Core Bariatrics
Welcome to Core Bariatrics, the podcast dedicated to walking your bariatric journey with you. Hosted by a bariatric surgeon and her very first bariatric patient. Their paths crossed as patient-doctor, but now they work and lead together. This podcast is your trusted source for valuable insights, expert advice, and inspiring stories that will empower you to make informed decisions about your health. In each episode, we explore the world of bariatric surgery, covering a wide range of topics such as different types of procedures, pre-surgery preparation, post-surgery care, nutrition, exercise, mental health and much much more.
But Core Bariatrics is more than just a podcast—it's a supportive community where you can connect with real people who have walked the same path you're on now. Listen to personal testimonials from individuals who have undergone bariatric surgery, sharing their challenges, triumphs, and the incredible impact it has had on their lives.
We will discuss the importance of post-surgery lifestyle changes, including healthy eating habits, regular exercise, and mental wellness strategies, ensuring your weight loss journey is sustainable and fulfilling.
Join us on Core Bariatrics as we foster a sense of community, providing a platform where you can find encouragement, motivation, and practical tips to navigate the challenges of obesity and achieve lasting weight loss success. Whether you're considering bariatric surgery, are in the post-surgery phase, or simply interested in learning more about this life-changing option, our podcast is here to support you every step of the way.
Remember, your path to a healthier, happier life starts here at Core Bariatrics. Subscribe now and embark on a transformative journey towards a better you.
Core Bariatrics
Episode 27: Robotics, Safety, and the Quest for Excellence with Dr. Ian Soriano
Embark on an enlightening journey with Dr. Ian Soriano, UCSF's head of robotic surgery, as he unveils his continuous quest for excellence in both the medical field and personal growth. Our recent conversation illuminates the transformative power of stepping outside one’s comfort zone, exemplified by both Dr. Soriano and even Tammie. Their stories serve as a beacon, guiding us through the importance of quality improvement and patient safety that has sculpted Dr. Soriano's illustrious career and his pivotal role in guiding UCSF's Clinical Performance and Improvement Committee.
Venture into the future of medicine as we dissect the advantages of robotic surgery beyond its clinical implications. Discover how cutting-edge technology not only enhances patient care but also safeguards the physical well-being of surgeons, offering a persuasive argument for the ergonomic benefits of robots in the operating room. Dr. Soriano demystifies the concept of robotic surgery, clarifying its intricacies and the necessity for surgeons to be at the helm, guiding with precision and finesse. His personal anecdotes underscore the seamless integration and adaptability of robotics in contemporary surgical practices, challenging the myths surrounding these technological marvels.
Our dialogue with Dr. Soriano extends to the delicate dance between efficiency and patient safety in the realm of surgery. He shares invaluable insights into how data-driven evaluations of surgical techniques contribute to refining a surgeon's craft, ensuring the highest quality of care. We wrap up with an appetite for more discussion, as we touch upon the symbiosis of robotics and surgery's future. Although constrained by time, our exchange was rich with the promise of continued exploration into how technological strides are reshaping healthcare and the global surgical landscape. Join us and be inspired by the innovation and unwavering dedication that propels the world of surgery forward.
Welcome to Core Bariatrics Podcast hosted by Bariatric Surgeon Dr Maria Iliakova and TMA LaCose, bariatric Coordinator and a patient herself. Our goal is building and elevating our community. The Core Bariatric Podcast does not offer medical advice, diagnosis or treatment. On this podcast, we aim to share stories, support and insight into the world beyond the clinic. Let's get into it.
Speaker 2:So today we have with us the head of robotic surgery from UCSF, the University of California, san Francisco. He's a Bariatric and Minimally Invasive Surgeon, also a recreational cyclist and quality fanatic. He's actually the co-director of UCSF's Clinical Performance and Improvement Committee. He actually hails from the Philippines, where he did medical school and residency at Einstein Medical Center fellowship at Cleveland Clinic. He's my personal mentor and guru. Ladies and gentlemen, we'd like to welcome Dr Ian Soriano.
Speaker 3:Hey Maria, Thank you very much for that Very warm. And is that really me? This is my UCSF's page bio. Thank you for having me. It's time to be here. Oh, it's so nice. Thank you for being here.
Speaker 2:yes, which is just such a delight and such a treat, because you have instilled in me a very intense focus on quality. That's something that, even from some of the very first discussions we got to have together, you were always focusing on how do you make yourself better and how do you make the whole process better. So can you tell me a little bit about where that comes from for you?
Speaker 3:Yeah, I guess it's something I've always been interested in is it's just how to be better, both from a personal perspective, from a professional perspective as well as from a health system or department perspective. So essentially, everything that comes from within involves everything outside of you and if you look at, if you want to make yourself better and you can get there, why not expand that to everyone else you work with, to everything else you do and everyone you interact with? Essentially, it's philosophy in life, because we never really end products right Until the day we die we are possibly changing.
Speaker 3:So why not do something about it and be like so? I guess that's how that got started. Professionally, when I was at Penn I became involved in a couple of projects that started with just trying to see how we can make things better within the department from a clinical perspective and that got me interested into formal processes as well as getting really involved in quality improvement from a curriculum and data perspective. And so I enrolled at the Center for Health Improvement, quality Improvement and Patient Safety at Penn and for initial certificate course there two years ago and in the process of finishing up that course as a full master's program, mostly in a couple of years, and so continuing that into a formal role when I was at Penn and then here now at UCSF for as Virgin Champion for the ACS or American Conscious Surgeon's Natural Circle.
Speaker 2:I think, because you're already such an accomplished person and such a well educated, you're at the top of your field in many ways and yet you're still continuing to educate yourself, both in informal and informal ways. Can you tell me a little bit about how is that common? Do all surgeons do that? Is that just something that you really find important, and what impact does that have on those around you?
Speaker 3:I think, by nature, surgeons are very curious people as well, as I think, physicians in general are always searching for. How can we know more? Because it never ends right. The minute you think we know something or we reach a state of more time or what has been formally termed as unconscious competence, where you can actually do things without even thinking about it, something new comes about. For example, I finished fellowship in 2007 and I'm dating myself now. Maria, we're probably still in Memphis. We're going to finish fellowship.
Speaker 2:Not, even Not again.
Speaker 3:That was fellowship right, and that was mainly invasive laparoscopic surgery Right. And then, a few years later, robotics started to come in. So now, what am I going to do with it? Am I just going to sit back and just watch everyone take on robotics and not learn it? Or do I accept the vicious technology that we can begin back on my patients? So how do we go about learning it? And so I have to, as an adult, learning new concepts and approaches, new skills. You need to have an open mindset that if you approach it in a systematic way, that you can actually do it. So I followed the protocol of learning, going back to now being consciously incompetent, meaning I knew I did not know what I was going to be doing and I progressively learned more and more things, to the point that I get to where I am right now, being proficient, and then also taking the next step, which is then learning how to teach that to others, and that in itself is also different.
Speaker 2:So you mentioned an unconscious competence basically when you're on autopilot and like you're able to do things so well that you don't even have to think about it to taking yourself to consciously incompetent, which is actively going into a field you really don't know anything about and trying and striving. That actually really strikes me as something Tammy also did. So Tammy is a respiratory therapist and took herself completely out of her comfort zone to become our bariatric coordinator. I just think that's such a brave thing to do to admit you don't know something and to try just to figure it out, jump in with both feet and do that. So I think that's actually something that links the two of you, even though you do very different things and have very different roles.
Speaker 3:And I think it does link everyone who has an interest in growing as, both as a person and as a professional. I someone says introduce yourself, get your title. Just this past week they actually had dinner with a couple of folks from Stanford, which was across all the nation, collaboration of our educational divisions, and everyone introduced themselves as staff surgeon. It was like we all wanted to just be there to learn. And I added to that I'm PGY 23. I love it. I'm just saying I'm an associate professor. I said I'm a PGY 23 because you've never stopped learning for always. How many years out from when we started learning?
Speaker 2:And so how does that manifest with your interactions with patients, the people that you take care of? When you talk with people about bariatric surgery, or you're thinking about innovations you mentioned robotics and others that you've learned along the way what kind of impact does that have on the people you take care of?
Speaker 3:I think what it does is it makes it fun to explain exactly what they're going through and what it means to actually have surgery, what that process entails, addressing their fears, addressing their concerns, and explain it to a way that actually they can relate to.
Speaker 3:One of the things I always ask patients is what do they do or what are their passions, and then what I try to do is then relate how I explain the procedure directly to what they do or what affects them personally. For example, if someone is a golfer, I thought that their gut probably won't get in the way of their swing and they probably hit them all fast. If someone is recently was a psychic, that's a pererobotic procedure and I mentioned why I think it should be done mainly invasive versus open. I said you can recover it quicker. You can get back to doing the things you do in one or two weeks versus three or five weeks. So by being able to connect what the procedure and how it directly affects them on a personal basis, then on a generalized risk benefits 1% bleeding, the usual shield we have we say 1% risk of bleeding. In fact, if it's from the organs, I actually say you will be able to ride your bike fast, you'll be able to swing harder.
Speaker 2:I may be able to fix your swing Exactly, but you can probably swing it harder because you'll have more flexibility and you'll be able to actually walk the path on a path, absolutely, and during the course of the time that you came out of fellowship, you said before robotics was really big in the field and now it's much bigger and you're actually the director of robotics surgery at UCSF.
Speaker 2:So in the time course that you went from really not having anything to do with robotics to now have you encountered, have those conversations with patients or other providers changed as you've changed the technology that you use?
Speaker 3:Yeah, I think early on, everyone was very reluctant or had significant concerns about technology, and rightfully so. Right the first time I performed robotic procedure, back in 2012, I was very upfront with the patient you are my first patient that I'm doing this procedure on and I won't be at the bedside doing this procedure. But at the same time, I answered their fears. If I say one of my trusted assistants will be at the bedside, I will be in the same room and not at home doing the procedure. I'm right beside you. The robot's not doing the procedure and so I am in charge of the controls and all the insurance that are.
Speaker 3:And then that got better. And then, as publications came about, there were questions were being put about the robot. That question goes up and down in terms of how patients like hearing about robotics surgery or not. Recently there are a couple of publications and questions about whether that robot surgery is of any benefit, as past physicians need to be able to track and update it. And all of these changes in perception, as well as reality, of the technology that we use for patients and evaluate whether it's fit into our practice, whether or not is robotics beneficial for all types of patients, all types of bariatric. I think you have to really evaluate who it's best for and think we are learning, but we have to put new questions and then learning from it.
Speaker 2:What drives this passion for robotics? What do you think is the benefit or what do you think? Why do you think it's so important to study it and to implement kind of new technologies as you go?
Speaker 3:I think that we need to provide the best care that we can give to our patients, but, at the same time, one of the things is that A lot of healthcare around us has forgotten is the health of physicians. Laparoscopic surgery is such a predominantly challenging position to perform for laparoscopic surgery, particularly bariatric, where we're finding the sticking novel wall. And I can tell you, having switched, I did laparoscopic surgery from 2007 to 2012, and I did my first robotic procedure and I only did have my bariatric procedure laparoscopic and after robotic for the first three years, and I can definitely see a difference in how my body felt after each day of laparoscopy versus a day of robotics. And so, unfortunately, you were such. I think we sometimes forget that we also need to be healthy for our patients in order to be able to provide them or compare, and a lot of physicians neglect their own health and a lot of surgeons who were the early about laparoscopic surgery and neck surgeries, back surgery, shoulder surgeries and all those things, and I don't want to be part of that.
Speaker 3:And so I think robotics does give us that advantage in prolonging surgeons for years, but we also have to do it correctly. We've got a couple of papers out there that show that if you do not position yourself properly at the console and if you don't position the robot properly, your assistant might be suffering from being non-organotic physicians, and so I think it's having just that general awareness that holding positions long term by a procedure can create a lot of strain on our joints and which can lead to injury, and I think there's just so many things that we are learning that we didn't know before. That's made robotics both an advantage in terms of our patients but also for uncertainties for you.
Speaker 2:There's a lot of folks who listen to this podcast that aren't surgeons and don't really have any touch to the medical field, necessarily. Would you mind describing a little bit what it looks like to do robotic surgery?
Speaker 3:Sure. So I think the better pain of nature is that we're describing how we did surgery for robotics, which is, with open surgery, you're standing at the patient's bedside, you make an incision and then the whole thing see what graspers and retractors, which are instruments that have jaws, that can keep things open while you're sewing, dividing and dissecting and putting things together. And usually that incision is about 10 to 12, 14 inches. For example, for bariatric surgery it's about the eight to 10 inch incision and you have to work through the stick of domo to be able to do that procedure. So that's how, and actually when I was in residency, we did open bariatrics and the complications rate were higher, the bleeding rates were higher, the infection rates were higher, patients stayed in the hospital much longer. Actually, for a while I did not imagine we could do bariatrics. As soon as finishing residency, laparoscopic surgery for bariatrics was becoming more developed, and so I did the fellowship and saw that two, four or five small incisions do the exact same operation. And that's what's important for patients to know is that, regardless of the approach, what is done is the same exact operation to find the stoma and the connecting things. But now I was doing it with densil-sized instruments put in through with incisions in the belly, but that meant that I had to fight the thickness of the abdominal wall to lift up the stoma, the liver and other organs, and then that also meant fighting the abdominal wall and the thickness and the weight of the patient.
Speaker 3:With robotics it's the same instruments, same incisions, but now the surgeon is sitting at a console, just like you would at the video game. At your game, just sitting at a console, your hands are on controllers that now control the instruments that are inserted into the patient, that are connected to the robot that essentially holds the instruments, and what that does is allows you to one-on-one what you do with your fingers, what the tips of the instruments do. So it's not robotic surgeon, the sense that the robot's doing the surgery. Now, there's now something in between the patient and the surgeon, which is the robot that does what the surgeon is doing inside the patient without having to be directly in contact with the patient. It's actually remote surgery, in a way, and allowing you to control instruments without directly handing them. And now you're gonna have to sit down all over.
Speaker 1:Sorry, I did not know that Maria was doing my surgery robotically and I found out when we were doing our accreditation and we had to go through the OR and take pictures of everything and I'm like, wait a second, she was over there, I was over here and you got this spider lot. Literally it's a spider, it looks like robot that is doing all the work, as she's sitting there with her crocs to the side of her at the console doing the surgery. It was crazy to see that technology has come in so far and that is something nobody even needed to tell me that doing it robotically really helps the surgeon because you're able to position yourself instead of moving around your body, around laparoscopic or open.
Speaker 3:Yeah, and that's one of the things that I think we forget, and so I think what happens is because of robotics. It also brings us back to open and laparoscopic surgery and learning how to do things differently, and I think that is one of the advantages of knowing all three different ways of surgeries, as you then can adapt to know and open what you know in laparoscopic, what you know in robotics, and put them together and be in a more ergonomic position. Know all set things differently. So now, when, actually, when I do robot, laparoscopic or open procedures, I just set it up the way I would do it robotically. Or when I say to do some things robotically, I set up the insights how I would do laparoscopic. So essentially, you're putting together all these different things that are separate and making it one approach to surgery, and so sometimes I will do part of a procedure open or part of procedure robotically and finish it open, or do part of procedure laparoscopic and finish it open. So then I can whatever I think would be best for the patient's own.
Speaker 2:It sounds like one of the biggest benefits of knowing these technologies, especially as newer technologies are coming out, is versatility. You basically become a more agile. You're able to take care of things in a way where one informs the other and you're not just limited to one approach or one specific way, but you have this way and it's, and you have a backup, many backup plans and many versions of informing the same thing. It's like knowing multiple languages, almost yeah.
Speaker 3:And what that does is that you get a more holistic picture not to some of the patient, but a more holistic approach to taking care of that patient. You're building on the foundation of your open, your laparoscopic robotic knowledge and not laring them on top of each other, but now mixing them up and seeing what best results in a better outcome for the patients.
Speaker 2:Yeah, cause just like you wouldn't cook like broccoli the same way every time, you wouldn't necessarily. Just there's not just one way to do things, there's many ways to do things and we evolve over time.
Speaker 1:And you don't always have to follow the recipe.
Speaker 3:Sometimes you add, want to add a little bit more salt, a little bit more sugar, based on how you want it to taste. Instead of you have a bad, you enjoy the experience.
Speaker 2:Yeah, I think this is the first time we've made an analogy to cooking on this show with surgery, but I really I enjoy that a lot because there there is a lot of creativity to it and I imagine I know, at least in art program when we started doing robotics we also brought in the ERAS protocol, the enhanced recovery after surgery protocol so it really made us reevaluate everything because we had brought in a new technology. It gave us a chance to actually look at the big picture and see what else we could improve and potentially change, and that's something that actually was very inspired by you, because that's a huge element of quality and improving things over time, taking the chance to actually reassess when you can. So you made a huge impact, even on the people that I got to take care of and that Tammy got to take care of, and I think I'm very grateful for that.
Speaker 3:Paying forward is always the best reward. You can't pay me back, but you can pay it forward and pay it to your benefit of people you work with your patients and, of course, your professional development.
Speaker 2:Can you talk a little bit about why you care so much about mentorship and professional development, because you didn't just touch my life, you've touched many other surgeons in the US, but even in the Philippines as well. If you do regular trips for education purposes, can you tell me a little bit about what that looks like for you and why that matters?
Speaker 3:Sure, as you alluded to, I went to medical school in the Philippines. I then moved to the United States in the residency here and since I finished residency in 2006 and in 2007, I've been to the Philippines at least once, not twice, a year to collaborate with the surgeons. And it's not just any directional, it's bi-directional. We both learn from each other by working together. They have approaches, not just in your body or in this topic, that I'm also able to learn from and bring back here. But I think it's just I look at things that are more global perspective, having not gone to medical school in the United States since that we might.
Speaker 3:There are other countries that are doing things that seem better or worse, just differently, and I think, as we started opening our minds to the fact that we there are so many ways we can be better by learning from others than if it helps with that.
Speaker 3:And the trip started with, initially just on the invitation of some of my mentors actually in medical school who share what I learned with with aparthotopic and robotic bariatric treatments. Soon it turned into more than that in trying to come up with various clinical and development and programmatic improvements, and then now also with robotics and ergonomics, where we, anything that we are in development here, we also try to incorporate into the same thing that they are doing the Philippines, whether it's in laparoscopic or robotic surgery, especially now that they actually are installing the XIs for the first time in the Philippines this year. So I'm very excited about that, that they are finally getting the latest technology that we have here in the Philippines, because they have excellent technical surgeons, excellent laparoscopic surgeons, excellent open surgeons and they just need to get access to technologies. We're able to sort the learning curve by working together and helping them overcome that learning curve in a shorter amount.
Speaker 2:That is pretty cool because I think a lot of folks don't necessarily realize this is a global community, that when we do bariatric surgery, when we figure out what's the best technique, what's the best way, new innovation in it, we study it. It's a global field. So I'm curious what is your take on? You said it was a two-way street. So what kinds of things are you learning from surgeons in the Philippines or elsewhere, or for programs that has informed your practice?
Speaker 3:Yeah, first of all, we're talking about Gluopdici. Gluopdici is just about the last week, I believe. There are now a billion people, with about 70 percent adults and 30 percent of that being teenagers, who are suffering from this. Wow, one of the most efficient surgeons in the world is in India and if you look at their experience, I believe he did 20 procedures in 48 hours in terms of efficiency and in a very efficient manner. Surgeons they're work with less resources and so they're able to adapt a lot of things that he takes for granted. The carbon footprint of the OR in the United States is two to three times bigger than the carbon footprint of procedures in other countries. Because of how there is a lot to learn.
Speaker 3:It doesn't necessarily have to do with technique. It might have to do with philosophy and approach. That's the limited resources, and that is certainly something that we can learn from resource challenge countries.
Speaker 2:What you're saying actually really resonates. You're in San Francisco, we practiced in Iowa City and the resources can be very different even within the United States and different communities in different hospital settings, and I do definitely believe that, like necessity is the mother of invention, lack of resources is the mother of efficiency, because you have to be efficient in order to get things done where your resources are not unlimited. Can you speak a little bit about what impact that actually has on safety and quality, though? I think that's a? Really we sometimes don't see the link between the two, but I think you've been really instrumental in helping people understand that better.
Speaker 3:Yeah. So in terms of what's, there's a I forget now which one of my buddies said this but first you have to be good, and in order to be good, you have to be safe. Once you're safe, then you can be good. Once you can be good, then you can be fast. Let's get fast. And so what it speaks to is that, first of all, you need to know the basics. You need to know how to perform a procedure from start to finish and do it safely, and then you learn how to do the exact same procedure in less steps, because you're finishing, for example, an SML system instead of taking 10 minutes and doing it in 5 minutes, and time in the OR is one, and then, rather than using two or three sutures, you're able to then finish it with one suture and then, with each instrument, one less instrument you're opening one less thing you're opening. Then you're reducing the carbon footprint, but then you know that you need to know that your outcomes are also good. So you need to track your, and that involves creating a database following your outcomes, following your patients.
Speaker 3:But also one of the things I think we've learned with robotics is that even in laparoscopies, there are ways to evaluate a surgeon's safety and efficiency by watching their moves in the OR there's various ratings, you know looking at laparoscopic and robotic skills and being able to assess with how that light's being taken, how that air is being exposed, and all that that teaches us about how to assess someone's safety.
Speaker 3:And then we've learned over time also that economy of motion, economy of time, is a good surrogate of evaluating that. I think we're learning too that time is a good surrogate of it's somewhat of might be a somewhat surrogate of evaluating efficiency. Economy of motion and not necessarily safety, but at least can give us a gauge of that surgeon's skills that we but we won't know about. But looking at how we can evaluate those things in a objective manner, not just a subjective manner, then we can get an idea of really how surgeons are skilled in terms of how surgeons, how skilled surgeons are. We do take that to the next step of evaluating patient outcomes. I think is still a work in progress. So I do think that we, by understanding that we have to be efficient, can have better outcomes on how being safe can also be to better outcomes. That's all important to put that all together as we evaluate our own outcomes and patient outcomes. That last a little bit. Let's go back.
Speaker 2:I think it's. I think you're right, it's complicated. I think it's a big picture here of it's not. I'm actually really glad that you're talking about it and not trying to just make it super simple, because I do think a lot of people don't necessarily understand how much thought and process goes into creating safe surgeries that have good outcomes. It's, there's actually a lot of thought put into this.
Speaker 3:Yeah, there's not. If you look at a couple of papers that have come out the past year or two, they're now looking at how to evaluate textbook outcomes in various procedures. Right, because a lot of outcomes are described in the textbook. We don't necessarily achieve them, so how do we get there? I think that is the big question. It's just like any complicated process. The way to simplify it is to break it down into component pieces, evaluate each component piece separately and then hopefully that gives you a bigger, a better picture of the big picture.
Speaker 3:And so, for example, if it takes a surgeon, the average surgeon and that's a science about robotics the whole thing is timed on the console.
Speaker 3:You can see your times. And so if it takes the average surgeon, for example, 16 minutes across the United States to do an ingol hernia, why is it that some surgeon are taking two hours and some surgeon that's 10% are doing it in 30 minutes? So what are the surgeons who are doing it in 30 minutes doing and are their outcomes just as good as the surgeon in 60 minutes? So the surgeons who are doing it in two hours have the same outcomes as the ones in 60 minutes, and how can they shorten that time. But then if the outcomes of the ones who in 30 minutes are not the same or worse than the ones who are doing 60 minutes, then they're doing it too fast in compromising safety, but they've been doing it in 30 minutes and the outcomes are just as good as the ones who are doing 60 minutes.
Speaker 3:Then we all need to learn what are those surgeons doing? Are they doing certain things less? Are they doing it with less or no? And that is how you develop being good, to being fast, to being safe and hopefully being value driven. Get a barrier of saying it, then cheat.
Speaker 2:Right and I do think you're creating a good setting where we understand the balance between. Faster doesn't mean better, necessarily. If they're not equal to each other, faster can, can, but there's got to be an element of safety in making sure that things are done properly. It's not just a matter of the time is the most important thing.
Speaker 3:Exactly, exactly.
Speaker 2:Yeah, there's a lot to discuss here, so I think we're just going to have to come have you back at some point to talk a lot more, because we didn't even get to some of the topics we wanted to talk about. But for this recording, it is how it goes when you've got interesting people who know a lot and have been in this space for a long time. I'm just really grateful you're here with us today and all of your insight about robotics and quality and global surgery. It's been a really great conversation, so thank you so much for having it with us.
Speaker 1:Yes, thank you.
Speaker 3:Thanks for having me Really enjoyed my time here and looking forward to being back and more discussions about so many other things, including how being a sous vide and then pan-frying it afterwards is combining two different techniques and having a better outcome.
Speaker 2:I love that. That's a great analogy. We all are food people, so we'll work on that path with you.
Speaker 3:All righty Sounds good Thanks.
Speaker 1:Alex, thank you so much Thank you.