The unpredictability of being human is part of what makes surgery so much fun. I always say surgery is like Christmas. You never know exactly what you're going to get until you get in there and then knowing what to do and figuring that out once you're in there is the joy and the art of being a surgeon. I really love that part.

Welcome to Becoming Virtuosa, the podcast that encourages you to become your best virtuosa self. Each week Dr. Susan Crockett goes where the scalpel can't reach, exploring conversations about how to be, heal, love, give, grow, pray, and attune. For the first time ever, she's bringing the personal one on one teaching that she shares with individual patients to you on this broader platform. A weekly source of inspiration and encouragement designed to empower you.

By evolving ourselves as individuals. We influence and transform the world around us. Please help me welcome board certified OB-GYN specializing in minimally invasive GYN surgery, internationally in the top 1% of all GYN robotic surgeons, a certified life coach, and US News top doctor, your host Susan A. Crockett, MD.

Well, hey there. Welcome back to The Dr. Crockett Show. I'm your host Dr. Susan Crockett. I'm a minimally invasive GYN surgeon in San Antonio, Texas. Today I've got a very special edition for you of The Dr. Crockett Show. We are coming up on the 10th anniversary of Virtuosa GYN, which is the practice I founded 10 years ago dedicated to making surgery easier for women. That's what we do. That's what we do here.

So for today's episode, I thought I would answer a lot of your questions about what's this MIGS thing that you keep calling yourself? What is a MIGS? Is that like the Russian MiGs in Top Gun Maverick? Well, no, it stands for minimally invasive GYN surgeon. That's what I am. Today's episode is all about why I do that and why it matters to you.

So what exactly is MIGS and why is it important to you? First of all, a minimally invasive GYN surgeon is somebody who specializes in doing very complex noncancerous benign GYN surgery through very small incisions. So the main way we are minimally invasive is through the size of our incisions. But as you'll hear, as I talk with you, there are a whole lot of other things that we do to make surgery less disruptive for your life. So we're minimally invasive on a whole lot of levels.

I practice in San Antonio, Texas, and I specialize in robotics as a form of minimally invasive GYN surgery. But I have some really amazing colleagues who don't do robotics. They actually do what we call straight stick original kind of laparoscopy, and they are also very fine Minimally Invasive GYN surgeons. There are now fellowships that are popping up actually quite extensively for GYN, OB/GYN residents who want to specialize in minimally invasive GYN surgery after they complete their four years of OB/GYN training.

So right now there are several different board certified specialties and subspecialties and OB/GYN. They include the older three sub specialties, which are GYN oncology, MFM, which is maternal fetal medicine or the OB experts, and reproductive endocrinology and infertility. Then there's also urogynecology or pelvic floor subspecialty. There's also a pediatric and adolescence subspecialty.

But the one that interests me the most, and the one I'm going to chat with you about today, is MIGS, minimally invasive GYN surgery. I'm going to give you a little bit of an idea why that is important to you and what the amazing things that we're doing these days in increasing the ease of surgery for women, and what the standard of care is and where it's going in the next couple of years because we're right on that frontier baby. So much fun.

All right, so I want to tell you a little bit about the characteristics of advanced MIGS surgical teams because I'm not the only one by a longshot. There are lots of us across the United States. But all of us that practice in this subspecialty share some very simple commonalities. So I kind of want to share them with you so you can know what to look for when you're looking for a minimally invasive GYN surgery for yourself or your loved ones.

So first of all, we usually have very minimal blood loss. It's unusual for us to need to do a transfusion during a surgery. The way that we do our surgeries is very clean and efficient with usually losing less than 25 or 50 cc's of blood, which is less than you would get if you just went to the doctor and had a lab draw.

Our conversion rates are generally less than 1%, our open surgical rates. That means that almost everything we do is through small incisions. Usually the biggest incision that I do is about any inch, sometimes a little bit bigger than that when we're dealing with really large fibroids or uteruses. But the other thing about a minimally invasive GYN surgeon is it's rare for us to take a case and start it out through small incision surgery and need to convert it to an open surgery. But that happens sometimes.

We also have very low complication rates. Now no surgeon has a zero complication rate. That's just not possible when dealing with the human body. Like the unpredictability of being human is part of what makes surgery so much fun. I always say surgery is like Christmas. You never know exactly what you're going to get until you get in there. Then knowing what to do and figuring that out once you're in there is the joy and the art of being a surgeon. I really love that part.

But all of us that practice these high volume robotic or minimally invasive GYN surgeries, the more we hone our craft, and the more efficient and capable we become, the lower our risk of injury becomes from injury to internal organs or infection or bleeding or having something go wrong with the case. It's just a matter of putting in so many more hours than we're able to do when I was doing general OB/GYN.

Our teams tend to be very fast and precise in the OR. We really increase our efficiencies. I hold the unofficial world record for the fastest robotic hysterectomy time. Not that speed is the only thing, but speed is something that happens naturally as a result of the surgical procedures becoming integrated into your subconscious and working on the efficiencies with your team.

So that's something that happens when you see these advanced MIGS teams. They become very fast and very efficient. We have very fast turnovers in most, most days. Most of our cases are same day surgery, which is really fun. That's something that really got emphasized during COVID when hospitals had bed sort of shortages. Now hospitals have kind of picked up on that and decided that being able to move patients to outpatient surgery rather than keeping them in the hospital is a good thing.

For my patients, this is one of the things that I think of as being minimally invasive to their lives. So for them to be able to go home to their own bed, take their own medicines, be with their family, eat their own food, not be waking up every couple of hours with vital signs or other hospital stuff going on.

If it's not necessary for them, I find that my patients do a whole lot better at home. They're more likely to get up and move around, which decreases the risk of complications from DVTs or blood clots in the legs. Most of my patients do really great at home, especially with some of the newer advances in pain control that we have.

Speaking of pain control, we as MIG surgeons usually minimize narcotic use. So my narcotic prescription rate is super, super low. It's not zero because there are patients that have special needs and tolerances. We certainly want people to be adequately medicated. But it's very common for us to do non-narcotic surgery. The way that we do that is with a numbing medicine called EXPAREL. Yes, I have been a speaker for Pacira in the past. I'm not currently sponsored by them for this talk. I just think that this product is has been an innovation and a revolution in how women experience surgery. So I love talking about it.

EXPAREL is a numbing medicine that we use as a local anesthetic in the incisions, sometimes is a nerve block. What it does is it time releases itself over a couple of days, usually three to five days depending on your metabolism. With that base, we're able to treat most of our patients surgically with nonsteroidal pain medicines and Tylenol rather than having to reach for narcotics.

That is just a breakthrough, especially in these times when we're really concerned about overdose and narcotic usage rates in our country. So not only is that a good thing for the rest of the country, but it's also great for patients because being on narcotics is not the most fun thing in the world. You have side effects from that. Well, more about that later.

Most of us also have very high patient satisfaction rates. It's not uncommon for my patients to come into the office and say hey, that wasn't as bad as I thought it was going to be. I always tell them I kind of live for that. That's what I hope for everybody. Sometimes I get that oh my gosh, I had no pain at all. I was great in three days. Your results may vary. There's also the patients that need more time and healing and don't heal up that fast. So I don't want to slant things their own way.

But the patient satisfaction rate with minimally invasive surgeries very high. Often because they've heard stories from their mothers and their grandmothers and their friends about what to expect from surgery. Then when we're able to over deliver on those expectations by getting them feeling better faster and making surgery easier for them. Well, of course, patient satisfaction is a great thing.

In fact, most of the time we can get our patients back to a normal desk job and normal activities within I usually say seven to 12 days. I like my patients to take a week and a half off from work just I think our bodies need to heal. We, as women, do so much and don't take care of ourselves enough. So can you get back faster? Yes. Should you get back faster? Sometimes no, probably not.

So, I mentioned the MiGs thing. I think that was pretty funny. Top Gun was one of my favorite movies growing up, and Maverick came out a couple of years ago. Tom Cruise was in the fighter jet at the beginning of the original movie, and he's like looking at the MiGs upside down shooting the picture.

So I'm not that kind of MiGs. Obviously, I'm minimally invasive GYN surgeon. But I wanted to go over a couple of characteristics of how surgeons, what things we have in common with fighter pilots. It’s kind of a fun list. So here you go.

One, we do intense, life risky work. Two, we play with very expensive equipment. My robot equipment costs over a million dollars per robot. That's not even figuring in the equipment of everything that I use with it and all the staff and the ORs that had to get built out and all that. So yeah, we deal with very expensive equipment.

I'm very grateful to my Intuitive and HCA partners. There's not a legally binding thing. It's more than a loose like my collaborators between Intuitive Surgical and HCA. I'm very grateful for the collaborators that have helped me build my practice and that I'm continuing to work with in building out our next feature.

Both being a fighter pilot and being a surgeon are learned skill sets. So I like to think of surgery much like a musician learning a musical instrument. In fact, the equivalence between watching a young surgeon start their surgical path and seeing a more mature surgeon have the confidence in their surgical path then seeing surgeons become the maestro's or the experts in surgery, that's really a really fun thing to do. The skill evolution is very similar.

So much so that when Intuitive Surgical, who tracks our hand motions on the robot, they can look at patterns of hand motions from surgeons across different parts of the United States, and they can actually see dialects. They can tell where we're from or who we are trained with by the way our hands move. I just think that's fascinating and such a cool correlation between music as a skill set, and maybe fighter pilots too, and being a surgeon.

That's part of why I named my practice Virtuoso GYN. It's a feminized version of being a virtuoso, which is an excellent musician. That's how the practice came to be named that. It's what I strive for every day. Both surgeons and Top Gun fighter pilots use intuition and our feel, how we feel things by touch. They both come into play where our technology stops. So we're both operating highly technical instruments, but we're using our personal intuition and touch to integrate with that.

That's where AI leaves off, which is another upcoming topic in surgeries. Theres a lot of discussion about what the need for the surgeon is in the future and where AI blends into that integration between the technology and the surgeon.

We both work in places where teamwork and trust are really integral to our mission. In my case, surgery. I have an incredible team. Nobody does this without a really great team. It's very, I liken it to any other great team a rock band or car assembly line or whatever you're doing that's a team. This is not a solo business. There are a lot of people with lots of varied skills and very incredible talent and intelligence surrounding me. I'm grateful to my teams every single day.

Both fighter pilots and surgeons, we push the envelope on what is humanly possible with efficiency and data integration. We are combining that with technology. Additionally, how we recover from the unexpected makes all the difference. Have you ever watched Tom Cruise in one of those movies, the Top Gun or the Maverick movie about how he recovers when something doesn't go right?

Well, newsflash, things don't always go as we planned in the operating room either. One of the best things you can do if you're choosing a surgeon is know that you have somebody that knows how to take care of the complications when they happen, not just do the surgery. So I like to joke with my patients and my residents. I teach residents from Brooke Army Medical Center now. They're really awesome. They come operate with me.

I tell them that you can teach somebody to do all of the surgeries that a GYN needs to do in about a year's time, but the rest of your residency and then the two years of MIGS fellowship are about teaching you how to make the correct decisions about what to choose, how to do the surgery, and then how to handle the complications and things that don't go right.

The last thing that we have in common with the fighter pilots and the surgeons is not going to surprise you. We both are people with huge confidence, competence, arrogance, and sometimes humility. So we always strive for that humility, but that arrogance and that confidence is something that we also have to be able to do the jobs that we do at the level that we do. I think that's kind of funny.

So I wanted to talk with you a little bit about the robotics itself, like what does that look like? I have patients who come in and they say is the robot doing the surgery? That is absolutely not true. Robotics is actually an advanced form of laparoscopy or small incision surgery that I started doing, I hate to tell you this. It's been almost 34 years, 33 years since I started doing laparoscopy. I was really well trained at the dawn of the laparoscopy era.

What the robotics movement has done has allowed me to attach technology to the laparoscopic instruments so that I sit at a terminal that looks more like a video game terminal than at bedside where we do straight stick laparoscopy. This has lots of benefits for me as a surgeon as far as saving my body from the stress and strain of being a surgeon and wearing down.

But the coolest thing is that the visuals and the haptics and how I work with the joysticks and the foot pedals, it all integrates and it makes surgery more fluid. I can do a whole lot of wristed action instead of just straight stick. It makes me able to do extremely complex dissections for patients much faster than I would if I was doing it straight stick.

So what kind of procedures do I actually do? Well, by far my most common procedure is hysterectomy. We do those for lots of different reasons. But the most common reasons are women that have really heavy bleeding or fibroids or have pelvic pain or have uterine prolapse, that means that things are falling down. My second most common procedures would be myomectomy, which are where we take out fibroids, which are tumors that are non-cancerous that grow in uteruses, and they cause a lot of pain and bleeding.

Then the third most common thing I do is endometriosis and probably the fourth most common robotic surgery I do is something called sacral colpopexy, which is the only surgery in which I still use mesh. But that is basically putting in a ligament replacement, like you would have a joint replacement, like a knee replacement. Well when women's insides fall down because their collagen is weak and there's no more connective tissue to connect to, we put in a mesh that suspends their organs up to the inside of their body, and that's called the sacral colpopexy, and that's done robotically.

So the other thing that's really cool about robotics is I mentioned that we can handle really complex procedures. Well, what makes something a complex procedure? Well, one is medical complexity. So I'm used to handling patients that have all kinds of very complex medical problems. Oftentimes, GYN surgeons or OB/GYNs who don't want to deal with those levels of complication will refer those patients to me to take care of because it's what I do all the time.

But some other things that increase the complexity of our cases are really large uterus or having fibroids. Depending on how big they are, the size, they can be very complicated cases. Very obese patients. San Antonio is the third heaviest city in the United States, a fact that I am both proud and appalled of.

What we've seen as the GYN surgeon is that the obesity rates have also paralleled not only diabetes rates but they also parallel the rise in estrogen related GYN problems like fibroids and endometriosis, making this one of the best places in the country for me to practice as a minimally invasive GYN surgeon that takes care of women with those problems.

Also, if a woman's had prior surgeries, they're often complicated by having prior adhesions, or if they've been pregnant and had C sections. Some patients have endometriosis, which is a condition that can deeply infiltrate their pelvic organs. Even though it's not cancerous, it can be very difficult surgery because of how it invades the internal organs. All of these things increase the complexity of cases and make a seeking out a minimally invasive GYN surgeon something that you should probably think of.

So I mentioned a little while ago that we're coming up on the 10th anniversary. Oh, I didn't mention that? By the way, we're coming up on the 10th anniversary of Virtua GYN, the practice that I founded on May 1, 2014. This practice was founded as South and Central Texas’s first dedicated MIGS practice. So we've been making surgery easier for women for a decade, and that's coming up this week. That's why I'm taping this for you this week.

So I just wanted to give a little shout out for our little practice and the little train that it could. I think again, I think again. What was the little train that was the little story I read growing up? I thought I could, I thought I could, I thought I could. It's really rewarding to me to see how far my team in the OR has come, the advancements that have happened in the last 10 years, how my clinic staff, my office staff who are amazing people, how that has come together, and how now more than 18,000 of you as my patients have come and let me have the honor of taking care of you. You've trusted me with your care.

Gosh, my friend was asking me the other day about how long I've been practicing and how much I had done. I mean, just to give you a little bit of background, I went to Texas A&M University, and I went there both for both undergraduate and medical school. I started my residency at Georgetown University in 1991 in OB/GYN. So I started delivering babies and doing surgeries 33 years ago. Yeah, it was like 12 at the time.

Oh my goodness. I calculated by the time I quit doing OB, I had done several thousand deliveries. Some of those now I've got patients that have come back to see me, and their kids are having kids. That's incredible. It's amazing to see these grown up little people that I watched over in the womb way back then. It’s so cool when I get to see the follow ups on those. It's like the rest of the story.

We were talking about how many surgeries I've done. I've done almost 3,000 robotic surgeries in the last 15 years. So I started robotics in 2009. I was one of the first 24 OB/GYNs in the country trained at the highest level, which is the master’s level. So plus all the other surgeries I had done before then. We came up with, I don't know, like almost 15,000 surgeries because I do about 700 surgeries a year now. 250 to 300 robotic surgeries, but then all of the other types of surgeries and procedures that I do too.

Golly, I thought that's an astonishing number, but I don't think it's that far off from having such a full, amazing career. Gosh, it's just incredible to me to think that I have seen the insides of so many women's abdomens. It's kind of funny. But just that I've had the tremendous privilege of taking care of so many of you.

So the next thing that's coming is we're planning on taking what we've done in the last 10 years, and I wanted to tell you a little bit more about what we're building and what's coming in the next 10 years for us.

First of all, I am really proud to announce that I'm Intuitive Surgical’s newest faculty member for the National Faculty for Teaching Benign GYN. This is a huge honor to me, and I'm the first woman that they've had on that team. I'm extremely grateful and honored to start that. So I begin my faculty training next week. So I'll be training other OB/GYNs around the country how to do the procedures that I do.

I've also been a speaker and proctor and observation site for Intuitive Surgical and assessed for many years. I've been a past speaker for Pacira, as I mentioned before, but also Cooper Surgical. So those are my disclosures.

So one of the things that I wanted to let you know about is we're in the process of building a new medical office and a new hospital outpatient department with Northeast Methodist in San Antonio, Texas. So our office for the new office for Virtuosa GYN is going from a 4,500 square foot office to a 6,000 square foot office.

Right now we are three providers. It's myself and my two amazing nurse practitioners, Michelle Self and Tam Krueger, and we are going to be expanding and hiring on two additional GYNs. So I'm bringing on an additional MIG surgeon who I'll be introducing you to later this year. She is graduating from her MIGS fellowship. We're excited about her joining us. Then I have another GYN, general GYN who has been in practice almost as long as I have who's going to be rounding out our team.

So our new Virtuoso GYN office is going to be located on the second floor above the new hospital outpatient surgery department that we're building next to Northeast Methodist Hospital. The surgery center has already been designated by Intuitive Surgical who, for those of you don't know, that don't know that they are the creators of the Da Vinci Robotic System, that's what I operate off of. But we've been designated as an epicenter. That's huge. An epicenter is a designation by Intuitive Surgical that means other surgeons are going to come and learn to do what we do. Our specific niche is to teach other surgeons how to increase their outpatient surgical rate and to increase their surgical skills.

So once a surgeon is trained at a basic level of robotics, there's a real gap between their original training and increasing their efficiency. There are not a lot of places for surgeons to learn that advanced skill set. Back when I was learning how to be a surgeon, when I was in early private practice, the system was a lot different. We almost always scrubbed with a senior partner. So we improved our surgical skills because we were scrubbing with a senior partner.

Now due a lot to the decrease in reimbursement and the cost of private practice, most new surgeons coming out are either practicing by themselves or with a first assist, like Lacey Aguero who's my incredible for surgical assist, or Ella Diaz, my other incredible first surgical assist. So they help me on most of my cases. But they aren't capable of teaching a young surgeon how to get better surgically.

So what we're building at this epicenter in San Antonio is a place for mentorship where not only can surgeons come for case observation and get to see what we do and learn about our teams or hire me as a proctor to go to teach them in their ORs or oversee what they're doing, but they’ll be able to come and do a mentoring visit, which means I could bring their cases there and have a mentor on site.

Since my office is going to be upstairs, and I'm going to be doing surgery in the building most days, having an onsite mentor is something that would decrease the amount of open conversions and be able to get more cases completed in a minimally invasive outpatient manner for their patients, which is better for patient care.

We're also working on setting up a program where they could come scrub with me for like a week. You can come be a resident for a week. So if you wanted to learn, as a surgeon, how I get big things out of small incisions, which that's one of my secrets I'm not going to tell today. If you want to learn how to do fibroids surgeries or advanced types of surgeries, there's a need for this mentorship type program where you could come and scrub with me for a week and learn those skills.

I do, let's see, about 12 to 20. The goal is 20. I think I did 17 surgeries last week. So in a week, we could certainly get a lot of experience and have a great time just hanging out together and learning more. I always learn from people when they come and hang out with me too. It's a lot of fun.

What else are we doing? We're building a new YouTube channel called Virtuosa Surgery. That's coming. What that's going to be is similar to The Dr. Crockett Show channel only it's going to be all about surgery. So we're going to be presenting cases in the office setting. Then we'll also be showing the technical side of it. So if you wanted to actually see what it looks like when I'm operating or if you're a surgeon and you want to increase your skills, we're going to have some special things coming for from that perspective also. Increasing the availability of teaching.

Let's see what else are we doing. We're getting some new robots in. I've played with the new DV 5, which is the latest robotic system. That's really cool. We've got AI stuff coming in and remote proctoring I'll be able to start doing remote proctoring.

Y'all this is crazy. Like, I'll be able to have a surgeon that's remote who says hey, I got a problem. I need for you to take a look at what's going on. From my robotic system in San Antonio, I'll be able to remotely log into their system securely and help get them through whatever they're dealing with. I won't be able to handle the instruments, but I'll be able to give them instructions about what I see and how to think about what they're doing and their options at that moment.

One of my favorite quotes of all time is this one that sits up on the wall up here. Y'all can't see it because it's behind the camera, but it's a Jack Welch quote. His quote is that the hero is the one with the ideas. The hero is the one with the ideas.

Everybody's all afraid of all this AI and what's going to happen to us. But what AI can't reproduce is the creativity and the ingenuity and the ideas that come from being human and wanting to serve and care for and take care of other human beings. That's the personal side. That's never going away. That's a promise for me to you.

So I look forward to the next 10 years of Virtuosa GYN and the evolution of minimally invasive surgery. Thank you for listening in today. Please make sure to drop your questions and comments below. If you liked this show, please share with others and like and subscribe. That's how we grow. I'll catch you on the next Tuesday. I'll see you then. Have a great week. Take care.

Thanks for listening to this episode of Becoming Virtuosa. To learn more, come visit us at DrCrockett.com, or find us on YouTube for the Dr. Crockett Show. If you found this episode helpful or think it might help someone else, please like, subscribe, and share. This is how we grow together. Thanks, and I'll see you next week. Love always, Sue.