Robotic Surgery: From Training to Innovation with Dr. Aaron Dawes

In this episode of Scrubcast, Assistant Professor Dr. Dawes discusses what drew him to colorectal surgery—including his love for intestinal surgery, the field's breadth from minor anorectal procedures to complex pelvic surgeries, the welcoming culture, and love of new technology.

Dr. Dawes highlights exciting advances in robotic surgery, including performing California's first single-port colectomy with Dr. Gahagan. He explains how single-port robotic technology is particularly beneficial for natural orifice procedures, such as transanal surgery for rectal polyps and cancers, as well as operations involving stomas. While he acknowledges that robotic surgery won't completely replace traditional open surgery—especially for complex reoperative cases—he believes it's lowering the technical barriers for minimally invasive procedures and expanding what surgeons can offer patients. As Stanford's Director of Robotic Education, he has been revamping the surgical residency curriculum to make robotic training more transparent and accessible, with clear milestones for both residents and faculty.

Read about his new K award: https://surgery.stanford.edu/news2/dawes-k08.html

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today we're speaking with Dr. Aaron Dawes. Welcome, welcome.

Dr. Aaron Dawes: Thank you so much. Glad to be here.

Rachel Baker: Thank you for joining us. We're very happy to have you here.

Dr. Dawes is an assistant professor in our Division of General Surgery, specializing in colorectal. What was it about colorectal that drew you to it?

Dr. Aaron Dawes: Yeah, it's a great question, one I get a lot, as you might expect. I always have to have kind of a, a group of funny answers, I think, and a group of true answers when people ask me that.

So, you know, there's the, "Well, I was told I could play 18 holes a day," those sorts of things. But the real answer is that I just fell in love with general surgery pretty early on in my residency. I loved intestinal surgery. I like gut physiology. I like operating in the belly. So [00:01:00] I was really looking to do something that was an extension of general surgery, where I could really be focusing on intestinal surgery.

And of the choices, I knew I wanted to go into academics, so I wanted to specialize a little bit more. And colorectal, I think offers a lot of breadth. I'm just someone that needs to be doing different things throughout the day, throughout the week and month. So I'm doing anything from really small anorectal disease that really helps people and they feel better, all the way up to yesterday I did kind of a redo pelvic dissection, a big large open surgery in the pelvis. So kind of that and everything in between.

And then a lot of new technology. So colorectal tends to be known for embracing new technology, robotic surgery, endoscopic-based surgery.

And then, you know, they say that there isn't a culture, but I feel like there is a culture to different subspecialties, and colorectal surgeons tend to, uh, be fun. They tend to not take themselves too seriously, which I think fits me pretty well. So [00:02:00] felt very welcomed in the field as I got more and more involved in it.

Rachel Baker: I agree. I think colorectal surgeons have the best sense of humor.

Dr. Aaron Dawes: Yeah, you have to, one, because of what we do. It seems a little silly at times, but I think it really helps with patients as well to be warm, to be able to take some of the edge off when they come to meet you, and they're having a- It's

Rachel Baker: a taboo subject

Dr. Aaron Dawes: Yeah. Right? A subject they may not want to talk about, an exam that's a sensitive exam.

Rachel Baker: Yeah.

Dr. Aaron Dawes: Some potential long-term changes to their health, you know, that may or may not be what they had expected. I think it really helps to be welcoming in that moment and have a little humor.

Rachel Baker: Approachable.

Dr. Aaron Dawes: Yeah.

Rachel Baker: Solid. Well, so this episode we are talking about robots, which you just mentioned colorectal, loving the new technology. I think the robot the public is most familiar with is the da Vinci Surgical System- Correct ... uh, by Intuitive. So I was doing some research It received FDA clearance in [00:03:00] 2000. Y2K. What?

Dr. Aaron Dawes: Yeah.

Rachel Baker: I mean, it did not meet my lexicon, I don't even think, for like another 10 plus years. But you're a surgeon. You got your MD at Vanderbilt in 2011, then did your residency at UCLA. Was robotic surgery on your radar when you started out?

Dr. Aaron Dawes: So maybe not when I started, started out in the field. I mean, you're right that the da Vinci in particular has been around for a long time, in part because it was a DARPA initiative.

It really started, the initial robot was started as a battlefield adjunct with this idea that we'd be able to not send expensive and well-trained military surgeons quite into harm's way in the same way that other battlefield-type people are. And so they'd be a little further back from the front lines and yet be able to perform care on injured soldiers in that way.

I don't know that it's ever [00:04:00] really fit quite that well. I, I'm, I'm not a military person myself, so I don't really know the logistics, but, um, that's certainly not…

Rachel Baker: It's been heavy

Dr. Aaron Dawes: …the main way we think about it anymore. But it had a big jumpstart on a lot of the competition for that reason, because it came up in that way. But it has certainly been the major robot that we've used my whole training.

So as you mentioned, I started at, in medical school at Vanderbilt in 2007. I'm sure we had robots. They were just not super familiar to me. I became a lot more involved in them as a resident at UCLA. We had a number of surgeons who were interested in, in using the robot.

We had a number of people who had gone off and gotten some more training and come back to UCLA. I think as many programs do, there are a lot of people that wanna come back and kind of build from where they had trained, and so we had a lot of people that were infusing energy and interest into this. And yeah, it was just something that struck my eye pretty early on as having applicability to what I wanted to do.

I think pelvic surgery in [00:05:00] particular done robotically is different. It's hard to argue against someone that does a really, really good laparoscopic pelvis, but that's a really hard operation to do. So being able to do it minimally invasively robotically, I think what's really changed the field is it takes the technical bar down enough.

It's still technically challenging, but it makes it so that most well-trained colorectal surgeons can be doing procedures minimally invasively. And so I think that was the major jump for our field, is things that we weren't able to do laparoscopically, that everyone wasn't able to do laparoscopically, now most of everyone is able to do robotically, and I think it's really changed the way we think about certain cases in colorectal.

Rachel Baker: That's awesome. Well, so you ended up being our director of robotic education.

Dr. Aaron Dawes: I am.

Rachel Baker: So you really like robots.

Dr. Aaron Dawes: I do.

Rachel Baker: You have been zhuzhing our curriculum for the past year or so. What [00:06:00] updates have you made so far?

Dr. Aaron Dawes: Yeah, so I think this was one of these, if you make enough of a fuss, they ask you to get involved sort of positions.

And I'm certainly honored to have it. I, I wouldn't say that I came here seeking it per se. You know, there was a good curriculum here to begin with, at least when I started. I, I think that what we've tried to do is make it very transparent to both the learner and the faculty.

So I think the first couple years at least that I was here, it was a little hard to know where individual residents were on their training scale. So unless you've worked with them or heard about them from others, it's a little bit of a black box until you start working with them. And, you know, with all of the wonderful rotations we have, we don't get to spend a whole lot of time with any one resident over a period of time. So it was hard to really understand what was appropriate to entrust to a trainee.

And so one of the major goals with the new curriculum was to make it clear what [00:07:00] needed to be done.

Rachel Baker: Mm-hmm.

Dr. Aaron Dawes: Make it clear to the faculty who had done what, to put some signposts along the way with responsibilities on both sides, and to say, "Look, if you want to sit down at the console," which is the place where you actually control the instruments-

Rachel Baker: Mm-hmm

Dr. Aaron Dawes: you need to know how the console works, and I can't be teaching you how to use the console while we're operating on someone. That's not the time to learn.

Rachel Baker: Right.

Dr. Aaron Dawes: You need to have demonstrated that you've done those things before it's appropriate for me to entrust that to you. But then on the other side, on the faculty side, we're saying, "Look, we're gonna show everyone the completion reports of our residents and demonstrate their knowledge," and it's now up to us as faculty to entrust more and more of the case to our trainees based on seeing that they've put in the work to be appropriate to do it. So I think that was the major change that we started to make.

We broke it up a little bit too into kinda what is [00:08:00] the basic kinda minimum that needs to be done. We're a general surgery program in the 21st century in Silicon Valley down the street from Intuitive Surgical. I tend to believe that anyone coming through this program and graduating from the general surgery program should have done enough robotic surgery to go out and do robotic surgery, at least basic robotic general surgery in their practice.

And so Intuitive has something called an equivalency certificate

Rachel Baker: Right.

Dr. Aaron Dawes:  ... which is their marker of having completed the, the minimum to be safe on the robot. And we said that all of our residents, by the end of their fourth clinical year, should be obtaining that. We wanted 100% of people to graduate from the program with that equivalency certificate.

If you're going into a field that doesn't tend to use the robot, that's okay. We're adult learners. We understand that, you know, certain things will be more and less important to each individual. But if you are going into a field that does use the robot, we wanted to [00:09:00] then allow for an additional experience.

And so we have kind of what we call the pre-curriculum or the early curriculum for our, usually our ones and our twos

Rachel Baker: Mm-hmm

Dr. Aaron Dawes:... who are learning how the robot works, how to use it safely, do the check-offs to be able to sit on the console. That's the pre-console curriculum. The console curriculum, still a little bit in flux, but working with individuals on building their basic skills to perform safe and efficient robotic surgery.

That ends hopefully for most people with an equivalency certificate at the end of their R4 year. And then if you choose to go on, we wanna be supportive of pairing individuals with someone in the field in which they're choosing to spend a lot of really intensive mentored time to learn about robotic colorectal surgery or robotic hernia surgery, robotic foregut surgery, whatever they will end up doing in their future career.

And then hopefully, as the carrot as well, be able to take advantage of Intuitive being down the road, get [00:10:00] them to a really neat course with maybe a visiting professor to learn about some new techniques. So those are kind of the major changes we've made over the course of... It's our first year rolling it out.

We're hoping things will continue to change, but that's where we are as of now.

Rachel Baker: Fabulous. I love it. So last year, you and your colorectal compatriot, Dr. Gahagan, performed California's first single-port colectomy. Why single port? Doesn't like-

Dr. Aaron Dawes: Yeah ...

Rachel Baker: I feel like that's gonna actually limit you. I mean, on the one hand, I don't want more incisions. I've got plenty already. I don't need more.

Dr. Aaron Dawes: That's true.

Rachel Baker: But why single port? What are the challenges? What are the benefits?

Dr. Aaron Dawes: Yeah, I think it's a great question, and one I'm not sure anyone really knows the answer to yet. Um, I

Rachel Baker: Planning some HSCR on that ?

Dr. Aaron Dawes: Yeah, yeah. I mean, I hope so. I hope we'll be able to really study it and try to understand it.

I think like most things, it's a really great [00:11:00] tool for certain indications. I don't think it's gonna completely replace multi-port surgery. I don't think anyone is really arguing that at this point. I don't know if you've ever seen one, but effectively it takes the four arms of the da Vinci XI or DV5 robot, the standard multi-port robotic, and it brings them all together, so they all work in conjunction in one port.

And so the benefit of that is it's a smaller incision than everything together. You have everything working together in one space. But the limitations are you can't keep the arms apart. They can only go a certain distance from each other. So certain moves that we do in multi-port robotic surgery, we've had to refine a little bit as we start to do more single-port surgery 'cause we don't have the reach to get the arms apart.

Rachel Baker: Yeah.

Dr. Aaron Dawes: Um, but to your question, I think that the clearest indication for us was actually natural orifice surgery. Part of it was actually designed for transoral surgery.

Rachel Baker: Oh, interesting.

Dr. Aaron Dawes: So some people here helped design through the [00:12:00] mouth doing tonsils and complex oropharyngeal surgery. We've taken our colorectal take on that and, and put it lower down, shall we say- Oh ... um, to do transanal surgery with it.

Rachel Baker: Oh, like all the way down.

Dr. Aaron Dawes: All the way down. Yeah. So, uh, we try not to tell the, uh, the ENTs what we do with their robot, but it's really an amazing change for patients and for us as surgeons doing transanal surgery.

So the older platforms we used to use, there's one in particular, uh, that we use here a lot called Transanal Endoscopic Microsurgery or TEM, that was... I was born in 1984, TEM was born in 1983, and has not been updated very much since then. And so it was really nearing the end of what we could do with that technology, and so being able to replace it with robotic single-port transanal minimally invasive surgery or TAMIS has allowed us to do things we were having trouble doing before.

So certainly rectal polyps, even some cancers, [00:13:00] we're able to take out through the anus now. So no incisions on the belly, but also usually not resecting a piece of the rectum, just taking a little bit from the internal lining. So in terms of the recovery, it's a very different operation, much easier to...

Most people spend the night in the hospital, if that. So, uh, a really huge change. Again, for a small indication, but something that we were kind of at the top of our ability with the current technology And now we're able to do more and more with the robot.

When we think about single port transabdominal surgery, I think the clearest indication for me at least, is operations where you're making some kind of a stoma. So an ileostomy or a colostomy, or you're taking down an ileostomy or a colostomy, because you have an incision that's now big enough to put the single port in through it. And so I have a colostomy takedown coming up, I think next week or the week after, where we're gonna try to use the robot that way to see if [00:14:00] we can minimize the additional incisions that we need to make.

So I think that we're trying to push the limits safely and try to understand for ourselves what are great indications for this newer technology, how does it fit in with slightly older but still really good multi-port technology that we use every day.

Rachel Baker: For sure. I'm all about it. So in addition to your single port robot, plastics recently got a microsurgery robot, which is really creepy looking, …in a good way. And then I hear pediatrics is getting a da Vinci 5 with the console that looks like Rosie from The Jetsons. Things are go- like crazy. They're advancing at the speed of light with technology. Where do you think we're going next in robotic surgery? Is- I mean, is the robot gonna take over and just do surgery itself?

No doctor required. You're gonna be like, "Peace out, da Vinci."

Dr. Aaron Dawes: Right. I hope not, for my, for my [00:15:00] sake. I mean, I think that questions of kind of AI-enabled, AI-adaptive technology are really good ones, not ones that I know a ton about. We've heard about them for years, and the idea of could we identify structures we don't wanna injure, the bile duct, the ureter?

Could we use video technology while we're operating to immediately capture and provide some feedback and say, "Hey, do you really wanna be down there? I think that that's not where you wanna be." So I think those are coming. I hope those are coming. I hope that they're something that we learn to use with our own expertise to be able to make us better surgeons for our patients and perform safer, more efficient operations.

I don't know that robotic surgery is ever gonna replace, replace open surgery. In particular you know, we at Stanford get a lot of reoperative surgery. We get a lot of complex things that we've either taken care of before or are being referred from outside, where I still do a decent amount of open surgery even though I try to [00:16:00] do as much as I can minimally invasively, because I do believe that on par, it's better for our patients…

Rachel Baker: Right

Dr. Aaron Dawes: to do minimally invasive surgery. So the physical limitations of what we can do minimally invasively, be it robotic or laparoscopic, I think are always still gonna limit some of what we can do. I do think you're seeing more and more of robotics take over from laparoscopic surgery in part because of the technological differences, the things that we can do.

Again, at least for me, it lowers the bar of the things that I can do minimally invasively. There are things I can do robotically that I'm not sure I could do laparoscopically. And so as we push more and more to try to do things minimally invasively, I think you're gonna see more robotic surgery.

Pediatrics is a great example. I've been working with them a little bit on how we're gonna adopt some of that over there. I've heard from the breast surgeons about potentially doing single-port mastectomies.

Rachel Baker: So cool!

Dr. Aaron Dawes: You know, I think the sky's the [00:17:00] limit. I think the most important thing is what is the true benefit? What is the true indication? How are we thinking about technology not for technology's sake, but technology to benefit the patients, to do a better operation, to improve disease treatment?

So as long as we're keeping that as our focus, I'm all for continuing to experiment and, and try to figure out how we can use technology better.

Rachel Baker: We could continue talking about robots, but that sound means it is time for our lightning round. On each episode of Scrubcast, we ask our guests the same three questions, and the first one is, who is a surgeon you admire and why?

Dr. Aaron Dawes: Wow. I have so many of them. I'm gonna take present company excluded, just to make it easier.

My first program director, who's now the chair at UCLA, Dr. Hines, is always a mentor to me, who was just here not that long ago, and I enjoyed talking with him again. Just very calm and cool in all situations. [00:18:00] He, I mean, talk about someone who's one of the best laparoscopic surgeons I've ever seen.

Parallax is this idea where you're kind of pointing one way with the camera, but you're pointing physically another way, and your brain has to put the two together, and I've never seen anyone who could just, was unbothered by that completely. So it was great to see him again when he was here recently.

Rachel Baker: Fabulous. Second question, what is the best advice you have received in 10 words or fewer?

Dr. Aaron Dawes: Ooh. It's a little corny, but I still really like, "If you can be anything, be kind." And I just-

Rachel Baker: Aw ...

Dr. Aaron Dawes: I try to put that in just the, not only my daily life, but i- with patients too. I mean, we, we see patients in tough situations, and just try to understand what they're going through and do what we can to support them.

And sometimes that means being nice, sometimes that means being a little firm but kind. But I think trying to keep a smile, uh, as you go through the day at least makes it easier for me to hopefully deliver the best care that I [00:19:00] can.

Rachel Baker: Gosh, my recent guests are all just making me- ... cry in the middle of these things.

Uh, okay, this should be a, a fun question. Don't make me cry on this one.

Dr. Aaron Dawes: Okay.

Rachel Baker: What is your preferred OR music? I think I know the answer, but ...

Dr. Aaron Dawes: So if I get to the controls first, I am almost always listening to the Grateful Dead. I'm a big Grateful Dead fan. I'm born in San Francisco, grew up down the peninsula, so definitely, you know, have some love for the Grateful Dead.

I also think the vibe is, is just- It's

Rachel Baker: a good

Dr. Aaron Dawes: vibe ... it's calm for what I need in the operating room. It's fun, it's relaxed. So Grateful Dead are gonna be my choice for sure.

Rachel Baker: Do you have a favorite song?

Dr. Aaron Dawes: Oh man. Scarlet Begonias is, I still like some of the words, some of the lyrics are just- ... uh, fantastic in there.

So I think it's probably my favorite.

Rachel Baker: Nice. Well, it has been an absolute pleasure chatting to you. Before we go, one final question. What is next for Dr. [00:20:00] Dawes?

Dr. Aaron Dawes: What is next for me? Well, I have some things to do to refine the curriculum a little further. We'd like to get that all the way to where we want it to be.

Hopefully, starting a K award next month. Ooh. So gonna get to focus a little bit more on some of the Medicaid research that I do- Great ... uh, supported by National Cancer Institute, so very excited about that.

Rachel Baker: Exciting! Awesome! Well, I look forward to that, crossing my fingers for your K award. Thank you so much for coming on the show.

Dr. Aaron Dawes: Thanks for having me. My pleasure.

Rachel Baker: And thank you to our listeners for tuning in to this episode of Scrubcast. Until next time, stay sharp.

And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts. Scrubcast is a production of Stanford University's Department of Surgery.

Today's episode was produced by Rachel Baker. The music is by Midnight Rounds and our [00:21:00] chair is Dr. Mary Hawn.