Are Robots Right for Hernia Repair?

Robotic Assistance

By: Shirin Towfigh

Published: 1/15/2019

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Robots are a good option for complex cases - and for surgeons inexperienced with laparoscopic repair.


FASCIA-NISTA Dr. Towfigh at the controls of the da Vinci robot, which she usually reserves for complex hernia cases.   |  Cedars-Sinai Medical Center

When you turn the page, you'll see a crease across my forehead and a smile across my face. That's how you can tell I just did a robotic-assisted hernia case. The crease is from leaning my forehead against the padded console as I look into the telescopes. The smile? That's from the fun of playing with joysticks and my back's way of thanking me for doing surgery while seated on a stool.

I've been fascinated with robotic hernias ever since I saw the video a few years ago of Arizona surgeon Conrad Ballecer, MD, using a robot to do a very complicated hernia repair. There he was, deftly transforming a no-doubt-about-it open procedure into a minimally invasive one, sparing his patient a major surgery, a few nights in the hospital, and a long and painful recovery. As a surgeon who specializes in complex hernias, I wanted to be able to offer this to my patients, many of whom had prior hernia repairs and now suffer complications with chronic pain.

For me, the robot really comes in handy (pun intended) for complex cases like transversus abdominis release for large or recurrent ventral incisional hernias. I can minimally invasively handle complicated procedures that I previously performed open. That's because the robot's arms let you operate in the abdomen similarly to how you would operate during an open procedure.

Easy to master

But here's the thing: The laparoscopic approach is sufficient for most hernias. Yes, for bread-and-butter hernia cases like inguinal hernia or abdominal wall hernias, you don't need an assist from the robot. In fact, a study of mine has been unable to show that the robot offers a benefit over laparoscopic options in most cases. We are currently looking at outcomes from the robot when removing mesh from the groin: Are there fewer injuries and less post-op pain? The study results are pending. We'll release the hard data soon. Regardless, I enjoy using the robot. It's fun, almost like playing a video game.

But in an interesting twist, robotics let many surgeons offer minimally invasive surgery despite having little or no experience with laparoscopic hernia repair, which is difficult to master. You need up to 500 laparoscopic inguinal hernia cases under your belt before you can get consistently good outcomes. With a robot, you can become proficient in as few as 50. We have surgeons in our hospital who conceptually know how to do laparoscopic inguinal hernia, but simply never chose to offer it because the robot is so much easier to master.

The arms of a robot can work at deeper lengths and sharper angles than the straight sticks of a laparoscope. For that reason, you'll notice that the size and location of the scars differ in a robotics case as compared to a laparoscopic one. The robot's scars are farther away, farther apart and larger (8mm) than a laparoscope's (5mm).

Economic benefits

BATTLE SCARS See the forehead crease and the smile? Yes, Dr. Towfigh just completed a robotics case.   |  Beverly Hills Hernia Center

In the absence of competition, robots remain a luxury that most outpatient surgery centers and many hospitals can't afford. The newest models cost around $2 million to buy and around $100,000 per year to maintain. But there are undeniable economic benefits to robotic hernias. Laparoscopy requires thousands of dollars of supplies — disposable instruments, a tacker fixation device, space makers and, of course, expensive mesh. With robotics, you need none of those things.

A barrier mesh used for laparoscopic ventral hernia repair is around $2,500-plus. You're paying for the extra coating so the bowel doesn't adhere onto the mesh. With robotics, you can place a less sophisticated mesh one layer deeper so that it will not come in contact with the intestine. A typical flat mesh for an abdominal hernia is around $500. From an institutional standpoint, robotics can reduce a hospital stay from 5 days to 1 day.

Robotics also make mesh-free repair a viable alternative. For the past 2 years, I have enrolled a number of patients to undergo robotic-assisted non-mesh inguinal hernia repair. Hopefully, more surgeons will learn this technique as an alternative and minimally invasive option for open inguinal hernia repair and without the use of mesh.

The advent of robotics has been transformative. But similar to laparoscopy, robotic surgery is not necessarily the best option for every patient. Also, similar to laparoscopic surgery, it is best performed by surgeons with a lot of experience, as it has its own risks. OSM

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