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Kai Nishi, MD, FACS

Bariatric Surgery

  • Board Certified bariatric surgeon at Khalili Center for Bariatric Care
  • Formerly the Assistant Director of the Cedars-Sinai Center for Minimally Invasive and Weight Loss Surgery
  • One of the principal investigators of the FDA trials on a new procedure called TOGA (incision-less weight loss surgery), and is one of only a handful of surgeons in the U.S. who have performed this procedure

 

Formerly the Assistant Director of the Cedars-Sinai Center for Minimally Invasive and Weight Loss Surgery, Dr. Nishi was also an attending surgeon in Trauma Services and Surgical Intensive Care at Cedars-Sinai. He is one of the principal investigators of the FDA trials on a new procedure called TOGA (incision-less weight loss surgery), and is one of only a handful of surgeons in the U.S. who have performed this procedure. Currently Assistant Clinical Professor of Surgery at the David Geffen School of Medicine, UCLA, Dr. Nishi has published widely in such journals as American Surgeon and Bariatric Times, and lectures on weight loss surgery at national and international bariatric surgery conferences. He is the recipient of numerous awards, including the Paul Rubenstein, MD Prize for Excellence in Resident Research Abstract and Awards Presentation; the Society of Laproendoscopic Surgeons Resident Achievement Award; and the Leo G. Rigler, MD Award for Academic Achievement from Cedars-Sinai. An Associate Fellow of the American College of Surgeons, Dr. Nishi is also a member of SAGES, the Society of American Gastrointestinal Endoscopic Surgeons; American Medical Association; and Society of Laparoendoscopic Surgeons.

 

After earning his Bachelor of Science degree in Biology from the University of California, Irvine and a medical degree from George Washington University School of Medicine, Dr. Nishi went on to intern in the Department of Surgery at North Shore University Hospital in Manhasset, New York, where he was named resident of the year. He received his surgical training at Cedars-Sinai Medical Center including a Fellowship in Surgical Critical Care.

View Full Bio

Episode Information


Bariatric surgeon Dr. Kai Nishi talks about the latest in robotic surgery, portion control in weight loss, and his love of fast cars.

 

Topics Include:

 

  • How he didn’t decide to go into medicine until senior year of college when he realized becoming a surgeon would allow him to use his skills in problem solving and using his hands
  • His love of cars and how he grew up fixing cars with his dad, loves driving and cycling through fast cars of his own, and even frequents racetracks
  • How he has always been a bit of an adrenaline junkie in his love for racecars and in his experience as a trauma surgeon
  • Why he went into bariatric surgery and how rewarding it is for him to see the positive change in patients’ lives and lifestyles
  • How robotic surgery has become an important tool in bariatric surgery and allows him to have more dexterity to perform more difficult surgical maneuvers, in addition to 3D optics to see better within the body
  • Exciting developments in robotic surgery and how new companies emerging will present new competition and advanced technology
  • How he let a patient film one of his operations for Buzzfeed that now has over 10 million views on YouTube
  • The double edged sword of online patient education as it’s good for patients to become more informed but sometimes they misdiagnose themselves
  • How his online presence has led to most of his patients (70%-80%)  finding him, rather than through referrals
  • Why a reliable online source of doctor-led information like Doctorpedia is so important
  • How he’s better at following his exercise guidance than his diet recommendations
  • How weight loss surgery surgery is not a magic bullet (and certainly not for everyone) because the hardest part is making the necessary lifestyle changes to keep the weight off
  • The misconception that weight loss surgery is removing fat, when it’s actually making the stomach smaller so that the patient doesn’t overeat

Highlights


 

  • “There’s some studies that suggested that surgeons that played a lot of video games in their childhood tend to be a little bit better at doing either laparoscopic or robotic surgery because you sort of develop that hand-eye coordination and I certainly had a love of video games growing up, so maybe that helped.”
  • “My recent fun car – I guess two fun cars would be a Nissan GTR that had 700 horsepower. That was a fun track weapon. I have actually driven it down the street and I would take my daughter to her elementary school in it and go to the grocery store in it but would also take it to the race track and scare myself half to death. That was a lot of fun. I also drive a BMW M3 as a daily driver. That’s fun.”
  • “I think the one problem in the healthcare industry still for physicians are our work hours and that’s because there are no restrictions on work hours. As a pilot or a truck driver, you can only drive or fly a certain number of consecutive hours and then you have to take time off to rest. And that doesn’t exist for physicians. As surgeons, we could be up 12, 24, or 36 hours straight if the emergencies keep coming in and if you’re the person on call or if you’re on call for a small group or something like that.”
  • “Everyone just has their own skills and one isn’t necessarily any more difficult or more important than the other. They’re just different.”
  • “Fortunately I would say in our business, we can’t really afford to make mistakes. When you think about it, every operation we do has to be done perfectly. It’s tough because you sort of set your standards so high that you’re bound to fail at some point because it’s hard to do everything perfectly.”
  • “When you see a patient for a post-op visit and they convey to you how grateful they are that you were able to correct their problem, whatever it may be, and they feel great now and they’re able to do things that they couldn’t do before or that they’re not worried about dying anymore because you took care of their cancer or whatever it might be. That is always so rewarding that I don’t think you ever get tired of that.”
  • “You really get to see how your operation affected this person. As I would see people a month out, six months out, a year out, I was just amazed at the effect that we had on people’s lives. People would come in a year out and would say, ‘do you remember me?’ and when you look at them and you don’t recognize them. You recognize the name but you don’t recognize the person.”
  • “A lot of people have the misconception that we just hook up a robot and it does the operation for us. That is not the case at all. The robot is just a fancy tool.”
  • “It’s such a luxury to be able to operate in 3D high definition, because it’s almost like your eyes are inside of a body looking at things and it gives you depth perception.”
  • “It’s one trend that I’ve noticed – 10 years ago, all of my business was based on referrals. Although that still exists, nowadays it seems like probably 70-80% of the patients I see are coming in because they’ve found me on the internet. They do a Google search and they figure out who is a well-known robotic surgeon that does weight loss surgery or hernia surgery and they’ll come in to see me.”
  • “If I preach to eat healthy and to eat in moderation to my patients, then I feel like I have to follow that. So I do try to follow that as much as I can. I’m probably much more successful at my exercise than I am with following the dietary recommendations.”
  • “Surgery is not a magic bullet. We tell people this all the time: you’re not just going to have surgery and it’s not just going to fix everything. You don’t magically lose a lot of weight and not have to do anything yourself. Surgery is actually the easiest part of it. The hardest part is afterwards and living the rest of your life and staying away from all the bad habits.”
  • “What we do is we make your stomach smaller – and there are a variety of different operations that do that – but you make your stomach smaller so that you can’t overeat, you eat far less food. We take your stomach from the size of a football and take it down to the size of a large egg.”

Figuring out what the problem is and fixing it - I love that. I love that aspect of it as a challenge. But then I love the rewarding aspect of it of talking to the patients afterwards when they've recovered and they're generally so thankful. I would say that's one reason why I chose to go into bariatric surgery.

Kai Nishi, MD, FACS

I was good at my hands and it just sort of dawned on me, I said, ‘what kind of a job or career could I get into where I would work with people - because I didn't want to sit in a cubicle all day - where I could use my hands and where I could use my problem solving skills?’ And the light bulb went off and I said, ‘oh, I guess I'll become a surgeon.’

Kai Nishi, MD, FACS

I think it's a great resource because it's much different than somebody doing a Google search on hernia surgery and getting 50% of the information being true and the other 50% being completely false. They can go to a reliable source like Doctorpedia, where they know that all of the information that's there is from a trusted physician and that makes the research aspect of it much easier and more reliable and hopefully will cut down on the amount of misinformation that they might receive otherwise if they just did a broad internet search.

Kai Nishi, MD, FACS

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice. Since every person is unique, please consult your healthcare professional for any personal or specific needs. This is Daniel Lobell with the Doctorpedia Podcast. On the line with me today is Dr. Kai Nishi. Hello. I have Dr. Kai Nishi on the line. This is the Doctorpedia show. Welcome. Thank you for doing it.

Dr. Kai Nishi: (00:37)
Thank you for having me on the show.

Daniel Lobell: (00:37)
Our pleasure. I have a lot of questions for you and I’ve gotten to do a fair amount of research on what you do and it’s fascinating, but before we get into any of that, I always like to start at the beginning and find out what inspired you to become a doctor in the first place. Can you tell me a little bit about that journey?

Dr. Kai Nishi: (00:58)
Sure, yeah. Every physician’s got their own story of why they went into medicine and I certainly had a lot of colleagues that knew from a very young age that they wanted to be a doctor. I was a little bit different. I was quite a late bloomer and I did not make that decision until I started my senior year in college. I just wasn’t sure what I wanted to do. I was exploring and enjoying all the different classes and subjects I was taking and I did well in math and physics and chemistry and all of those problem solving classes or subjects. I was good with my hands because I had grown up working on cars with my father and working on do-it-yourself projects at home, doing carpentry and things like that with my father. So I was good at my hands and it just sort of dawned on me, I said, “what kind of a job or career could I get into where I would work with people – because I didn’t want to sit in a cubicle all day – where I could use my hands and where I could use my problem solving skills?” And the light bulb went off and I said, “oh, I guess I’ll become a surgeon.” I guess for selfish reasons I would say I initially decided to pursue that career because it seemed like something that would fit my skillset. Along the way as I started medical school and then you actually start seeing patients and seeing the effect you have on patients, that’s when I realized what a great effect that could have on people’s lives. And that just sort of continued my motivation to pursue that field.

Daniel Lobell: (02:57)
Yeah. Pretty cool. That’s an interesting story how it came from working with your hands and essentially what you wound up doing is very hands-on. Almost ironically, you’ve transitioned a lot of what you’re doing from what I can see to working with somebody else’s hands – robotic hands.

Dr. Kai Nishi: (03:17)
Yeah. Which is just kind of funny. In some way, it’s often said that it’s like playing a video game, which is not not that far off from the truth. There’s some studies that suggested that surgeons that played a lot of video games in their childhood tend to be a little bit better at doing either laparoscopic or robotic surgery because you sort of develop that hand-eye coordination and I certainly had a love of video games growing up, so maybe that helped. [Laughs]

Daniel Lobell: (03:50)
Take that, anti video game people! [Laughs] All that Mortal Kombat paid off, huh?

Dr. Kai Nishi: (04:00)
It sure did!

Daniel Lobell: (04:00)
What kind of cars did you work on with your dad?

Dr. Kai Nishi: (04:04)
Nothing expensive – just our cars that we had at home. We had a lot of Hondas growing up. I think we were definitely a Honda family. I would say that my extended family in general are a bunch of car nuts. My aunts and uncles were heavily involved in muscle cars and drag racing and I was exposed to that at an early age. Both my parents worked in the automotive industry, which exposed me to a lot of cars and car racing and motorcycles, and so I got to sort of play with all of that growing up and that definitely influenced my passion for cars, I would say.

Daniel Lobell: (04:47)
What kind of car do you drive now?

Dr. Kai Nishi: (04:50)
I have always liked cycling through different cars. So I’m in the middle of a cycle, meaning I just got rid of a few cars. My recent fun car – I guess two fun cars would be a Nissan GTR that had 700 horsepower. That was a fun track weapon. I have actually driven it down the street and I would take my daughter to her elementary school in it and go to the grocery store in it but would also take it to the race track and scare myself half to death. That was a lot of fun. I also drive a BMW M3 as a daily driver. That’s fun. That’s about as crazy of a car as the GTR. The plan, I guess, is to make the GTR faster. As if 700 horsepower isn’t enough, I know that sounds crazy–

Daniel Lobell: (05:56)
[Laughs].

Dr. Kai Nishi: (05:56)
–I had the idea of going to 100 horsepower and that sounds really nuts but I have multiple friends that have that car with that much horsepower and I’ve driven them and it’s actually quite drivable.

Daniel Lobell: (06:11)
Where do you drive at those speeds, in the desert?

Dr. Kai Nishi: (06:14)
Just on racetracks. We have a couple racetracks in Southern California and some in Northern California. So I’ve been to those. Actually 1000 is really too much for even a road racing circuit like that. But there are other events that are just straight line of half mile events. The quarter mile is actually too short these days, so they stretch it out to a half mile. And then it turns out that the one mile events are too long because cars are getting 300 miles an hour. So that’s too fast. [Laughs]

Daniel Lobell: (06:52)
Yeah. You sound like Dr. Strange to me from the Marvel movies. [Laughs]

Dr. Kai Nishi: (07:02)
[Laughs] Well, I don’t know about that, but I’m just a bit of an adrenaline junkie, I’ve always liked speed. I love skiing. I’m not crazy like I used to be, but I used to love going just as fast as I could skiing, on the water – jet skiing or water skiing or anything speed related. Surgery, in a way is also a little bit for adrenaline junkies. It depends on what you do. You often picture… I think when you ask people, what do you think of when you think of a surgeon performing surgery? And a lot of times you think you could hear classical music playing and it’s very calm and quiet and someone’s doing delicate work. And although that does occur sometimes some of us like to just blast top 40 music.

Daniel Lobell: (07:57)
[Laughs] Heavy metal in there or something?

Dr. Kai Nishi: (08:01)
Sometimes. I think it’s really whatever music you enjoy that helps you be in a better frame of mind and helps you perform better when you operate.

Daniel Lobell: (08:11)
Do you love doing surgeries? Do you look forward to it when you have a surgery?

Dr. Kai Nishi: (08:16)
Oh yeah, absolutely. I love it. I couldn’t imagine doing anything else. Actually growing up, the one thing I wanted to do was to become a professional race car driver. Since I did not end up doing that, I can’t imagine doing anything else because it’s just the most rewarding occupation – in my eyes, at least – because I’m doing important work, I’m affecting people’s lives and it’s something that I enjoy. It’s hard to find a job where not only do you enjoy it, but you’re doing some good for people around you.

Daniel Lobell: (09:09)
You were going to say something else and I interrupted you. “The other something,” what was it? I’m curious.

Dr. Kai Nishi: (09:15)
Oh, so prior to doing what I do now, earlier in my career when I worked for a hospital, I would also work as a trauma surgeon. That’s sort of the ultimate in terms of adrenaline because we would take care of a lot of gunshots and stab wounds and car accidents. So the only time we could get called is when there was a severe trauma that required a trauma surgery team. These people come in extremis, many are on the verge of dying and you either really love being in that environment or you really hate it.

Daniel Lobell: (10:06)
[Laughs] Yeah.

Dr. Kai Nishi: (10:06)
You can tell very quickly. During the training, we all have to do that and the line definitely gets drawn and you see people gravitating one way or the other. I loved it. My wife is a nurse – or was a nurse – and she could never understand how I could enjoy doing that because that’s not her nature or her personality. But I think it’s the ultimate test. Every time somebody comes in, you literally have a couple of minutes to do what you’re trained to do to save someone’s life. So it’s quite the adrenaline rush.

Daniel Lobell: (10:48)
It’s funny to me to think that somebody’s almost coming into the hospital with a gunshot wound and you’re like, “that made my day! Alright, it’s on.” [Laughs] I know it’s not quite that.

Dr. Kai Nishi: (11:00)
Yeah, it’s a little different. We don’t want to see those people, but when they do come in, you just get geared up for it. I think the one problem in the healthcare industry still for physicians are our work hours and that’s because there are no restrictions on work hours. As a pilot or a truck driver, you can only drive or fly a certain number of consecutive hours and then you have to take time off to rest. And that doesn’t exist for physicians. As surgeons, we could be up 12, 24, or 36 hours straight if the emergencies keep coming in and if you’re the person on call or if you’re on call for a small group or something like that. My friends have always asked me like, “how do you perform if you haven’t slept in 24 hours?”

Daniel Lobell: (12:01)
Right.

Dr. Kai Nishi: (12:01)
Or if it’s in the middle of the night, which it often is. I tell them that it is tiring, but when that event happens, you’re so pumped up full of adrenaline that you’re wide awake and you take care of it. There were times when I would operate all night long – six, seven hours – and finished in the morning. And then you finish whenever you have a chance to sit down and you come down from that high and then you’re really exhausted. I think we always really rise to the occasion.

Daniel Lobell: (12:30)
I know the feeling. I think it’s like – I’ve been doing standup for many years.

Dr. Kai Nishi: (12:38)
Oh, okay.

Daniel Lobell: (12:38)
That’s my background and I think it’s the same thing. Like you get up to the stage and you perform with so much and you’re on almost an adrenaline high from getting laughs and hitting the punchlines and then you get off stage and it’s like (whoosh) all of the energy sucked out of you. It’s gotta be your surgery is your standup or my standup is your surgery or something like that. [Laughs]

Dr. Kai Nishi: (13:09)
Right, right. Yeah. It’s exhausting when you’re done.

Daniel Lobell: (13:14)
Yeah. Afterwards it’s like, what did I just do? You crash.

Dr. Kai Nishi: (13:24)
[Laughs] And that’s tough – talk about doing standup, people say, “wow, that’s amazing. How do you do what you do?” And I tell them that everyone just has different talents and so you talk about standup – I look at that as the same way. There’s no way I can get up on stage and do any kind of standup. [Laughs] I would fall flat on my face.

Daniel Lobell: (13:47)
I don’t think I’d be any good at a bariatric surgery. [Laughs]

Dr. Kai Nishi: (13:54)
Well, yeah. So that’s the thing. Everyone just has their own skills and one isn’t necessarily any more difficult or more important than the other. They’re just different.

Daniel Lobell: (14:04)
But you know what, sometimes you get off stage and you’re just so amped up from being on there that it’s hard to get to that crashing place. You still want to like… you’re still going. Do you have that also with surgery? Have you ever finished a surgery and you’re like, “I need a little more surgery right now. Come on. Can somebody come in with something? I’m in the zone.”

Dr. Kai Nishi: (14:27)
Well, sometimes you would feel like that but I think what we do is after a big difficult operation like that, afterwards we’ll probably end up talking to our partners who assisted us or our colleagues and be talking about it for the next hour or two. Just talking about how difficult this was or how close we were to having a problem in this scenario. We like to talk about it afterwards and talk about how we could have improved or congratulate each other or whatever it is. And we probably come down that way. Although sometimes, I’ll tell you I’d finish for some sort of emergency at two, three in the morning and then I would leave and go back home and hop in my car. Like you said, you’re all amped up and you just want to like take off and just go flying in your car sometimes. [Laughs].

Daniel Lobell: (15:32)
Yeah.

Dr. Kai Nishi: (15:32)
And then you think “yeah, but that wouldn’t be good to get a ticket or get into an accident, that would be terrible. So then I have to just save it for the racetrack.

Daniel Lobell: (15:43)
Have there ever been surgeries that went wrong or you feel like you could have done better for the patient had you just not done that one wrong move or this or that and if so, how do you deal with that afterwards?

Dr. Kai Nishi: (16:00)
Fortunately I would say in our business, we can’t really afford to make mistakes. When you think about it, every operation we do has to be done perfectly. It’s tough because you sort of set your standards so high that you’re bound to fail at some point because it’s hard to do everything perfectly. I would say we don’t necessarily make mistakes frequently, but I think there are times when you think, “I guess I could’ve probably done it a little bit differently. Maybe that would have been better.” But a lot of that is in hindsight, so there’s nothing you can do about it at that point but learn from that experience and try to perform better the next time around. I think that’s why people ask, “why is your training so long to become a surgeon?” We’re talking four years of med school and then usually six years of general surgery training and then another year or two or three of fellowship after that. You’re looking at 10, 11, 12, 13 years of training to become a surgeon, why does it take so long? And I tell them that’s why it takes so long because you need to see a lot of operations and when you finish and you’re out on your own, hopefully you’ve seen enough that can get you through the rest of your career and not have problems occur and things like that. There are times when I guess you think that maybe you could have done something a little bit differently and we just use it as a learning tool to help us improve our techniques.

Daniel Lobell: (18:06)
Do you ever get jaded by what you do or do you still marvel at the incredible thing that you’ve been given – the task that you’ve been given?

Dr. Kai Nishi: (18:20)
I definitely don’t get jaded by it because every time I do an operation, I think in the back of your head you always know that there are problems that can arise and when things go well, you’re happy about it. But more than that, when you see a patient for a post-op visit and they convey to you how grateful they are that you were able to correct their problem, whatever it may be, and they feel great now and they’re able to do things that they couldn’t do before or that they’re not worried about dying anymore because you took care of their cancer or whatever it might be. That is always so rewarding that I don’t think you ever get tired of that.

Daniel Lobell: (19:21)
Yeah, it’s pretty incredible. I’m thinking about your background in repairing cars and now repairing bodies. And one striking difference, I guess, is that the car doesn’t continue to repair itself after the surgery, but the body is like, “alright, I’ll take it from here,” which is incredible.

Dr. Kai Nishi: (19:39)
[Laughs] Right. Yeah. There’s that. I have a lot of friends in the automotive industry and I’ll tell them how it’s like working on a car, but they say, “yeah, but you know, when we put a car together, if it doesn’t start then we take it apart again and figure out what the problem is. [Laughs] But in your case, it’s got to start when you hit the start button.

Daniel Lobell: (20:04)
[Laughs] Yeah.

Dr. Kai Nishi: (20:04)
That’s true. Yeah. Figuring out what the problem is and fixing it – I love that. I love that aspect of it as a challenge. But then I love the rewarding aspect of it of talking to the patients afterwards when they’ve recovered and they’re generally so thankful. That’s – I would say that’s one reason why I chose to go into bariatric surgery. During my training, we get exposed to everything – all different types and specialties within the field of surgery. While I found all of them fascinating and interesting – I could have done so many different things – when it came to bariatric surgery, I had no preconceived notions that I would enjoy it or want to do it. A lot of my colleagues in training at the time felt like, “gee, that’s no fun. I don’t want to do that and deal with overweight people all day long. How could that be fun?”

Daniel Lobell: (21:22)
Right.

Dr. Kai Nishi: (21:25)
I went into it and my mentor who I’m now partners with and have been for quite a long time, he started the weight loss surgery program at our hospital and grew it into one of the largest in the country. I had a lot of exposure to bariatric surgery and I quickly discovered that it’s not just about the operation, but the operation itself actually is one of the most difficult to perform of all the different types of operations out there, both in the complexity of the procedure and also doing an operation that’s sort of technically difficult in someone who’s 300-400-500 pounds is exponentially more difficult. There was a challenge there, but what really turned me onto it was seeing the patients afterwards. And it’s different than other types of surgery. You know, if you had your gallbladder taken out or your appendix taken out, you only go back to see the doctor once – a week or two after surgery or you have a post-op visit and then you never see them again. With weight loss surgery, it’s different because you perform the operation and then you follow the patient for the rest of their lives. You see them at a week and then at a month and every three months after that for the next year and then every year annually after that. You really get to see how your operation affected this person. As I would see people a month out, six months out, a year out, I was just amazed at the effect that we had on people’s lives. People would come in a year out and would say, “do you remember me?” and when you look at them and you don’t recognize them. You recognize the name but you don’t recognize the person.

Daniel Lobell: (23:22)
Wow.

Dr. Kai Nishi: (23:22)
They would often bring in a picture of themselves before surgery and you look at them now and they’ve lost 80 or 100 or 150 pounds or 200 pounds and it’s incredible. They look like someone who’s never been overweight and they’re usually crying because they’re so happy. Their stories are amazing about how prior to the surgery, they could not fly on an airplane or they could not take their kids to Disneyland and go on a ride or do all the normal things – they couldn’t sit down and cross the legs. All the things that we take for granted, they couldn’t do because of their weight. And now they’re able to do that and feel like normal human beings. They can buy clothes off the rack that fit and they’re just crying with joy because they’re so happy. You really change their lives. And once I saw that, I said, “this is what I want to do.” Because I feel like I’m having a great impact on people’s lives. And it’s not that, for instance, during trauma – that’s gratifying as well. You’ve saved someone’s life, but it’s different. Like when somebody gets shot, for instance, and you save their lives, they’re not necessarily happy afterwards or grateful that you took care of them. They’re usually upset at the world and the person that shot them and it’s sort of a different kind of vibe.

Daniel Lobell: (24:51)
Yeah, it sounds pretty beautiful what you’re able to do for people. Just improving people’s quality of life and giving people life, extending their longevity.

Dr. Kai Nishi: (25:04)
Yeah, it is pretty amazing.

Daniel Lobell: (25:07)
What made you venture into robotic repairs? I know we touched on it a little earlier, but how did that come about?

Dr. Kai Nishi: (25:16)
Well, I’ve always been a bit of a nerd when it comes to technology and I always liked using the newest computers or phones or gadgets or whatever it is. With robotic surgery, it’s interesting. It’s been around for quite a while. It’s only really been popularized in the last several years, the last five years I would say it’s really exploded. But prior to that, if you go back to say 2002-ish or 20003, my partner – Dr. Khalili – he was really one of the pioneers in robotic surgery. One of these first robots was brought to the hospital and he did a bunch of weight loss operations – the first that were ever done on the West coast. The problem is the medical system couldn’t quite figure out what to use a robot for. Like we have this cool device, but we didn’t really know why we needed it. After he did a number of cases, he decided that it’s super expensive and we haven’t really figured out that it’s any better. So it was sort of abandoned and the only people that were using them were the urologists to do prostatectomies. And that stayed that way for many years until a couple of years ago. And the robots went through multiple generations and they got better and better and better. Then that issue was revisited and then the thinking was, “is there anything that the robot could be used for that would help surgeons or general surgeons with what we do today?” I had the interest in using it, although I – like everyone else – didn’t really know what it would be good for. We just knew that it was a neat instrument. To sort of explain to the listeners what is robotic surgery: a lot of people have the misconception that we just hook up a robot and it does the operation for us. That is not the case at all. The robot is just a fancy tool. So when we do laparoscopic surgery, which is minimally invasive surgery, we are holding rigid instruments in our hands that we insert into the abdominal cavity. We move these instruments around and we open and close our hands – it has scissor handles that open and close the jaws of the instrument. That’s typically how all of the laparoscopic operations are done across the world. Where robotics is a little bit different is that it replaces those instruments with robotic instruments and these instruments have wrists attached to them. The tips of the instruments – we call them wristed instruments – meaning I can move my hand on the outside, any which way I want to and the instrument will move just like my hand will on the inside. What the robot has done is it’s increased our degrees of motion significantly so that we can perform much more delicate maneuvers and much more difficult maneuvers.

Daniel Lobell: (29:02)
Amazing.

Dr. Kai Nishi: (29:02)
Prior to that, there was no way to bend your instrument and reach around and grab something from behind. You had straight sticks as instruments. The robot offers us that, so it’s sort of a fancy instrument that gives you more dexterity. The other bonus with using the robot is the optics. We use 3D high definition cameras and that’s changed things significantly as well because we’ve been used to operating in two dimensions forever. We have a video camera inside and we look at a flat screen on the outside and that’s in two dimensions. That works fine and is still used every day – more so than robotics is. But it’s such a luxury to be able to operate in 3D high definition, because it’s almost like your eyes are inside of a body looking at things and it gives you depth perception. That’s the biggest part of it.

Daniel Lobell: (30:03)
Wow.

Dr. Kai Nishi: (30:04)
All of that was very exciting to me and I wanted to use it. I started using it on all types of operations – weight loss, surgery, hernia operations, colon cancers, gallbladders appendix – as did other surgeons. We slowly figured out what it was good for and where we didn’t really need it. For easy operations, you don’t really need it but for really difficult operations, it can be helpful. I don’t know if I would say you absolutely need it. I don’t think that’s the case because I operated for my entire career without the robot and I still do and that’s fine. But using the robot is certainly a luxury to have. It’s sort of like having a black and white TV versus that 4K 3D TV these days. You could still see the image, but it’s a lot better with the newer technology.

Daniel Lobell: (31:06)
Yeah. Pretty amazing. Are there any developments in that technology on the horizon that excite you?

Dr. Kai Nishi: (31:13)
Yeah, there are a couple of things. One would be what we call a single incision surgery. That concept has been around for a while. What that means is typically when you do a laparoscopic or robotic operation, you make three, four, five, six small incisions. They’re all maybe a half an inch in length. We put all of these instruments in and we do the operation and that’s fine. That’s causing minimal pain. You don’t have a big 12 inch long incision going up and down the middle of your abdomen. But single incision surgery takes all of those instruments and sticks them through one larger hole so that you don’t have all of the other smaller holes. I’ve done a lot of that and have tried to be a pioneer and to push that. I’ve done a number of operations and I would basically take multiple robotic instruments and the camera and put them through an incision in the belly button and take out the gallbladder or repair a hernia. The benefit is that in the end when you’re done, it’s virtually scarless because you try to fit all of that within the belly button and hide the scar within the belly button. So it looks like you’ve never had surgery.

Daniel Lobell: (32:35)
Can you do that with bariatric surgery as well?

Dr. Kai Nishi: (32:40)
Not with bariatrics. It’s too complicated. It’s too difficult and you need too many instruments. The staplers that we use are too big to fit through that. We can’t do it with bariatrics, per se, but I’ve certainly done a lot of gallbladder surgery and hernia surgery that way. Is it better? It’s not better. But it’s better cosmetically. Living in LA, we obviously have a lot of people that are concerned about their appearance. A lot of people in Hollywood – actors and things like that – they inquire about having surgery without any scars and that’s one way we can do it. That technology is continually evolving and one of the robotics companies recently introduced an entirely new robot dedicated just for that. So that’s exciting. And then the other things on the horizon are what we call haptic feedback or forced feedback. The current robot that we use doesn’t have any forced feedback. Our hands, when we’re moving the instruments around, we can’t feel the resistance that the instrument is feeling. You have to do it all by visual cues. And that’s fine. We’ve gotten very good at doing that. But the next level will be to introduce forced feedback so you can feel the same force that the instrument is feeling inside of the body. That technology exists – it’s not commercially feasible yet due to cost, but it’s getting there. Then the other really exciting part is that for decades now, the only robot on the market has been the intuitive surgical DaVinci robot. They’ve had a monopoly on this market and we now have two new companies introducing robots: the Verb robot and the Hugo robot, which will be coming to market soon and will present competition. That’ll be very interesting to see how that all plays out.

Daniel Lobell: (34:55)
Robot Wars.

Dr. Kai Nishi: (34:58)
[Laughs] Exactly. And I think it’s great because it’ll push the technology that much further cause they’ll be competing against each other and it will bring costs down and then make the robotic technology available to more hospitals. Because it is unbelievably expensive. A robot is about $2 million. So it’s quite an expensive tool.

Daniel Lobell: (35:22)
How close are we to tiny little robotic bugs that can go through your ear into the body to perform the surgery? [Laughs]

Dr. Kai Nishi: (35:32)
[Laughs] You know, that sounds really farfetched, but I bet if you spoke to the military and DARPA and those programs, I bet they probably already have something like that that we just haven’t seen yet. [Laughs]

Daniel Lobell: (35:47)
What do you think has been the most fundamental outcome of your research in robotic surgeries?

Dr. Kai Nishi: (35:52)
I’ve found that it has allowed us to do things that we could not necessarily do before. There’s been a lot of research on robotics in general and a lot of it has been targeted towards safety. Is the robot safe? Is it more dangerous than laparoscopic surgery? There have been a lot of arguments about that. I think the consensus is that the robot is just a tool. It’s just an instrument. So it’s not more dangerous than laparoscopic surgery. It all comes down to the surgeon. We’ve sort of figured that out. But the other thing that a lot of opponents of the robot say, they cite a couple of things. One is that obviously the cost is outrageous and you can do an operation without the robot. And that’s true, but having done tons of – we’ll say hernia operations for instance – I’ve discovered that there are hernias that were quite complicated and difficult to repair that I probably might not have even tried to do it laparoscopically because it would have been impossible. But by using the robot, we’re able to push the boundaries of minimally invasive surgery and actually do an operation robotically and do this as a minimally invasive operation completed successfully, which we probably could not have done laparoscopically. I think ultimately that’s what we’ve sort of discovered is that you might not need it for the run of the mill operation, but it can certainly allow you to do things that were probably out of your scope, laparoscopically.

Daniel Lobell: (37:52)
Yeah. Wow. It’s really fascinating to hear you talk about all this stuff and I’m not a doctor, obviously, but just knowing that these things are available and that they’re developing is reassuring to me as a potential patient – hopefully not a patient – but somebody who could need it at some point.

Dr. Kai Nishi: (38:16)
Right. I like talking to people about medicine and what we do because it’s kind of like a black box. As a consumer or as a patient, you don’t really have any idea what we do and what it’s really like. So it’s nice to be able to explain that. One incident where that occurred: I had a patient who came in, had a hernia and when we were done with the consultation, he said, “Hey, can I film the operation?” And I said, “no you can’t film the operation.” [Laughs] And he said, “no, no, no. Let me explain. I work for Buzzfeed” and Buzzfeed is a huge online news and media resource. He said, “we do a lot of video segments and I’m in a lot of those and we just thought this would be great. Not only can I be a patient, but I can also star with it and we can, we can film it all and it’d be a great educational piece for people.

Daniel Lobell: (39:24)
Right.

Daniel Lobell: (39:24)
And I said, “okay, sure, yeah, let’s do it.” It was funny. I guess not many other surgeons, I’ve discovered, would want to do that. I remember seeing a bunch of surgeons on the day we were filming and they said, “Hey, what are all these cameras here for?” And I said, “Oh, we’re filming.” And they said, “for what?” I said, “Oh, it’s for Buzzfeed. They wanted to film the operation.” And they’re like, “wow, you’re willing to let them do that? Aren’t you worried?” And I said, “no I’m not worried. I’ve done this a thousand times and I’m not expecting to have any problems and I’m not worried about anyone seeing my operation.” But it certainly made other people nervous. So we filmed the whole thing and he posted that on Buzzfeed and on YouTube. I just thought it was kind of neat. I didn’t know if anybody would watch it and it’s now gotten over 10 million views.

Daniel Lobell: (40:20)
Fantastic. Wow.

Dr. Kai Nishi: (40:21)
I think it was really interesting for consumers to be able to see that because they got to see the before, during, and after of what it’s like to go through an operation. So yeah, that was a neat experience.

Daniel Lobell: (40:42)
Well, it’s a perfect lead in also for me to talk to you about the next thing I wanted to bring up, which is the online health space and how it’s really affecting the doctor-patient relationship. People are now coming in, sometimes informed, better informed, better educated, sometimes misinformed. What do you find from talking to patients? Do you feel that it’s been beneficial? What’s your take on it?

Dr. Kai Nishi: (41:13)
Overall I think it’s beneficial. There are pros and cons to it, but overall I do think it’s beneficial for a number of reasons. Prior to having the internet and all of this information that was available, patients really had to just take a leap of faith and take their doctor’s word as the absolute truth and had really no say in it. That wasn’t good, I think, in some instances because it’s certainly better for patients to be well-informed. I don’t mind that patients do a lot of research these days and I think it’s great for them to be well-informed with whatever disease process they might have and the treatment options and that sometimes makes it easier to explain what they have and what we do and what we need to do to treat their problem. That part of it’s good. It also allows people to figure out which physician they want to see. It’s one trend that I’ve noticed – 10 years ago, all of my business was based on referrals. Although that still exists, nowadays it seems like probably 70-80% of the patients I see are coming in because they’ve found me on the internet. They do a Google search and they figure out who is a well-known robotic surgeon that does weight loss surgery or hernia surgery and they’ll come in to see me. Even if their primary care doctor referred them to some other surgeon, patients won’t necessarily go to that surgeon. They’ll do their own research and end up coming in to see me. It’s changed the landscape a lot. But can it be detrimental? It can because there’s too much misinformation on the internet as well. And so you have to sort of take everything that you read with a grain of salt. Some patients will come in and they’ll say, “I think I have this diagnosis because I’ve read about it on the internet and I’m convinced I need this particular operation.” And sometimes they’re right and sometimes I’m like, “wow, where did you get that from? That’s the craziest thing I’ve ever heard.”

Daniel Lobell: (43:58)
That’s why I’m passionate about the work I’m doing with Doctorpedia because I was one of those patients at several points in my life when I’d go online and just get these crazy notions in my head of what’s going on with me because there wasn’t a reliable source like Doctorpedia to go to where you can actually find real information.

Dr. Kai Nishi: (44:16)
Yeah. So I see a lot of that and I’m usually able to relay the correct information to them and make them understand what is really going on. But there are instances where some are just insistent, “no, no, no – I need this procedure or I don’t need this operation.” Or they want to dictate their own care based on what they read and they have really no idea what they’re talking about. So that does happen sometimes. And that’s one of the downsides to all of the online health information that’s out there.

Daniel Lobell: (44:51)
Well, yeah, I agree. I brought up Doctorpedia, but while we’re on the topic: what do you think Doctorpedia can do to assist the online health space?

Dr. Kai Nishi: (45:03)
I think it’s a great resource because it’s much different than somebody doing a Google search on hernia surgery and getting 50% of the information being true and the other 50% being completely false. They can go to a reliable source like Doctorpedia, where they know that all of the information that’s there is from a trusted physician and that makes the research aspect of it much easier and more reliable and hopefully will cut down on the amount of misinformation that they might receive otherwise if they just did a broad internet search.

Daniel Lobell: (45:51)
Absolutely. I really appreciate you giving us this time today. I always ask all of the doctors the same question to wrap up the interview and that is: what do you do to stay healthy?

Dr. Kai Nishi: (46:08)
Oh boy, that’s a good question. I think because I do a lot of weight loss surgery, maybe I think about it a little more than others. But if I preach to eat healthy and to eat in moderation to my patients, then I feel like I have to follow that. So I do try to follow that as much as I can. I’m probably much more successful at my exercise than I am with following the dietary recommendations. But the other thing I do is I exercise quite a bit – probably four or five times a week. I’m in the gym trying to stay healthy because I find it easier to do that than to eat as healthy as I would like to.

Daniel Lobell: (46:57)
How do you recommend that patients eat? I know that you probably have people who come in for bariatric surgeries- do you say go for the surgery always? Or do you sometimes say maybe try changing your diet up first? Is that something that happens?

Dr. Kai Nishi: (47:17)
Right. Actually, we always tell people to work on modifying their lifestyle first. We never just jump to surgery. If somebody has never tried eating healthy and exercising, they usually are not candidates for surgery right off the bat. We work with them with dieticians and psychologists to try to work on actually modifying their lifestyle and eating healthy and exercising. They’ll start doing that and once in a blue moon, somebody will do that and do so well that they won’t even need weight loss surgery. And that’s totally fine. People have said, “well doesn’t that mean that you’ve just lost a potential patient?” And I tell them, “yeah, that’s true, but that’s okay.” The ultimate goal is to help somebody lose their weight. If they’re able to do that with eating healthy and exercising that we’ve asked them to do and they don’t need surgery, then more power to them. That’s great. There’s certainly no shortage of patients out there who might need weight loss surgery, so that’s fine. But as long as they’ve done that and shown some determination in changing their lifestyle, then they become a candidate for weight loss surgery and then we go ahead with surgery. Afterwards, it’s a lifelong challenge. Surgery is not a magic bullet. We tell people this all the time: you’re not just going to have surgery and it’s not just going to fix everything. You don’t magically lose a lot of weight and not have to do anything yourself. Surgery is actually the easiest part of it. The hardest part is afterwards and living the rest of your life and staying away from all the bad habits.

Daniel Lobell: (49:25)
Yeah.

Dr. Kai Nishi: (49:25)
That’s the hard part and surgery is the easy part. We try to make that clear to people. But we also tell them that we don’t want you to go on a diet – that’s never the plan because diets are too extreme. That’s why we call them diets. You hear about people doing these high protein zero-carb diets and do they work? Sure, they make you lose weight, but they’re so extreme that it can be unhealthy in other aspects to your health and it’s also almost impossible to maintain that for the rest of your life. So the idea was really to eat in moderation. We do try to minimize the amount of sugars that people consume and the amount of carbs and we focus more on eating protein and lean protein and vegetables. But ultimately it’s sort of just a balanced diet and far less of it. So volume is also part of it and staying away from the things that are really bad and consuming soft drinks is really bad in terms of sugar intake.

Daniel Lobell: (50:39)
Right. It’s like drinking a cake.

Dr. Kai Nishi: (50:43)
Exactly. You wouldn’t believe it, but I’ve seen people drink unbelievable amounts of soda. More than just a couple of cans of soda or a two liter bottle of soda. I’ve seen people that were drinking two and three, two liter bottles of soda a day. It’s just eating in moderation and doing some exercise. You don’t have to be extreme and spend hours a day in the gym, but you’ve got to do some exercise because you need to burn off some of these calories that you’re consuming.

Daniel Lobell: (51:19)
I read somewhere that the most dangerous fat that we have is the fat that wraps itself around the organs, which I think comes from saturated fats. Is that correct?

Dr. Kai Nishi: (51:32)
Yes, you’re right. The fat that is around your organs – it’s what we call central obesity – that is the worst form of obesity. If you had a lot of fat in your glutes, your behind or your thighs or your arms, that’s not nearly as bad as someone who has skinny arms and legs and just has a bunch of fat in their belly, like the old man beer belly.

Daniel Lobell: (52:15)
When you prefer these surgeries, do you remove that fat from around the organs? Is that part of it?

Dr. Kai Nishi: (52:22)
No actually it’s not that. That is one common misconception, that A. It’s a cosmetic procedure and B. That we’re just removing fat. People will say, “you’re a bariatric surgeon – can you just take some fat out of me?

Daniel Lobell: (52:37)
[Laughs].

Dr. Kai Nishi: (52:37)
I’m like, no, that’s not how it works. What we do is we make your stomach smaller – and there are a variety of different operations that do that – but you make your stomach smaller so that you can’t overeat, you eat far less food. We take your stomach from the size of a football and take it down to the size of a large egg. In the case of a gastric bypass or in a sleeve gastrectomy, we take your stomach from the size of a football and convert that down to maybe the size of a small banana. So we’re restricting how much food you can take in and by doing that, that makes your job easier because when you look at the three pieces of the puzzle for weight loss or weight in general, it’s what you’re eating, how much of that you’re eating, and how much you’re exercising. If we take away “how much you’re eating” portion of it, then now the patient only has to worry about what they’re eating and doing the exercise. So that’s sort of what the operation does.

Daniel Lobell: (53:49)
It’s a portion-control operation.

Dr. Kai Nishi: (53:53)
Yes, portion control. That’s basically what it does. The weight loss can be pretty rapid. You can see people lose a massive amount of weight in six months, even three months. Typically it takes about a year to finish losing all of your weight. But I’ve seen people in three to six months lose a massive amount of weight and it’s pretty dramatic.

Daniel Lobell: (54:20)
And it’s all basically – or mostly all – from portion control, is what you’re telling me.

Dr. Kai Nishi: (54:29)
Yeah, portion control is a huge part of it. And then also what you’re eating. One problem we have probably everywhere, but certainly in the US, is that the foods that are cheap tend to be bad for you. Anything that’s $2 for two burgers – whatever it is – none of that really is healthy for you.

Daniel Lobell: (54:57)
It’s a conspiracy, man. They’re out to get us! [Laughs]

Dr. Kai Nishi: (55:01)
It may be! My wife is all about the conspiracies and that certainly can be one of them. But it’s a problem because socioeconomic status plays a role in it. If you don’t have a lot of money, then you buy whatever you can afford and that often is unhealthy food and then that can then lead to a dramatic weight – just because of the type of food that you’re eating. Definitely what you eat can affect what you become.

Daniel Lobell: (55:38)
Well, I appreciate it. Sounds like sound advice and it was a pleasure talking to you on the show today. Thank you so much for your time.

Dr. Kai Nishi: (55:53)
Oh yeah, thank you so much for having me on. It was a pleasure.

Daniel Lobell: (55:53)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice.

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