WILMINGTON "“ As Dr. Peter Santoro of ChristianaCare prepares for surgery to repair a patient's hernia, he turns on some country music, discusses the procedure with his nurses and anesthetist, and gets seated nearly a dozen feet from the operating table to start a procedure that could last as long as five hours.

[caption id="attachment_171157" align="alignright" width="555"] Dr. Pete Santoro, director of robotic surgery at ChristianaCare, uses this $2.4 million robot to complete complicated hernia surgeries. | Photo by Jacob Owens[/caption]

His hands are still at the patient's side, however, in the form of a $2.4 million Intuitive da Vinci XI surgical robot, which he manipulates using a control center with a virtual-reality-goggles-like viewfinder and robotic hand grips.

Santoro, a Delaware native, is one of the nation's leading robotic surgeons when it comes to hernias, an injury that occurs when an organ pushes through an opening in the muscle or tissue that holds it in place, most commonly the small intestine or colon.

He's among the very few surgeons in the state or Philadelphia area using robotic technology to do what's known as transversus abdominis release (TAR) procedures, the most difficult and technically challenging type of surgery for complex ventral hernias. Santoro has become a proponent for the technology, presenting to conferences of the Society for American Gastrointestinal Endoscopic Surgeons, America's Hernia Society, and the Clinical Robotic Surgery Association in the last two years and helping train other surgeons interested in the tech.

[caption id="attachment_171158" align="alignleft" width="359"] The robot's tools are just millimeters long, and allow for less invasive surgeries. | Photo by Jacob Owens[/caption]

As the director of robotic surgery at ChristianaCare, he advocates for the technology because it has shown an impressive ability to cut down on patient's stays in hospitals and their use of narcotics in post-operative care. Peer-reviewed studies from 2017 and 2018 in the journal "Surgical Endoscopy" on the comparison of robotic and traditional TAR surgeries found that robotic procedures resulted in 60% less blood loss, no complications and five fewer days in the hospital.

Dr. Gerald Fulda, chairman of ChristianaCare's Department of Surgery, said that Santoro has been a valuable addition to the hospital system, especially as ChristianaCare pursues designation as a "Center of Excellence" for hernia care.

"Peter really brought the national recognition, technical skills and a large social media footprint in the hernia world to us," Fulda said. "One of the advantages to having a local expert is that knowledge will diffuse to others, and our surgeons will be able to advance their own practices from his leadership while providing positive patient outcomes. We've already seen growing interest in the use of robotics here."

Although Santoro has found success with robotics, it wasn't always a path that he imagined he would take.

"During medical school, I went in thinking I was going to do neurosurgery," he said, noting he studied biology and psychology as an undergrad. "I spent a summer after my first year of medical school with one of the neurosurgeons at Christiana, and I found that I liked some of it and didn't like some of it."

In search of what to do, Santoro rotated among hospitals doing general surgery, where he completed a lot of laparoscopic surgeries, where small incisions are made to insert a fiberoptic camera and tools to complete minimally invasive surgeries.

"Laparoscopic surgery has become the standard of care in a lot of different areas," he said.

[caption id="attachment_171156" align="alignright" width="468"] Dr. Santoro demonstrates the controls for the Intuitive da Vinci XI surgical robot. | Photo by Jacob Owens[/caption]

But the procedure also has its challenges, such as the need for an attendant to hold the camera for a surgeon to see the work. The long metal tools also have limited ranges of motion when working in just a few inches of space inside a patient.

"That's where the robot is really a game changer," he said, noting the robot's appendages have seven degrees of motion. "They mimic the motion of the human wrist and more."

Surgeons at ChristianaCare had been using robotics in inguinal hernias, where the intestine bulges near the groin, when Santoro began investigating its use. Robotic surgery in general has only come into use in the past decade, with hernia surgeries utilizing it in the last five or six years, Santoro said.

"My first thought (in seeing robotic surgery) was looking at the camera and the picture on the robot was very different and better than laparoscopy," he recalled. "The fact that the robot arm has an attached camera is much better than having someone at bedside holding one, who constantly has to be repositioned and rested."

"The ability to put the camera where you want it, leave it there and have a still picture is invaluable," he added.

About five years ago, Santoro sought out a robotic surgery training program to hone his skills and began doing simple hernia procedures at ChristianaCare, which he said has been supportive of the burgeoning technology. He began doing the more complex ventral hernia cases in May 2017 and to date he's completed 31 cases.

"The hospital has always been very supportive in getting us the things we need and doing appropriate procedures. Certainly, they've seen the benefits in terms of patient outcomes," he said.

Historically, patients after ventral hernia surgeries would stay in the hospital for seven or more days. With robotics, that same operation with the same techniques for abdominal wall reconstruction can be done minimally invasively, and patients typically stay in the hospital for a day afterward, Santoro said.

"That's a huge cost savings, because every day in the hospital costs thousands of dollars in care," he said, noting robotic laparoscopy also results in less blood loss, fewer post-operative narcotic prescriptions and fewer accompanying medical issues.

Santoro said that because of those positive outcomes, he approaches each patient with the procedure in mind. They, almost universally, don't have a question about it, because at this point robotic surgery is mainstream, he said.

"Everybody has heard about it or seen it on "˜Grey's Anatomy.' Robotics in general is more commonplace in our lives," he said.

Patients also like the dramatically smaller scars "“ six 8-millimeter incisions on the sides with the robot versus inches long scars on the stomach for traditional ventral hernia surgeries. The cost of robotic surgery to insurance companies is no different than other laparoscopic surgeries, Santoro noted.

"To the patient, it doesn't cost any more money to have robotic surgery, but it allows them all of the benefits of the technology," he said. 

By Jacob Owens
DBT Associate Editor

Editor's Note: This story originally inaccurately reported that Dr. Santoro was the only surgeon in Delaware or the Philadelphia region to complete ventral hernia repairs using robotics. A subsequent correction stated that he was the only one doing abdominal wall reconstruction for complex ventral hernias. We now know of at least one other surgeon in Delaware, Dr. Michael Conway, who has completed the TAR procedure robotically, and we've updated the story to reflect that info. We regret the errors.