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The Medical City pioneers robotic hernia surgery in PH

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Hernia surgery currently takes on many forms and premier health institution The Medical City (TMC) has proven that a robotic approach can achieve the same treatment results but with minimal trauma to the abdominal wall leading to quicker recovery.

On January 12, 2017, a team of surgeons performed the country’s first hernia and diastasis recti surgery at TMC.

The patient, a 70-year-old male, was able to ambulate the next day with minimal pain and discomfort and was discharged after merely 36 hours.

Robotic hernia surgery / CREDIT: algsn.com / Manila Bulletin

Robotic hernia surgery / CREDIT: algsn.com / Manila Bulletin

A hernia is a bulge that has formed when the internal organs of the body push through a weak spot in the abdominal wall.

Diastasis recti refers to the gap that may exist in between both sides of the muscle called the rectus abdominis. It looks like a ridge, running from the bottom of the breastbone to the belly button in the middle of the abdomen.

Aside from the unsightly bulge during straining, common complaints include low back discomfort, constipation and in extreme cases, the condition causes a tear, allowing abdominal organs to protrude through the tissue which then results into a hernia.

“Hernia surgery can be done using open surgery or minimally invasive surgery which is either laparoscopic or robotic. I presented these three options to the patient and since he wanted a procedure that is less painful and that would allow him to recover faster, he opted to undergo robotic surgery,” says Dr. Vincent Ocampo, head, General Surgery Section at TMC.

Dr. Ocampo was assisted by fellow surgeons Drs. Edwin Bernardo and Eulogio Coz during the procedure which was performed using the da Vinci Si Surgical System. The three are part of an elite group of surgeons in the Philippines fully trained to perform robotic surgery.

On January 27, Dr. Ocampo and his team performed their second hernia robotic procedure on a colon cancer survivor, a 70-year-old woman who had incisional hernia. An incisional hernia, also called ventral hernia, is a bulge or protrusion that occurs near or directly along a prior surgical incision.

Though both cases are considered hernias, an umbilical hernia is usually a congenital defect that is more common in children with a tendency to close by age one or two, sometimes longer. If the type of defect fails to close beyond age four or appears in adulthood, these patients will need surgical repair in order to avoid complications of incarceration or strangulation of organs passing through the defect. In contrast, an incisional hernia is an acquired defect from a previous surgery whose causes are multi-factorial.

The robotic system consists of a surgeon’s console or work station, a patient-side cart with four interactive robotic arms, a high-performance vision system (3D camera) and miniaturized surgical instruments.

While performing the surgical procedure, Dr. Ocampo was seated at the surgeon console while Drs. Bernardo and Coz were at the patient-side cart.

During a robotic surgery, the surgeon makes two to three small incisions away from the bulge and inserts a laparoscope which is a fiber-optic tube with a light source and camera attached to it, and other special miniaturized instruments through the incisions. The robotic arms hold the laparoscope and these instruments in place. These instruments help the surgeon perform the procedure with precision and control.

“Compared to the instruments used in laparoscopic procedure, the wrist parts of the robot arms are flexible and easily maneuverable mimicking the wrist movement of the surgeon at the console. This makes dissection and suturing in the ceiling of the abdominal wall, where the hernias are, easier to perform,” adds Dr. Ocampo.

Since the robotic arms are wristed, the mesh placed is easily sewn into the defect, avoiding the use of transfascial sutures or tuckers. This produces an even lesser post-operative pain compared to the traditional open  as well as laparoscopic hernia surgery.

The advantages of robotic surgeries are manifold. Compared to open surgeries, it only makes tiny incisions on the patient’s body where holes are placed, as in laparoscopic procedures. Through these holes, the arms of the machine are inserted to perform the needed operation within the patient’s body. The doctor operates the robot through a console that allows him to see the inside of the patient in 3D view without having to open him up. Since the patient has smaller incisions, the chances of infection from external causes and post-operative adhesions are minimized.

“It is less traumatic, less bloody, causes less pain post-operatively, and promotes faster recovery,” says Dr. Julius Cajucom, head of the Robotics Surgery Program of The Medical City.

Dr. Ocampo also cited that robotic-assisted surgery may offer the advantage of lower rate of complications and lower rate of conversion to open surgery particularly for complex cases.

Just like the two recent robotic hernia procedures, the first robotic cystectomy and radical prostatectomy in the Philippines were performed at TMC in 2014 and 2010 respectively. A radical cystectomy is a surgical procedure to treat invasive cancer of the urinary bladder while a radical prostatectomy is an operation done to remove the entire prostate due to cancer.

Robotic-assisted surgery is presently available at TMC for urologic, colorectal, gynecological, head and neck, trans-oral, thoracic, vascular, hernia and other general surgical procedures.

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