Robotic-Assisted Minimally Invasive Surgery: More accurate surgery, few complications

In 2000, the groundbreaking da Vinci® Surgical System became the first robotic-assisted surgery system approved by the FDA. Today, an estimated 8,000 of these systems are in use around the world. Surgeons have used them to perform more than 10 million minimally invasive procedures including gynecological, urological, head and neck, thoracic, colorectal, cardiac and general surgeries.

Eisenhower Health has acquired six of these industry-leading systems, considerably more than most hospitals of similar size. This enables an ever-growing number of its highly trained surgeons to give patients access to this remarkable technology that delivers faster recovery times, less pain and, with the improved visualization that the robot affords, more accurate surgery with fewer complications. Eisenhower surgeons have performed more than 13,000 cases since first acquiring the technology. 

Eisenhower has also made a significant investment in a robotic system specific to orthopedic surgeries: with Mako™ arm-assisted robots. More than 3,300 hip and knee procedures have been completed using this technology. 

Steve Choe, MD, Board Certified in General Surgery, completed a fellowship in advanced foregut surgery prior to joining Eisenhower in 2016. The foregut includes the esophagus, stomach and upper small intestine, including the duodenum and jejunum. Some of the conditions he treats surgically include esophageal and gastric cancer, hiatal hernia, gastroesophageal reflux disease (GERD), achalasia (when food can’t pass from the esophagus into the stomach), and gastroparesis (when the stomach doesn’t empty properly).

“About 80 to 90 percent of the nearly 450 surgeries I perform each year are done with the robot,” Dr. Choe says. “Even versus conventional laparoscopy (in which a fiberoptic camera and instruments are manually inserted through small incisions in the abdominal wall), robotically assisted surgery has better outcomes. And robotic outcomes are definitely better when compared to traditional open surgery, which requires larger incisions and a longer recovery.”
 
Norby Wang, MD, Board Certified in General Surgery, specializes in hernia repair, gallbladder removal, and colon and intra-abdominal surgery, and he uses the robotic system for most of his procedures as well. In fact, in April 2022, he completed his 1,000th robotic-assisted surgery — the youngest surgeon in the Coachella Valley to achieve this milestone. 

Dr. Wang says he finds the robot so beneficial because it extends the capabilities of his eyes and hands.

“It gives me a three-dimensional, high-definition view of the surgical area that’s magnified ten times,” he explains. “And the instruments move like the human hand and wrist but with no unintended movement like a twitch or tremor.

“In hernia repair, this makes for more precise mesh placements; I can place the mesh so it’s perfectly centered and flat,” he continues. “This decreases post-op pain and many of the mesh complications that have occurred in the past with conventional laparoscopic or open surgery.” 

Who’s a candidate for robotically assisted surgery?
“The vast majority of patients who require hernia repair, colon or foregut surgeries are candidates for robotic surgery,” Dr. Wang says. “The only patients who can’t be considered are those who’ve previously had multiple complex abdominal surgeries in which the abdominal cavity has so many adhesions (scar tissue) that there’s not enough room to safely work with the robot. But this is rare,” he adds. 

Notably, experience shows that obese patients — who once were not considered candidates for robotic surgery — are particularly well-suited for this minimally invasive approach because the incisions are so small there is less risk of wound infection, Dr. Wang notes.

Another advantage of minimally invasive surgery, whether performed via conventional laparoscopy or using the robot, is that many procedures can be performed on an outpatient basis so the patient can go home the same day.

“About sixty percent of the procedures I do are performed on an outpatient basis,” says Dr. Choe.

“The vast majority of what I do is outpatient as well,” adds Dr. Wang. “Most patients want to recover at home and get back to their daily lives as quickly as possible. Minimally invasive techniques make that possible.” 

What are the signs or symptoms of hernia and foregut issues that warrant a surgical solution?

“I recommend that when patients have ongoing pain or discomfort, or are inhibited from doing their regular activities, that surgery be considered,” says Dr. Wang.

GERD
Dr. Choe is particularly outspoken about considering surgery to address GERD.

“With longstanding acid reflux, a pill isn’t the answer,” he says. “GERD is a major disease in the U.S., and you don’t like to hear that patients have developed osteoporosis [from long-term use of proton pump inhibitors (PPIs), the commonly prescribed medication to treat GERD] or esophageal cancer.

“Also, hiatal hernias often get disregarded, but if you repair them when they’re smaller, you can reverse or better manage their impact,” he continues. “I’ve done close to 300 hiatal hernia reflux procedures and I feel the benefit is there for the patient. We need to change the paradigm,” he adds.

What’s on the horizon when it comes to robotically assisted surgery in general, and foregut and hernia repair surgeries specifically?

“In this field, we’re always pushing the envelope,” says Dr. Wang, “like tackling larger hernias and more complex GI surgeries that wouldn’t have been thought possible years ago. Instrumentation is also improving each year and the more data we gather, the better we can fine-tune and improve procedures and outcomes.

“Plus, as we’ve gotten more efficient as surgeons and operating room teams based on greater experience, many robotically assisted procedures are performed as fast or faster than open surgery,” he adds, dispelling an early criticism of the technology.

What aspects of their specialized work do these surgeons find most rewarding?

“For me, the fact that we can identify a problem that can be addressed with surgery, and we generally see rapid results and improvement, usually as soon as two weeks post-op,” says Dr. Wang.

Dr. Choe agrees and adds:

“Knowing you’ve made a difference in a patient’s life. I really enjoy helping patients understand that there’s a problem here that surgery can fix, and if we do this, you can live as a new you.”    

Speak with your primary care physician about concerns that may require surgical intervention. To find a physician, call 760.568.1234.