Transcription:
da Vinci® Surgery: Minimally Invasive Surgery for Hernia Repair

Melanie Cole (Host): The introduction of laparoscopic surgery for treating many common surgical conditions, such as gallbladder disease and abdominal wall hernias, has transformed the landscape of surgery. Thanks to innovations in robotic technology, surgeons are able to perform hernia repair surgery through tiny incisions rather than large incisions associated with traditional open surgery. The result is less damage to surrounding tissue, less pain for the patient and a much quicker recovery. Here to speak with us today about robotic hernia repair is Dr. Jonathan Schilling. Here's a practicing general and laparoscopic surgeon with the Christ Hospital Health Network. Welcome to the show. Explain a little bit about the evolution of robotic surgery.

Dr. Jonathan Schilling (Guest): Robotic surgery is not a new technology at all. It’s almost been out for about 20 years. General surgeons are a little slow to join the revolution of robotic surgeons, but what it is, is a platform that offers a lot more technology so that more surgeons can offer more complicated types of operations to more patients through a minimally invasive technique. The robot is not an automated platform. It offers 3D high definition optics, it offers a very stable wristed technology so that you can do lots of surgery simply by using the robot, whereas traditional laparoscopic surgery requires a lot of extra tools and workarounds. Robotic surgeon offers all the benefits and more through its existing platform. General surgeons now for the last five years are starting to adopt the robot in part of their practice, and I'm one of them.

Melanie: As it’s more precise, speak a little bit about the da Vinci® surgical system and what that offers patients.

Dr. Schilling: The da Vinci® surgical system offers precision like you've never seen before with traditional open or laparoscopic technique. I have up to 10x magnification with three dimensions, and also using fluorescence. I'm able to go in and cause much less tissue trauma or damage to surrounding areas when I'm going after a hernia or gallbladder or colon cancer I'm operating on. I can go in, do what I need to get done and then close it up. What it gives the patient is less pain, less bruising, less scarring, and that often translates into less time spent in the hospital, less time spent recovering, quicker resumption of normal activities, and, hopefully for most people, improved satisfaction.

Melanie: What about for the surgeons? What are the benefits for you with this more precise surgical system?

Dr. Schilling: It comes in a lot of different ways. I can offer more minimally invasive surgery to more patients. Typically, when you're doing a lot of laparoscopic surgery, there are limitations; not every patient is a candidate for laparoscopic surgery. While not every patient is a candidate for robotic surgery either, using robotics definitely increases the number of patients I'm able to offer minimally invasive surgery. I think that alone is a great benefit to the surgeon. In addition to that, it offers improved ergonomics and comfort for a surgeon. A lot of times, laparoscopic surgery is not very comfortable to do. You're often contorting your back and your neck and your arms in ways they weren't really designed to do for long hours in a day. Being able to use a robot, your ergonomics are a big part of the operation where you're sitting in a comfortable area using a tool designed to actually take the pressure and strain off your back and neck instead of add to it.

Melanie: What about the learning curve? Is it difficult to learn?

Dr. Schilling: Actually, the robot I think is easier to learn as a new technology versus someone who’s never done laparoscopic surgery. Laparoscopic surgery definitely has a role, a big role, in general surgery, but it’s pretty cumbersome to learn. Residents and medical students and everybody spends a lot of time to try to learn these techniques because they're not always intuitive whereas with a robotic surgery, often times you can sit behind a console, even as a novice, and at least get the general idea about how to use the technology. It's a lot more user-friendly and I think what a lot of surgeons are finding is it's easier to make the jump between open to robotic surgery than it is to make the jump between open to laparoscopic surgery. I think you see that a lot in a hernia specifically because in hernia repairs, we have data that shows laparoscopic hernias are better than open hernias by and large for most things. For some reason, even though people have been doing laparoscopic surgeries since the 90s, we don't see a majority of laparoscopic hernias being done. The majority of hernia repairs that are done in this country are open still. We think a lot of that is because of the time it takes and how difficult it is to learn laparoscopic hernia surgery, so you don't get everybody adopting these techniques. With robotics, I think it offers another platform for open hernia surgeons to transcend into that minimally invasive world because I think there's a lot of benefits for patients there. If they're able to make that transition, I think it should offer and promote more minimally invasive operations for most people.  

Melanie: What's the clinical presentation of a hernia? How is it identified, some complications, if left untreated, and what are some common conditions and factors that lead to a hernia?

Dr. Schilling: The best way to describe to a presentation would be a painful bulge and the most common kinds of hernias you're going to see are either in the abdominal front in the umbilical region or in the groin in the inguinal regions. A painful bulge, and sometimes that bulge sticks out and you can't push it back in; that’s called incarceration. Other times, that bulge gets easily pushed back in and that’s called a reducible hernia. There are different stages of these hernias. If you have a symptom free or painless bulge that easily pushes back in, that would be typically considered an asymptomatic hernia. Often times, those patients aren't offered surgery or aren't recommended surgery. They can manage their condition expectantly, which means once you start developing pain, then it is an indication for a hernia repair. That's based on a large amount of data that shows that once you start developing a painful bulge, then the predictability of that hernia becomes unsure; you don't know if that hernia is going to become incarcerated or the worse complication, which would be strangulated. A strangulated hernia is where a hernia itself is not reducible and it's trapped in the hernia sack outside of the body, and then the blood supply to whatever is trapped in here gets compromised – that means if it's a piece of fat like the omentum or pre-peritoneal fat or if it's a piece of intestine. Those types of tissues then, without a blood supply for several hours, will start to develop ischemia, and then potential necrosis. Necrosis is a pretty serious complication; it can lead to sepsis. If you have necrotic tissue within a strangulated hernia, that's going to be a much more difficult and challenging repair with higher complication risk. Sometimes you don't get to use a permanent piece of mesh that you'd want to use.  

Going into that mesh topic, it’s another topic in it of itself, but what I tell my patients is this: when you have a painful hernia, you should get it fixed. If it is a severely 10/10 sharp pain that brings you to your knee and you can't push it back in and you're looking at a strangulation, there's no doubt about it; you got to get it fixed immediately. The idea is to find those patients with hernia and get them fixed before they're strangulated because that strangulated hernia repair, while odds are someone’s not going to die from that kind of presentation, it’s certainly not the best most advisable way to just wait until you absolutely have to get the hernia repair done. You're looking at increased infection rates, increased hernia recurrence rates, the possibility of a bowel resection or intestinal resection, you're looking at several days in the hospital, and on top of all that, there's the inability to predict when this type of thing is going to happen. Often times, you're doing these on the weekends, at night, on the holidays; it just adds a lot of stress and trauma unnecessarily if you can find these patients ahead of time before they get strangulation and get them fixed.

Melanie: Speak about patient selection criteria. Does the selection of patients appear to interfere with the success of the technique when you're using robotic hernia repair?

Dr. Schilling: It's all about patient selection and tailoring the type of operation for that specific hernia and for that specific patient. There are a few things about hernia repairs that patients coming in with preexisting conditions like rather significant heart and lung disease that would prevent them from undergoing general anesthesia. Right away, for those very sick patients that maybe have a pretty significant hernia problem, those types of patients aren't going to be good candidates for minimally invasive hernia surgery; they would go towards an open hernia repair still. If you have patients that are habitual smokers or morbidly overweight, more often than not, if a hernia is not an emergency, then you spent time counseling that patient for smoking cessation and weight loss because those are two major factors that are controllable and modifiable that will, if the patient is able to stop smoking for four to six weeks pre-op or if the patients are able to reduce their BMI, then not only is the surgery going to go smoother for somebody but also their risk of recurrence is going to drop for them. Those are the types of things we see in the outpatient setting and what we talk about with patients. Once we've optimized the patient the best we can, then we go ahead and perform that elective hernia surgery, and that procedure is based on the location of the hernia, whether it's incarcerated or not, whether we anticipate a lot of scar tissue, whether we anticipate the size of a mesh we're putting in the body, if patients are diabetic or have a history of skin infections, then a minimally invasive repair is going to be preferential. We look at all those characteristics of a patient and then customize an approach whether it's going to be a minimally invasive approach or an open approach.

Melanie: Are there some technical challenges that still need to be overcome?

Dr. Schilling: Sure. There are always techniques that you can work on. I think the knee-jerk reaction for most people when you talk about the robot is cost. For my robotic journey and learning the robot and adapting it to my patients, the first thing you do with a robotic hernia or robotic anything is you get safe at it. You make sure that you're providing sage surgery for patients. The next thing you do is you worry about getting faster at it because robotic surgery, and minimally invasive surgery in general, takes more time. You don't want to put a patient under anesthesia any longer than you have to. Once you've proven that you can do a safe operation, then you try to improve the speed of it so that it's not a racing surgeon, but working efficiently. You perform technical mastery of these skills so that you're able to do this surgery in a very effective amount of time, and then you can start reducing the cost of these surgeries. I think the knee-jerk reaction is that robot surgery is so much more expensive than traditional surgeries. When you compare them to open surgery, I'm completely in agreement. Open surgery typically costs less than a robotic surgery or laparoscopic surgery. That's the cost of using the instruments, the tools and the cost of the operating room time. I think where you find differences and where you find improvements is once you're safe and efficient at using the robot, you start trimming down some of the instruments that you're using with the robot. You can actually make robotic hernia surgery very cost effective. When you look at the bigger picture of cost, you're looking at how much narcotics the patient is using post op and when are they getting back to work. The bigger picture of the cost is ‘are we returning people back to work sooner so that they're not missing extra time off work' or if they're caregivers or children or for the elderly, are we getting them back to normal activities sooner? I think that's an often overlooked part of the cost that we don't take into consideration, but I think that's where you find the technical challenges. When people are learning these robotic techniques, you're trying to get safe and then you're trying to be efficient, and then you're trying to use technology to drop the cost so that this is the type of operation that you can offer to most people regardless if they have commercial insurance or Medicare or Medicaid or anything; essentially, it becomes the right thing to do for people.  

Melanie: In summary, tell other physicians what you'd like them to know about hernia repair using the da Vinci® surgical system and when to refer to a specialist.

Dr. Schilling: For robotic hernia repair, it's not for everybody all the time, but it is for most people most of the time. I think by and large robotic hernia surgery should be done by somebody experienced in all different types of hernia treatments whether it's an open repair, a laparoscopic repair or a robotic repair. I tell my patients and referring doctors all the time that hernias are complicated and patients are complicated. At any point in time, when I'm sitting down to counsel my patients, first and foremost, we look at the hernia, we try to get all the information on board with the patient, if they've had prior surgeries, prior hernia repairs, old mesh products used, we talk to the patients about their medical problems that might be involved in complicating the hernia repair, and then we talk about their goals of a hernia repair. One of the most important concepts to understand with a hernia is nobody cures hernias. Hernias are a hole in the connective tissue of the abdominal wall and nobody cures that; nobody cuts out a hole and just replaces it with a larger hole. Every time a patient undergoes hernia repair, it is a repair – it is a patch. All doctors that are trying to fix hernias are trying to put their best patch forward and trying to do what they think is the right thing to do to reduce not only complication rate of the operation itself but to reduce the recurrence rate long-term. Understanding that's the kind of work that a hernia surgeon is doing and understanding how complex it is, I think anybody that has a bulge whether it's symptomatic or not deserves a consultation with a hernia specialist. Talking to those patients helps them understand when and why they need to get hernia surgery. There's plenty of patients out there with hernias that don't need to drop everything they're doing to go and get their hernia done immediately, but there's plenty of patients out there that probably have a hernia that maybe 10 years ago someone said they didn't need to get it fixed, but maybe they should get it fixed now, but nobody's really told them that. Those patients are out there lurking around and I'm trying to find them all, just to inform people and teach people about hernias whether it's the primary care base or individual patients through events like this and trying to understand where hernia repair fits for everybody. I think having a minimally invasive option that lets people get back to work quickly using fewer narcotics is more favorable than the traditional open repair in many instances.

Melanie: Thank you so much. It is great information. You're listening to Expert Insight Physician Views and News with the Christ Hospital Health Network. For more information on Dr. Schilling and all of the Christ Hospital physicians, you can go to tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.