St. Joseph’s leads innovative hernia repair using da Vinci Xi surgical robot

His fingertips flit across the controls with a careful, deliberate touch while his right foot lightly taps two pedals on the floor. Like an organist at his console, each movement is so practiced as to seem effortless.  

Surgeon Dr. Ahmad Elnahas agrees there are parallels between musicianship and robotic surgery. “Everything has to be in harmony. Fingers, feet, focus – they all have to work together to make the surgery successful.”

This year, Elnahas, a specialist in minimally invasive surgery, pioneered the use of using da Vinci Xi surgical robot at St. Joseph’s Health Care London (St. Joseph’s) to perform hernia repairs and he has done about 20 so far.  

The innovation makes St. Joseph’s a pioneer in this procedure among Canadian ambulatory hospitals and provides an innovative, effective use for a surgical robot that’s more often used here to aid in urology surgery.

“We believe St. Joseph’s is one of Canada’s early-adopter hospitals to use this procedure for hernia repair,” Elnahas says, noting that patients with complex hernias have experienced less pain, less scarring and faster recovery time than in conventional or laparoscopic hernia surgery, he says.

Conventional, open surgery usually takes place with the patient under local, regional or general anesthesia.

In the laparoscopic option, the abdominal area is illuminated with one thin camera-equipped tool through one small incision, while the surgeon operates another long inflexible surgical tool to repair the tissue through a different small hole.

But the da Vinci Xi surgical system, manufactured by Intuitive Surgical, enables even more precision since it offers a three-dimensional look at the patient’s tissue and better control of instruments.

When the robot’s command console is docked to a four-armed patient-side cart with surgical instruments, Elnahas uses his pincer-grasp and foot pedals to direct the machine on where and how to cut, move, stitch and cauterize.

While the robot does that work, Elnahas is in control of the procedure at all times.

He received extensive training including hours of simulation and hands-on instruction, from experts in the field.

“The transition felt easier for me because I was taking the principles I knew from laparoscopic surgery and applying it to robotic surgery,” says Elnahas, who performs this surgery at St. Joseph’s but ordinarily works from London Health Sciences Centre.

Improved patient experience

The community donated more than $1.25 million through the St. Joseph’s Health Care Foundation towards the purchase of this da Vinci Xi robot system (and, almost 20 years earlier, donors fully funded the da Vinci Si system that preceded this version).

The da Vinci Xi is generally used at St. Joseph’s in urology, in prostate, kidney and bladder surgeries.

Its use in hernia repair not yet considered standard of care in Canada, although his team is preparing to present a paper at an upcoming conference, comparing results of robotic and laparoscopic hernia procedures.  

Elna has found that patients undergoing robotic surgery benefit from similar operative times to laparoscopic hernia repair, have less post-operative pain and faster return to work; particularly when compared with patients having open hernia repair surgery.  

Robotic tools also allow the surgeon greater movement of their instruments in certain areas of the body, or in patients with some body shapes where laparoscopic tools are challenging and might otherwise cause the patient to have to undergo a standard open hernia repair.

Having expertise in robotic hernia surgery in London allows surgeons here to lead the country in training surgical residents in robotic surgery and in building specialized skills for the next generation of surgeons.  

It allows surgeons to tailor the type of surgery to what is best for each individual patient: whether conventional open surgery, laparoscopic surgery or robotic surgery. No single approach is best for all patients.  

For example, people who don’t do well with general anesthesia may be better suited to conventional open surgery under local or regional anesthesia, he says.

“As an ambulatory-care centre and a teaching hospital with a state-of-the art da Vinci surgical robot, St. Joseph’s is the ideal place for this hernia procedure,” he says.

Expanding use of an important hospital resource

Beyond its direct benefit in patient care, the procedure is a stewardly use of limited hospital resources: it fills in gaps when the da Vinci isn’t otherwise being used for urology procedures such as prostate removals.

“It’s exciting to see St. Joseph’s leading the country in robotic surgery being performed in ambulatory hospitals,” says Dr. Muriel Brackstone, a St. Joseph’s surgeon and Lawson Research Institute Scientist, who leads the initiative with Elnahas.  

“While currently there is very limited access to the robot for surgeons to perform these procedures in London, we hope this will increase in the future to allow surgeons the ability to offer all types of surgical access and make those decisions based on which approach is best for each individual patient,” she says.

“This expertise builds on St. Joseph’s leadership in ambulatory care and as an institution known for its innovation and clinical excellence,” Brackstone adds.

“Robotically assisted surgery is gaining traction across Canada and eventually will become just another skill set taught in Canadian medical schools, as it is at Western’s Schulich School of Medicine & Dentistry,” says Elnahas, who is also an associate professor of general surgery at Schulich.

“If we want to be leaders in the field, we have to continue to grow programs and procedures like these,” Elnahas says.