Robotics and General Surgery

"With the robot, we can look at the blood supply, nerves and other structures in exquisite detail," says Iyoob Ilyas, MD
Iyoob Ilyas, MD, MS, MRCS, FACS, FASCRS, fellowship-trained and Board Certified in General Surgery and Colon/Rectal Surgery, joined Eisenhower Health in February 2021, rounding out a team of seven general surgeons — the largest group of its kind in the desert. During his 22 years of training and practice, he has seen remarkable changes in his specialty as it has evolved from traditional open surgery to laparoscopic techniques to robotically-assisted procedures. He speaks about the positive impact of this evolution on patients as well as surgeons, and how Eisenhower is committed to making these advances available to the desert community.

“During the first third of my career, I did only open procedures,” he relates. “In the next third, I did many laparoscopic procedures. And for the past six years, I’ve been doing mostly robotically-assisted surgery. Having seen all sides, I can appreciate just how much robotics offers to patients and to general surgery as a whole.”

Dr. Ilyas believes that while an operation is essentially the same regardless of how the surgeon performs it, the robotically-assisted approach confers clear advantages.

“If you need to remove a gallbladder or a section of the colon, you go in, remove it and sew it up,” he says. “The open surgical approach has long been the standard of care and it works.

“But it has issues compared to less-invasive approaches,” he continues. “There is more pain with open surgery, a longer recovery time and a bigger scar from a bigger incision. There may be adhesions and scar tissue that form postoperatively and increase the chances of developing an incisional hernia months or years after surgery. And if the patient needs another operation down the road, we have to first remove that scar tissue.

“In other words, if we make a large cut, we leave traces of being there,” he adds.

Laparoscopic techniques, which became popular in the 1990s, have offered a less invasive option with much smaller incisions, less scarring and pain, and improved recovery time. But this approach also has limitations.

“The surgeon’s field of vision and depth perception are restricted when using a laparoscope, and our shoulders, wrist and elbows have only so much range of motion,” says Dr. Ilyas. “As a result, a portion of these procedures end up being converted to open surgery in the midst of an operation — and the patient misses out on the advantages of the minimally invasive approach.”

Robotically-assisted surgery, however, not only overcomes the limitations of open and laparoscopic surgery but also delivers a significant upside for both patient and surgeon. [MORE]

“We make tiny holes and can get in and out, leaving less aftermath,” he says. “This translates into less pain, less need for narcotic medication, a faster recovery, fewer short- and long-term complication rates, and patients can get back to regular life more quickly.

“Plus, the surgeon can see better with the robot than with the naked eye or the traditional laparoscope,” Dr. Ilyas continues, noting that the da Vinci™ system creates a high-definition 3D image (conventional laparoscopy is limited to two-dimensional vision). In addition, the image is magnified 10 to 15 times, enabling the surgeon to be significantly more precise about dissecting critical structures by fractions of a millimeter. 

“It’s like watching National Geographic on a 4K-resolution television,” he says. “You can see a butterfly extremely close up, something you can’t do in real life. Similarly, with the robot we can look at the blood supply, nerves and other structures in exquisite detail.”

Further, during standard laparoscopic surgery, the surgeon must stand in sometimes awkward positions for several hours, which can be tiring. With the surgical robot, however, the surgeon sits at a console near the operating table from which he or she controls the robotic arms. These improved ergonomics result in less fatigue and strain for the surgeon.

Yet another distinct advantage of using the surgical robot is that the instruments at the end of the robotic arm rotate and angulate in multiple directions, imitating normal wrist and elbow motion (in standard laparoscopy, the instrument tips are fixed). In fact, the robot’s range of motion is significantly better than human hands, elbows and shoulders. This enables surgeons to operate in tight spaces that they otherwise could only access through open surgery. 

Ultimately, Dr. Ilyas says, “the overall quality of an operation improves and patient outcomes are as good as or better than with open surgery.”  

The key to achieving these consistently good outcomes is training and experience.

“Robotic-assisted surgery is more complex and requires a more complex learning process, so training matters,” he says, noting that his colon/rectal surgery fellowship was heavily robotics oriented. In fact, he was one of the first group of colon and rectal robotics-trained surgeons in the United States. 

Dr. Ilyas’s advanced training is evident in the range of procedures he is able to perform robotically, from routine gallbladder and appendix removal to complicated bowel resections, gastrointestinal tract tumor removal, and ostomy surgery. And his conversion rate — the percentage of procedures that must convert to an open approach mid-operation — is extremely low at two to three percent, a testament to his proficiency with the da Vinci system.

“Because we can visualize everything so much better, there’s much less need to convert to open surgery,” he says. “And while it generally takes a little longer to do robotic surgery versus an open procedure, patients recover better. I’m able to discharge many patients in just one day, something I could never do after an open operation.”

He also says that there is virtually no general surgery procedure that can’t be performed robotically. “Most surgeries can be done; it’s a matter of whether the surgeon has the training to do it,” he adds.

Eisenhower purchased its first da Vinci robotic surgery system in 2008 — the first acquisition of the leading-edge technology by any hospital in Riverside County. Today, the organization has three of the most advanced versions of the da Vinci system. Despite the pandemic and the restrictions it has imposed on elective surgery, Eisenhower surgeons across multiple specialties completed nearly 1,600 robotically-assisted operations this past year alone. And volume continues to grow, with an estimated 2,000 procedures expected to be performed in 2022.

What’s more, Eisenhower has become an observation center for Intuitive, the company that manufactures the da Vinci system. An early adopter and high-volume center, Eisenhower surgeons have, to date, performed more than 8,000 robotic procedures, more than twice that of any other hospital in the Coachella Valley. As a result, the medical center has an exceptional track record of safe outcomes and serves as a role model for other hospitals around the world seeking to learn best practices for a robotics surgery program.

Eisenhower’s continued investment in this advanced technology has enabled the organization to recruit top-notch surgeons like Dr. Ilyas. 

“We may be skilled surgeons, but if the institution doesn’t embrace new technology and techniques, it won’t succeed,” Dr. Ilyas says. “Eisenhower has assembled an excellent group of surgeons and invested in the most advanced technology. This translates into a successful robotic surgery program.”

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