Latest / Behind The Knife: The Surgery Podcast / Clinical Challenges in Minimally Invasive Surgery: Emerging Robotics and Adapting Laparoscopy – An Interview with Dr. Jim Porter
Transcript
- BTKRoboticsFinal === [00:00:00] Before we start to show this episode is gonna feature an interview with a prominent leader at an industry partner at Medtronics. Because of that, we would like to disclose our conflict of interest of the start of episode. For this discussion, Dr. Porter is a Chief Medical Officer at Medtronic, and I am an consultant for intuitive surgery. Hi everyone, and welcome back to another episode of Behind the Knife. I'm James Jung, a minimally invasive surgeon at Duke University, and I'm joined today by Joey Lev, one of our research residents at Duke University. So when we talk about minimally invasive surgery today, the landscape of things, we're not talking about just the future that's coming. We're talking about a shift that's already here. The robotics platform has moved from a nice to have. To a dominant force across many procedures and hospitals. We're really at an inflection point with robotic platform. And to help us unpack what's driving that change and what's coming next, we're [00:01:00] thrilled to be joined by Dr. Jim Porter, chief Medical Officer of Robotics and digital technologies at Medtronic, and a pioneer, pioneering, minimally invasive urology surgeon. So Jim, welcome to the show. Thank you, James. Really pleasure to be here. Okay, so before we get to the meat of the conversation with Dr. Porter, foreground our discussion. Joey, why don't you talk a bit about the paper for discussion today, which is entitled The Death of Laparoscopy ab? Absolutely. This is a retrospective observational study using a CS NSP data from 2012 to 2023 to look at utilization of laparoscopic versus robotic technique for a variety of operations. This is an update to the study of the same name published in 2021. The article touts several benefits of robotic surgery, including enhanced dexterity, precision control, visualization, and integration opportunity with AI and telesurgery with laudable goals such as improving patient outcomes, shortening the learning curve, and expanding access to complex procedures. Essentially, they found that where robotic [00:02:00] surgery already has an edge over laparoscopy is in neurologic procedures like prostatectomy, nephrectomy, and cystectomy. Its expansion has only continued. In some surgeries such as proctectomy, pancreatectomy, and esophagectomy, robotics is surpassing laparoscopy for the first time, but an open approach remains very common. Finally, where laparoscopy remains dominant as the minimally invasive approach, such as in colectomy and hepatectomy, robotic surgery is still expected to surpass it by the end of 2026. In other words, robotic surgery is the future of minimally invasive surgery. Joey, I think that's a fantastic summary of this article. I'm really thrilled that Jim has joined this episode because not only is Jim, uh, a chief medical officer for a major player in this robotic platform and robotic industry, but you've had a long journey in MIS and especially adoption of robotic platform from very early on. So. Jim, I'd love to kind of hear from you about your journey, your personal journey, your decision to adopt robotic platform so early, your career and its [00:03:00] trajectory. Yeah. Well, thanks. I was, I think I was really blessed to have a career that lined up with technological advance in surgery. A lot of people have careers where not a lot of things change, but there's been some big shifts in my career. So 30 years ago I started doing surgery. First as an open surgeon, and then early on I went to Germany to do a fellowship in laparoscopy, so I learned laparoscopy in Europe, brought that back to my department at the University of Washington in Seattle, and then did laparoscopy for many years. Did over a thousand procedures, started doing laparoscopic prostatectomy, kidney surgery, kidney donor surgery. And I was very facile at it, but it was challenging. It was very, very hard and it was very hard to teach because it took me quite a long time, an extended learning curve to learn the skills of laparoscopy because you're working in a 2D environment. I think to me, that was the major limitation, was not having depth that you would normally have with open surgery. We [00:04:00] were doing surgery and then the robot came along and actually my first robot was not the robot that's currently out there, my first robot. Mm-hmm. Was a robot called Zeus from a company called Computer Motion. Mm-hmm. Computer motion. So there, there was competition back in the early two thousands. It was computer motion and Da Vinci and Zeus was a three arm robot with an open console. It was essentially three. Arm controlling robots. They were, they were called ESOP on its own, but with three together they were called Zeus. We had this, I was part of the FDA trial for computer motion for prostatectomy. Mm-hmm. And about halfway through the trial, the company called me and said, trial's over, we've been purchased by Da Vinci. Thanks for your help. Good luck. Good luck. But it, to me, it was actually, it was, it was actually a blessing because DaVinci had, I think a better two robot. They had a better platform. I was very happy to get on it. So at that point I started doing robotics. So that was early 2003. [00:05:00] I used their first robot, their three arm standard robot mm-hmm. That they first came out with. And then went to the forearm from the forearm, went to the s, the si, the xi, the single port. So I have a single port da Vinci as well. Mm-hmm. So, yeah, I've had a, a long run of, of the technology, so I'm, I'm pretty versed in how it's gone. It's been a great. Great thing for my career and a great thing for my patients. Mm-hmm. I mean, your, your area of expertise in urology, especially in prostatectomy, has really been the leading case use for this robotic platform. And really, I think if we read our paper that Jot presented really robotic platform is winning and it's by far right. So from your vantage point, why has robotic surgery crossed that threshold from adjunct to the. Default or standard in so many procedures? What are some of the real advantages? Yeah. Well, I think the drivers, first of all, it became apparent to the public that surgery could be done a different way. You did [00:06:00] not need a big subcostal incision for a gallbladder surgery. You didn't need to be in the hospital for a week after that. So when that started, and then it went to to GYN and, and hysterectomy. Then it went to other specialties. The public knew that they did not have to have the same pain and suffering and recovery that you do without surgery. That was one driver. The second driver was that laparoscopy was very hard. It was working in a 2D environment with straight instruments, and you had limited, uh, mobility. You didn't have the, your fingers in your wrist and your hand, you know, you were doing things with limitations. Mm-hmm. And amazingly, the, the surgeons who were doing laparoscopy. Overcame those limitations and were able to do essentially almost everything that was done open. Mm-hmm. And that was just a credit to I think, perseverance and surgeons. Mm-hmm. And the technology. The technology and laparoscopy advanced as well. Some of the companies like Medtronic that. As advancing robotics, they were pushing some of the laparoscopic technologies. So there's [00:07:00] been this, this dance between industry and surgery for a long time to help improve minimally invasive surgery. So that, so that, so, so what happened was laparoscopic was hard, and then the robot came along and it really changed the difficulty. So first of all, you went to 3D. Mm-hmm. And to me, 3D view is probably the best. Benefit of robotics it, I can see things with the robot that I couldn't even see with my own eyes because of the magnification. And then you had wristed instruments from intuitive. And then you had an ergonomic position, which was superior to laparoscopy, which was standing at attention for five to six hours. Mm-hmm. I mean, I was young when I started doing lap, but my back and my neck were a problem for a long time. And then I sat down and everything changed. So I think it was really the surgeons who saw that they could do better surgery with the robot than they can laparoscopically. I did laparoscopic partial nephrectomy as another procedure and the the partial nephrectomies I could do, [00:08:00] were pretty simple, pretty middle of the road. Now with the robot, I can pretty much do any. Laparoscopic partial nephrectomy that anybody does open. Mm-hmm. And that's because of the technology. It allows you to do things that you just couldn't do laparoscopically. Mm-hmm. So it sounds like even though you were an early adopter, even a laparoscopy and very skilled in that, you still felt that switching over to the robot sort of brought end the patient population, set of conditions you could operate on. Is that fair? Yeah, I could do better surgery and I could do it with less impact to me. And I think the other thing that drove this is that when I was doing laparoscopies, like for example, the prostatectomy trial, in the early two thousands, there were maybe 20 or 30 surgeons in the US who could do laparoscopic prostatectomy. Mm-hmm. And honestly, if the robot hadn't come along. It would've probably been 20 or 30 surgeons for a long, long time. Mm-hmm. What the robot did is it ex, it expanded the surgeon pool, who could do MIS. [00:09:00] There were surgeons who were never gonna do laparoscopic surgery, but those same surgeons now are doing robotics because of the way the technology allows them to do MIS. Mm-hmm. Mm-hmm. Yeah. With the improving ergonomics, the improving patient perception, broadening capability, democratization of this technology and ability to use it. I'm curious how you perceive how the hospital economics of this have evolved, right? The comparison of clinical outcomes and sort of all of these factors that kind of have plus and minus to both sides of them as new technologies are adopted. How all that's moved forward with the switch to the robot? Yeah. Well, I think economics is a great question when it comes to robotics, because I think there's a great example about how economics impact robotic surgery, and that is if you consider the United States and everything outside the United States, because the economics outside the United States are very different, and because they're different, robotic surgery is different outside the United States. Mm-hmm. The adoption is not the adoption we have in the us. [00:10:00] The number of surgeons doing laparoscopy is still quite high. Outside the United States and they're quite skilled and they're quite good. A laparoscopy I did in the late nineties, early two thousands is not the laparoscopy that's happening right now. It's a very different type of surgery and it's very high level. So what we see outside the United States is some places robotic surgery only happens if either the patient pays for it or they have a pool of money that goes towards robotics, and after that pool of money is expired, they're doing laparoscopy or they're doing open surgery. Mm-hmm. That's not the way it is in the us. In the US we have pretty much unlimited access to funds for robotic surgery. That's why the US is the largest robotic market in the world. It's where most robotic surgeries have have started, and it's where we've seen the greatest advances in robotic surgery. Mm-hmm. Yeah, I can certainly attest to that. Having trained at the University of Toronto, Canadian trained, the adoption of robotic platforms, [00:11:00] even in the high resource setting like Toronto, has been quite limited because of the ability or lack of ability to pay for the the add-on costs. And, you know, the lack of training and so forth. So if we were to limit this rise of robotics in the us Jim, why do you think the robotics winning in terms of, is this a, a, a technological story that the advancement in technology is so good that this is the dominant force? Or is it the new emerging workforce that's maybe. More getting used to the robotic platform and is being retained in their robotic practice? Or is it the lack of laparoscopic training or advanced laparoscopic training that's enabling the robotic to be used more and more frequently and be a, a dominant player. Yeah. Well, I, I think it's, again, it's unfortunately it's not one answer. There's several when it comes to this. Um, but I think we have a situation in the US where, because [00:12:00] robotics was supported from the, from a very early time, we just have more and more access. So when need to get a robot in the hospital for the urologist. All of a sudden the general surgeon has access to it, and then all of a sudden the geo surgeon has access to it, and that's gonna grow markets, that's gonna grow procedures that were never intended to be robotic. All of a sudden they have access to it. I mean, think about how hard it is to a Whipple, right? Mm-hmm. I mean, and now we're doing Whipples with the robot. And that's, that's a, that's a technological feat, and that's because the robots in the operating room, nobody is gonna buy a robot for a Whipple program. Nobody's gonna do that. That happened because they had access to the robot. So I think that's a factor. I also think the company was very good at convincing surgeons that they needed a robot to do surgery, and I think mm-hmm. When you get on that robot and you're a laparoscopic surgeon, you believe it. You believe that this is a much better way to do surgery and many aspects of it are, but I [00:13:00] think. I don't think we look at that critically. I think there are procedures where you can do it well laparoscopically and patients have the same outcome. Then the economics are, are very, very different laparoscopically. I think there are some procedures where the outcomes were better for prostatectomy, for example, you know, we, we saw blood loss change dramatically. We saw catheter dwell time change dramatically, length of state change dramatically. These were real, and these were without randomized trials. Those, those were real changes. So I think outcomes also drove a lot of this as well. So, you know, I, I think we're still gonna see more and more robotics happen, but I think at some point what has been true is that every time the robot has gotten better, the cost of care has increased as well. And that's a reality. And we need to someday address that. So the other. Reality is that when you have one dominant vendor for a product, you're never gonna see the cost change. So that's why we need [00:14:00] competition and we're seeing it, and that's why I'm involved in bringing competitions to the robotic space and I look forward to it. This is very insightful and you've given us a lot to unpack, and I think this will serve as a roadmap for the next few questions that we have. So the, the first question is, the opponents of robotic platform adoption, and my colleagues in Canada still argue about this a lot, is that when you look at this. The study evidence, when you look at the outcomes, thinking about the gallbladder, bile duct injury outcomes, comparing robot to laparoscopic, the outcomes tend to be equivalent, or sometimes there are in some procedures, like higher rates of adverse outcomes in robots. So do you think this migration to robot in the US is justified, like without that overwhelmingly better outcomes with robots? Yeah, I, I think if you were going on evidence alone, you would've a hard time justifying the growth. Mm-hmm. Uh, the evidence has been, I mean, in many cases it's been [00:15:00] against robotics, to be honest. It's not been pro robotics. I mean, we have mm-hmm. GN oncology trial, we have a, a hernia trial from 2020 where laparoscopy was, was superior. We don't, we don't have many trials saying robotics is better. So if it's based on evidence, you would question the growth, but. As you know, there's more factors that influence surgical practice. Mm-hmm. And I believe we're in a place now where we are going to start to listen to what surgeons say about their bodies and their practice and their careers. We're in a new age with surgery. I know you talk about that on your podcast, but I think surgeons are gonna stop just suffering in silence and mm-hmm. We've done that for generations and now we realize that. It has a toll and I think the robot helps with that. I think it really is gonna extend people's careers. I think they're gonna be able to do more and do it more efficiently. So I think that's another factor that's driving this. [00:16:00] I don't, I think it, that goes beyond evidence and it's very hard to, to show that in an evidence-based way. I also believe, and again, probably one of the hardest things we've had to show in IS is what happens to the patients outside the hospital. We can do a lot of data analysis inside of a hospital, but to show that somebody's really benefiting and getting back to work sooner, improving their quality of life outside the hospital, nobody's done that well, that's almost absent in the literature. So I think that's something that, I think it's there. We just haven't been able to prove it. So evidence is important, but it's not the full story. I wonder too, as a trainee, when I think about learning new procedures and we're learning them open and we're learning them laparoscopically, and we're learning them robotically, the teaching capacity of the dual console, the facility with using the robotic arms compared to trying to manipulate laparoscopic instruments. As its own set of learning skills on top of the procedural, the anatomy of the case, progressing the case [00:17:00] and all those things. I wonder if at teaching institutions the educational component has pushed some folks one way or the other. Yeah, I think there's no doubt to that. I think it's a there premier teaching platform as well. It's not just a surgical platform, it's a. Teaching platform and we all have, we all, you know, your surgeons, you understand this teaching has to happen, our medicine's over. So teaching is something we have to do, but we have to do it well and we have to do it responsibly. And I think the robot really allows that because it allows a very clear line between the surgeon and the trainee. And that line can be very quickly, you know, moved if needed for the patient's benefit. So I think when you consider everything we do is video based. It can be captured. It can be reviewed. I think reviewing video is probably one of the major strengths of robotic surgery. I think it's how people climb the learning curve faster. I think it's how we disseminate good [00:18:00] techniques is through video. There can also be bad techniques disseminate to video. Mm-hmm. I've seen that as well, so we have to be careful there. Mm-hmm. The robot itself is just easier for a trainee to manipulate. Then laparoscopic instrument. I just believe it is. I mean, think about what you have between you and the patient with a robot. You have a computer, which is taking your movements, refining them, making them better. Think about the tremor, removal, the scaling a robot provides to get rid of tremor. Think about how important that is, how precise you can be without that tremor. I mean, I know I sound like an ad for robotics, but it's a real thing. It's a real thing. Yeah. Yeah. I mean, it makes you better. Yeah. And if you can see better and you can move better, you're gonna do better surgery. Yeah. I think this brings up a real interesting, somewhat philosophical question. A notion in our training of our residents and trainees is that, like you said, Jim laparoscopic, especially advanced laparoscopic movements, maneuvers are very technically challenging and demands, lots of practice [00:19:00] times focus and a lot of fine movements. Um, as a, as a bariatric surgeon. Some of them could be an asthmatic closure with sutures, all those things. And I'm sure that's the same with the Prostat Ectomies as well, that. I feel that the current residents today are much better on robotic platforms than doing it in laparoscopic. And, and some of the opponents of this will say, well, are we expecting less from trainees? Like, are we graduating trainees that are achieving less of the standard than the generation before? And then the on the flip side. What I think is, so what if the clinical outcomes for the patients are equivalent, whether the trainees are able to do laparoscopic advanced movements or do it more easily on robotic platforms, you know, even if the skill sets that are required may be less on robot, if we're training graduating surgeons that are achieving the same [00:20:00] or even better outcomes, then does it really matter that we're treating them all these very challenging laparoscopic moves? Yeah. I would say things change in surgery. I mean, we see this all the time. And you mentioned the standard, well, the standard changes over time because mm-hmm. The tools you have, what you're doing changes, you know, I mean, there's a lot of examples of this in surgery. For example, early in my career, people used to talk about doing kidney stones. Used to be done with open surgery, big flank incisions. Or a, or a GIBS incision or these incisions that every stone, ureteral, stone, kidney, stone, all done open. And then when minimally invasive techniques came to remove stones, the term is called endourology. I mean, the open surgeons thought people were gonna die, that everybody without that, without the ability to open patients, fix things with open surgery, then there would be a very considerable decline in the way we treat patients. It didn't happen. It just didn't [00:21:00] happen. Nobody opens anybody for kidney stone surgery anymore. That was standard of care 40, 50 years ago. But that story came and went. So as our tools evolve, as things get better, what we do evolves and the standard should evolve with that. So look, surgery is dangerous. You can't ignore the danger of surgery. You have to be ready to do things, and we all know MIS is limited access to the abdomen. We, but we could do a lot of things MIS to deal with problems that you would not believe you could do even 15 years ago. So I think modern training has to be in line with the technology and that's where we are right now. I wanna briefly ask you about on the trainer's perspective. So we're seeing generation of laparoscopic heavy or laparoscopic only MIS surgeons who are training a generation of mostly robotic trained trainees. And then I [00:22:00] hear at conferences, they feel that. A little bit of dissatisfaction that they're not appropriately training the same centers of trainees as before, and they wonder if they could continue performing laparoscopic surgery at a, at an academic teaching hospitals with a new set of trainees. What's your comment around that? What do you see in your colleagues who are reaching those status? So, yeah, I think obviously everything, if the trainee is gonna change, the trainer has to change. We had the same argument for prostatectomy back in the two thousands, 20 years ago. We had the same things. The open surgeons who had built their whole careers on open surgery, they were very much against. Robotic prostatectomy. They were questioning the safety of it, questioning the oncologic capability of robotic surgery. We got pushback and we learned prostatectomy from the open surgeons. That's who started a [00:23:00] prostatectomy. So our goal was to recreate that, which we did. So we heard a lot from that group. And then over time. The outcomes were published and we could see where these outcomes were going, and we saw they were better, we were getting better outcomes. And this gets back to a point I made earlier. There was again 20 great open surgeons doing prostatectomy in the US and they were all at academic centers and they were the kings of prostatectomy. And, and they, and if you wanted a prostatectomy at a, at a high volume place, that's where you went. Well, there's 500 of those people now in robotics. We've expanded the pool of people who can do really good prostatectomy, and again, that's the technology along with the, the learnings we've had o over the years to make this better. So I think trainers have to adopt to and adapt to what they're doing. Look, there's still great laparoscopic surgery that happens. I go outside the United States all the time and I see some of the best laparoscopic surgery. I think, wow, that guy [00:24:00] is as good as I am with sticks, and it's amazing what they can do, but only a few can do that. And we gotta think about how we're gonna treat our population with a few experts. We're just not gonna be able to do it. Yeah, I mean, I think you give the haters a lot to think about when it comes to what is the future direction? How have we seen this time loop before with the introduction of new technology into surgery? Um, I do wonder is the title of that article that we brought up in the beginning, the Death of Laparoscopy, is the Death of Laparoscopy. A little bit of hyperbole when you talk about internationally. We're seeing it, obviously we're still seeing it here, but when we think about our lap, co, laser, lap, appies, all these things, do you see everything, even the most common general surgery operation? The most common urologic operation moving to the robot eventually. Do you think it's just a matter of time or do you think that that corner of the market's gonna persist for us learning laparoscopy and practicing it even in the us? Yeah. I really, I think it's a great question, and I think about it quite a bit because [00:25:00] I, I think there is an inflection point for the benefits of robotics versus the cost of robotics. I think there's a, there's the curve's crossed on certain procedures. Hmm. I don't wanna, I don't wanna get people excited because I know that people are pretty evangelistic about what they do, but honestly, outcomes with Open are really good. And the patients go home the same time. And the, and if you're talking about, um, developing a. Care pathway based on a few milligrams of morphine difference in a study, then you're probably missing the bigger picture on this. So, sure. Again, I'm MISI don't think every procedure is gonna see the same benefit, and I think the, the benefit varies depending on the procedure. We haven't had to do this, but eventually we may have to start thinking about our resources in a broader sense. You know, like we have limited resources or we have. Restrain resources, and we have to think about how we're best gonna use that. So yeah, I, it's a tricky, tricky question, tricky [00:26:00] challenge. Mm-hmm. So I wanna talk a bit about the, the robotic surgery market. And you know, as it's been really dominated by the incumbent, and obviously there are many emerging players in this market, including Medtronics. So as you represent Medtronic, how does Medtronic think about entering and competing in this space where the surgeon habits and hospital infrastructure, the training pipelines have really been deeply entrenched? Yeah, well, it's a challenge, there's no question. Fortunately, the US is not our first go-round with our robot, with Hugo. We've done this outside the US and Europe and Asia, and we have seen kind of what that looks like, bringing a new robot into an established robotic market. Not as penetrated as the US for sure, but still very penetrated and we've seen the challenges involved there. But it turns out people are [00:27:00] very interested in choice. They're very interested in alternatives. That's why there's not one car out there or one anything out there. There's multiple, and people like alternatives, they like choice. And I think in robotics, the choice we offer has some very unique offerings that the current robot does not. And I think people are very interested to see how that would impact what they do surgically. The interesting thing is you really don't know some technologies, how they're going to pan out until they're applied. I, I think that's an unfortunate thing about technology 'cause you wish you could know that right away. But that's the reality and, and I think what we're seeing is the application of the tool in a way that we never really thought of. And the same went for intuitive, by the way. I mean they started in cardiac surgery. That was their first market was they were going after cardiac. It didn't go well and they, and they landed on the prostate. Prostate was really what drove their growth in their market. So that's what happens with the technology. Things are not always as predictable as you would hope. But getting to your question, I think choice [00:28:00] is a big driver. I think people want that. I think people want competition. They know what competition can do to. Cost. They know a competition can do to improving technologies. Certain companies are gonna offer certain things based on other things that they do. So for example, Medtronic. We not only do robotics, we do laparoscopy, we do open surgery, we do a lot. We do interventional surgeries. We do a lot of different things. And so based on our background and our portfolio and our strengths, we can offer certain things on the robot that others may not. I'm curious thinking about what the Hugo does offer uniquely, even at face value, right? Even when you see the machine and thinking about how that differs and seeing these arms that are separate and can be manipulated and moved completely separately from each other, such that you see some even interesting reverse positioning or a hand that maybe you wouldn't initially would've thought as the left is now the right. I'm thinking of this rectal surgery paper that came out recently. Do you see some of these [00:29:00] features that are. Different that are bringing something different to the market, maybe applying to specific populations or specific surgeries, or how do you see that differentiating the system for, I imagine this is never gonna be an individual surgeon buying one of these things, right? It's like a hospital system investing in another system. So how do you think about those sort of differences? Yeah. Well, the way I think about it is you just answered my question, which is when a hospital buys a robot, they don't buy it for one specialty anymore. They buy it for multiple specialties, and every specialty has a very different need when it comes to robotics. They have different access needs. They're in different parts to the abdomen. They might have to be all over the abdomen. So when you are tethered to a boom. Like the da Vinci, your arms are limited in, in how far they can really go. They can go far, but they can't go as far as a modular robot where you can put these arms and they're not tethered to each other, so they're independent, which means that you can put these arms in places that you just can't reach with a boom robot. So what does that mean? Let's say you're doing a left colectomy and you've gotta go from [00:30:00] the splenic flexor all the way down. Into the pelvis. All of a sudden with the Hugo, we don't see any problem doing that. In fact, we have surgeons now discovering ways how to do this with three arms instead of forearms. I mean, because they can really move the arms in ways that you just can't move with a boomer robot. And so I think what Hugo offers is we, if you wanna stay in one place the pelvis and do something, Hugo can do that If you wanna cover the entire abdomen and do many different types of surgeries. You can do that. So that's where I think the the choice matters here. The choice allows surgeons to really expand what they can do and allows hospitals to offer many different robotic specialties. Thank you so much. As a resident, I love the DV five 'cause that's what I've gotten to play with. So when am I gonna get to get to know the Hugo, do you think? Yeah. More broadly on the market. We're available for urology in the us. We're [00:31:00] starting our launch soon. We haven't started it yet, but we are getting ready. I think as you know, once a robot's in the hospital, it's a fair game, so you never know. You might be on it soon. Amazing. Perfect, Jim, that's really fantastic. Unfortunately this is like, I think all the time we have for this episode, but I think we could just go on, talk for hours about the, the robotic really revolution of our minimally invasive surgical techniques where electronics and you are playing a big role. I think just to summarize our discussion with you, Jim, you know, we talked about how the prevalence of robotic surgery is increasing over the last few years, and that's supported by some clinical evidence as well as. Being able to perform complex tasks in certain anatomy, and also supported by surgeon ergonomics as well as what patients wanted. On the flip side, we talked about some equivalent or some inferior clinical outcomes demonstrated in some of the studies and the cost that's associated with adoption of this robotic platforms, which may [00:32:00] limit widespread adoption in certain parts of the world outside of the United States. Um, Jim. As we kind of wrap up our discussion, what is something that you want the listeners of the Behind the Knife who are usually surgeons, trainees, and people in healthcare to take away from our discussion today? Yeah, I think the robot has changed surgery forever. I think that is clear. I think I agree with the paper is a bit hyperbole. I don't think Lap Cross's dead, but it's definitely on life support and I think we're gonna continue to see. More robots. We're gonna continue to see dedicated robots. Right now we're talking about soft tissue, multi-port rob robots, but they're single port robots. There's and Illumina robots. There's now going to be robots made for a specific. Place and a specific job. And that's exciting to me. 'cause that is the next stage in robotics. We're gonna now develop functional specific robots that will [00:33:00] again, improve what we do. So I think it's, I think we're an exciting time. Um, and I think everybody should really look forward to where this is gonna take us. Mm-hmm. Thank you so much, Jim, for your time. Thank you all for joining us. Go get those hours of an simulator and dominate the day.