you get this drive? Where do you get this passion for what you do?
Doctor Rich:
I have this… really a blessed privilege to be able to go into clinic (the OR) every day and have a patient trust me to put their life in my hands so that they can take whatever malady they’re suffering from. Maybe it’s super painful periods, or prolapse, or they can’t leave the house because they’re embarrassed about their toileting habits, whether they’re leaking or whether they’re having trouble with their bowel. And in one surgical episode — maybe thirty minutes, maybe three hours — I can completely change their quality of life, and they can wake up on the other side smiling. And I get to see the patient during their two-week post-op and knowing that I did my little part to have an impact on their life. That’s what drives me, and I want to be the best at that. And every little reminder along the way, every little thing, every smile, every little note, every home baked cookie… each of these things is made and given with love. And I just can’t imagine doing something more gratifying with my life.
Estela Casas:
It’s been a long while to build up to the four thousand surgeries — robotic surgeries. When you go to bed at night, what do you think about before you just fall asleep?
Doctor Rich:
Sometimes (this sounds crazy!), I’ll run the surgery in my head for the next day. I’ll think, try to navigate my way through — especially if I know it’s going to be a difficult or a challenging case — and I’ll run scenarios and things that can make it better, easier, safer, more effective, more efficient.
I once performed and published the first robotic single-set hysterectomy in the world. And what that means is we just do the surgery through one incision with the robot rather than multiple incisions. And that inspiration came to me in a dream. I sat up in the middle of the night, sat straight up, and I said, “I finally put it together! I finally figured out how I’m going to do this!” after months of consideration. And again, I had a patient trust me with her life. I said, “Look, this is going to be better. There’s going to be fewer incisions. It’s never been done before!” And we had an appropriate comprehensive counseling session (consenting session), and we did. And we had amazing results, and we made history in El Paso.
Estela Casas:
And you changed lives! So tell me about a new tool that you will soon be getting. A new tool…
Doctor Rich:
I’m getting excited!
Estela Casas:
It’s not a “tool”… I like to call it a tool, not a toy. Because you take this seriously —
Doctor Rich:
[Laughing] I love it! We can call it a toy!
Estela Casas:
[Laughing] Okay. Well, let’s call it a toy! So this new toy that you’re about to get, tell me about that! It’s exciting!
Doctor Rich:
That we’re about to unleash on the city!
Well, so there are always improvements in technology. Nobody’s running around with an iPhone 5, right?
So with every iteration of the technology, we’ve learned from the failures, shortcomings, what have you. We get feedback from patients, from physicians, and from surgeons about how to make the technology better. We learn how to interact with the patient better — but even how to interact with the surgeon better.
And so this newest version is the fifth generation of surgical robotics called the da Vinci 5 (or DV5). It’s kind of cool — we’re one of the first three hospitals in the entire tennant (of the Providence organization) in the entire country to get this technology. And we’ve had a lot of firsts in El Paso with robotic surgery. We were also the first in the world to use a ureteral fluorescence dye. So the first humans ever in the world to have the technology that (when it is finally FDA-approved, hopefully next year) will save anywhere from ten to a hundred thousand lives a year. And the very first time it was ever done was here, in El Paso.
So we’re not the first, but we’re one of the very, very early launches for this new robotic technology. This technology (in terms of computing, some people think of it that way) is ten thousand times the computing power of the immediate predecessor of the last generation.
For me, having suffered the aches and pains of four thousand robotic surgeries, there is a physician ergonomic benefit that’s built into this technology. So robotics is far superior for ergonomics compared to laparoscopy (or kind of standing by the patient’s bedside), in as much as we get to sit and operate from a console. But one of the challenges was that there was an unadjustable position, so the physician had leaned forward, and that’s kind of resulted in us long-timers getting shoulder and neck pains. And so this robot is lighter, more lightweight. It’s got all of the unnecessary, I guess, components stripped out of it, and it moves to any position that you feel like you want to stand in. So if you have good posture and you want to sit straight up, not only will it allow you to do that, but it’ll force you to do that because the console that you peer into, there’s a few millimeters one way or the other until you can’t see the image. So once that position is set, you can readjust it, but it’s set for the duration of the surgical episode.
Estela Casas:
So you’ve heard the saying “to whom much is given, much is expected” or something like that, right? That’s a big responsibility. You’re given a new tool to do the job even better. How does that make you feel, to have this bigger responsibility?
Doctor Rich:
With great power comes great responsibility, right? Uncle Ben [from Spider-Man] was right. So this newer technology has, for the first time in surgical robotics, something called haptic feedback (which kind of just sounds cool, I guess). But basically what it is, is if you were to have surgery performed and the surgeon was going to do an open incision and put their hands inside your abdomen/pelvis to do the surgery, they obviously can feel with their fingers what is going on. And with laparoscopic surgery, they can’t do that — but they can tell if they push up against something and it stops moving; they get that haptic feedback propagated through the instrument.
With robotics, we never had that. With robotics, we just see on the screen, but we just have to develop over time, as a surgeon, the ability to appreciate through the way that your eyes see the tissue respond, how much force is being applied to the tissue. So in somewhat of a revolutionary development, they’ve engineered haptic feedback. So you can actually move your instrument, and it’ll push back against you as you’re moving. So you know, you now actually have something objectively quantifiable! It’ll give you a measurement number of how many newtons of force you’re actually putting on different tissues. And I think ten years from now, we’re going to look back and say, “How did we ever do surgery without this technology?”
Estela Casas:
Dumb it down for me.
Doctor Rich:
People might think of something like Oculus, right? You put these goggles on, and you get this immersive environment, but you can’t really feel anything, right? You can’t actually have feedback for what you’re pushing up against. Now there are technologies, like games, that you wear a vest, and it pushes back on you. So it’s something like that. So you are interacting with the “game” (with the surgical episode), and you’re actually getting touch feedback. So it’s not purely your sense of vision, you’re now getting a second sensory system involved in what’s going on.
And truly, I think (and Intuitive believes) that this will become the standard of care. Surgeons that adopt the technology and use less tension on the tissue are going to have better outcomes. And surgeons that don’t do that, and there’s more tissue tension and patients have a harder, longer time recovering as a result of that, maybe won’t be selected to do surgeries or will have some effect on their reimbursement.
Estela Casas:
Let’s fast-forward ten years from now, where is Doctor Rich going to be…
Doctor Rich:
Retired! [Laughing] No, on a beach in the Caribbean, somewhere!
For sure, there’s going to be more me time involved in that timeframe. But I don’t know. I don’t know if I ever want to hang up the scalpel. It is truly gratifying for the reasons that we talked about, but I do think I have more to give the world. I just got back from Atlanta, and they brought the entire sales team in for the company (the entire GYN and neurology sales team!). We did a day-long lecture, and I role-played with them about how to help our surgeons to understand this technology and value for their patients.
At the conclusion of the session and standing ovation, I mean, I felt like this is another area that I feel I can give and have a greater reach. In the OR, it’s one surgeon affecting one patient’s life. And we mentioned some of the innovations that have come out, including the ureteral fluorescence dye that will prevent ureter injuries. So there’s an innovation that I had the fortunate part to be the principal investigator, and so I had a big part in its development, and that’s something that now many people will be able to use and have an improvement for their patients.
I do a lot of teaching as well for other surgeons. I’ve gone to a hundred different hospitals and over the last eighteen years probably taught at least a hundred (maybe two hundred) courses so that I can try to share what I’ve learned with other surgeons.
Estela Casas:
So you’ve touched a lot of lives — including those four thousand surgeries (and with the teaching). How do you want to be remembered?
Doctor Rich:
[Thoughtfully] Oh, what’s the legacy? Well, I think really, at the end of the day, I want to be remembered as someone who was gifted to use my God-given talents to be able to help that individual patient with their individual medical condition. But they don’t necessarily bake me cookies for that! A lot of that gratitude comes from what we call bedside manner — just from how that care is delivered. They don’t care how much until they know how much you care. I want to be remembered as someone who truly cared for their patients, that they could feel that compassion and that care, and at the same time I was able to deliver top-quality healthcare.
