The skilled physicians at Baptist Health’s Center for Robotic Surgery perform more than 2,000 robotic surgeries each year at South Miami, Baptist and Doctors Hospitals. Many of the more than 50 surgeons who are part of the Center are considered pioneers in the field. Dr. Estape is among the first surgeons in the country selected to be trained to perform single-incision robotic surgeries.
Providing the most effective care in the least invasive manner is the philosophy of Baptist Health’s Center for Robotic Surgery, where gynecological, thoracic, prostate, kidney, abdominal, colorectal, weight-loss and throat surgeries are done with the help of a robotic system. Baptist Health Center for Robotic Surgery is part of Baptist Health South Florida, the largest faith-based, not-for-profit healthcare organization in the region. Baptist Health also includes Baptist Hospital, Baptist Cardiac & Vascular Institute, Baptist Children’s Hospital, South Miami Hospital, Homestead Hospital, Doctors Hospital, West Kendall Baptist Hospital, Mariners Hospital, Baptist Medical Group and outpatient locations in Miami-Dade, Broward and Monroe counties. Baptist Health Foundation, the organization’s fundraising arm, supports services at all hospitals and facilities affiliated with Baptist Health. DIANE MAGNUM: Hello. I'm Diane Magnum, and welcome to BaptistHealth.net. Today we're coming to your live from the Baptist Health Center for Robotic Surgery here at South Miami Hospital, where you're about to see a cutting-edge surgery. An entire hysterectomy performed through one small incision in the abdomen. Now, if you take a look behind me, the director of the Center, Dr. Ricardo Estape has just finished prepping his patient. While beside me is his esteemed colleague, Dr. John Diaz. Over the course of the next hour, together these two men will be answering all of my questions about this procedure, and also the questions that you send in to us live via the web. So please keep those questions streaming in over the next hour. Doctors, thank you both for allowing us into your operating theater today. And Dr. Estape, let me start with you. There is a lot of equipment in this room right now. Can you give us a lay of the land and what we're looking at? DR. RICARDO ESTAPE: Sure. Well, first what you're looking at here, the patient is here underneath the blue drape. You can see the overhead shot I've marked, because we're going to be going right around the patient's belly button. I've marked where the chest is at on the patient since you can't tell, and where the legs are at-- the left and right leg, sitting down here. In just a minute after we put all the instruments, there's going to be a robot that you'll see come in between the legs once we get the procedure started. So for right now, what you're just seeing is the patient. And we're going to start the procedure as soon as you're ready. DIANE MAGNUM: I'm going to let you go ahead and start the procedure and tell me what you're doing. But first, can you tell me a little bit about your patient? Who is she? What kind of symptoms was she presenting? And why did she need this hysterectomy? DR. RICARDO ESTAPE: This is a 53-year-old patient that about eight years ago came in with an ovarian mass. We have removed her right ovary, and it didn't look quite abnormal enough to be an ovarian cancer. It wasn't even bad enough to be called a borderline cancer, but it was atypical. She wanted to preserve her ovary and uterus, and we watched her every six months with an ultrasound. And over the last year or two we've been following just yearly. And now she developed a new mass that looks a little irregular on her left ovary. Because she's 51, the chances are it'll be benign, but it definitely is concerning because it's a new mass that wasn't there before. And she's already going into the menopause and there should be nothing on that ovary. DIANE MAGNUM: All right, Dr. Estape, we're going to go ahead and begin. And if you would just explain to us what you're doing as you're moving along. And as you get started, Dr. Diaz, let's start with a short tutorial. What is a hysterectomy? DR. JOHN DIAZ: Well, Diana, a hysterectomy is the removal of the uterus. And oftentimes in combination with this procedure, we'll remove the cervix, the fallopian tubes, and the ovaries. DIANE MAGNUM: And what are the causes of a hysterectomy? Why would a women present to you with symptoms that would require the uterus be removed? DR. JOHN DIAZ: There are many indications for a hysterectomy. Among them, one of the most common is fibroids. Fibroids, as you know, are benign tumors of the uterus and they can grow and cause some problems. The most common things that patients may experience will be abnormal vaginal bleeding, sometimes resulting in anemia, pelvic pain. And sometimes these fibroids can actually interfere with fertility. DIANE MAGNUM: And how common is this surgery? I'm certainly at this age, and it seems like more of my friends than not have undergone a hysterectomy. DR. JOHN DIAZ: Hysterectomy is actually the second most common procedure that a woman will undergo in the United States. DIANE MAGNUM: Is it really? DR. JOHN DIAZ: Behind only cesarean sections. There are about 600,000 hysterectomies performed each year in the United States. DIANE MAGNUM: And can you tell us right now, Dr. Estape, exactly what it is we're seeing on the screen? DR. RICARDO ESTAPE: Sure. One of the unique features of this surgery is that we do everything through one incision. And we do it so the incision is sort of hidden at the top of the belly button, almost like if it's a tummy tuck incision. And so first what we're doing is here's the belly button, we're lifting the belly button up and we're going to get through down here to the lower part of the skin called the fascia so that we can get into the abdomen. So right now we're just separating the skin from the base of the belly button, and getting essentially the subcutaneous tissue, or the fatty tissue, away from this area so we can open up and get into the abdomen. DIANE MAGNUM: And can you tell me a little something about the instruments you're using? DR. RICARDO ESTAPE: Sure. We have these two simple graspers called allises. I have a bovie knife, which is an electrical knife, right now. And then in just a moment we're going to bring in a couple of retractors that will pull the tissue up and out of our way. DIANE MAGNUM: Now, there is a smell of burnt tissue. Is that because there is some heat used in that tool? DR. RICARDO ESTAPE: Yes. This instrument is electrical energy, and so that's the reason that you smell that. DIANE MAGNUM: All right. Dr. Diaz, 20 years ago how would a hysterectomy have been performed here in the US? DR. JOHN DIAZ: Well, Diane, the traditional approach for a hysterectomy is the abdominal approach. And this would require an abdominal incision, a much larger scar than what you're seeing now. Anywhere from 12 centimeters or even larger, depending on the size of the uterus. And this required an incision both through the abdominal skin and into the abdominal cavity. And really, this incision would cause most of the post-operative discomfort that patients experience from this procedure. DIANE MAGNUM: And it would make it a higher risk procedure, would it not? Whenever you're opening the abdomen, you have a higher risk of infection. I would assume the procedure would take longer, so the patient would be under anesthesia for longer as well. Correct? DR. JOHN DIAZ: Well, there are increased risks with abdominal approach. The rate of infection in that approach is anywhere from 1% to 3%. And depending on the patients, if they're a little bit overweight or have diabetes, it could be even as high as 10%. Which doesn't sound like a lot, but as we said before, with 600,000 of these cases occurring annually, a 3% infection rate would leave to about 18,000 surgical site infections a year. DIANE MAGNUM: Oh my goodness, those numbers are astounding. Dr. Estape, fill us in. Where are you now, and what exactly is happening? DR. RICARDO ESTAPE: So now we've created the hole into the abdomen. And if you can see there in the picture, you can see the hole right here into the abdomen right through here. When I move it around, you can see the intestines, or the small bowel, right underneath this. So this is the opening that we're going to put it in our port where we're going to put all our little openings through. DIANE MAGNUM: All right. And we actually have a port over here. Dr. Diaz, can you show us that port on camera and explain how it works? DR. JOHN DIAZ: Sure. This is the actual port that we'll be using in these types of procedures. This is the robotic single site port. As you can see, it's very malleable, and this is how we get it into the abdomen. DIANE MAGNUM: Oh, it really is. DR. JOHN DIAZ: So Dr. Estape shortly will put a clamp on this port and we'll be able to slip it through that small incision. As I said earlier, a traditional incision is about 12 centimeters wide. The incision we'll use for this single site procedure is only 2.5 centimeters wide. DIANE MAGNUM: Incredible. DR. JOHN DIAZ: If you look at this port, you'll notice that there are five separate openings in this gel port. One of the openings allows for our laparoscopic or robotic camera to enter, two other openings for our robotic instruments, an opening for our assistant where they can put in their instruments to assist during the surgery, and then additionally, this tubing which allows for the gas that we used to distend the abdomen to come in, and some of the smoke that's created to exit the abdomen. DIANE MAGNUM: Tell me about that. DR. RICARDO ESTAPE: We're going to put the gel port in now. DIANE MAGNUM: OK, let's go back to the operating shot then. Go ahead, Dr. Estape. DR. RICARDO ESTAPE: So we're lifting up, and here's the same port that you were just seeing. And essentially we're just going to push it into the abdomen. DIANE MAGNUM: So it's a very spongy material that you're using. DR. RICARDO ESTAPE: Yeah. DIANE MAGNUM: And that allows you to keep the instruments you're inserting steady, is that correct? DR. RICARDO ESTAPE: It does. It keeps them all through one hole, and allows me to put all the holes in at one time. DIANE MAGNUM: It's incredible just to see this visual at this point, how the belly button is actually a portal. DR. RICARDO ESTAPE: I'm going to make the opening a little bit bigger. I'm trying to keep it to the minimum on her. DIANE MAGNUM: And you're making the opening bigger just to allow-- DR. RICARDO ESTAPE: Just to get a little bit more room for me to work through. DIANE MAGNUM: I see. DR. RICARDO ESTAPE: Allis clamp? DIANE MAGNUM: And all of this work is done over the patient, obviously, before Dr. Estape moves over to the robot. Correct? DR. RICARDO ESTAPE: That's correct. DIANE MAGNUM: And Dr. Diaz, when we look at this, this surgery has evolved up to this point. We started talking just a few moments ago about the open abdominal surgery. But it didn't go right from that surgery to this robotic surgery, they were a few steps in between. Can you talk to us about the first phase of minimally invasive hysterectomies? DR. JOHN DIAZ: Correct, Diane. Minimally invasive surgery initiated with the laparoscopic procedures. And actually, these procedures were pioneered by gynecologists rather than the general surgeons. And this approach allowed for access, usually through the belly button that we're seeing now for a camera to be placed, and then an additional site to be placed in the abdomen, depending on which kind of procedure, how many additional sites you would need. This allowed for a minimally invasive approach to the traditional surgical procedures. DIANE MAGNUM: So it was a quicker recovery, a smaller scar, all of those benefits that we associate with minimally invasive surgery. But even then, it evolved once again to a single site minimally invasive surgery, correct? DR. JOHN DIAZ: Correct. There has been a single site laparoscopic surgeries which really has not caught on with surgeons in particular. There are a lot of limitations to the single site laparoscopic surgeon. The instruments are not bent, and it really limits the application of that procedure. DR. RICARDO ESTAPE: If you guys want to give me just a couple minutes here, we'll finish putting in all the ports. DIANE MAGNUM: Yes. Go ahead, Dr. Estape. Tell us what you're doing. DR. RICARDO ESTAPE: So we have our gel port here, it's in the right place. You can see the four little holes that we're going to put all our instruments through. So the first thing we're going to do is we're going to put in our camera port right through there. We'll pull it up, camera. We'll grab our camera where we're going to look in. DIANE MAGNUM: Now is the light also on that camera port? DR. RICARDO ESTAPE: The light is on the camera port as well. This is how we'll look up into it. DIANE MAGNUM: We lost our shot for just a second. There we are on the inside. So what are we looking at now, Dr. Estape? DR. RICARDO ESTAPE: Let me bring the light intensity up, because the light intensity for some reason is really light. So I'm going to start up to the upper abdomen. We're going to look up to the upper abdomen. Let me see if I can get some more light intensity here. For some reason we're really bright and it's really not bright at all. I have almost no picture. DIANE MAGNUM: Yeah, certainly light would be key to this surgery, I'm sure. DR. RICARDO ESTAPE: All right, there's some now. So here we're looking at the liver-- nope, it went away again. DIANE MAGNUM: It did go away again. DR. RICARDO ESTAPE: So here's that liver up here on this side, this is the right lobe of the liver. We'll slide across, here's the left lobe of the liver. You can see the heart beating. DIANE MAGNUM: I can. DR. RICARDO ESTAPE: Let's see if I can clean the camera for you so I can get a little-- DIANE MAGNUM: So it's very easy to insert and take out the camera. DR. RICARDO ESTAPE: Yeah, absolutely. DIANE MAGNUM: All right, back in with the camera so we get that inside. DR. RICARDO ESTAPE: There's the heart beating right there on the other side of that diaphragm. DIANE MAGNUM: Oh my goodness, that's astounding. DR. RICARDO ESTAPE: There's the heart right there. So now we're going to switch around. Max, turn [INAUDIBLE], please. We're going to bring the patient's legs up. So all that you're seeing there on the bottom is all intestines. It's all small bowel. And then behind all this is where the uterus is going to be at. So as you start to slide up, all that bowel will slide out of our way. You can see it sliding already. And this is what makes the surgery easier-- by getting all the bowel out of the way, we'll be able to do the surgery much easier. DIANE MAGNUM: So you're electronically moving her on the table-- DR. RICARDO ESTAPE: That's correct. DIANE MAGNUM: --which makes it very easy for you as the surgeon. Dr. Diaz, you made a comment about inflating the abdomen. What's the purpose of that? DR. JOHN DIAZ: Correct, Diane. Inserting CO2 gas into the abdomen allows us to provide space so that we can work and complete the surgery. DIANE MAGNUM: So are more instruments now going into the port, Dr. Estape? DR. RICARDO ESTAPE: Yes. Now we're putting in our other three instruments beside the camera port that are going to help us with the case. So I'm going to have two arms, a right and a left arm, and then we're going to put an accessory port, which is where my assistant Dr. Phrada will help me with anything I need to do through that port. And so we're going to put all the ports in first, and then we're going to bring the robot in and hook it up. DIANE MAGNUM: Now, Dr. Estape, you will be operating the two arms from the robot across the room. And your assistant will be operating the accessory port that's now in his right hand? DR. RICARDO ESTAPE: That's correct. I'll be operating actually the camera and the two arms, and he'll be coming right through here to this hole for anything that I need extra. DIANE MAGNUM: Now, how do you do that with only two hands? DR. RICARDO ESTAPE: When I need the camera I press a camera pedal, and my two hands essentially control the camera. And then I let go of the camera pedal, and I'm back to using my two hands. DIANE MAGNUM: So we had another doctor describe this as being in the cockpit of an airplane, and it really is like that, isn't it? DR. RICARDO ESTAPE: That is correct. DIANE MAGNUM: And just, if we take a wide shot now of the operating room, you'll see they're bringing in the robot which is quite large. DR. RICARDO ESTAPE: If you have an overhead shot, just before we dock the robot, this is a good time to look at the port, how it looks. DIANE MAGNUM: OK, let's take a look at that port from the overhead shot if we can get it. It does appear to be very full. You've got as much equipment in there as you can. DR. RICARDO ESTAPE: So you see our camera port will come right here. The two arms, the two instruments, come through here, and then my accessory port is here. So everything is crammed through one little 2.5 inch hole right there. DIANE MAGNUM: Unbelievable. All right, as you go ahead and continue to hook up the various tubes and arms, Dr. Diaz, let me ask you. We talk about the evolution of this surgery-- why is it this robotic approach is considered the gold standard now over what we were seeing before? DR. JOHN DIAZ: Well, Diane, I don't know if this is considered the gold standard, but it is from the evolution of minimally invasive surgery. Despite the fact that laparoscopy's been around for decades now, the adaptation by surgeons of laparoscopic surgery has really plateaued over the last two decades. And what robotics has done with laparoscopy, it's allowed us for patients and physicians who weren't comfortable or didn't have the skill set for laparoscopic surgery can now offer a minimally invasive approach to patients. So patients are really benefiting from this, in that they're being offered a minimalist approach to many surgeries that previously surgeons simply weren't providing them. DIANE MAGNUM: So speak to why doctors are so inclined to go with this approach in terms of improving their field of vision and their surgical dexterity. DR. JOHN DIAZ: Well, I think for many physicians who weren't comfortable performing laparoscopic surgery, robotics has allowed them to transition from the traditional open techniques to robotics, which really utilizes a lot of the same similar motions that we perform in open surgery. And robotics offers several advantages over your traditional laparoscopic surgery. Some of the advantages of the robot is one, you're seeing the camera inserted that we use. This offers greater magnification, 10 times the traditional laparoscopy. It's a high definition picture, as opposed to traditional laparoscopy where we're looking at the old screens. And think of the TV screen everyone has in their homes now is high definition picture. That's what finally we as surgeons are able to have in the operating room. And additionally, we're getting a 3D picture. So with robotics, the optics are far superior to traditional laparoscopic surgery. DIANE MAGNUM: So if you were to make an analogy here, before you were doing surgery when it was minimally invasive with a set of blinders on either side, and now your field of vision has been expanded? DR. JOHN DIAZ: Absolutely. The optics are far superior with robotic surgery to a traditional laparoscopic approach. Robotics allows us to have a lot more control over the operative field. We sometimes say that performing laparoscopy is like eating with chopsticks where you hold one stick and someone else is holding the others. With laparoscopy, you held one instrument, your assistant held the other. Now with robotics, it's also starting to control the camera, control both the robotic arms. In addition, robotics has eliminated any surgeon tremor. And this resulted in less blood loss, quicker return to work, and allows us to tackle more complex cases that we simply weren't able to with traditional laparoscopy. DIANE MAGNUM: And as Dr. Estape is making his way over to the console, I'd just like to bring in one of these pieces of equipment. This is one of the arms that he would be using. Can you explain what this is and how it works in the robot? DR. JOHN DIAZ: Correction, Diane, these are one of the instruments that we use. DIANE MAGNUM: Instruments, yes. DR. JOHN DIAZ: Once we have the port placed, we put in some rigid instruments through the port. This is then connected to the robot and inserted into the patient. As you see here, it's pliable, so actually the left arm is going to be controlled by an instrument in the right arm of the robot. And the nice thing again about using robotics is with a simple push of a button, you can switch it so that your hand is controlling that, versus with traditional laparoscopy single site, you had to make the adjustment DIANE MAGNUM: I understand. So what you're saying is, you'd have to move your right hand if you wanted something on the left hand side to take place, and vice-versa. So that would be a big learning curve for anything surgeon. DR. JOHN DIAZ: Absolutely. And again, why it has not been widely adopted by surgeons in the past. DIANE MAGNUM: I see. And this particular instrument on the end there, what is that and how is it used? DR. JOHN DIAZ: This instrument here is our Maryland Dissector. You can see on the backside here is where the instrument's controlled by the robot to allow for opening and closing of these jaws here. This particular instruments is called the Maryland Dissector, and we use it for dissecting during the procedure, grasping. And we can also apply a little heat through this or some bipolar energy source. DIANE MAGNUM: All right, Dr. Estape, let's take the shot of what you're doing at this very moment. And if you could explain to us where we are in the procedure. DR. RICARDO ESTAPE: OK, so we're just getting started. I like to get everything out of my pelvis. These are pieces of small bowel that are just sitting back behind the uterus. She's had prior surgeries, so you can see some of this scar tissue down here. And I'll give you a tour once I get the bowel out of the way. DIANE MAGNUM: Now that scar tissue would have been from a former surgery? DR. RICARDO ESTAPE: From when we took out her right tube and ovary. You can see here-- let me get the camera clean so you can see better. Clean the camera, please. DR. JOHN DIAZ: So for any surgical procedure, Diane, you're going to have some post-operative adhesions that form inside the abdomen, and this is what you see. However, with a minimalist approach, the traditional laparoscopy robotics, you see much less adhesions than you would with an abdominal approach. And again, making any subsequent surgery easier for the surgeon, which translates into an easier experience for the patient. DIANE MAGNUM: So prior surgeries would be a indicator as to whether a patient would be a good candidate for this kind of surgery? If they had had too many prior surgeries and there would be a likelihood of scar tissue, perhaps a minimally invasive approach would not be best for that patient? DR. JOHN DIAZ: Well I think, Diane, in our hands, minimalist approach is our preferred method, regardless of previous surgeries. But certainly, previous surgeries makes is a more challenging case. And again, this goes back to surgeon experience, certain expertise and their comfort. So that's a discussion that patients should have with their surgeons. DR. RICARDO ESTAPE: Can we get in here before we get started? DIANE MAGNUM: Sure, go ahead. DR. RICARDO ESTAPE: So this is her uterus sitting right up here. You see a fibroid sitting right here, but this isn't really her problem. She has this irregular cyst on her left ovary. This is her left ovary here. This is her fallopian tube right here. Colon is sitting right back here behind us. And then you can tell that her right ovary is missing over here. We've removed her right ovary before. DIANE MAGNUM: Yes, we can see that. DR. RICARDO ESTAPE: And in areas like this, this is just scar tissue which I'm going to start taking down now. This is just scar tissue from her prior surgeries that we're just going to clean up a little bit. DIANE MAGNUM: Now, Dr. Estape, if you wouldn't mind at some point also pointing out-- there we go. We can see it now. The fibroid is a common cause of hysterectomies, is it not? DR. RICARDO ESTAPE: It is. It's the most common cause of hysterectomy, period. DIANE MAGNUM: And Dr. Diaz, can you speak to why that is an indicator for someone needing a hysterectomy? What is it about fibroids that lead women to make the decision to undergo surgery? DR. JOHN DIAZ: I think, Diane, it's very important to remember, lots of women have fibroids. And simply having a fibroid doesn't mean you need a hysterectomy. However, these fibroids can cause some symptoms-- pelvic pain, abnormal bleeding actually resulting in anemia. And so for those reasons, a lot of patients, after failing medical management, desire to have a definitive surgical approach, and that would be a hysterectomy. DIANE MAGNUM: Now, is there a way to manage fibroids without surgery? DR. JOHN DIAZ: Absolutely, Diane, and that's always our goal. If we can control the symptoms they're experiencing with medical management, it's preferable. But oftentimes patients fail this medical management. And when they do, then the option of surgery is discussed. DIANE MAGNUM: All right, Dr. Estape, fill us in. Where are you now, and what exactly are you doing? DR. RICARDO ESTAPE: All right, so because she's had a prior right tube and ovary removed and there's some scar tissue here, there's certain organs that we don't want to damage. And one of the key ones is the ureter, which is a tube that goes from the kidney down to the bladder and it runs usually right along here. Because you see scar tissue here and everything sort of pulled medially, I wanted to make sure that my ureter isn't going to be damaged by this portion of the procedure. So what I'm going to do is I'm going to dissect this tissue out here a second, and we're going to find where our ureter is at, get it out of our way. DIANE MAGNUM: So you're very slowly making your way toward the area? DR. RICARDO ESTAPE: That is correct. We're slowly making our way down towards the uterus. We've got to release its blood supply and get some structures that can be injured during the surgery out of the way. DIANE MAGNUM: I see. And can you give us some idea, Dr. Estape, of the real time movement of this robot? As you look at the video, do you feel like the robot is just an extension of your hands, there's no lag at all between your movement and the robot reacting? DR. RICARDO ESTAPE: Absolutely. There's zero lag at all between mine. You can set the robot to move. For every centimeter you move, you can set it to move 1.5 centimeters, 3 centimeters or 5 centimeters, depending on where you're working at. And so you can decide how fast the robot's going to move compared to your hand. I like moving it at this speed, because it's almost identical to my speed when I'm dissecting it out. So it doesn't give me any delay whatsoever. DIANE MAGNUM: This seems like a good time to remind our viewers that this procedure was just approved by the FDA, and that Dr. Estape was the very first to perform this surgery here in South Florida. That's correct, right doctor? DR. RICARDO ESTAPE: That is correct. DIANE MAGNUM: I'd also like to remind our viewers at home that we are taking your questions live via the web. So be sure and send them in to us, and we will ask those questions of our surgeons over the course of the rest of this hour as we see this procedure go forward. Dr. Diaz, when we talk about the ovary on the left-hand side, does that ovary look like a healthy ovary? Doe it look like a diseased ovary? Give us some idea of what we're looking at there. DR. JOHN DIAZ: The ovary looks a little bit abnormal, and given her previous history of having had atypical cells in that ovary, that's our concern with this patient. Unfortunately, we don't have any good way to screen for ovarian cancer. And with her history of abnormal cells in the past, this was a patient who she didn't want to take any risks to continue to observe once this abnormal cyst developed. DIANE MAGNUM: The instruments are very clean and very small in there. And again, this seems like it's a procedure with almost no blood loss. Is that how it's meant to be? DR. JOHN DIAZ: Absolutely, Diane. Again, one of the advantages of minimal invasive surgery is decreased blood loss. You can see that because we're using electrocautery instead of in traditional open procedure where you see more cutting and tearing, blood loss is really minimal for most of these procedures. DIANE MAGNUM: All right, Dr. Estape, you seem to have moved to another area. What are you doing now? DR. RICARDO ESTAPE: We've taking down now one of the support ligaments of the uterus called the round ligament. When we get through some of this thicker tissue, we produce a little bit more smoke. We have what's called a smoke evacuater getting the smoke out of the way. This ligament is called the round ligament, and so we're taking it down. I was just able to see the ureter which we were looking for, and I'll show it to you here real quick. We don't want to dissect it out to cause bleeding, but this structure right, and you're going to see it move in just a second, this structure right here is the ureter. I'll pull it down, you can see it right there, that little bulge right above me. DIANE MAGNUM: I see. So you're moving your way around that. DR. RICARDO ESTAPE: This is the ureter. So by doing this, I've been able to get it away from the area where we're going to the hysterectomy at. DIANE MAGNUM: And once again, the smoke we're seeing is because the tissue is being burned and cauterized so that it won't bleed. Am I correct in saying that? DR. RICARDO ESTAPE: That is correct. DIANE MAGNUM: And that is just a little bit of steam we're seeing from the heat, right Dr. Diaz? DR. JOHN DIAZ: Correct. DR. RICARDO ESTAPE: So now we're going to continue here to take down the right side. So the approach to any surgery is to devascularize, or get all the blood supply to the organ that you're going to remove out of the way first. So what we're doing here is we're now getting to the first set of blood vessels on the right-hand side. Since her ovary had already been removed, the upper set of blood vessels to be ovary on this side are gone. But now we're coming to what's called uterine artery, which is the blood supply to the uterus itself. We're going to dissect it out here. We have the uterus right here. The cervix, the lower part of the uterus, is here, and this little balloon you see here is the Foley catheter in the bladder. So we need to get the bladder off of the cervix, so that we can get the uterus out. Because this is another common place where the bladder can be injured. DIANE MAGNUM: So much of the time of the hysterectomy is spent separating the uterus from the tissue around it. DR. RICARDO ESTAPE: That's correct. And its blood supply. DIANE MAGNUM: We do have our first question from a viewer. They'd like to know what the fluid is we're seeing at the bottom of the screen. DR. RICARDO ESTAPE: There is probably fluid from a cyst that she ruptured. We're going to take out some of that fluid in just a little bit and send it. Because her concern was if she could possibly have that borderline ovarian cancer. And so we send that fluid usually out to make sure that it's got no cancer cells in it. DIANE MAGNUM: Now, is that something that's done while he's on the operating table? DR. RICARDO ESTAPE: Yeah, we'll do that now in just a little bit. DIANE MAGNUM: And if, God forbid, the pathology comes back saying that there were cancerous cells, would it change how you continue on with this hysterectomy? DR. RICARDO ESTAPE: This part of the procedure would be the same, but then we would add taking out lymph nodes, and taking out a piece of the omentum, and doing what's called the staging procedure to make sure that the cancer hasn't spread anywhere else. Visibly that was the first thing we did when we looked around the abdomen to make sure that there was no growths, cancer anywhere else, and there wasn't. Everything was clean, the diaphragm was clean, the liver was clean, the common areas where this cancer goes to look pretty clean. DIANE MAGNUM: Now, I know we're taking the second ovary in this procedure. But are the ovaries always removed during a hysterectomy? DR. JOHN DIAZ: No, Diane, the ovaries are not always removed. And it depends on the indication of the hysterectomy, and that's a good part of our time when we meet with patients. It's counseling them on what to do about their ovaries, the implication that may have on menopause, the role of hormone replacement therapy. So it's really an individualized choice for patients if they would like their ovaries removed at the time of hysterectomy. DIANE MAGNUM: Dr. Estape, you want to fill us in on what you're doing at this moment? DR. RICARDO ESTAPE: We're going to go now to the opposite side. We're going to start releasing the opposite side, because she's got some scar tissue here. Clean my camera for me again. DIANE MAGNUM: And once again, this is the other side where the ovary is still there. The first ovary was removed several years ago. DR. RICARDO ESTAPE: That is correct. DIANE MAGNUM: And the second ovary will be coming out today. Dr. Diaz, you started telling us about the indications of menopause coming on, if in fact you do remove the ovaries. Is there one school of thought that's better than the other in terms of that? If you're younger, you want to keep your ovaries for a little longer. If you have no family history maybe you want to keep your ovaries for a little longer. Or do you just want to decrease your risk of getting cancer by getting rid of the ovaries as long as you're in the operating theater? DR. JOHN DIAZ: You know, Diane, the old school of thought was that if you were going to be the operating room then go ahead and remove the ovaries. But we have a lot of new data that's shown that actually there's a benefit for them to keeping their ovaries, even up to the age of 60, which is about 9 to 10 years after the onset of menopause. So again, this goes into the counseling, the long discussions that we have with our patients. Certainly if you have a family history that puts an increased risk for breast or ovarian cancer, it's a very different conversation. DIANE MAGNUM: What is the benefit of keeping your ovaries, aside from the fact that you aren't thrown into menopause? DR. JOHN DIAZ: Well, in those patients that they followed, and this was a study from Harvard looking at the nurses who kept their ovaries, they actually lived longer, had less cardiac disease, improving bone health. So it's a long conversation that we have with our patients to discuss the benefits and risks of ovarian preservation. But if there is no abnormality of the ovary and there's no significant family history, our bias is to have patients retain their ovaries. DIANE MAGNUM: Well, that's encouraging to hear. Dr. Estape, what are we looking at? DR. RICARDO ESTAPE: Well right now, this is bark part of the uterus. It looks like she's got some old blood here on the ovary, maybe an old endometriosis sitting here. Although the first time around she didn't have endometriosis, and it's rare for it to happen into the late 40s or 50s. But there's a cyst or something that was producing some old blood up here. DIANE MAGNUM: Now when you say endometriosis, for our viewers who aren't familiar with what that is, can you explain that please? DR. RICARDO ESTAPE: John, you want to handle that a second while I get this colon off? DR. JOHN DIAZ: Endometriosis is a condition which affects women in where the endometrial tissue, which is normally inside the lining of the uterus, is found outside. And this can cause some significant pelvic pain, it can form into endometrial cysts, and actually has been associated with infertility. DIANE MAGNUM: We have another question from a viewer who wanted to know if this procedure is generally longer or shorter than the old procedure of hysterectomy, both the open surgery and the minimally invasive three port procedure. DR. JOHN DIAZ: That's an excellent question. Diane, as with any new technology or new procedure, there is a learning curve. So in the initial adaptation to any new technology, there is going to be some learning curve compared to how it was done previously. I can tell you in our hands and our experience, our minimally invasive techniques do not take longer than our open techniques. And as we've gained additional experience with the single site technique, we've been able to complete our hysterectomies now in less than an hour's time with the robot. DIANE MAGNUM: And the old procedure, how long would a traditional hysterectomy take? DR. JOHN DIAZ: Wall again, it depends on the indication, but the traditional time, it would be less than an hour. DIANE MAGNUM: It would? DR. JOHN DIAZ: But again, this all depends on the surgeon experience, surgeon comfort, and indication for the surgery. DIANE MAGNUM: Dr. Estape, I'm going to come back to you. I seems like a lot is happening at this moment. DR. RICARDO ESTAPE: Yeah, she has a bit of adhesion of the colon to the back of the uterus and cervix. So this thing right here we're seeing is the colon. And what I want to do is to try to prevent injury to that colon. So I'm slowly dissecting the colon off the back part of the cervix and it's relatively stuck back here, which sometimes does go along with endometriosis. That blood you probably see come out of there. DIANE MAGNUM: Right. Now again, you are just very carefully working only on connective tissue. Your goal is not to grab hold of the organs themselves. Is that right? DR. RICARDO ESTAPE: Well, I grab the uterus to move it around every once in a while. The one organ I don't want to grab is that ovary. I don't want to rupture it, even though she has some adhesions there and that blood looks like it was between the ovary and the uterus. So anytime we're dealing with something that could be an ovarian cancer, the goal is to not rupture it in the abdomen. Because if the cancer is limited to the ovary, then we could have possibly just worsened her prognosis. DIANE MAGNUM: All right. Dr. Diaz, we've just had another question. We've actually answered this, but we have some people tuning in. Another viewer wants to know why there's so little blood that we're looking at when we're actually looking at so much cutting. DR. JOHN DIAZ: Diane, that's a great question. The instruments that we're using in this case all use electrical energy. So as we cut, we're using electrical energy to seal as well. And this is why with a minimal invasive technique you see less blood loss than with traditional open surgery. Additionally, our visualization is so good, we're working in such precise space, the movements are so precise that you do have less bleeding, less trauma to the surrounding tissue. DIANE MAGNUM: Now Dr. Estape just talked about one risk of this procedure, and that's if there are cancer cells that somehow a tumor could rupture and release those cells into the abdomen. But what are the other general risks with this kind of surgery? DR. JOHN DIAZ: Diane, any time you have surgery there's inherent risk to it. There's always the risk of bleeding, there's the risk of infection. Patients routinely receive antibiotics prior to these procedures to help reduce those risks. There's always the risk that we may injure another organ while we're working inside there. And again, this is where surgical technique and experience help to minimize those risks for our patients. DIANE MAGNUM: Dr. Estape, if you have a minute and can tell us where you're working now? DR. RICARDO ESTAPE: Sure. This structure that you see right here is called the infundibulopelvic ligament which carries the arteries to the ovary. Going to see if I get this to defog. Clean my camera please? Hold on, that's fine. It defogged, it's fine. So again, like we did on the other side, I'm going to find the ureter which is the tube that goes from the kidney down to the bladder, and we're going to make sure we get it out of our way. I think we can see it right here. DIANE MAGNUM: And once again, is this procedure taking a little longer than it normally would just because this patient has a few issues that other patients would not? DR. RICARDO ESTAPE: Absolutely. Once we get past the upper scar tissue and we get down in the cervix, it's going to move a little bit faster. But right now, the problem is just getting past all this scar tissue. DIANE MAGNUM: We just got another question in from one of our viewers who wanted to know, Dr. Diaz, would everybody be a candidate for this surgery, or are there some people who just would not fare well with this kind of robotic scarless procedure? DR. JOHN DIAZ: Again, I think this is the discussion to have with your practitioner. For one, not all surgeons are offering this scarless or single site approach for hysterectomies. In our selection for patients, we tend to limit the size of the uterus. Again, we are working in a confined space. Although we have gone up to a 500 kilogram uterus, for the most part, we try and limit the size of that. The recommendations are for patients who have not had previous surgery. But as you see again, that's surgeon dependent. This patient has had previous surgery. But in our hands and in our opinion, she was a candidate for this procedure. And we try and limit also the size of the patient-- again, the gel port that we're using. So patients who are a little bit overweight certainly can benefit from this. But we again limit to how high a BMI we will get. DIANE MAGNUM: Dr. Estape, where are we now? DR. RICARDO ESTAPE: I'm just isolating now the vessel that comes to the ovary. And one of the problems sometimes we see with the single site is that I can't come back any further than that trocar is right there. So I have to get all this tissue out of the way. So here we see the vessels, the external iliac artery right here. And our ureter was right over here. So this structure right here is actually the blood supply to the ovary. So what I'm doing here is I'm going to cauterize it now, which means I'm going to seal the blood vessels so it doesn't bleed. DIANE MAGNUM: And why is that important, to seal the blood vessels? DR. RICARDO ESTAPE: If you don't, then you're going to see some significant bleeding. And most of the areas that are connective tissue that we've been going through so far doesn't have a big blood vessel. So the instrument on my right-hand side can go through that tissue without seeing a lot of bleeding. But the structures like this one has got an artery coming directly from the aorta can bleed quite significantly if we don't cauterize it appropriately. DIANE MAGNUM: That certainly makes sense. Dr. Diaz, is there a certain age where hysterectomies become more common in women? DR. JOHN DIAZ: Absolutely, Diane. We see less hysterectomies in our younger patients. And the reason is obviously these women have an interest in retaining their uterus and for future fertility. But as women age, the incidence of fibroids become more common, the abnormal bleeding becomes more common. And once childbearing is no longer an issue, these patients may desire to proceed with removing of the uterus or have a hysterectomy performed. If you get to the higher age groups, 70s age, and you haven't yet had a problem come up, and at that point you're in menopause, there is no bleeding, you shouldn't have fibroids develop, you see it less common in that population. DIANE MAGNUM: Now, if a woman has a cancer diagnosis and you can tell through prior testing that the cancer could have spread outside of the uterus, do you still take a robotic approach, or would you try an open surgery just so you could have the very best open field of vision. DR. JOHN DIAZ: Well, Diane, as we spoke earlier, our field of vision is so much improved with the robot. So actually, even with the diagnosis of cancer, you're certainly a candidate for robotic surgeon. In fact, for patients who have endometrial cancer, that's the cancer inside the lining of the uterus which is the most common GYN cancer in the United States, robotic surgery for a hysterectomy removal of the ovaries and the lymph nodes is really the preferred technique for performing this surgery. Patients get to recover much faster and return to work much earlier. DIANE MAGNUM: And again, we're talking about the least invasive procedure with the best surgical result when you're talking about robotic surgery, even though it's only been around a very short amount of time. I would think the learning curve for the surgeons has to be very steep on a machine like this. There has to be a lot of additional training. Am I correct in assuming that? DR. JOHN DIAZ: There is certainly a learning curve that goes on with the adoption of any new technique or technology. And it just depends on the surgeon's surgical abilities and their desire to learn. But again, robotics allowed those surgeons who previously were either unable to or reluctant to adopt laparoscopy to now offer their patients a minimally invasive approach. And the learning curve for robotics is less than your traditional laparoscopy. And I think that's why we've seen so many, particularly of our surgeons who did not train with this when they were in residency, adopt this new technology now. DIANE MAGNUM: Once again, if you're just tuning in, you're watching Dr. Ricardo Estape perform a single incision hysterectomy on his patient through the use of a surgical robot. A reminder, we invite you to send in your questions live via the web, and we'll effort to answer as many of those questions as we can before the surgery is over. Dr. Estape, you're making real progress now. Where are we in the surgery? DR. RICARDO ESTAPE: We're starting to get there. We've taken down the blood supply to the ovary now. And now we're headed, like we were on the other side, down to the blood supply of the uterus, called the uterine artery. And so now that we got past all those upper scar tissue, we're almost down to the point where we're almost down to the bladder now. So we're starting to make a little bit more headway here past all this scar tissue the patient had. DIANE MAGNUM: Now, just a few hours ago, we watched another robotic surgery, a gallbladder removal. And there seemed to be much less connective tissue around the gallbladder than we're seeing now with the uterus and the ovaries. Is that anatomically a clear assumption, or is that just in this particular patient we're seeing? DR. RICARDO ESTAPE: I think this particular patient had. I mean, there's always more connective tissue down here. There's only a little bit of tissue that connects the gallbladder to the liver, but down here you have all this support. This uterus has to be held up during a pregnancy with a seven pound baby. So you have to have strongly ligaments to hold it up. You have to have ligaments to keep it in place. And there's blood supply coming-- the gallbladder has one vessel coming in. This one has four vessels coming in, two on each side, one high, one low, and some thick ligaments keeping it in place, so it's a little bit different. DIANE MAGNUM: It is a more complicated surgery for sure. Now, is that the fibroid again we're looking at there? DR. RICARDO ESTAPE: Here's that fibroid right here. DIANE MAGNUM: Holy cow. DR. RICARDO ESTAPE: And here's the uterus. We're going to [INAUDIBLE] now, we have a sponge stick in the vagina that we're going to push up so I can find the vagina and we can get into the vagina. So Dr. Prada's going to now push in. You're going to see a big bulge come up here. DIANE MAGNUM: And the purpose of that is what? DR. RICARDO ESTAPE: Is to one, get the bladder out of the way. And two, to get this uterus out, I actually have to get the bladder completely out of my way and open up the vagina, because we're going to remove it through the vagina. DIANE MAGNUM: Well, that was going to be my very next question. How do you remove the tissue? Do you have to bag it, or you can just pull it straight out of the vagina? DR. RICARDO ESTAPE: This one, we'll take it straight out through the vagina. So here we're getting our bladder out of the way. I'm pushing up on the bladder and getting it out of the way. And we can see where Dr. Prada is pushing up on the sponge stick from below. DIANE MAGNUM: I see. That also explains why it's important in this procedure to not only have you at the robot, but to have a physician at the bedside. DR. RICARDO ESTAPE: Absolutely. DIANE MAGNUM: It is definitely teamwork here. This surgical team involves how many people, Dr. Diaz? The room is quite full. DR. JOHN DIAZ: At the bedside we have our assistant, Dr. Prada, who assists Dr. Estape during the procedure. He will be introducing any instruments through the system port, which can either retract for Dr. Estape, use a suction irrigator to remove any of the smoke of blood that we're seeing. And you'll see later where he will introduce the needles for the closure of the vaginal cuff. In addition, we have a surgical tech at the bedside who will be providing the instruments to Dr. Prada. We have our anesthesia team that's caring for the patient, as well as a nurse surgical circulator who will bring any additional instruments we need during the time of surgery. DIANE MAGNUM: We had another question-- I'm sorry, go ahead. DR. RICARDO ESTAPE: You can see here the sponge stick. This white structure here in the metal part, this is in the vagina, and he's pushing up to show me the vagina. So you can see we already have our opening into the vagina here. And so now we just need a second one to go out a little bit more lateral and finish releasing the blood supply to the uterus. DIANE MAGNUM: This all looks very magnified on our screen here. How small or larger of an opening are we actually looking at there? DR. RICARDO ESTAPE: That's about a 3 centimeter opening right there. DIANE MAGNUM: And all of this issue is going to be extracted through that opening? DR. RICARDO ESTAPE: That is correct. DIANE MAGNUM: And we have a question from our viewer. At times your camera gets fogged and it appears difficult to see. Is that a problem for you during the surgery? DR. RICARDO ESTAPE: Well, I actually have two eyes inside. The camera has two cameras inside of it. So sometimes one eye is a little fogged up and the other one is not. If both of them get fogged up for me, then it becomes a problem and I have to have Dr. Prada clean the camera for me. DIANE MAGNUM: Yeah, you have asked for that several times, and we can attest to the fact that that takes under five seconds for him to extract that camera, wipe it clean, and put it back into the port, correct? DR. RICARDO ESTAPE: That is correct. DIANE MAGNUM: So that's not ever an issue during a surgery? DR. RICARDO ESTAPE: Not really, no. We can always pull it back. If it gets to where I can't really see at all, I'll try to pull back and see if it'll defog itself. Because here we have the heat and the smoke that comes off of the electrical instruments that actually pull up. And even though I have a smoke evacuator, sometimes it just doesn't quite clean it fast enough for me and we've got to take it out and clean the camera. DIANE MAGNUM: Are there ever times when you start this procedure robotically, laparoscopically, and have to open up the patient? Is that ever an eventual outcome because of some complication? DR. JOHN DIAZ: Sure, that's an eventual outcome. And again, it depends on certain skill and experience how often that occurs, and that's something we discuss with our patients. There's always the possibility that we may not be able to complete the case robotically. We may have to convert to an open procedure. I can tell you that the rate of that occurring in our hands is very low. DIANE MAGNUM: And what are we looking at now? DR. RICARDO ESTAPE: Actually, that's a really good question. There was a study done by the Gynecologic Oncology Group called the LAP2 protocol, where they were doing patients that have endometrial cancer. And half of the patients were assigned to regular laparoscopic surgery, and the other patients were assigned to robotic surgery. Actually, just laparoscopic surgery, there was no robotics in it. It was straight laparoscopic surgery. In about 25% of them that you tried to do laparoscopically, you had to convert to an open procedure. The data that we've done here from this institution, and other people have matched the same thing, is that our conversion rates to open with laparoscopic surgery is well under 3%, no matter whose hands. So we're converting fewer cases to open cases because of the ability of the robot as well. DIANE MAGNUM: That's very low. And Dr. Estape, what are we looking at now? DR. RICARDO ESTAPE: So this is the vagina again here. So I'm finishing releasing the vagina here from the side. And then the other thing that we have to pull up here, finish getting our colon off of the back of this uterus. DIANE MAGNUM: And while we take a look at this fibroid, Dr. Diaz, we had another question from a viewer wanting to know if fibroids can could get even bigger than the one we're looking at. DR. JOHN DIAZ: Absolutely, Diane. Fibroids can actually grow to be very large. We've seen fibroids that look like the patient is nine weeks pregnant. DIANE MAGNUM: Oh, my goodness. DR. JOHN DIAZ: So fibroids can grow very large. DIANE MAGNUM: And on the backside here Dr. Estape, what are you doing? DR. RICARDO ESTAPE: Now we're coming to the other side to release the blood supply from the patient's left-hand side. So now we're getting the blood vessel that comes to the left side of the uterine artery, we're going to release that up here. And then the last thing that we're going to have to release after we come through here is going to be that little colon attachment that the patient had to the back of the uterus. DIANE MAGNUM: Now, is there any danger in cutting off these blood supplies long-term in terms of tissue necrosis? DR. RICARDO ESTAPE: No, because the tissue that we're actually cutting the blood supply to, we remove. DIANE MAGNUM: Ah, OK. Let's talk a little bit about post-surgical pain, Dr. Diaz. What will this patient experience when she wakes up? DR. JOHN DIAZ: Diane, with any minimally invasive surgery, you can have less post-operative pain than traditional open approach. It's been our practice to at the time of closing inject some local anesthetic to the incision to help reduce the immediate post-operative pain. Most of these patients will require some narcotics in their post-operative period. Or simply over the counter medications, anti-inflammatories such as Advil, Motrin, Ibuprofen or Tylenol. DIANE MAGNUM: And how long will she be in recovery here, and how long of a hospital stay is required with this? DR. JOHN DIAZ: This patient will stay overnight with us here. And then she'll be evaluated in the morning and she'll be discharged home in the morning. We usually ask the patients to take it easy for two weeks-- no heavy lifting, don't put any strain on the incision sites. We'll then see them in the office, and they're usually returning to work in two to three weeks following this procedure. DIANE MAGNUM: Wow, that's a big improvement over the traditional hysterectomy. Wasn't the home time about six weeks if you had an open hysterectomy? DR. JOHN DIAZ: Absolutely. With an open hysterectomy, a patient would stay in the hospital three to five days, and would not return to work until about four to six weeks after. So this is a huge advantage for patients allowing them to get back to their regular lives. DIANE MAGNUM: Now what about the incision site itself? Are there any marching orders about how to take care of the incision site? Is she send home with any kind of a Band-Aid or patch over the incision? DR. JOHN DIAZ: We put a small dressing over this incision site. We ask them to keep it covered until they see us at the office in two weeks. And the cosmetic results have been fantastic in our initial experience. Patients have been very satisfied with these results. DIANE MAGNUM: Dr. Estape, I'm coming back to you once again. What are we looking at? DR. RICARDO ESTAPE: Again, we're inside this vagina here. So we've released everything anteriorally and laterally. Now the last thing I have to release is this back part of the uterus where the colon was attached and see if we can get this uterus straight up here. And so the last thing I have to release back here is going to be the colon from here, and you still see the colon pulled up. So let me have suction irrigator on number two. I'm going to get a little water in here to clean off that area so that we can see a little bit better where we need to get that colon off. Because that colon is really densely attached to the back of the cervix. DIANE MAGNUM: And that's, just once again, this patient's individual anatomy? DR. RICARDO ESTAPE: That is correct. DIANE MAGNUM: Dr. Diaz, is it safe from someone like myself to assume that this is the exact same procedure that a patient would undergo in terms of the severing of the tissue away from the other organs? The only difference with this procedure, as opposed to the old-fashioned way, is that it's all being done through this one single incision. But the anatomy that's taking place inside is exactly the same as a traditional hysterectomy. DR. JOHN DIAZ: That's correct, Diane. It's the same steps. We're using the same basic surgical principles, but we're applying it through a different instrument. We're using the robot to assist us in the surgery, again, resulting in more precise movements, less blood loss. But it's the same basic surgical principles, and it's the same basic procedure. DIANE MAGNUM: Now, do you have a problem with some of your patients wanting to do too much too soon? Because as opposed to the old days where they had that big scar across their abdomen to remind them that they just had major surgery, your patients are going home with a little suture in their belly button. And they might not realize how much work has actually been done internally during the surgery? DR. JOHN DIAZ: You're right, Diane. When we see patients in the office following this procedure, they're oftentimes asking, well, what can I get back to my pilates, and when can I get back? I feel great. And you have to remind them that yes, you feel great, the incisions are healed, but you did undergo a major procedure, and you do need to take a little bit more time off to allow everything internally to continue to heal. DIANE MAGNUM: And can you tell us what's happening now just with the robotic arm and what's being done there? DR. JOHN DIAZ: We're changing instruments. That's Dr. Prada who you see who's inserted back to the bipolar and monopolar instruments for Dr. Estape after inserting the suction irrigator device. And you see how quickly Dr. Prada's able to switch between the instruments that Dr. Estape needs. DIANE MAGNUM: So Dr. Estape never has to leave monitoring the surgical station that he has across the room during the course of the surgery? DR. JOHN DIAZ: Correct. Once we sit down, take a surgical console we're immersed in the surgical environment, with our bedside assistant handing any exchange of the instruments. So we never have to leave that console until we've completed the case. DIANE MAGNUM: So how long has this particular procedure been performed here at Baptist Health? DR. JOHN DIAZ: We performed our first single site surgery about two months ago. And in that time, we've performed over 38 cases at South Miami Hospital. DIANE MAGNUM: And you've been pleased with the results all along. What kind of extra training have you and Dr. Estape and other surgeons here at Baptist Health had to undergo to become proficient at this particular procedure? DR. JOHN DIAZ: Well again, there is a learning curve. The company that makes the robot and provides the single side trocars does provide for additional training, specific mostly to the use of the trocar and the installation of that single side trocar. But again, it's the same basic surgical principles. So really the adaptation is in placing that single site. DIANE MAGNUM: So as a patient, if I'm faced with a diagnosis and a treatment plan of a hysterectomy, how do I go about choosing the right surgeon and the right procedure to fit my particular health needs? DR. JOHN DIAZ: Well, I think choosing the right surgeon's obviously a very personal and important questions that you make. Get recommendations from friends who have undergone this procedure, see what their experience was like. There's plenty of information now on the internet as far as to surgeon experience, where did they train, and what their outcomes have been. And when you go see your doctor, your surgeon, ask your questions. How long have they been performing this procedure? What have their complications been? How many of these procedures they've done. And you can always ask them if they'd allow you to speak with other patients who've undergone this procedure and get their experience with this. DIANE MAGNUM: Dr. Estape, I'd like to come back to you and just find out where we are now in the procedure. DR. RICARDO ESTAPE: I'm almost to the last portion-- that's fine. It's good right there. It cleared itself. I'm getting to last part. You can see here's the uterus up here now, the ovaries here. Everything from side to side has cleared up. The only thing that isn't cleared up right here is this colon that I need to just finish freeing up right here. Once I free this up, we'll almost be at the point-- because it was so stuck, I like to take down the lateral tissue first. Clean it up as far as I can lateral, and then it will sort of now fall away from the field. DIANE MAGNUM: Just let gravity work in your favor. DR. RICARDO ESTAPE: Yeah. If you try to do that too early without going laterally, then it won't fall away, it'll stay attached to all the lateral tissue. And usually when we're dealing with the colon, it's easier to go out laterally. Just like we had bad scar tissue on the bladder, go out laterally and get away from the area where it truly is stuck at. DIANE MAGNUM: Now Dr. Diaz, Dr. Estape said something before about sending some fluid out to pathology. Is the tissue also sent about pathology post-surgery to find out if there's anything suspicious? DR. JOHN DIAZ: Yes. The entire specimen we send to our pathology service. They'll look at the uterus, the cervix, and particularly the ovary and fallopian tube that we're concerned about. And they'll be evaluated and make sure that there's no evidence of either a malignancy or pre-malignant condition. DIANE MAGNUM: We have another question from a viewer wanting to know if there are any stitches externally. I think you answered that before, but they just tuned in. So if you wouldn't mind repeating that. DR. JOHN DIAZ: Yes. When we'd finally closed the 2.5 centimeter local incision, there are no external sutures. We use a dissolvable suture inside. And we place a little bit of glue, it's almost like a Superglue over the incision. So once that heals, there'll be no external sutures to visualize. And the scar is hidden inside the [INAUDIBLE], really no visible scar. DIANE MAGNUM: It's amazing just to watch this surgery taking place, and how easily Dr. Estape is able to maneuver that equipment. DR. RICARDO ESTAPE: We're about to almost finished releasing the uterus, and then we'll have Dr. Prada take it out through the vagina. So here I'm coming out almost through the back part of the cervix. DIANE MAGNUM: And as we watch you continue, we have another question from a viewer wanting to know what percentage of surgeons are robotic surgeons. You're still part of a rather small fraternity, aren't you? DR. JOHN DIAZ: I think it's a great question. We're very fortunate here in the Baptist system, we have one of the largest robotic centers nationally. We've performed over 19,000 surgeries since we started this program back in 2006. We currently have over 50 surgeons who are trained in robotic surgery. And we do about 3,000 robotic surgeries a year in the Baptist system. We have nine robots throughout our hospitals, five here at South Miami Hospital. So we are a very prolific robotic surgery program. And again, that's one of the most important things in choosing your surgeon. You want someone that has experience and a center that's devoted to this technology. DIANE MAGNUM: You just answered my next three questions, why somebody should come to Baptist Health, why experience is so important, and just the scope of robotic surgery offered by this world-class health facility is truly astounding. Living here in South Florida, we're very fortunate to be exposed to that, aren't we? DR. JOHN DIAZ: Absolutely. And again, with over 50 surgeons performing robotic surgeries, we're one of the busiest and most prolific centers in the United States, and we cover all specialties. Obviously, we're watching gynecologic surgeries here, gynecologic oncology surgeries. Previously we saw general surgery with the [INAUDIBLE]. Our thoracic surgeons are utilizing this technology. Our throat doctor is using this technology, urologists. So really it's been adopted by many of the physicians here in the Baptist system. And again, we're one of the leaders in the United States in performing these surgeries. DIANE MAGNUM: And I think it's amazing that in these economic times this robotic center is expanding by leaps and bounds, is it not? DR. JOHN DIAZ: Absolutely. And that's a credit to Baptist Health and their belief in these sort of procedures. And really it's a benefit to the patients. Again, that quick a return to work-- instead of having to take six weeks off, you're taking two to three. And return to your daily life, getting back to your family and friends and enjoying your activities. So the true benefit of this are the patients. There's no extra cost to the patients undergoing a robotic procedure versus standard laparoscopic or an open technique, but you get all the benefits of robotic surgery. DIANE MAGNUM: And really, the cosmetic benefit is huge for a lot of women, especially younger women who find themselves faced with this surgery. DR. JOHN DIAZ: Absolutely. No one wants to have surgery and have a visible scar. And even though the scars are very small with traditional robotic approach, you're talking about 8 millimeter incisions. Nonetheless, if you can avoid a scar, I think most women, and men as well, would prefer not to have that scar from a surgical procedure. DIANE MAGNUM: Dr. Estape, you've been doing a lot of work while Dr. Diaz and I have been talking here. Can you tell us where you are now in the procedure? DR. RICARDO ESTAPE: We're right in the back part. We finally got the colon out of the way, colon is down here. And here, if you just stick with me for two seconds, you can just see the vagina, the uterus, completely released from the vagina. So here we see the hysterectomy's completed. So now Dr. Prada is going to take out the whole specimen through the vagina. DIANE MAGNUM: All right, we're going to stand by to take a look at that. DR. RICARDO ESTAPE: All right, go ahead. So now he's pulling it out with the manipulator we put in. DIANE MAGNUM: And again, this is one large piece of tissue that's all coming out in one piece because of the way you dissected it. DR. RICARDO ESTAPE: Yeah. And here he's pulling it out. Here's the ovary right here. The uterus is right here. And in a moment you'll see it just slip out through the vagina, and there it goes. DIANE MAGNUM: And that's it? DR. RICARDO ESTAPE: And that's it. DIANE MAGNUM: And what needs to be done to the cavity? It's all taken care of already? DR. RICARDO ESTAPE: No. Now we're going to close this vagina. We're going to suture it back together. DIANE MAGNUM: I see. DR. RICARDO ESTAPE: Which has been one of the bigger problems that we've seen with single site. Because in the normal robotic surgery, you have wristed instruments that can sew a little bit easier. Here we've had to create a little bit of a different technology, a different technique to be able to close it up a little bit easier. So give me needle driver and crocodile. DIANE MAGNUM: So in other surgeries-- DR. RICARDO ESTAPE: Actually, give me suction irrigator a second. DIANE MAGNUM: I'm going to let Dr. Estape do what he's doing right now. Dr. Diaz, in other surgeries what Dr. Estape has said is the surgeon doesn't generally have to suture internally. Did I hear that correctly? DR. JOHN DIAZ: Well, one of the most challenging aspects of a traditional laparoscopic surgery is suturing inside the abdomen, what's called intracorporeal suturing. And that's one of the things that really limited the adaptation of laparoscopic surgery, particularly to the field of GYN where after a hysterectomy we need to close the vaginal cuff with suturing. Robotics has allowed us to do this through the same motions we do through an open technique. And so suturing has become much easier task using the robotic system versus traditional laparoscopic approach. DIANE MAGNUM: Again, I think it sounds like a whole new skill set to be able to do that internally. DR. JOHN DIAZ: There's certainly an adaptation, and you need to grow as a surgeon to do this. But again, with robotics we're allowing those traditional surgeons who maybe didn't train with laparoscopy when they were younger have been able to adopt a minimally invasive approach and they'll offer these benefits to their patients. DIANE RAGNUM: So is ongoing education a regular part of doctor participation at Baptist Health? DR. JOHN DIAZ: Absolutely. We often have physicians from around the country, and actually around the world, join us in the operating room to observe our techniques. And even some who are already robotically trained, they're trying to improve their times and improve the quality of their surgeons. And we're happy to share with us the techniques that we've learned to help develop these programs, both outside of South Florida and outside the United States. DIANE MAGNUM: So Baptist Health is not only a world-class medical facility, it's also a teaching facility? DR. JOHN DIAZ: Absolutely. We often have fellows, residents, and again, physicians who are in their 50s and maybe didn't train with the technology who are now coming to learn from us some of the techniques that we've developed to help provide this for the patients that they serve. DIANE MAGNUM: So is it my imagination, or with this laparoscopic robotic surgery medicine seems to have jumped by leaps and bounds in the last 10 years? DR. JOHN DIAZ: You know, again, I think it's the evolution of laparoscopy. And we're offering minimal invasive surgeries to patients who traditionally required an open technique, and the benefit is for the patients. DIANE MAGNUM: Now, as we go back to the wide shot of the operating table, what are we looking at now? I see some activity going on. DIANE MAGNUM: We'll see there Dr. Prada will be introducing now-- well, the camera's going to get cleaned first and that takes a few seconds. And then he's going to be introducing this suture which will be used to close the apex of the vagina. DIANE MAGNUM: And how long does the suturing take, Dr. Estape? DR. RICARDO ESTAPE: It generally takes about 10 minutes to close up the vagina completely. DIANE MAGNUM: About 10 minutes? DR. RICARDO ESTAPE: Yeah. With regular robotics, you can do it in about three or four minutes. With this one, we've had to develop a different technique to close it, because without the wristed instruments it just becomes a little bit more difficult. But you'll see we can still get it done. We'll get it done in two layers. We use an interesting suture. It's a barbed suture, almost like if it was a fish hook. Fish hook, once the hook goes into the fish it won't come back out, it's a one-directional hook. And this one is the same thing. I don't know if you can see there with the magnification, it's got these little specks throughout the suture. Clean that camera again, please? DIANE MAGNUM: So about 10 minutes to do the internal suturing. And then, Dr. Diaz, how long to do the final suturing in the belly button? DR. JOHN DIAZ: The external suturing takes about another five to 10 minutes. We begin by closing the fascia to help prevent also the development of any hernia. We then do a two-layer closure to close that umbilical incision. And like I said, the final step is applying that Superglue which helps in the healing and to help reduce the chance of developing a scar in that incision. DIANE MAGNUM: And we talked about the patient's marching orders going home, but we didn't talk about sexual activity. Post-hysterectomy, what are your marching orders for your patients concerning sexual activity? DR. JOHN DIAZ: Again, we ask our patients to wait at least four to six weeks before indicating vaginal intercourse. And again, you see there's a scar line that's going to form here at the vaginal apex, so we don't want to put any undue trauma or stress to that scar line while that heals. But once the initial healing period is over, patients are able to return to a normal sexual activity. And having a hysterectomy for them really has no impact on sexual satisfaction or sexual ability. DIANE MAGNUM: And what's the rate of post-surgical complications? It seems like they would be very low, considering how much this procedure has progressed over the years. DR. JOHN DIAZ: Absolutely. With the robotic technique, we've looked at our incidence of complications following robotic surgery here in the Baptist system, and we're looking at about a 0.03% rate of surgical complications. So it's not none, there are some risks. But it's certainly much less than 1%. DIANE MAGNUM: That's astounding. DR. RICARDO ESTAPE: And Diane, I can add to that, too. Because that's been all over the years lately. Even yesterday in the New York Times they were talking about under reported complications and complications due to robotic surgery. Well, it's really not complications due to robotic surgery, it's complications due to surgery. There are no unique complications to robotic surgery that you don't see in open surgery or see in laparoscopic surgery. DIANE MAGNUM: I see. DR. RICARDO ESTAPE: The difference is that I think to me what's going on is that most people are seeing this company that's got some money and I think attorney's are going after it. That's just my own opinion. I have got nothing to do and no qualms with the company, but it's becoming a real problem because every time you open up a thing in a newspaper or a journal they're talking about complications. There are over 3,000 papers on robotic surgery, and not a single one of them has a higher complication rate with robotic surgery. DIANE MAGNUM: Wow. DR. RICARDO ESTAPE: What we are seeing though is that laparoscopic surgery had the same rate for the last 20 years. About 10% to 15% of all GYN cases were done laparoscopically. That hasn't changed because it's a difficult procedure. What we're seeing now is that we're doing a lot more complex procedures, and still the complication rate is very low, much lower than if we were to do an open. It's almost a 10-fold lowered rate of complications by doing it robotically than by doing it open. And so where all this information is coming from, it's just misinformation is being put out there about complications of robotic surgery. We just don't see that. We publish papers on it. Everybody else has published papers on it. You just don't see a higher complication rate with this type of procedure. It's the same as any other type of procedure, but a lot lower than open. DIANE MAGNUM: It's astounding. Dr. Estape, if you could just tell us a little more about exactly what you're doing now? DR. RICARDO ESTAPE: We're finishing closing up the vagina now. We're just trying to get to the angles here. If you had wristed instruments, you could almost turn your wrist and put suture where you wanted. Here you almost have to bring the tissue to your suture to be able to come through. So it's a little bit of a different learning curve-- where you grab, where you pull, what you do so you can get through the closure a little bit faster. This was probably the one part of the technique that took us the longest to learn how to do this. But we've been able to do it now pretty efficiently. DIANE MAGNUM: Well, I was going to ask you that, Dr. Estape. How long before you felt proficient in this? DR. RICARDO ESTAPE: I think with this part, once we got to probably about the 10th, 12th case I started going to this, I would come in at times at night and just work on materials, trying to figure out a faster way of sewing it up without having to use wrist. And this is almost going back to laparoscopic techniques of bringing the tissue to where we needed to have to put the suture in, not the other way around. You can't take the needle to the suture, you have to bring the tissue to the needle. DIANE MAGNUM: So I'm going to ask you what may be a politically incorrect question, Dr. Diaz. But if you have an OB/GYN who's been performing hysterectomies the traditional way, or laparoscopically without the use of the robot, and you're watching this broadcast now and you can see the benefits of using the robot, how do you go about finding the surgeon to be right for you if it's not the doctor you've been seeing for 10, 15, 20 years? DR. JOHN DIAZ: Well again, there's a lot of information on the web. Baptist has a great website with a lot of information as to the different surgical disciplines that we have that utilize robotic surgery, so that's a great place to start. And again, ask your friends-- as you state, you're in that age group now where women are having these procedures done-- what their experience was like. But it's not hard to find a robotic surgeon. And like I said, when you meet with your doctor, ask those questions. How many of these procedures have you done? What is your complication rate like? And ask them if they could speak with someone who's undergone this procedure and get first-hand knowledge of what that experience was like. DIANE MAGNUM: And within the surgical community itself, even those doctors who are not trained in robotics, they could certainly see the advantage of this kind of procedure. Would they recommend a robotic surgeon more likely than not? DR. JOHN DIAZ: Well, you would hope that your physician has your best interest in mind. And I think there's no question that minimum invasive surgery, be it traditional laparoscopic or robotic surgery, has an advantage over an open technique and your doctor would point you in the right direction. DIANE MAGNUM: Dr. Estape, because this procedure was a little more involved than normal, your patient has been under anesthesia for a few minutes longer. Is she going to be more sore than the average patient when she wakes up later today because you had to do a little extra work inside? DR. RICARDO ESTAPE: Probably the bowel might be a little bit slower to recover because we had to release this colon right back here from the back. But really, it won't be anything appreciably different. And every patient to me has been different. Some I do massive surgeries on, and they're already walking around the same afternoon and ready to go home. But in her, we probably are going to be an extra 15-20 minutes in a normal case, but that's probably not going to add to her post-op recovery. DIANE MAGNUM: We have another question from a viewer. This viewer wants to know, why don't these instruments have wrists? That sounds like a medical student question to me. DR. JOHN DIAZ: You know, that's a great question, and one we've asked the company ourselves. One of the big advantages of robotic surgery is that the traditional robotic surgeries have wristed instruments. What this allows us to do is have complete mobility inside the patient. So again, one of the big advantages over traditional laparoscopies you have these instruments that move just like your hand and your wrist move. So it is a limitation of this initial phase of minimum invasive single site surgery where the instruments do not have wrists. But we've been assured by the company that they're working on these wrist instruments. But as you can see, even without having the wristed instruments, Dr. Estape was able to complete what was a fairly complicated hysterectomy in a patient who had previous surgery, dense adhesions, in just under an hour. DIANE MAGNUM: So how many of these procedures would you or Dr. Estape perform any given day here at Baptist Health? DR. JOHN DIAZ: Dr. Estape and I have a pretty busy practice. In the given week, we perform anywhere from 15 to 20 robotic procedures a week. DIANE MAGNUM: As you said, this is a very busy robotic center here at Baptist Health. Aside from gallbladder, and you said some thoracic surgeries are being performed as well, what else is being done robotically here? DR. JOHN DIAZ: At our center here, general surgery is using this for gallbladders, some colon surgery, our thoracic surgeries, for lung surgeries, urologists are using this for prostate surgery, the gynecologists and gynecologist oncologists for all of GYN's surgeries. In addition, we have our ear, nose and throat doctors who've started to use this for some of their surgeries. So we have a very robust program. DIANE MAGNUM: And you obviously believe this is the future of medicine, not only here at Baptist Health, but around the world? DR. JOHN DIAZ: Absolutely. I think this has been the evolution of laparoscopic surgery. And for those people who don't perform robotics but are able to offer their patients a minimum invasive approach with laparoscopy, I say fantastic if that works for you. Robotics is simply another platform. It's my preferred platform. Both myself and Dr. Estoppe are trained and are very comfortable with laparoscopic surgery. But there's no doubt for the complicated cases, the advantage that the da Vinci System robotics offers us and our patients is bar-none superior to what we can do with traditional laparoscopy. DIANE MAGNUM: If we can go back to our surgical shot and see what's happening now. Dr. Estape, how much more do you have on the interior suturing? DR. RICARDO ESTAPE: Probably just have about two more bites left over here to finish closing up this vagina. We're almost all the way across on our second layer. We could get one layer already on the vagina. And you can see here, there's a thick layer that was inflamed probably from the old endometriosis that she had back here. You can see the colon being right here on this part coming right behind. We're almost all the way across to this corner of the vagina, so we just need to finish closing up this vagina. So probably two more bites, and we'll be done here with the closure. DIANE MAGNUM: And again Dr. Diaz, speak to why this suturing is so very important. I would assume these are permanent sutures? DR. JOHN DIAZ: Actually, Diane, these sutures will dissolve. DIANE MAGNUM: They will? DR. JOHN DIAZ: You wouldn't want to use permanent suture at this point in the vagina. Again, you may interfere with intercourse, either some discomfort for the patient or her partner. So these sutures will dissolve once a healthy vaginal cuff has healed. And these are the same suture types that we use for our open techniques. DIANE MAGNUM: So how long would it take for a suture to dissolve? DR. JOHN DIAZ: For these patients, we ask them to preclude from any sexual activity for four to six weeks at least. DIANE MAGNUM: And so the sutures would be gone by six weeks? DR. JOHN DIAZ: Absolutely. DIANE MAGNUM: Oh, no kidding? Well, the technology is amazing. And the fact that we can see inside the body with such a clear field of vision, I mean the picture is spot-on perfect. I can understand why doctors would gravitate to this kind of technology. It's almost even better than standing over an open surgical field. DR. JOHN DIAZ: Absolutely better than standing over an open surgical field. Again, we can get 10 times the magnification from traditional laparoscopy, much less an open procedure. The picture we're seeing is good quality, but inside the robot console where the surgeon sits, you have a 3D image and you have high definition. DR. RICARDO ESTAPE: And talk about surgeon comfort, too, after doing eight or 10 cases a day. DR. JOHN DIAZ: I'm sorry, Ric, I couldn't hear you. DR. RICARDO ESTAPE: Talk about surgeon comfort, too, after doing eight or 10 cases a day. DR. JOHN DIAZ: Well sure. One of the things probably that we don't talk enough about, from a surgeon's standpoint, the ergonomics of sitting down comfortably performing this surgery is a huge advantage to the surgeon. As we've said, we perform anywhere from 15 to 25 robotic surgeries a week. The lack of surgeon fatigue because of these techniques has helped. There's no doubt in a heavy traditional laparoscopic surgery, you suffer certain fatigue. I've had colleagues who have had to require surgery, injuries to their rotate cuffs, because of the demands for some of the complicated laparoscopic cases we were performing. DIANE MAGNUM: That's amazing. We had another viewer question who perhaps missed the beginning of our broadcast wanting to know how many robotic arms are used over the course of the surgery. DR. JOHN DIAZ: In this particular surgery, we have two robotic arms that Dr. Estape's controlling. You can see them there with the neon green. There is a third arm that's controlling the camera-- you see it there in the center. And then we have an additional port inside our single site where our assistant can bring in additional instruments to help. There is another arm that isn't utilized during the singe site surgery which we use for our multi-site robotic surgeons. DIANE MAGNUM: And again, as we're watching these arms move around, it is Dr. Estape sitting at the console who is making all those movements happening. DR. JOHN DIAZ: Correct. Dr. Estape's controlling those arms. And what you're seeing is that, as you notice, the arms move on a pivot on the patient. That again results in less discomfort for the patient, versus traditional laparoscopy where the surgeon and his assistant are holding the arms, oftentimes causing a little bit more trauma, a little bit more pain at the surgical sites. So this procedure is much more precise than we would be as humans. DIANE MAGNUM: And it looked like we just saw some fluid going into the abdominal cavity. What were we looking at there? DR. JOHN DIAZ: There, Dr. Estape was irrigating the area. We've completed our surgery now. We want to check to make sure that there's excellent hemostasis, in other words, there's no bleeding at any of the surgical sites. And now that we're satisfied there's no additional bleeding, what Dr. Estape is going to use here is a product which adds an additional layer of sealant over the area for all the raw tissue. And again, it's the second layer to ensure that there's no additional bleeding at the completion of the procedure. DIANE MAGNUM: And is this also how that extra anesthesia is administered? DR. JOHN DIAZ: No. This is inside over the surgical areas. The extra anesthesia will be injected into the incision site to help with immediate post-operative pain. DIANE MAGNUM: I see. And are there any side effects to being under anesthesia for an hour? Any drowsiness over the next few days or lethargy because you've been under general anesthesia? DR. JOHN DIAZ: This patient will go to recovery room. And within about 35-40 minutes you'll see her. We'll be able to talk to her about the findings at the time of surgery. This evening she'll be eating, she'll be walking around. And in fact, some centers are actually discharging these patients on the same day of surgery. DIANE MAGNUM: The same day after all this surgery? DR. JOHN DIAZ: Here at Baptist we'd like to keep them overnight just for observation, but certainly something to consider. DIANE MAGNUM: And what are we seeing now? DR. JOHN DIAZ: The surgery now is complete. You can see the teams removing the robotic arms. Dr. Estape now will leave the surgical console. He will scrub again and join his assistant at the bedside to complete the surgery, closure of the fascia, and close the incision site. DIANE MAGNUM: So this whole robotic system wheels back away from the patient and the doctor has direct access once again to his patient? DR. JOHN DIAZ: Yes, ma'am. DIANE MAGNUM: And again, you said that only takes about five or 10 minutes once he comes back up to the patient in terms of closing up the surgical site. I'm just going to move out of the way a little bit, because some of the surgical team needs to get around us here. Once again, Dr. Diaz, if you wouldn't mind coming over and just talking about the size of the single incision. If anybody missed at the beginning of the program, just if you could hold up to the camera, let us know how large the incision is itself. DR. JOHN DIAZ: Yeah, the incision itself is only a 2.5 centimeter incision on the umbilicus. You're looking at an incision about that big, compared to your traditional 12 centimeter incision made from a [INAUDIBLE] skin incision which is visible in the abdomen. This is going to be hidden in the belly button. This is why some have dubbed this "scarless surgery." DIANE MAGNUM: It really is scarless. I mean, there is going to be no indication that she had any kind of surgical procedure on her abdomen once she is healed from this one inch and a half incision. DR. JOHN DIAZ: Like I said, we've done 38 of these surgeries here at South Miami Hospital. And the patients have been very satisfied with the cosmetic results. DIANE MAGNUM: That's wonderful. All right, Dr. Estape is already back at his patient. Let's take that shot and hear from the doctor about what's happening now. DR. RICARDO ESTAPE: Well, you can see now, you have the overhead shot, we're going to start closing up the abdomen again. DIANE MAGNUM: We just need to adjust the light. We're missing the overhead shot just at the moment. But Dr. Estape, if you could go ahead and just explain to us what's happening. DR. RICARDO ESTAPE: All right. So what I'm going to do now is, because the incision is 2.5 centimeters, I'm going to close the thick part of the skin underneath called fascia, which is what actually keeps hernias from happening. We're going to close that up now with three stitches. DIANE MAGNUM: And that's the important closure, is it not? DR. RICARDO ESTAPE: That is correct. That's the important layer to make sure you close, everything else is cosmetic. But this layer of fascia has to be closed to prevent hernias. DIANE MAGNUM: And we're just adjusting the light there so that we can see the overhead camera. We're not seeing it. OK, we'll continue along and just describe it as we tell our viewers at home exactly what's happening. Dr. Diaz would you just explain what Dr. Estape is doing? DR. JOHN DIAZ: Sure. So right now, Dr. Estape is closing the fascial incision. This is what obviously separates the innards from the outters. And we'll do this in three stitches to add some strength to the incision. Once he completes that, we'll then close the next layer, the subcutaneous tissue under the umbilicus. And then we'll do a final layer on actual skin incision. And when all is said and done, you'll see just a very small infraumbilical incision hidden inside the umbilicus there. DIANE MAGNUM: So it's plastic surgery at the very end of this procedure to make it look like any other belly button. DR. JOHN DIAZ: Absolutely. Here you can see Dr. Estape placing this suture through the fascia, and this is what holds the incision together and to bring strength to this incision. DIANE MAGNUM: And again, the skin is just stretched there. So once the skin is no longer stretched, it will look just like any other belly button. DR. JOHN DIAZ: Absolutely. And you'll see once Dr. Estape completes the case, there'll be some swelling just from the immediate procedure. But when patients come to see us two weeks after surgery, the swelling has dissipated. And when we take off the bandages, again, you'll see that they're very satisfied with the cosmetic result. DIANE MAGNUM: Would you mind explaining fascia to our viewers at home. Some people are not aware of what you're talking about there. DR. JOHN DIAZ: Fascia is that layer next to muscles that kind of holds the muscle together. So in order to gain entry into the abdomen, we have to make an incision in that area called the fascia. And then once we're done with our surgery, we then bring that fascia together. And again, as we spoke before, these are basic surgical principals. So whether it's an open approach, a laparoscopic approach or robotic approach, we bring this fascia together to help it heal and help prevent any future hernias developing at the incision site. DIANE MAGNUM: Boy, just looking at the speed of how you're working over there, it's just astonishing. How long has the umbilicus been used as a portal for surgery? DR. JOHN DIAZ: The umbilicus has been used as a portal for minimalistic surgery since its inception. This is where the camera would go traditionally for a laparoscopic procedure. And again, it adds from a cosmetic result. You can gain entry into the abdomen with minimal scarring for cosmesis. And this is what makes it a great entry point for this single site, or as it's been dubbed, "scarless surgery." DIANE MAGNUM: So Dr. Estape, when you go out and speak to this woman's family about how things went in here today, your comments will be what? DR. RICARDO ESTAPE: Oh, I think everything went real well. I'm still waiting for the pathologist to call me back. I think it's going to be benign. But I'll let him know that everything went well but she had more scar tissue than we thought she was going to have. Had to do a little bit more work around the colon to get it down. But I think overall everything went really well. DIANE MAGNUM: But even with all that scar tissue, you still believe this was the best procedure for this patient? DR. JOHN DIAZ: Absolutely. DIANE MAGNUM: And Dr. Estape, I asked Dr. Diaz this, but I'm going to allow you to sing the praises of your team here at the robotics center. Why should a patient comes to Baptist Health over other medical centers? DR. RICARDO ESTAPE: Well, if you look at down here in South Florida, we started the program here in 2006 when it was first approved for GYN surgery. We have developed all types of protocols for safety of patients, to improve training, to train ourselves, to train our colleagues. We've been pretty inclusive about training and following up, making sure we're monitoring our complications, we're monitoring our follow-up. All the surgeons that do robotic surgery throughout the entire Baptist Health system sit here, and come to our committee meetings, and follow-up on all these patients. And if you look at the data on robotic surgery, we have been in the top three in the world in number of cases now from the very beginning, really from 2007, 2008 forward. So we have the most experience here. Some of the most experienced surgeons we have. Our guys are called all the time to go and lecture. We lecture throughout the world. We lecture here. We have training programs here. So we're not just robotic surgeons, we are a true robotic training center. DIANE MAGNUM: Top three in the world, that is certainly something to brag about. And again, if you could just explain what you've done right there? DR. RICARDO ESTAPE: Well, now I'm starting to put the belly button back together. You see her base of the belly button there. So now you start to see the belly button take shape again. DIANE MAGNUM: Right. DR. RICARDO ESTAPE: So we're going to start bringing this back down so that it takes shape again. And you're going to see once we finish it'll be just this little circular incision. DIANE MAGNUM: Dr. Estape, are you astounded sometimes when you look at the medical field you came into at the beginning of your career, how far it's come just over the course of your career? DR. RICARDO ESTAPE: There's no question I am. I did my original training with biomedical engineering, so I've been a technodweeb for a long time. So clearly, robotics was an easy transition for me. But every other specialty in the world, no matter what industry you're at, has taken advantage of technology. Why have surgeons been so reluctant at times to take advantage, to see new things coming in, when there's lots of companies working to try to help us out? Why can't we be more comfortable at the bedside? Why can't we have more magnification? Why can't we take advantage of all the things that every other industry has taken advantage of. And to me, in my hands and Dr. Diaz's hands, I think we can do better surgery. We can do more radical surgery. We have the same outcomes if not better outcomes. We can do more lymph nodes on the patients. So to me, it's a whole lot better this way. To be able to get the advantage to the patient, and to be able to get even more technology down the road that'll advance even further. We have some things coming down here on robotic surgery where we use fluorescence imaging to be able to find the ureter, to be able to find the sentinel lymph node, to be able to find nerves, to make sure that we spare nerves when we do this kind of surgery. Why do we have to be stuck to an old knife and standing at the patient's bedside all the time when we're dealing in a micro world with micro blood vessels? One of the most difficult things for people to understand and for surgeons when they start learning this, is that now you're seeing more blood vessels, more nerves, more structures, more anatomy than you ever saw in your whole life because you have more magnification. DIANE MAGNUM: Right. And you talked about this being a world-class medical training facility. I would suspect that a lot of your patients are also coming in from overseas because you offer this service. DR. RICARDO ESTAPE: That is correct. About 10% of my practice is from outside of the three county area. And about half of that is international that comes in for the surgery. So we do have a significant amount of outside patients that come in for all types of surgeries, whether it's cancer surgery or benign surgery, that'll come here to have it done. And a lot of them, we've gotten pretty proficient at doing the complex cases because a lot of them are sent over because they found out that they could have robotic surgery, but there was nobody skilled enough to take on their 20 centimeter uterus, or their 30 centimeter ovarian mass, or their cancer that they have. And so I usually don't get simple cases. We usually get the more complex cases here. DIANE MAGNUM: So you're looking at cases other doctors just don't want to delve into? DR. RICARDO ESTAPE: That is correct. And we've been very open with other physicians. We train them. We show them what to do so they can learn how to do robotics. But still it becomes sometimes they're so complex that they'll still send them over to us. I don't try to steal cases. We want to teach. We do it because it's the right thing for the patient. So we've been very inclusive with all our surgeons here, with all our physicians in the Baptist Health System. We've been inclusive with all the ones that come here to train. And by doing this, we've actually increased our number of referrals, because they know what they can do, their limitations, and they know what we can do. DIANE MAGNUM: Again, I'm just amazed watching you work here and how you're closing up this operating area. It wasn't a very large incision to begin with, but in just a matter of a few minutes, you've recreated this woman's belly button. DR. RICARDO ESTAPE: Yep. And she'll have a scar that we'll be able to see. Let me just speak with the pathologist real quick. Yes? DIANE MAGNUM: What about discomfort caused by the gas that was inserted to expand the surgical area? Is that significant, post-surgery? DR. JOHN DIAZ: It is one of the common occurrences that can happen following laparoscopic surgery. We follow a few protocols here to try and expel all that gas with the assistance of our anesthesiologists and the ventilation system that we use to try to minimize those side effects. DIANE MAGNUM: And how quickly post-surgery will this patient be awake? DR. JOHN DIAZ: This patient will be awake before she leaves the operating room. So once we finish our incision closure, we'll let the anesthesia team know. They will wake the patient up. And like I said, on her way to recovery she'll be awake. We'll speak with her about 30, 40 minutes after, let her know how everything went at the time of surgery. She'll be having dinner tonight and walking the halls of the hospital. DIANE MAGNUM: Oh, my gosh. Now, how uncomfortable is she going to be having to walk the halls of the hospital? DR. JOHN DIAZ: You know, it's been shown that patients with this minimum invasive approach have a much smaller requirement of pain medications post-operatively. So she'll have some discomfort, and she'll have the option of whether she'll need, like I said, just some over the counters-- either Tylenol, Ibuprofen, or whether she'll need something a little bit more for her pain control. DIANE MAGNUM: And it sounds like we're putting in just the last few sutures here. DR. RICARDO ESTAPE: I got the call back from the pathologist, and she had a benign fibrothecoma of her ovary, which is a benign mass. So it's great news for her. DIANE MAGNUM: That's excellent news. And again, just to finish up here Dr. Estape, you'll finish these last couple of sutures, and then you're going to put what on top of this surgical area? DR. RICARDO ESTAPE: Then what we'll do is we'll put a little gauze inside the circular part of the belly button. She really didn't have an outie or an innie. She sort of had a flattie. So we're going to put a very small gauze in the inside, and then cover it all with a clear tape just to keep the entire incision covered. DIANE MAGNUM: All right, wonderful. As we close out our procedure today, I'd like to thank our doctors for what's turned out to be a truly informative hour. By the way, if you missed any part of this surgery, you can always tune in to BaptistHealth.net and see the entire procedure anytime, day or night, 24/7. I'd like to thank our doctors, everybody on the surgical team today. I'm Diane Magnum. For everybody here at BaptistHealth.net, we hope you'll consider us the next time you face any kind of medical issue. We hope to see you here also next time on BaptistHealth.net. Take care.