Ep11: Pioneering Surgical Robotics with the da Vinci Surgical System at Intuitive with Dr. Barry N. Gardiner

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Dr. Barry N. Gardiner, MD obtained his medical degree from the University of Pennsylvania in Philadelphia. He completed his internship and a five year residency in general surgery at the University of California Medical Center in San Francisco. In addition, he was the recipient of an N.I.H. Fellowship in Gastroenterology, completing a two year study in clinical gastroenterology and research investigation into the formation of cholesterol gallstone formation under the tutelage of Donald M. Small at Boston University in Boston, Massachusetts.

Dr. Gardiner served as a Lt. Colonel in the U.S. Army, both as Staff Surgeon and Director of the Department of Investigational Surgery at the Presidio of San Francisco. He then joined the clinical faculty of the University of California San Francisco School of Medicine until entering private practice in general surgery in the East Bay.

Dr. Gardiner pioneered the introduction and development of laparoscopy in general surgery in the early 1990’s and was the principal clinical advisor to Intuitive Surgical, Inc. during the development and clinical trials of the da Vinci™ surgical robot.  He was the principal investigator for the clinical trial of the da Vinci™ system in Mexico City and testified before the FDA panel meeting in 1999 which resulted in the FDA clearing the da Vinci™ surgical system for general laparoscopic use.  Dr. Gardiner has vast experience in minimally invasive surgical techniques, and uses these techniques extensively in the field of general surgery, including innovative surgical approaches with the da Vinci™ robot.

Interviewer: Omar M. Khateeb, Director of Growth at Potrero Medical

Interviewee: Dr. Barry Gardiner

Khateeb: Hi everyone, this is Omar Khateeb; the director of growth of over at Potrero Medical and I came out to a sunny San Ramon, California to have a very special interview with a surgeon who had the opportunity to get his hands early on some exciting technology that has revolutionized the way surgery is done.

Dr. Barry Gardiner, thank you for joining us. So, a great first question to start with is: how did how did you get into medicine? How did it all start for you?

Gardiner: Well, it started when I was in the sixth grade. I was very close with my father and he got rheumatic fever at a time when they were just coming out with the heart-lung machine and they were starting to do some cardiac surgery for a medic heart disease. I looked at that and I thought: Well, that’s what I want to do.

Probably, in the back of my mind, I was thinking I would save my father’s life. It was a very pure and very idealistic path that I followed.

Khateeb: So, that got you started into medicine. Now, your father, was he a physician as well?

Gardiner: No, he was an amusement park operator.

Khateeb: Interesting.

Gardiner: He was he was a real Renaissance guy. He was one of the brightest people that I ever had the encounter to run up against and he could do a little bit of everything.

Khateeb: Interesting. Well, funny enough you chose general surgery and, as you know, depending on where you’re located you have to be a renaissance man or woman to be a good general surgeon, right?

Gardiner: Well a little bit I guess. When I went to medical school, I was planning on walking the path toward cardiac surgery. In medical school, you start to rotate through different services and when I rotated through the cardiac surgery service, it was treated pretty badly by some pretty arrogant physicians.

I began to look at it and say: Do I really want to associate myself with people like that for the rest of my life?And I had just the opposite and experience with the general surgeons. They were very receptive, warm, education-oriented and supportive. So, I switch mid-stream.

Khateeb: Well, you know, one thing if I seem to find is it’s very often that physicians pick their specialty based on the people that they get introduced to in that specialty.

Gardiner: I think that’s true. You know, I think if you have a positive relationship and a personal relationship with people in that specialty, you tend to gravitate to that field. I think that’s pretty that’s pretty common.

Khateeb: So when you were rotating through general surgery, what did you see that gave you that “Aha!” moment and made you say: You know, I think I’m home. This is what I need to pursue.

Gardiner: I think it was largely the broad cross-section of surgical disease which we’re beginning to lose now in the specialty that we would interface with. We could do hysterectomies and nephrectomies. We could operate on the colon, the stomach, the gallbladder and also do breast surgery and head and neck surgery.

So, it was an all-encompassing specialty?at least when I started. It isn’t anymore. But when I started, it was. We have all these sub-specialties now picking on the Gen. surgeons.

Khateeb: Yeah, they are. General surgery as a specialty is beginning to wither away.

Gardiner: You know, we’ve lost the colon surgery to the colon and rectal guys. We’ve lost nephrectomy to the urologists. We’ve lost breast surgery to the female breast surgeons, blasted neck surgery to the ENT people.

I can remember when I was was a resident, the flexible colonoscope had just come out and we were very busy, we didn’t see much utility for a flexible tube that you would put inside the colon.

So, we basically gave that up to the gastroenterologist. Well, look at them now!

Khateeb: That gave birth to their whole industry, right?

Gardiner: Yeah. So, technology plays into that too, of course. Because, when the flexible colonoscope was developed, it was purely a diagnostic tool. Well now, of course, it’s therapeutic as well.

So, things change in industry, both with evolution and innovation changes. But it has certainly impacted my specialty, probably from a surgical point of view, as much as any?I think. It’s not more.

Khateeb: I don’t want to put you on the spot and we definitely want to get into the intuitive DaVinci years. But, let’s say before the intuitive robot came out, what was the most groundbreaking and paradigm-shifting technology that came into general surgery?

Gardiner: Prior to intuitive?

Khateeb: Prior to intuitive.

Gardiner: We did open surgery and had been doing open surgery for generations in the same way that generations of surgeons were taught to do that.

Probably the thing that was the most impactful was the development of nutritional support with the Total Parenteral Nutrition (TPN).

Absent the technological advances that robotics has introduced. But prior to that, general surgery hadn’t changed for generations until the advent of Total parenteral Nutrition (TPN).

We were able to keep people alive and do things for them that …., you know, we couldn’t. They’d starve to death. So, from a technical point of view, that’s probably the biggest impact prior to the advent of electro-mechanically controlled instruments.

Khateeb: So, with that Innovation to be able to keep tape patients on the bed for a little bit longer, do you feel like that was a big stepping stone to allow surgeons to start exploring laparoscopic surgery?

Gardiner: Probably actually not. I think the advent of laparoscopic surgery came about primarily from the gynecologists. They were the first to really use the laparoscope and got the idea that you could put a tube into somebody’s abdomen and then inflate the abdomen and you could actually see in there.

But they were only able to do tubal ligations, which was really what it was pretty much limited to. Because you, as a surgeon, had to look through the scope with your eye, holding the telescope with your hand. That meant you only had one hand to operate with and nobody else could see anything.

You’re the only one that could see; so you really are a one-handed surgeon. You know, in reality trying to tie your shoe with one hand, you’re pretty limited. And that was true with surgery.

Laparoscopic surgery had been in existence for a long time, but it was very limited in terms of its applicability because you couldn’t use an assistant and you can only use one hand.

Khateeb: While you were in residency, you got exposed to a variety of different procedures as general surgeons did back in, as my dad says, the good old days.

Gardiner: Yeah, I think we all have kind of pined for those days.

Khateeb: [Laughs] It’s funny. Even new surgical residents now think so. I have friends of mine who went into general surgery. They talk about this and I’m like: “You’ve only been a resident for a couple of years”. And they’re like: “Yeah, but we’re allowed to do back then.

What were some of the procedures you got excited about doing when you were a resident?

Gardiner: Oh, yeah. In general surgery, the bigger the case, the more interesting it was, the more challenging it was and the more awe-inspiring it was, really.

I mean, some of the things that we would do. For instance, we’d take out somebody’s rectum and colon, then look at this in the field and suddenly recognized: “Gee! If we don’t have point A and connect it point B, how are we going to do that?”

Also, taking something that is a threat to the patient, excising it and then reconstructing. The anatomy was probably the fascination that I had with surgery.

Khateeb: I think general surgery from history is very much treated like an apprenticeship and it’s very important to have a strong mentor. Who were some of your mentors when you were[1]  a surgeon?

Gardiner: Well, they’re on the wall back there.

Khateeb: Oh?[laughs]

Gardiner: Dr. Blaisdell at UCSF; Doctor Dunphy, Dr. Hunt, and Dr. Lim.

Khateeb: What were the most valuable lessons that you got? I’m sure there’s many, but do you mind sharing a few that influenced your career as a surgeon?

Gardiner: I think the most valuable lesson that I ever had was from Dr. Dunphy. We used to have a surgical GI conference every Friday up on the ninth floor at UCSF, and he had just come on as the chief of surgery there. Actually, I was the first internship class that he had selected.

Anyway, we would have this medical-surgical GI conference. It was set up so that all of the attendings were there and they would sit in the front row. Then the residents would sit behind that and then the medical students would sit behind that. They would present challenging cases and go around to ask the most inexperienced people first and move to the more experienced before finally getting to the chief to ask: “Well, how should you handle this problem?”

The chief resident presented this particular patient who had a pancreatic fistula. He had struggled through multiple operations, and they’d finally gotten this down to a fistula from the pancreas. So, they presented this case and then brought the patient in.

Just as a mentor, Dr. Dunphy would first introduce himself and then he’d always ask the patient: “May I examine you?”And that made a big impression on me! I mean, asking the patient permission? That’s noble. I hadn’t seen anybody do that.

He exposed the patient’s abdomen and there was a four-by-four bandage on the patient’s abdomen. And so, Dr. Dunphy put a pair of gloves on which also with a good object lesson. He didn’t say anything about it, but it was the right thing to do and he says: “May I take this bandage off?”The patient replied: “Sure.”

Dr. Dunphy took the bandage off, looked at it and there was a little spot on the bandage just a very tiny spot. He put it back down and he said: “When was this changed?”The patient responded: ”Oh, last night.” And he said: “Thank you very much.”

And this guy had had half a dozen operations and darn near died through some of them. At any rate, they went on with asking all the residents and doing what they do in the attendance [2] and everybody was saying; Well, you need to take his pancreas out. You need to do a ….. You need to do a whipple. You need to do, you know, this extensive life-threatening operation. And then they finally got to Dr. Dunphy [Laughs]. I’ll never forget it.

The chief resident, it was actually Dr. Larry Way at the time, said: “Well, Dr. Dunphy, what would you do?” And he just sat back in his chair and he said: “Lifetime supply of four by fours.”

What that is telling you is that not every problem has a surgical solution. They had gotten this guy down, after several years of suffering, to just a little tiny bandage that they had on his abdomen, and you’re gonna put him through a life-threatening operation just to stop that little bit of drainage? Don’t do it.

So, my takeaway from that was there are times to sheath your scalpel and not use it. And sometimes the best thing to do is to say no.

Khateeb: I’m sure, Sir William Osler would have been very proud at that moment if he heard that.

Gardiner: Yeah.

Khateeb: And I think he’s always said that a physician’s first duty is to educate the masses and not to take medicine.

Gardiner: And you know, Hippocrates said: “first do no harm”.

Khateeb: Absolutely.

Gardiner: At any rate, that’s the kind of training that I had.

Khateeb: Wow. Would you say that that’s a mark of a good surgeon? I mean, to exhaust all options before taking a patient to surgery.

Gardiner: Well, I think within reason, sure. And I think Dr. Dunphy was known for his surgical judgment. Not necessarily his surgical flash and panache as an operating surgeon, but as a real clinician.

Khateeb: After you finished your training you served as a surgeon in the military, correct? Do you mind sharing a little bit about that?

Gardiner: Well, I came along at the time of the Vietnam War; I was in residency in during the Vietnam war. And there was a program called: The Berry Program. If you were selected for that, you the military would defer you and not draft you until after you finish training. Then when you finish training, you’d go into the military as a surgeon.

So, I was selected for the Berry Program and I finished my residency, but then I had a commitment to go into the military after that. I got stationed at Letterman, which now is shut down, with a teaching hospital within the Army system. That’s where I had been stationed.

They put me in charge of their surgical research lab. It was called LAIR: Letterman Army Institute of Research, and I spent a couple of years there basically working on the formation of cholesterol gallstones. I didn’t ever fit into the military very well. I never actually got a complete uniform much to the chagrin of my commanding officer.

I remember one day I was walking from the research institute to the hospital. Usually, if you had a white coat on, you had what they call “cover” and you didn’t need to wear your hats and things. Well, I had this hat on. It’s one of those hats that’s pointed in the front and in the back and it said my insignia was a major at the time.

So, I had both my hat and white coat on and I was walking over to the hospital. Then I saw this other dude coming up from a different pathway and we were definitely going to meet. I saw that he had all sorts of ribbons and stuff on his chest. I didn’t know what that was, I just knew that I didn’t want to have to salute him.

So I sped up and got ahead of him. I was walking along and I thought Well, I beat that one. I’m on the way to the hospital and all of a sudden, I hear: “Major!”And I’m like Oh, no!

I turned around and said: “Yes, sir.”He was a sergeant. He put his arms around me and he whispered in my ear: “You got your hat on backwards.” [Both laugh] That was my life in the military.

Khateeb: How long did you serve?

Gardiner: Three years.

Khateeb: Wow. Thank you for your service.

Gardiner: Well, I didn’t do anything like what you see these guys doing now. Those are people that we ought to thank for their service.

Khateeb: Absolutely. Did you enjoy M*A*S*H when it came out?

Gardiner: A little bit, yeah. It’s a fun show. Everybody says I look like Alan Alda; I don’t see that but,  maybe in my younger days. [Laughs]

Khateeb: You know, I can kind of see that actually. I mean, of all the characters and people in M*A*S*H, you want to look like “Hawkeye”, right?

Gardiner: Yeah. [Laughs]

Khateeb: So, you finished your training, went to the military and got out. Then you start private practice here in California?

Gardiner: Yeah, I started in Oakland

Khateeb: In Oakland?

Gardiner: About 30 or 40 years ago. It’s been a long time ago,

Khateeb: I’m sure the people listening to this are eager for this part of the conversation opener, but what was your practice like and at what point did you meet Fred Moll? Where did those crossroads fit?

Gardiner: Well, it happened just at the advent of video laparoscopy.

Khateeb: And what year was this? Sometime in mid 90’s?

Gardiner: Oh, yeah.

Khateeb: Okay. All right.

Gardiner: We had an endemic population in Oakland: patients that had gallstones through the Native American population. And that it is a very common problem that they have. So, I had a huge experience with cholecystectomies.

The typical cholecystectomy was done through a 6 or 8 inch incision and the patients would have nasogastric tubes in and it was a big deal.

As I got more and more experience and became more comfortable with the operation, I started to shrink the incision down.

And one of the assistants that I had one day while I was doing this tiny incision, probably an inch and a half long, said: “God, you’re going to be doing these with a laparoscope if you get the incision any smaller than that!”

Well, right about that time, Eddie Joe Redick in Nashville, Tennessee had done the first laparoscopic cholecystectomy. And the thing that facilitated that was the addition of a high-definition color television camera to the telescope. Prior to that, you’d have to look through the scope and you’d have to hold the scope with one hand; so, you only had one hand to operate with and nobody else could see.

When you attach the television camera to the scope, that enabled somebody else to hold the camera so that they can move your field of view to where you needed it. So, now you had two hands. You could put additional punctures in and put additional instruments in.

Now you had two hands to work with and you can bring in an assistant.

That’s what really enabled the laparoscopic revolution. It was the union of the high edition color television camera, which they’d been using in industry for years, to the laparoscope. And once you did that, it freed us up to be able to really do surgery.

We can now do more than just the tubal ligation. And so, of course, we started with the laparoscopic cholecystectomy.

I’d heard about what Eddie Joe was up to and I called him. Fortunately for me, that was a time he wasn’t so busy that he wouldn’t answer.

He answered the phone and he was describing what he was doing and then said: “Well, why don’t you come on back here and I’ll show you what I’m up to.” So I flew back to Nashville and watched Eddie Joe do his third and fourth laparoscopic cholecystectomy.

For a surgeon who was used to open surgery, to see the first video-scopic surgical procedure being done was more than eye-opening.

It was revolutionary to me! I watched him do his first case, and then do a second case. By the time he’d done his second case, the first case had been sent home. And I said: “This is going to change the way we do surgery!”

Khateeb: That must have given you goosebumps.

Gardiner: Oh, it was an unbeliever. That’s one of those experiences in your profession that you will never ever forget. It was a stunning thing. You know, now we take it for granted but back then it was amazing. I mean, to take this gallbladder out through these punctures just by using a television camera, who ever heard of such a thing?

So, on my way back home, I said to myself: “I have got to learn how to do this.”

Khateeb: Did that idea scare you at all?

Gardiner: No.

Khateeb: Or you were just excited.

Gardiner: Oh, no. You could just see the potential, it was just written all over it. So, I went back to the hospital. In the basement of our hospital, I had the Head Nurse get me a camera in a laparoscope and I started to practice. I’d get cow livers and put them in a cardboard box along with scopes. Then I’d put my instruments in there and I’d operate.

I did that enough so that I was then pretty comfortable that I was safe and I knew what I was doing. At that point, we didn’t even have a clip applier.

Now, they’ve got clip appliers that are automatic and will go through the laparoscope. At that point, there wasn’t a clip applier that went through a laparoscope. We had to make one, a jerry-rigged one.

Regardless, I did all that and I was comfortable that I was going to be able to do this.

Then I went up to the head nurse in the operating room and said: “There’s this new operation I want to do. I want to take the gallbladder out with a laparoscope.”

And she says: “Oh, I’ve kind of heard about that. Why don’t you just go up and talk to the medical staff office to just be sure that it’s okay.”

So, I went up to the medical staff office and talked to them and they said: “Well, that sounds okay. But, maybe you just ought to talk to the chief of surgery.”

So, I went talk to the chief of surgery and he said: “Well, that sounds okay. But, maybe we ought to have a meeting.” By that time, I thought this isn’t going well.

At any rate, I had the meeting and I played the videos from Eddie Joe. Then I told them what I’d done and that I was all ready to do this and they said: “Well, this thing should never be done in a community hospital. It ought to be done in a University Hospital and, no, you can’t do it.”

So, I left that meeting and I called Dr. Blaisdell, the doctor up on the wall there, and I said: “Bill, Barry here.”

I told him the story and he said: “Well, why don’t you come up and do it up here? You can work with Dr. Bruce Wolf.” At this point, he was up in Sacramento.

So, I went up and they put me on staff at the University of Davis (UC Davis) in Sacramento. We went into the lab and worked it out until Bruce and I were comfortable that we could do this.

Then we started to do cases that you see us do at UC Davis. In the meantime, I had actually gone to Dr. Way at UCSF and asked him if we could do it there because it would just make so much more sense. It’s not 50 miles away and he was not interested.

Khateeb: I just want to recap for the people listening. You believed in this vision and you were so excited about it that you went on your own time and started making boxes with cow livers on it just to practice. And the fact that you couldn’t do it at your hospital motivated you to find a way to drive 50 miles away just to do it.

Gardiner: Yeah.

Khateeb: See, that’s incredibly inspiring!

Gardiner: So, what happened is, as I mentioned, I had a very large population of patients who needed their gallbladder out. I knew that this operation was available. And so I told them: “If you can hold on for a little

Our first patient was actually one of my patients from Oakland. She’s a gorgeous, young woman. I took her up to Sacramento and took her gallbladder out. [Laughs] Yeah, I remember.

Khateeb: Did she appreciate that small decision?

Gardiner: Yes, she did. She was a beautiful woman and yes, she did. I can remember when we got the gall bladder out. There was just a gasp in the operating room and everybody started to applaud [Laughs]. It’s really interesting.

Anyway, I kept going up to Sacramento to help Dr. Wolf with his cases and I’d also bring my cases up. We got about 50 cases done and they all had done very well. Then I thought: Well, I’m going to go back again and see if I can get privileges to do these cases in my hospital.

Eventually, we did. The doctors weren’t happy about it. And they said: “We want to make the criteria very stiff and rigid to get credentials.”

Khateeb: For who can do this?

Gardiner: Yes, for who can do them. So. I said: “That’s fine, you can make it whatever you want.”

Then they put a set of criteria in such a way that the only person that could meet them was me because nobody else had already done 50 cases. This slowed them down for about a year and a half in terms of actually having anybody else learn how to do that.

Khateeb: Because you were the only surgeon?

Gardiner: Yeah, the only one around. Soon enough, Kaiser came to me and asked if I would train the Kaiser doctors how did how to do this surgery. So, they identified two surgeons at each of the Northern California Kaiser facilities.

They would bring their patients to my hospital and I’d teach them how to do the laparoscopic cholecystectomy until they become comfortable and proficient.

Then they’d go back and teach the other surgeons in their hospital. So it became kind of a ‘trainer of the trainers’ if you will.

Khateeb: A form of classic surgical apprenticeship, right?

Gardiner: Yes.

Khateeb: It sounds like that was more or less in the late ‘90s.

Gardiner: Yes, it was in the late ‘90s.

Khateeb: So, at the time you were just getting comfortable, and I’m sure there was still a lot of excitement, with this new surgical skill.

Then, where does surgical robotics come in? Because, if you got excited about videoscope, I can’t imagine how you felt when you saw or heard the idea of a robot.

Gardiner: Well, what happened is I was leading out the way I did with the laparoscopic cholecystectomy that caught the attention of the industry.

Before long, Ethicon came to me and a number of other surgeons that were doing similar things in their communities and asked me if I was interested in working with them to develop new equipment.

It turned out I did that for a couple of years. I went back to Somerville in New Jersey and we were working on an anastomotic device for colon surgery.

Then, Fred Moll heard about me just by word of mouth and invited me to come to a company that he had just founded called Origin Med Systems.

They were developing some balloon technology to enable laparoscopic surgery to be done outside the peritoneal cavity and hernia repairs primarily.

I’ve worked with Fred on that project for a couple of years. When they finished, they sold that company and I went back to doing my surgery.

One morning, Fred calls me and he says: “Hey, can we have lunch?”  And, you never turn Fred Moll down. I mean, you only do that at your peril.

Khateeb: I’ve heard that many many times and that’s actually funny because it’s great to hear that in industry, but it’s something else to hear directly from a peer from him.

Gardiner: Fred is a remarkable human being. So, he called and said: “I’ve got an idea that I would like to kind of bounce off of you. Can we have lunch?” He came up to our hospital and we had lunch. And that was the inception of Intuitive Surgical.

Khateeb: That happened out here in California?

Gardiner: Hmm hmmm. [Affirmatively]

Khateeb: I’ve got to ask this question mainly for myself, but also for the other industry professionals because we always talk about the stories of when Intuitive and this whole thing was conceived.

What restaurant did this exactly happen? [Barry laughs]

Because, I’m sure some of us would like to go and feel like this is the place that it actually happened.

Gardiner: Well, we had lunch at the cafeteria in the hospital. It wasn’t any more dramatic than that, but he was describing an idea that he had about electromechanical control of instruments. There was a company called Stanford Research Institute. They’re a group who had developed a robotic surgery system that ultimately morphed into what Intuitive has become.

Khateeb: And that was SRI, right?

Gardiner: And that was SRI: Stanford Research Institute. It was a research that was funded through the defense department.

The idea is that if you had robotic surgery capability, you could scoop up the wounded soldier, bring them into a surgical facility right at the front lines and have the surgeon in the back line, safe from injury, basically conduct the operation. That was their premise.

So, Fred asked me to go down and take a look at what they had. Well, I went down and they had a very primitive, but effective, telemanipulator, where you could work at a console and actually control instruments that work inside a different cavity.

I went down, looked at that and called Fred back. He said: “What do you think?” And I said: “Well, you should do this. I think it’s preliminary and rudimentary. Although, it’s going to be a lot of work and a lot of development, but you should do this.” He said: “That’s what I thought too.”

Fred and I have known each other ever since and it’s very uncommon for Fred and I to basically go different pathways. We almost always see things the same way and this was no different. So, Fred asked me if I was interested in getting involved and I said: “No, I don’t think so.” [Both laugh]

Khateeb: Well, I thought you said Fred Moll’s somebody you can’t turn refuse? [Laughs]

Gardiner: No, I’m kidding.

Khateeb: Wow. Okay. [Laughs]

Gardiner: That began about a four- or five-year involvement with Intuitive, as he had just found Intuitive with Rob Young.

Khateeb: But it started as origin and evolved into Intuitive or Intuitive on its own?

Gardiner: No. Fred started out as a surgery resident in Seattle and he had an ID. He went into the lab for a year after the first year of residency and he thought, there are safer ways of putting trocars into patients’ abdomens and what they’re doing.

Khateeb: That’s right.

Gardiner: He developed the safety shield of the trocar. He tried to sell that and actually never went back to finish his surgery residency. He sold that idea to the U.S. Surgical and then he was free to go on to his next venture.

Well, his next venture was Origin Med systems. That’s where I met Fred that was developing this balloon technology for doing retroperitoneal surgery at the time.

He sold that to Eli Lilly and then, he founded Intuitive. So, it’s been a litany of companies.

He went on from intuitive to found Hanson Medical. And then he’s gone on from Hanson medical to found Auris Health.

So, everything he’s touched has turned out just exactly the way he had envisioned with the exception, probably, of Hanson.

Hanson didn’t turn out to be as effective or as successful as the other companies. But his other companies have been hugely successful.

Khateeb: Wow!

Gardiner: Any rate, when he asked if I wanted to be involved; I said: “I’d love to be involved.” So, they brought me on as Intuitive’s first, and probably, clinical advisor.

Khateeb: And I saw that it was 270 cases to be done before presenting to the FDA. You did 50 of those. So, you really pioneered the surgical robot and went to lands and bowels that surgeons have not gone to.

Gardiner: Well, yes. I think what really happened is we worked for a couple of years developing the concept that the that SRI had into an actual workable robot.

What we were actually trying to do is to develop a robot to do coronary artery surgery with. It just made business sense for them to go after a high-volume expensive procedure.

So, were trying to go after coronary artery surgery. Well, turns out that bar is a hard one to jump over. The visualization is difficult. You don’t have any safety net underneath you. If something happens, you have a dead patient and so it was very very difficult. Very challenging, to say the least.

We tried back in Leipzig to get a coronary artery anastomosis done and we never were able to do it. We took the system to France and did some microvalve reconstructions with Dr. Carpentier and those went sort of okay.

I can remember after watching Carpentier do his first mitral valve surgery, he came back and held court with all the companies in his Amphitheater there. He walked in and wiped his brow and he said: “Well, you’ve succeeded in making a very easy operation very difficult.”

And it was really true. I mean, it really was true. Heart surgery is really a tough thing to get done. So, intuitive was really hanging by its fingernails in terms of whether it was going to survive or not.

Khateeb: We were hearing about this [can’t hear the last word you said here].

Gardiner: They may not see it that way but that was really true because we had a product that would work and we had FDA clearance for it.

The whole concept of Intuitive is to try and immerse the surgeon back into the surgical field. We also wanted to do so in a way that returns to them the capabilities that they lost when they went from open surgery to laparoscopic surgery, namely: the wrist.

It was Fred and I who really insisted on having a wrist at the end of the instruments and that enabled Intuitive.

Well, we got through the FDA process we had clearance for this device, but we didn’t have any operations that we could do with it.

Khateeb: That’s a big problem, right?

Gardiner: Yeah. Fred called me one night and he said: “Hey, I’ve been thinking…”?and this is Fred again for you?”…I’ve been thinking and looking at this. What do you think about a prostatectomy? Do you think we could do a prostatectomy with this device?”

Khateeb: Where were you and where was he when that phone call happened. This is like robotic surgery history. [Laughs]

Gardiner: I don’t know where Fred was; I was at home. And, you know, it just made all the sense in the world because you’re operating in a small space.

You need to be able to sew. You also need to have your instruments come from the back by the television camera and focus down on a small area deep in a hole. Well, that’s exactly what prostate surgery is about.

You need to do all of those things. And so I said: “Fred, it just seems like a like a tremendously rich field to explore.” And I wondered why we didn’t do that before.

Khateeb: What’s fascinating about that moment, at least for myself and many of my peers who are in surgical robotics, is a classic case where they talk about the value of technology applied to the procedure to change the workflow.

Gardiner: There’s no question about it. Most prostatectomies are now done with the robot. So what happened is I said: “Well, let’s do this. The only problem is that I don’t do prostatectomies and the prostatectomies don’t do a laparoscopy.” So, he and I looked at that and said maybe we could work together.

I contacted the one guy out here who does most of the prostatectomies and told him about this and asked if he’s willing to work with me. Turns out he was. So, we started and we did it in a series of stages. We do part of the dissection and then open and finished the operation.

Khateeb: Who was that surgeon that you reached out to?

Barry: Jim Carroll. Eventually, we would just do a little bit more of each operation. After about a half a dozen cases, we were able to get through the first one. We got through it successfully and it just went on from there.

Khateeb: What year was that? Was that around 2000 or 2001?

Gardiner: Mm. Mm. [Affirmatively] Probably 2000, 2001 or 2001. Something like that.

Khateeb: I’m going to speak specifically for general surgeons now. What I’ve noticed with general services is they get excited about technology, new techniques and things like that.

But since what you alluded to in the last few decades, specifically, I think from the ‘70s up to the ‘90s, a lot of other specialties picked procedures off from the heaven of surgeons.

So, how did the general surgical community react when they heard about the robot and the radical prostatectomy?

Gardiner: Pretty negatively.

Khateeb: I heard about those. Tell us a little bit about that.

Gardiner: Surgeons tend to be pretty conservative. And, you see, it’s still that way today. They want to do things the way they were trained and not have to step outside their comfort zone. They don’t want to reach, stretch, and grow. It’s just natural history for surgeons to be that way and the majority of surgeons still don’t use the robot at our hospital.

So, it was very slow to be adopted. In fact, the initial business plan for Intuitive was not to sell the razor, but to sell the razor blade.

Khateeb: Right.

Gardiner: They didn’t care about selling the capital equipment; they wanted the disposable instruments.

The whole idea was we’re going to have these disposable instruments where they use them 10 times and we would be able to charge for each use. Initially, they didn’t really care whether the damn thing was used very much. The hospital was happy to sell it and sit in the corner.

I didn’t think that they were going to be successful in a million and a half dollar piece of equipment that didn’t get used but, in the early phases, that’s what happened.

Gradually, the surgeons began to come around to see the same thing with robotic surgery that you saw with laparoscopic cholecystectomy.

And that if you didn’t adopt the laparoscopic cholecystectomy, pretty much you’re going to give up your cholecystectomy business.

I think that surgeons are now beginning to recognize the same thing with the robot. If they don’t learn how to use the robot, accept it and adopt it, patients will go to surgeons who have.

Khateeb: How much of it was influenced by the market and by patient demand?

Gardiner: Early on, it was all patient demand. Later as things went on, Intuitive got into the marketing game and started to promote certain robotic surgery. They did it initially with the prostatectomy, next, they centered on hysterectomy.

Finally, although we had talked about this a lot with him. I said: “We ought to focus on hernias.” Incisional hernias are very common. It’s a high-volume procedure and this is an ideal device for it because you’re sewing on the ceiling of the cavity.

They were focused on the prostatectomy and the hysterectomy. Well finally, Intuitive has started to market incisional and even inguinal hernia repair.

Now, the market is being driven by the company. They’ve actually saturated the market for hysterectomies and moved into general surgery.

And they’ve had to, because while the prostatectomy is a good operation in a lot of cases, I think increasingly people are recognizing that we’re doing more of them than probably need to be done. There are a lot of people being treated with radiation therapy now or just watchful waiting. As a result, the volume of prostate surgery is going down.

Well, that’s a death knell for a company like Intuitive which had based its entire success on the prostatectomy; so, they moved to hysterectomy.

They’re now branching out into other surgeries. You can use this robot to do pretty much anything; you can do Whipples with it, pancreatectomies or hepatectomies. There really is no limit to it. It’s just a matter of how skilled you are.

Khateeb: Once you got a taste of that side of medicine, introducing disruptive technology that really elevates the standard of care and provides better treatment for patients, I guess you were up for another ride with Fred and you spent some time with Auris, right?

Gardiner: That’s where I met Jeff actually.

Khateeb: For those listening, Jeff is my boss. It’s Jeff Albers the VP of products. As I hear, Jeff wasn’t even employee number one; he was employee zero. [Laughs]

Gardiner: When I was first invited to Intuitive by Fred, the company had 12 people in it. That’s where it was. There was Fred, 12 engineers and me. We would meet every Friday and we would talk about things like “What does this piece of equipment need to do?”

This is another one of those things I’ll never forget, the discussion about the wrist. Fred and I were absolutely insistent on the fact that you need a wrist and the engineers just rolled their eyes at us. However, we kept persisting that they put a wrist on the end of those instruments and that’s what made Intuitive. Had we not done that, Intuitive would have died because its major competitor was Computer Motion.

Khateeb: Educate the listeners on what happened with Computer Motion.

Gardiner: Yes. They had a very pledgee ability to do a wrist, but they never really were able to execute it. This was because they were using a platform that had existed primarily as a camera controller. Rather than start out from scratch, they used their existing platform as a vehicle to try and put this wrist on. Well, it never worked and it’s dead now.

Intuitive on the other hand started out with a blank slate so, we could do anything we wanted. We built that system up to have the capabilities that we wanted and we weren’t held in place by some pre-existing platform. So, I worked with Intuitive for about five years and then left about the same time Fred did. Then, Fred called me again.

Khateeb: [Laughs] Around what year? Where were you? Where was he?

Gardiner: It’s been about six or seven years ago. I was actually in the office at that time and he said: “I’m going to do this again.” [Khateeb laughs] And I said: “What?” He said: “I want to build a state-of-the-art robot!”

I can remember, when Fred and I were at Intuitive, we kept looking at what we had and thinking ahead for about three, four years. Well, what about if you could maybe hang it from the ceiling? Or do something different? And we were never able to do that.

Well, Fred founded Auris, and we had lunch again. This was at a little Mexican restaurant in Orinda. We were talking about what would a state-of-the-art robot look like because Intuitive surgical was innovative at the time, and they still are, don’t get me wrong.

Khateeb: Absolutely!

Gardiner: But it was built on technology, at the time, that was probably 10 years old. It was basically the same system and Intuitive has the issue of being tied to their platform just the way Computer Motion is tied to its platform. Intuitive has got 3,500 robots out there. They can’t abandon them!

Khateeb: It is a remarkable record.

Gardiner: Oh, there’s no question about it. It has been beautifully engineered and built. There’s no question about that but, you’ll still look at it and say, Well this is 2018, can we do better? Can we do something different?

So, Fred and I started to talk about it and it was his idea again. He said: “What do you think about putting it on the bed?” This has got to be about six or seven years ago.

Khateeb: And you’re thinking the big DaVinci and thinking “how are we gonna do that?”

Gardiner: I said: “Yes, maybe you could do that. You’ll have to fold it up somehow.” And he says: “Yeah, you may be a [….] You can put it in the bed.”

And I said: “Oh! You mean when somebody turns it on that, it transforms into a robot?”  And he said “Yeah!” And I said: “Oh, you’re talking about building a transformer?!” [Both laugh] And that was Auris!

So, we started out at Auris. Fred and I knew exactly what we wanted to build and what needed to be built.

We started and kept running into roadblocks because the engineers would keep telling us, “You can’t do that. You can’t put the robot down there, it won’t ever work.”

But we kept pushing back at them and they also kept pushing back at us. We went on for about three or four years that way.

At one point we then said, okay, before you say it can’t be built, let’s at least try and see what we come up with. Because, I’ve seen too many times where people will say, look this is going to be a great idea.

Then you actually get it in your hands and it doesn’t work or it’s not going to be useful. I’ve also seen the same just the opposite, whereby until you really try it, you don’t know how well it’s going to work.

Those bloody Engineers came up with the engineering design that turned the mathematics on its head and, it is working.

Khateeb: I have to say it’s a beautiful robot.

Gardiner: Yes.

Khateeb: I got to see it in person and it’s quite remarkable. So, three to four years of just pushing back and forth?

Gardiner: Yes.

Khateeb: You know, there’s that saying that with pressure you can do one of two things: You can either use it to burst pipes or you can make diamonds. [Barry laughs] It looks like you guys definitely made some diamonds.

Gardiner: It’s been an amazing story and a really amazing ride. It’s like Henry Ford says: “People say it can’t be done until somebody does.”

Khateeb: With the Auris robot, was it similar to Intuitive in the sense that you guys started out with one procedure and realized that it does not fit here and then you changed it to what it’s being used for today?

Gardiner: No, it’s just the opposite. What we’re doing at Auris is to develop the next state-of-the-art 21st century robot. We certainly are climbing on the shoulders of Intuitive to get there but, it’s a robot that has capabilities that have been designed into it not just to do a specific procedure, but to do every procedure.

That kind of goes to confirm what the engineers have put into it. There’s been a tremendous amount of thought that has gone into where we are. It is to get us to be able to gain access to anywhere in the abdomen and do anything.

At Intuitive, we were after the coronary artery bypass. But at Auris, we were after all of surgery.

Khateeb: With the way the system is set up, the way it moves the elegance of it, I can definitely see it doing that. The main thing that it was commercialized for was lung biopsies, correct?

Gardiner: Actually, that’s the Monarch and that’s a flexible platform for bronchoscopy.

Now, we can do that with a system that we have but, they’ve basically taken that procedure and built a cart around that.

That’s the Monarch system which has been introduced already. That was the thing that Fred brought with him from Hansen which is flexible endoscopy.

He’s got a lot of experience and capability, being able to move flexible instruments around.

So, the Monarch is different than the I – Platform; the I – Platform being primarily a laparoscopic device.

Khateeb: I see. Is that that public knowledge by the way, the I- Platform?

Gardiner: I don’t know, I would think it is. I mean, we’ve been acquired by Johnson & Johnson

Khateeb: Acquisitions are always exciting, right?  But things change when that happens. So, for you, are you still involved with Auris?

Gardiner: Oh, yes.

Khateeb: I’m wondering what that next phone call is going to be for Fred.

Gardiner: I don’t know. I wouldn’t even begin to venture a guess at that. I think that Fred is committed to Auris and to see that it is successful.

Khateeb: That’s a great team to have.

Gardiner: He’s got a lot left to do; so, I don’t think he needs a next project. I think he’s got this one

Khateeb: He’s got plenty to do. I want to be mindful of your time and we’ll wrap this up shortly but, just out of curiosity, the one thing that we’ve noticed in the last few years is within the medical device and medical technology industries is that now tech giants like Apple, Google, and Microsoft are entering highly regulated public sectors like education, transportation, and healthcare which is a big one.

Of course, with that, there’s this advent of Big Data or Artificial Intelligence. As a surgeon, what are your thoughts about that? How do you think the surgical community looks at that? Where’s the value in it?

Gardiner: I have no idea and I don’t think they do either. I’ve never yet had anybody be able to explain to me how they’re going to use this Big Data.

Now, that having been said, I would be the first one to acknowledge that sometimes you need to build it and try it. This whole field of dreams thing that says if you build it, they will come.

Maybe once this thing gets realized, we will find things about it and for its use that we don’t right now. It’s a little hard for me to envision where this Big Data story is going. I know Google is very committed to it.

That’s a big part of what verb is all about. But, I’ve not yet been able to have anybody describe to me concretely how that’s going to be translated into better patient care.

It may be translatable into less expensive patient care, but I don’t see how it’s going to get translated into better patient care. Now, I would be the first one to say that. The story hasn’t been written yet. Once we understand what Big Data is, then we may be able to find a use for it.

Khateeb: Well, I’ll ask you this question that I know makes a lot of people, at least in the surgical robotics world, wonder.

If you had a robot or a smart surgical OR that could monitor your movements as a surgeon. For instance, your success rate; just like when you watch a pro football or basketball and you get stats on it.

On one side I think surgeons, knowing their how competitive they are, wouldn’t enjoy that; but on another side, I don’t know if they would enjoy having that kind of like ‘big brother”.

Gardiner: No. No, they’ll be scared to death of it. I’ll just tell you frankly.

Khateeb: Educate us. Why?

Gardiner: At least as of right now, the face of medicine is changing tremendously. For instance, our hospital is being bought up by other larger companies.

Khateeb: Nobody’s independent anymore. It’s too hard. [Laughs]

Gardiner: No. Stanford owns part of Valley Care hospital and UCSF owns part of John Muir. So, the idea of going into practice and hanging up your shingle and being available, good and technically skilled is not as important now as it used to be. I can tell you that surgeons tend to be threatened by somebody looking over their shoulder in a critical fashion.

They don’t want to be told how to do this cholecystectomy. If I’m going to do this cholecystectomy open, I should be able to do it open, right?

Khateeb: I guess you go through five or six years of training getting sold what to do.

Gardiner: Yes.I don’t want somebody telling me that I shouldn’t have converted this operation from a laparoscopic procedure to an open procedure because I was there and I know what the difficulties were.

Or that it takes me twice as long to do this operation as it does Dr. Jones.

They’re threatened by that; or that I have fewer complications than Dr. Smith does. They’re threatened by that, but it’s on the way. So, get used to it.

Khateeb: All right. Although we do this in the industry, but I guess it’s important to say that you have to spend as much time as possible side-by-side with physicians developing these technologies versus what I’ve seen in the past with companies. I, fortunately, did not work for those companies but I could imagine showing up to surgery and seeing some new technology not there before and then being forced to use it.

Gardiner: Yes, that’s right. I think that the input of people that are using the device or potentially could use the device is hugely important and a company is foolish to not recognize that. There are lots of different ways of doing a surgical procedure from draping to the closing and all the steps in between.

One of the reasons I think they’re doing such a wonderful job at Auris for is because we have given a huge amount of thought to exactly that.

Khateeb: Fantastic. Before we end, I got to ask one final question. We do have a lot of medical students and residents who listen to this and I’m sure a lot of pre-medical students at this point. In your career as a physician, are there any books that had an influence on the way, you are as a leader and as a physician. Is there anything that you would recommend?

Gardiner: It’s the people that have impacted my life. The place deals in, the Dunphys of the world and the Fred Molls of the world. I guess my advice to those that are just starting out is to diversify and don’t shut off avenues that hold promise for you because making a living now out of just doing piecework and surgery is going to be increasingly difficult.

So, keep your options open. That’s basically what has led my career in the path that it went. I spent as much time with Fred and for his company as I do in my practice. Had I not taken that phone call from Dr. Moll 25 years ago, that whole avenue would have been shut down to me. And so, keep your options open.

Khateeb: Hmm. A lot of my classmates are just getting out of residency and lifting their head up to see the world. I think there’s this exciting opportunity that a lot of young physicians don’t know about which is to look for those opportunities to advise partner get involved with technology and have a hand in developing it.

Gardiner: Yes. And it takes time to do that, you know, you need to develop the relationships. You need to be trusted. You need to be honest and upfront. You need to keep confidences and if you do that.  Eventually, these opportunities will gravitate to you, but if you don’t, they’ll be shut off. Don’t limit yourself to doing piecework would be my advice to anybody coming out of residency now.

Khateeb: All right. Doctor Garden we really appreciate you taking time out of your practice to sit down, chat with us and share a bit of your story. I’m telling you there’s a lot of people who are saying somebody should record this or write it down. [Laughs] We really appreciate.

Gardiner: I gave a lecture in Taiwan a couple of years ago. It was an hour lecture and one of the participants in the seminar listened to the story that I was telling about Intuitive and the founder of Intuitive and what happened. Then he came up to me and said: “You need to write a book”. And I said: “Well, I’ll write it for you!” [Both laugh]

Fred and I have never done that. I’ve told Fred that before he needs to sit down with somebody that can write his story because it’s an amazing American success story.

Khateeb: Absolutely.

Gardiner: I call him the Steve Jobs of the medical device industry and I think that’s the accurate description of what he’s done.

Khateeb: I don’t think that’s too far off. He’s a lot nicer though, I think. [Both laugh] Ah, that’s for sure!

Gardiner: Fred is not only nice, he’s a very loyal person too.

Khateeb: Absolutely. Fortunate enough for me, the last two companies I’ve been with have been Fred companies. He’s been on the board and I’ve been very fortunate to work with them.

I have something to share with you about when I first left medical school. I love medicine but I just figured out medical school and being a physician wasn’t for me. I had a father who’s a surgeon and was very supportive of it.

I remember that time, I was very scared. We didn’t have LinkedIn or Facebook, we did have Facebook, but I didn’t know what I was going to do. I remember my father and some of his friends saying, Don’t worry you’ll be okay. There’s actually a couple of surgeons who either left med school or residency and are involved in technology. You should look into med device.

So, I appreciate Fred and other surgeons like you as well who not only pioneered an industry for us but also really led by example and opened everybody’s eyes to the idea of trying new technology, doing something new and innovative to push this envelope in doing things better.

Gardiner: Yes, that’s what it’s all about.

Khateeb: Absolutely. Thank you so much. I appreciate.

Gardiner: Okay, you bet.