Tomorrow's Medicine, Ep. 10: Bariatric Robotic Surgery Expert - Abraham Krikhely

With Abraham Krikhely, Bariatric Surgery Specialist. Hosted by Arseniy Arsentyev. Published December 22, 2025.

https://aarsentyev.com/podcast/ep10-abraham-krikhely

Machine-transcribed and lightly edited: filler words and false starts are removed, and the wording is otherwise as spoken. Where the two differ, the recording is the record. Times are minutes into the recording. Not medical advice.

[0:00] Arseniy Arsentyev: Welcome everyone, it's the 10th anniversary episode of Tomorrow's Medicine podcast and today I'm talking with Dr. Abraham Krikhely. He's the chief of the division of minimally invasive surgery and bariatric surgery at Columbia University. Dr. Krikhely, please introduce yourself and tell us more about what you do.

[0:19] Abraham Krikhely: Great. Thank you so much. Thank you for having me. I'm excited to be here. So, as you said, I'm chief of the division of minimally invasive and bariatric surgery. I focus largely on complex laparoscopic and robotic approaches to bariatrics, foregut, and general surgery. I also lead a lot of the robotic surgery initiatives at Columbia. And I spend a lot of time thinking about how technology and data and AI and training is going to help evolve the next phase of surgery.

[0:49] Arseniy Arsentyev: That's great. And let's begin with the field in which you specialize with bariatric surgery. What is the bariatric surgery? Let's describe it for the broader general audience.

[1:01] Abraham Krikhely: So, bariatric surgery is in a nutshell an effective way to help long-term treatment of metabolic disease in patients that have obesity. Obesity is characterized by weight being a certain amount relative to somebody's height. And obesity is associated with lots and lots and lots of reversible medical conditions. Comorbid conditions such as diabetes, high blood pressure, sleep apnea, different types of cancers, and so on and so forth. Pretty much if you look at any organ in the body, you're going to have some dysfunction that may be related to obesity.

[1:47] And a lot of these conditions on their own are very chronic and affect somebody's quality of life as well as their life expectancy. And with bariatric surgery, the surgical approach, everything we do is minimally invasive, laparoscopic or robotic, with a one or two-hour operation and a one night hospital stay. And you are able to achieve very meaningful impact on not only somebody's weight, but as well as all these medical conditions that go along with that.

[2:22] Arseniy Arsentyev: And what is the most frequent case when patients go to you? Is it a weight loss or curing some metabolic condition?

[2:32] Abraham Krikhely: Well, they go hand in hand. And for insurances in this country to approve bariatric surgery, there is a minimum weight requirement. The weight has to be above a certain amount for them to qualify and pay for the insurance. But majority of the time, these patients also have associated medical conditions that go hand in hand with that, and many of them tend to get better.

[3:02] Arseniy Arsentyev: Is it the weight or is the BMI of the person that matters when passing the insurance company's hurdles?

[3:10] Abraham Krikhely: Well, insurance criteria is about BMI. And if you'd like, I can explain what BMI is. I usually try not to get too technical on these settings. But basically, a BMI, just to clarify, is basically a measure of somebody's weight relative to their height. So if you say, hey, I'm 300 pounds. Well, it kind of depends on what that means. If I'm 300 pounds and I'm Shaquille O'Neal and 7 feet tall, it means something very different than I'm 300 pounds and 5 feet tall. And also 300 pounds and full of muscle versus 300 pounds and low muscle. Again, very different sort of thing.

[3:48] And what ends up happening is, as people get metabolic disease, insulin resistance, fat tends to accumulate around the organs inside the body, around the organs in the belly, and they cause a lot of metabolic harm to the body.

[4:09] Arseniy Arsentyev: Is it true that people go to bariatric operations after they've tried nutritional intervention, sports interventions, or other cases when the surgeries might be needed even before actually trying to do the regular stuff people do to lose weight?

[4:28] Abraham Krikhely: So that's a great question. I always advise my patients. One of the first things I tell people is surgery is not a replacement for lifestyle, nutrition, exercise. For Arseniy to be healthy, he still has to make healthy choices. And surgery is not going to change that. We try to put a pause on people who haven't done anything, because all the same negative habits that they had, that led them to the point where they needed to even consider the surgery, if they're all present after the fact, it's going to affect their outcome from the surgery as well.

[5:12] Arseniy Arsentyev: Okay, and do you see this kind of stigma when a patient goes into your office? Because bariatric surgery in some circles are associated with some kind of when you're lazy, when you cannot lose weight, when you do not do exercise properly. Could you address the stigma, please?

[5:33] Abraham Krikhely: Yeah, unfortunately, our society has lots of stigmas, lots of stigmas. And the issue is that it's not right. I think that obesity is a disease, it's a disease partially of our biology, our behavior, and our environment. It's an imbalance between those three factors, right? And so, it's not fair to be calling, somebody based on those stigmas, whatever the stigma is, when in reality, it's your biology that's predisposing you towards the tendency to get sick like that, similar to other diseases like heart disease or cancer and whatnot.

[6:20] Arseniy Arsentyev: Could you provide some cases from your experience when people just after doing some bariatric intervention, they transformed their lives, and it was 1000% worth it? So, tell us more about your best cases.

[6:36] Abraham Krikhely: Yeah, I love that. I love that question. I get to give you my ESPN highlight reel. So, this has jumped to mind a patient I saw very recently, a young lady who actually came to me because she had very refractory diabetes. She had been suffering with diabetes for many, many years. And she had been on insulin, lots of medications, including the GLP-1s. She was taking, I think, tirzepatide for it, and she couldn't get her sugar under control. And her BMI was over 35. It was like 30-something.

[7:17] And she tried not to come to surgery, but who wants to go to surgery, right? Nobody wants to have an operation, right? And eventually, she decided to come to surgery. And I just saw her. She's six months after surgery. We did a robotic duodenal switch operation, which is one of the bariatric surgeries. And it just blew me away. She was off all diabetes medications, and her sugar was completely under control. And it's outcomes like that that keep me going, keeps me offering this towards patients, because it's such a huge meaningful impact. And this is not the only one I've seen that way. I've seen other patients similar. I remember this gentleman from a few years ago when I first started doing that operation and he also had very severe diabetes.

[8:19] Very severe diabetes and he had stents in his heart. He was losing his eyes, losing his kidneys. And again, the same operation, did a minimally invasive duodenal switch and his sugar was under control. His vision was better. His kidneys were better. And he was off almost all diabetes medications. Very meaningful impact. The biggest patient I've operated on is BMI of 93. It was over 700 pounds.

[8:50] Arseniy Arsentyev: Wow. That's crazy.

[8:51] Abraham Krikhely: And I did a robotic sleeve gastrectomy on that gentleman and he lost hundreds of pounds, and such a meaningful impact. And oftentimes I like to try to see the human impact on patients afterwards. Beyond just the metabolic metrics and ask patients, what do you feel different? And it's very touching sometimes hearing the little details that just jump out to them that we take for granted. You're not even thinking about being able to cross your legs, to tie your shoes, to lean forward.

[9:36] Being able to chase after your kids or grandkids, these little details, the human element. And it's such a meaningful impact.

[9:47] Arseniy Arsentyev: That's great. And I mean, when you were speaking about the case of a woman, you told me that it's been six months since the surgery. And what is the usual amount for a person to recover after this bariatric surgery and to actually see the results? So complete recovery time.

[10:09] Abraham Krikhely: Yeah. So when somebody asks about complete recovery time, generally I like to reframe that question. What people are really asking for is when am I going to feel okay? When am I going to feel like myself more or less? And so because surgery that we do is all minimally invasive, laparoscopic, robotic, recovery tends to be relatively quick and easier than other types of operations that are not minimally invasive. People go home the next morning after the surgery. Most people feel significantly better after a few days to a week.

[10:46] And most people go back to work after two to four weeks. I've actually had people go back to work immediately after surgery. Depends on how they feel, what they need to be doing and how they need to feel to do what they need to do. It was an older lady who I did a bariatric surgery on and she, I was supposed to see her a week after the surgery. She came late to that meeting. The reason she came late to that meeting was she was giving a podium presentation in front of a thousand people. And that was like literally days after the surgery.

[11:18] So I guess people feel, can feel well enough, afterwards, but everybody's different. I think you can't plan for the best case scenario. You need to kind of give yourself some buffer. What if I don't feel perfect? What if I am tired? What if I have some pain? And usually what I advise patients is to give yourself a little bit of time, like two weeks. But if you feel well enough, you go back to doing the things you need to do. I think the difference, the thing that also impacts, I guess, what people consider recovery is not just their strength, but also in terms of what they're able to eat and drink.

[12:00] Because it's part of bariatric surgery. There's about three or four different surgeries we do commonly. All of them impact to some degree decreasing the size of the stomach. And so you're not able to take a large volume right away. And you gradually transition from liquids, which go down pretty easily in a tight space all the way to regular food over the course of a month.

[12:28] Arseniy Arsentyev: Have you, sorry to interrupt you, have you seen people who actually go back to this unhealthy state? So were there people who just, they got their stomach cut and they were eating the same?

[12:42] Abraham Krikhely: Yes. Look, habits are hard to break. Habits are hard to break. And not only are they hard to break, but industry and advertising and everything around us is literally designed to trick our psychology into doing the things we know we shouldn't be doing.

[13:01] Arseniy Arsentyev: And tasty food, of course.

[13:03] Abraham Krikhely: Tasty food. So it's hard.

[13:08] Arseniy Arsentyev: Because I don't consider myself an overweight person, and I was refraining from sugar, added sugars, of course I was eating fruit and stuff, for two or three months. And when I, got off this kind of sugar, diet, I started binge eating everything I could, and I'm not sure it's healthy and it's just human nature. You need to battle with it or just adjust the environment you're in.

[13:35] Abraham Krikhely: That's right. That's right. So the human nature, you talk about psychology, and it's a huge part of it, right? Training habits, training, the mind training, how you react to your environment. And oftentimes I tell patients that, listen, the movie, the story about temptation versus willpower, we all know how that movie ends most of the time. You can have discipline to a degree, but you know, if you keep being faced with the same temptation over and over and over and over again, at some point when you're tired, when your mind is not quite there, you're going to cave in, give in to the temptation.

[14:23] And so what I try to advise patients is to set things up, set your environment up in such a way so that you're not constantly being faced with the delicious cookies or whatever it is that is your drug of choice sitting in front of you constantly, reminding yourself that every time you pass it, you have to say, am I going to have it or not going to have it? Because at some point you're just going to cave in.

[14:49] Arseniy Arsentyev: That's exactly what I wanted to talk to you about. My next question was, what is the psychological aspects of patients recovering from these surgeries and what help, you outline already, you advise your patients to do the environment change, but are there any additional steps? Maybe you straight, push them to visit psychiatrists or anything else? What can you say on this topic?

[15:16] Abraham Krikhely: Absolutely. That's a huge part of it. I'm glad you asked the question. So it's a mandatory part of every evaluation. Actually, we have a psychologist on the team, sees every single one of our patients as part of the pre-surgery process, the pre-bariatric surgery process to try to identify, these unhealthy sort of thought processes, unhealthy relationship with food and other unhealthy, things from a psychological standpoint that we have in our environment and make sure that there are no psychological sort of impediments that will kind of get in the way of you having a successful outcome afterwards. And you were talking about kind of bad habits afterwards and weight regain. I would say the most common reason for weight regain is life happens.

[16:06] You thought you had it right. Things were in a steady state and you were doing things healthy, but things change. Maybe you lose a loved one or changing your job or you're working more or now you have a kid and you're not sleeping and you're also working and all of these things. And what life happens means different from one person to the next, but it can certainly serve to take the spotlight off of yourself and change the balance, change the equation that was working before, but now is not working anymore because the factors have changed.

[16:44] And so it's important to keep that in mind. And sometimes it's necessary to again, visit the psychologist afterwards and make sure that the way you're thinking about things is still in the right balance. And I say psychologist, but it's not just a psychologist, but it's also a nutritionist. And we don't have a life coach on the team beyond that. But you know, life coaches are also an important sort of adjunct.

[17:14] Arseniy Arsentyev: And let's get a little more technical. I often confuse this three terms and not quite understands interactions. So first, gastric bypass, second, sleeve gastrectomy, and third, bariatric surgery. Do I understand correctly that gastric bypass and sleeve gastrectomy is kind of a subset of bariatric surgery and bariatric is a field's name? Can you go through the details, please?

[17:45] Abraham Krikhely: Yes, that's exactly right. So bariatric surgery is the overarching label of all these surgeries and bariatric surgery is just like the shorter, easier label for it. But you know, many places also they call it metabolic surgery, metabolic and bariatric surgery and highlights the fact that these surgeries, all of these different surgeries work through different pathways. One is you're creating restrictions. So you're not, because your stomach is smaller, you can't eat as much and you'll feel uncomfortable if you try to overeat. The second one is hormone change.

[18:26] Which would have tied into the previous topic we were talking about in terms of the psychology. It's not just the psychology, but also kind of your biology, your hormones, which drive you to be more hungry or less hungry. And so bariatric surgery changes those gut GI hormones, gastrointestinal hormones, and then the degree of absorption and all three of these factors can contribute to the impact on the weight. And so bariatric surgery is the overarching thing. The most common bariatric surgeries that are done are the sleeve gastrectomy, the gastric bypass, the duodenal switch, and the gastric band, not so much anymore, but it's still being done in some places.

[19:17] Do you want me to go through the different ones?

[19:20] Arseniy Arsentyev: Could you kind of summarize them or describe in a very general terms just for people to distinguish them somehow?

[19:27] Abraham Krikhely: Exactly. So the most common bariatric surgery in my practice and in the world and country largely is what's called a sleeve gastrectomy. Basically, in that operation, you make the stomach smaller. You remove a part of the stomach and make the stomach into a small tubular stomach into kind of like the shape of a banana, more or less. Sometimes I have patients walk into my office saying, Oh, I want the banana operation. And so usually they're asking for the sleeve gastrectomy. So the average weight loss there is about 25% of your weight, roughly.

[20:01] And it's thought to occur because the stomach is smaller and a reduction in a hunger hormone called ghrelin. So that ghrelin level goes down and people tend to be less hungry afterwards. Not everybody, but most people. The next operation is a gastric bypass. Now this has been around since the 1960s and its form has evolved over the many years and while other operations have come and gone, this one has kind of passed the test of time. And in this operation, I don't remove any part of the stomach, I divide the stomach into a small part and a big part and I bring up a piece of intestine to connect it to the small part.

[20:41] So that when the person eats, the food goes into the esophagus, into the smaller stomach and then directly to the intestines bypassing the rest of the stomach and a small portion of the intestines. The average weight loss is also about a quarter of your weight, about 25% of your weight, 25 to 30%. And so a little bit more than the sleeve. And it's particularly better for diabetes and for reflux. And so if somebody has already bad reflux or diabetes, we tend to steer them in this direction rather than steer them towards the sleeve. Then the third operation is the duodenal switch. It's kind of a combination of the other two. You do a sleeve gastrectomy and then you bypass about two thirds of the intestines.

[21:27] And that's the most effective option against diabetes, has the most weight loss, about 30 to 35% of total body weight. And so if somebody comes to me and their main challenge is the diabetes and they want to do the option that's best for diabetes, we steer them towards that option. And then the gastric band is not really being done very much anymore. It's still an option that's out there. Basically, you put like a belt, an adjustable belt, around the top of the stomach. And that squeeze limits how much the person eats and makes the person less hungry. So it just works through restriction.

[22:11] And you can adjust the size of that belt through needle injections. So overall weight loss is not as good as the other options and has kind of faded away over time.

[22:23] Arseniy Arsentyev: Is there a notion of a metabolically healthy fat person? So a person who is extremely overweight, can he or she possibly be metabolically healthy?

[22:34] Abraham Krikhely: Absolutely, I would say yes. But at the same time, that same person may seem to be metabolically healthy and may have some underlying disease sort of building up, just hasn't kind of crossed the threshold to being diagnosable yet.

[22:52] Arseniy Arsentyev: And what are the key risk factors for obese people?

[22:58] Abraham Krikhely: The key risk factors, I guess the comorbid conditions really, people that tend to be sicker from metabolic disease, the distribution of the fat, the weight tends to be in their midsection in the belly around the organs. So you may find these people have skinny arms, skinny legs, but their belly is sticking out a lot. And so that's a sign of metabolic disease. These people tend to have higher blood pressures and they get sleep apnea where they stop breathing in their sleep and their brain doesn't get the right oxygen. They get diabetes, they get fat in their liver, lots of medical issues.

[23:48] Arseniy Arsentyev: Okay, and getting back to the diabetes, you mentioned GLP-1s. Can you briefly outline what are these magical GLP-1 antagonists?

[23:59] Abraham Krikhely: Sure. Excellent. So I'm glad you brought that up. So we're really excited about all of the recent advances with regards to these medications, these category of medications called GLP-1s. Basically, they target some of the same hormones that are targeted during bariatric surgery. And I don't view them as either surgery or medications. I kind of view them, these are all kind of adjuncts. These are options along the same spectrum. And I think the right way to think about it is not either or, but both and. There's a time and place for each of these options. Basically, these category of medications, they mimic GLP-1 hormone, which basically is impacting your sugar metabolism as well as your appetite through affecting how the GI tract slows down in the process.

[25:05] And they contribute to weight loss. And the more recent ones have been very promising with regards to having a very meaningful impact. So the degree of weight loss has not been to the same degree as surgery, but still has been very, very effective and very meaningful impact on people's comorbid conditions, such as sleep apnea or heart disease and so forth. So we're really excited to have the privilege of being able to offer, this additional tool in addition to everything else that we're doing.

[25:37] Arseniy Arsentyev: And can we, by combination of this GLP-1 antagonist and of course the surgery, quote unquote cure diabetes?

[25:48] Abraham Krikhely: So I think I would unpack the word cure a little bit. I think diabetes is a chronic condition and you may achieve remission of diabetes from the sense that you're measuring somebody's sugar and you're measuring hemoglobin A1C, which is a measure of the impact that that sugar has on the body. And when that level is high, you're calling it diabetes. And when that level is under control, you say it's in remission. And so you're able to achieve remission of diabetes. But at the same time, sometimes over time, being this chronic condition, sometimes it comes back to a degree in the long, long term. Now, if you're taking these GLP-1 medications, you may achieve control of the sugar and lower the level, but dependent on continuing to take the medication.

[26:53] If you stop taking that medication, then oftentimes the weight comes back and the diabetes could come back as well. Now, with the surgery, you do a two-hour surgery, you're done. The impacts are long lasting. And recently I came across some very good studies out of the Mayo Clinic looking at both bypass and sleeve gastrectomy, showing very sustained results 10 and 15 years out after surgery. Some people will regain weight and that's a given, but the vast majority of people were able to achieve sustained results long term just for the surgery alone. But touching on the topic of life happens, right? And some people will regain weight. Some people will have habits kick in again.

[27:49] Having the option to try to use these GLP-1 medications for those patients when that happens also is a very promising thing.

[28:00] Arseniy Arsentyev: And what's the biggest predictor of a person to maintain the weight? I'm sure you've worked with hundreds, if not thousands of patients. And I'm also sure that sometimes you can predict the outcome even before the operation. Could you walk us through the biggest predictors of obesity?

[28:24] Abraham Krikhely: Biggest predictors of success with treatment? Is that what you're saying?

[28:29] Arseniy Arsentyev: Yes.

[28:32] Abraham Krikhely: So for one, I like to say, regardless of how well I think I could judge somebody, I try not to judge people because I've been surprised so many times. There are people that I thought that wouldn't have succeeded that blew me away and they were so inspirational. And there are people that I thought would have everything under control, but then life happened. And then even though they had everything in control yesterday, life threw them off balance and they couldn't do it. So I try to believe in my patients. I do believe in my patients. I believe that anybody can achieve success. Not everybody will achieve great success, but I believe we all have the potential to. So I preface it with that.

[29:23] Now, that said, when somebody comes in and start the process for the workup and they're doing all of the things, you tell them you need to do X, Y, and Z in terms of getting certain tests, making certain changes, starting the exercise and so forth. Some people do everything right away. Some people end up just forgetting everything, doing like one or two things, but not the other things. The people that tend to be able to set an objective, make a plan and stick to it, they tend to be ones that are more likely to achieve more sustained success. Whereas people who don't do that, they tend to be less committed and perhaps less likely to succeed.

[30:10] I think having the right support structure, a healthy home environment makes a big difference. Those are the main things. I think other factors such as access to certain resources, such as gyms, environment, education, all of these things play a role to some degree as well.

[30:34] Arseniy Arsentyev: And what is this cognitive change after the surgery when people start to notice their weight extremely decreasing at an extreme rate? What is this psychological changes? What do people report to you feeling during this process?

[30:51] Abraham Krikhely: The thing that I've heard many times that stands out to me that that was surprising to hear, but perhaps shouldn't be so surprising to hear is, let's say somebody had bariatric surgery, they lost the weight, and they look in the mirror, skinny. The skinny person sitting in front of me, looking healthy, looking well, vibrant. And he or she tells me that they look in the mirror, they still see the person that they were before. They see themselves as a person that has obesity, and they're afraid that it's going to come back at any minute. It's the same person.

[31:32] So that's kind of from a psychological standpoint, that's kind of the biggest thing that I've seen. But it's a huge impact, huge impact in terms of how they view the world, they have more confidence overall, and it dramatically improves their quality of life. It's also an impact on the people around them. Are they supportive? Are they not supportive? Is it going to affect their relationship and so forth?

[32:05] Arseniy Arsentyev: Okay, and when I was preparing for this episode, I researched your background a bit. And you seem like to have a fascinating story. You had your bachelor's in finance, and then got into medical school and started progressing in the fields of bariatric surgery. Can you walk us through your biography, maybe some key events that led you to reconsider your career?

[32:29] Abraham Krikhely: Sure, absolutely. I'm actually an immigrant to the country from a country called Georgia, and I'm a son of a surgeon. And my father's a surgeon, my mother's a dentist, and I was always inspired by them and wanting to follow in their footsteps. When I went to school, initially, I wasn't sure which way I wanted to go, but I was pre-med. I was also fascinated by other things. I wanted to learn, if I was going to become a doctor, I didn't want to just focus on just biology. I wanted to have other skills that perhaps could complement what I wanted to do in life.

[33:11] I went to NYU and I was very fascinated by Stern, by finance, and I decided to study that. It was very interesting and I loved it. I actually worked in finance for a year. Even though it was super interesting and I met a lot of great people and very appreciative of the mentors I had there, healthcare, being a doctor, medicine, being a surgeon, it was a calling for me. And so no matter how much I enjoy the finance side of things, I didn't scratch that itch. I had to go back. And so after a year in finance, I went back to med school and then I followed that path. I did my training in NYU, did my med school in NYU and then did fellowship in minimally invasive bariatrics.

[34:15] Arseniy Arsentyev: Okay. And was it hard to transition from finance to medical school? Speaking of subjects, I'm sure you were studying different stuff in college. Were you doing additional years to compensate for your pre-med?

[34:29] Abraham Krikhely: No, actually, I was able to do the pre-med requirements while I was still in college. So I finished both tracks.

[34:40] Arseniy Arsentyev: And the first part of your position is the chief of division of minimally invasive surgery. So it's a rational step to go into this direction. Minimally invasive surgery, from my understanding is synonymous to robotic surgery nowadays, because there is little interaction inside the human body. And may you walk us through the recent advancements with robotic surgery and this minimal invasive surgery stuff.

[35:10] Abraham Krikhely: Yeah. So minimally invasive surgery nowadays is really synonymous with robotics and laparoscopy. But back in the day, it was even through just doing the same operations through smaller cuts. Basically doing as little disturbance to the body, as little of a cut as possible on the body to achieve whatever purpose you needed to achieve to cure the disease. It makes it easier for the body to recover and to get back to doing normal things. And so when I first started, minimally invasive surgery was about laparoscopy, which basically makes a few small cuts on the body, and you put in what's called a laparoscope, which is a camera attached to a skinny tube, into the body.

[36:03] And you work on a TV screen and you do everything that way. And I was doing that for many years. And then, as robotic technology developed, early on in the process, I was a very early adopter of robotic surgery with regards to general surgery, foregut and bariatrics, to the extent that I joke that I drink my coffee nowadays with a robot, I do everything with a robot nowadays. And so robotic surgery is pretty much an evolution of laparoscopy, it's a form of laparoscopy.

[36:39] It also works that way. You do small cuts on the belly or on the chest or whichever part of the body somebody's operating on; I operate on the belly. And you work on a TV screen. And the future of surgery, the present is also robotics, but the future of surgery is robotics and artificial intelligence. And so the big thing, initially is steady hands, steady eyes. You're able to do more complex movements, maneuvers in a minimally invasive way inside the body with much greater precision, much better consistency from one patient to the next, from one surgeon to the next, because of how a lot of the variability is taken out of it through robotics.

[37:39] And then that's been around for many years now. I think that the real revolution is the data layer on top of it, the data that the systems are collecting about the surgery that's being done. Surgery finally is measurable, in a more regular way and the potential to collect all this data. That's kind of the future to collect all this data and to correlate it with outcomes and to be able to give doctors better insights into what they're doing to help kind of challenge judgments and to make good judgment better.

[38:26] That's what I'm excited about. I think the future of surgery is largely going to be defined by robotics and artificial intelligence.

[38:36] Arseniy Arsentyev: And that's what I'm also excited about. I'm waiting for this day when surgeries would be, not mainly done by robots, but robot assistants. This, sci-fi displays during the surgery when AI corrects your cuts, helps you with some important information that may be of use at the current moment. And if the internet is not lying, you've done close to 2000 da Vinci operations. So for the listeners, da Vinci is Intuitive Surgical's advanced robotic system that is in use in pretty much everything today. And could you address that? How's it working on such a complicated system? Maybe you'll provide us some details of your experience with it.

[39:31] Abraham Krikhely: Oh, it's been amazing. It's been really great. I've done over 2000 cases. And you know, I started off by just doing the easier, simpler cases. And now I do the most complex of all cases. And so it already gives you lots of augmenting information that gives you feedback about what you're doing, control about different elements of the case. At the press of a button, you're able to see what the blood flow looks like to different organs, which helps you identify anatomy in that way. Gives you recording, the ability to record and to get insights from the recording. So you're learning from every case. It's not just you doing the case and remembering what you remember, but you have tools that help you objectively in a technical way and learn from each and every case.

[40:27] And the beauty is going to be not just where you learn from each and every case, but how there's a thousand people just like me and the machine collects data from all of us and gives us the feedback that allows us not to learn just from my own case, but from everybody's cases, and to make even better and better decisions from one patient to the next. The way the system works is basically I set up the instruments at the bedside and I have an assistant who's at the bedside managing that. And after I have it all set up, I go to the control, which is also in the same room, just a few feet away, where I control everything that's going on with the robot.

[41:19] So the robot, when people think about robots, they think of like autonomous robots, like R2-D2 and something that's walking like a humanoid robot. In this scenario, basically, it's more of a machine that's under human control. Technically, I guess I'm the robot, and I'm controlling it. Luckily, I grew up in the Nintendo generation. So all those years that my parents thought I was wasting my time playing video games. I was training my hand-eye coordination to be able to do robotic surgery. And the experience for me, it has definitely helped achieve more consistency from one case to the next, take away the variability, help me achieve the same precision in very complex anatomy that I would like to, that would be a lot easier to achieve in simpler anatomy, but helps level a playing field.

[42:16] And I think of that BMI 93, 700-pound sleeve gastrectomy patient that I told you about. I did that case robotically, and I contrast that with other cases that I had done similar with laparoscopy without the robot. And I just remember the challenges, the physical strain that my body used to feel doing those cases. And I didn't feel any of that when I did it robotically, and that allowed me to focus on doing the surgery right, as opposed to focus on overcoming the pain, from doing the case.

[42:55] Arseniy Arsentyev: And for the listeners, the da Vinci robot system is this kind of two-part system, when you have a console, where the doctor, it's not like you are a robot. It's like da Vinci's kind of exoskeleton that you put your face into, and you have controls. And the second kind of octopus-shaped machine does the operation controlled fully by a surgeon. And a little childish question, is it hard to master it? What's the typical process to learn robotic surgery? Does it teach you in college, in post-medical education?

[43:41] Abraham Krikhely: So, my path was different since I was kind of early in the game, right? I sought out the training, largely self-taught, because these pathways weren't in existence back then. But today, all of my residents, all of my surgical trainees, the future of surgery coming out of training today, are fully trained on how to operate in this way, and using this modality. You don't get it in college or med school, but actually, I have med students in my cases who are already kind of learning the different aspects of it, how it works, and such. So, they're not doing the surgery, but they're learning how the surgery is done.

[44:27] And almost all training programs nowadays have some element of robotic surgery, or should. Because it is the future of surgery, but it's also the present of surgery in many places.

[44:40] Arseniy Arsentyev: How do you see the bariatric surgery evolving? Will it be the evolution of these robotic operations or completely different approaches to help a person lose weight?

[44:53] Abraham Krikhely: I would say that bariatric surgery today already is increasingly being performed robotically. I think that bariatric surgeons were kind of early in the curve with regards to minimally invasive surgery, both laparoscopy and robotics. And so they already have that sort of mindset in terms of how they approach cases. And I think it's an exciting time. It's an exciting time, both regards to being able to do more complex things with robotic approaches, but also evolution of different tools that we have, such as the GLPs.

[45:37] And also with regards to evolution of artificial intelligence and with regards to what we're going to do about that. Now artificial intelligence is both going to be from the standpoint of how it integrates into the performance of surgery and into robotics and the current robotic platforms like the da Vinci, they have that mindset. They have the hardware built into it to do the compute. And that will be necessary to give insights during the cases and so forth. But in addition to that case insight during the case will be to have, let's say artificial intelligence co-pilots, that will help augment a doctor's judgment with regards to the recommendations they give patients just along the way.

[46:35] And in that way, hopefully we can give more personalized recommendations, more personalized medicine. I feel that I find myself talking about this a lot where through the years, I think healthcare has become very fragmented. There's so much information out there. It's cognitive overload for any individual. And as a result of a desire to want to be at the cutting edge of everything and up to date with everything, in order to do that, you have to narrow your focus more and more and more and more and more. But as a result, everybody specialized in such a narrow area, healthcare became fragmented, and how do you connect everything? And I'm optimistic that artificial intelligence will help us to do that.

[47:25] Artificial intelligence can, with its ability to synthesize from consuming, large chunks of data and papers and literature, can allow us to get insights from this large volume of studies. And then to be able to kind of increase our scope a little bit so that we're not so siloed into small, tiny specializations and we're able to treat the whole patient, in a more holistic way. So very optimistic about the future of medicine and surgery, together with robotics and artificial intelligence. We think about artificial intelligence, kind of being machines, right? And you think of machines as being, less, less human, right? But I kind of wonder if the opposite is happening, let the machine do whatever's, repeatable, and mechanical. We focus on judgment, we focus on being thoughtful, being adaptable.

[48:34] Maybe we were able to spend more of our time being human rather than just doing repetitive tasks.

[48:42] Arseniy Arsentyev: Have you considered the possibility that you may be replaced by robots that there would be a day when robots do surgeries completely autonomously?

[48:54] Abraham Krikhely: I wonder about that. I wonder about that. And it's a conversation I have often, And I think what it comes down to is there's a difference between having data and applying this data. There's a difference between, hearing, let's say, like a wisdom, a line from Sun Tzu and taking that line and applying it to your day to day. And I think that's where meaning comes in. That's where judgment comes in. And I think that that's where it's important to still have humans in the equation. So I'm sure there's some scenarios in which certain things could be automated.

[49:45] But as of right now, it still seems to be important to have a human in the mix in some way.

[49:52] Arseniy Arsentyev: Because if you asked me like three years ago, I would laugh and say it's completely impossible. But after GPT started to solve my advanced mathematical analysis problems, I'm not so sure, not so sure that there wouldn't be a time when especially we have two eyes, we have this limited frontier of vision, and robots can manipulate with multi dimensional data, different cameras, different sensors, and so everything is possible. So that's my sense in this point.

[50:26] Abraham Krikhely: I totally agree. I think it's totally possible. But I think that the question to really ask, and I don't know that I fully, fully understand the answer to, is the robot doesn't have judgment, robot doesn't have meaning. In order to have meaning, it requires lived experience. It requires not just like the out of the box idea and approach, but the application of that to each scenario. And so what would it take for a robot to be able to replace that? A robot would have to become sentient to have its own lived experience, before it can replace the meaning part. But I gotta tell you, every time I interact with GPT or any other AI, I'm blown away that you're telling me this is not already alive. It understands me better than I do sometimes.

[51:32] It's crazy. So it's an interesting time. And I think it's a very important time where we're at the cusp, where things are changing exponentially. And what's changing exponentially is the technology. What's not changing is what matters. The meaning part of it with all of society. With regards to surgery also, what matters with surgery is judgment, understanding human anatomy, understanding how you handle tissue and how tissue responds. And those little nuances are critical and they translate across all platforms. It's whether it's open surgery through big incisions or laparoscopy or robotics with da Vinci or any of the other robotic platforms that will come out.

[52:29] It's going to be important to be very facile and fluent with regards to what are these timeless principles and be able to translate from one system to the next. And be able to have good judgment and be able to decide what's important, what matters. It's not about can you do something, but should you or shouldn't you and when should you. And I think that these nuances are things that can't quite be captured in the data just yet. They need to be applied at the level of the individual.

[53:04] And so, I guess time will tell.

[53:08] Arseniy Arsentyev: Meaning, meaning. There is a missing part in your description of your biography connected to meaning. What was the time, this aha moment when you decided to go to bariatric surgery? Because there are varieties, as you've told, extremely fragmented, different kinds of healthcare, different kinds of surgeries. Why? Why did you go to bariatric surgery?

[53:31] Abraham Krikhely: It's a great question. So, my focus is more than just bariatrics. But when I finished and today also, things are specialized. So, you can't just be somebody that does everything. You have to focus to some degree. And I was always technology inclined and I was very excited about the impact of what we could do in the field. And specifically with regards to bariatrics, I saw the impact that we can have on patients. You have somebody who is suffering with so much chronic disease, with 10 medical problems and weight, and there's been a thousand medications.

[54:12] And you see the number of medications there are: they're just adding more medications, not taking them away. And all of a sudden you do this two-hour operation. And they go home the next day and you see them in the office five days later, like walking in, feeling comfortable. And then in the following months, you see kind of the weight decreasing and their burden being raised off their shoulders and walking in with more ease and on some of these medications going away and these medical problems going away. You see the impact that you can have on somebody.

[54:48] That's what brought me in. That's what keeps me here. Keeps me offering this.

[54:55] Arseniy Arsentyev: Two follow up questions on the robotic theme. First is, have you noticed any glitches in the system? Was there a moment when something from the side of robotics went wrong? Maybe some hand glitch or something else is the first question. And the second follow up is also about safety. How safe is it? And what are the systems put in place to ensure the safety of robotic surgery?

[55:32] Abraham Krikhely: Those are all very good questions. Very important questions. So firstly, it is safe. It is very safe. And the system itself is safe, secure, reliable. It's been around for decades. And it's been refined through thousands, not thousands, millions of cases all over the world. In terms of, has there ever been a glitch? Not like in the way that you may be thinking that like a, like a game changing, very, super dangerous robot goes rogue sort of glitch. I haven't seen that.

[56:15] There were a handful of times where I had to like reset the system, like rebooting the machine, so to speak. But they have safety measures in place where when that's going on, the arms are not moving and things are staying steady waiting for you to go back. But I'm surprised, how few of those episodes I encountered having done thousands of cases.

[56:46] Arseniy Arsentyev: And the next question is getting back to bariatric surgery. And is there an age limit? What is this lifespan for this surgery? I'm sure you're not doing it for kids, or maybe I'm wrong. Are there age ranges?

[57:08] Abraham Krikhely: There are age ranges, but there are no strict cutoffs. In my practice, we focus on adults, so generally 18 and over. There are surgeons who focus on adolescents, teenagers with obesity as well. And I don't have a strict cutoff on the upper end of it. Really, what you want to know is: is the person 75 years old or 75 years young? Two very different patients. It's about frailty and about, the impact that that will have on their quality of life going forward and recovery from the surgery. I've had patients that I've operated on that I felt were 75 years young and their bodies were holding them back from still living vibrant lives.

[58:01] And I did the surgery and they lost the weight and they were traveling the world and doing things they wanted to be doing. But then if there's somebody else who's 75 years old, let's say they're not walking, somebody wheels them in with their wheelchair and they're not in charge of their own food or this or that. And that person would probably be less likely to have a thriving, meaningful impact from the operation.

[58:35] Arseniy Arsentyev: Proceeding to the final topic of this episode, tomorrow's medicine. I want to ask you one last question connecting to your practice. In the beginning, we talked about your kind of winning cases, your cases when people get an astonishing results after the surgery. And can you walk us through the worst cases? Because we're all human: doctors make mistakes, robots make mistakes sometimes, everyone does it. What are the maybe not even tragic, but the sad cases in your practice?

[59:16] Abraham Krikhely: I think the things that I find most challenging is from a mental standpoint, if people don't have the right expectations, that's why I try to try to set the expectations, right? It's very important to me that people really know what they're doing, what they're going into, and I've had situations where a handful of times where people were saying all the right things, like they knew, they understood the surgery, explained, they yes me to death. They tell me, yes, yes, yes, yes, yes.

[59:54] And they seem enthusiastic. And when you tell them that the stomach is going to be smaller and they understand, but then afterwards, they're crying because their stomach is smaller. They didn't realize that they weren't going to be able to eat X, Y, or Z specifically as a result. And I find those to be the more challenging cases for me from a mental side.

[1:00:26] Arseniy Arsentyev: Okay. So the future of medicine, you outlined your vision for the surgery. So AI copilots, more advanced robotic systems, high technology infiltration of medical profession, I would say. And what are your expectations about the systematics, the economic level of the US healthcare, of the global healthcare, maybe? What are your thoughts on it?

[1:00:53] Abraham Krikhely: So are you asking specifically the economics of robotic surgery?

[1:01:01] Arseniy Arsentyev: No, no, no, no, no. General outlook on the future of medicine and healthcare. What do you wish to see in like 10-15 years connected to any services that provide well-being? So very general question, very general answers.

[1:01:16] Abraham Krikhely: Yeah, it's a great question. I would think that we shouldn't have big disparities in care. It would be good for healthcare to be accessible for everyone. And it would be good to have personalized medicine, combining all the vast amount of data that's out there with AI to help guide what would be just right for you. You can give like a general thing that's right for most people, but it may not work specifically for you, given your biology, your DNA and your path. And so I'm hopeful that artificial intelligence will help us to do that. I'm hopeful that medicine becomes less fragmented.

[1:02:10] I wish it were more holistic. And I think artificial intelligence gives us a tool to do that. And a tool to allow us to refine our judgment. And also to give us an opportunity to be more holistic and to be more human, to focus on, trying to find what the meaning is rather than just doing repetitive tasks.

[1:02:40] Arseniy Arsentyev: Thank you. Dr. Abraham, it was a fascinating hour talking with you. We covered many different topics. I know the audience enjoyed it a lot. And yep, everyone, you know what to do: subscribe to my channel, like the episode, share it with your friends, and see you on the 11th episode of Tomorrow's Medicine. Goodbye, everyone.

[1:03:00] Abraham Krikhely: Thanks so much. Bye-bye.