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Archive August 2017 XVIII, No. 8

The Case for Robotic Hernia

They're a minimally invasive opportunity for the vast majority of surgeons who haven't had a chance to master laparoscopic hernia repair.

Shirin Towfigh

Shirin Towfigh, MD, FACS


Dr. Towfigh ROBOT ADVOCATE Dr. Towfigh has demonstrated that for mesh removal and revisional hernia surgery, robotic surgery is more effective than laparoscopic surgery.

Minimally invasive surgery has become standard for a steadily increasing number of procedures. But for inguinal hernia repairs, the minimally invasive approach is still the exception. Robots have the potential to help bridge that gap.

Laparoscopic hernia repairs, when performed by surgeons who have the requisite skill and experience, provide shorter recovery times, less chronic pain, less scarring, less chance of infection, and earlier returns to work and normal activities. But for residents, laparoscopic training for hernia repair tends to be minimal, at best, and admittedly, the learning curve is extremely high.

That's because a lot of things can go wrong if surgeons aren't totally comfortable with the complex anatomy of the area. They have to watch out for the iliohypogastric, ilioinguinal and genitofemoral nerves. The spermatic cord and its associated structures are vulnerable. The bladder and other organs are right nearby. If they use tacks, the tacker can cause injuries. Even if they do everything else right, if the dissection isn't wide enough, there's likely to be a recurrence. Same thing if the mesh the surgeon uses is too small.

It's no wonder that some say it takes about 250 laparoscopic inguinal hernia repairs to ease the anxiety and become truly comfortable with the procedure. Others say 250 is actually optimistic, that complications don't really begin to plateau at an acceptable level until you have about 500 laparoscopic hernias under your belt (so to speak).

So it's also no wonder that most general surgeons continue to use the open approach, despite study ( after study ( showing that patients who have laparoscopic repairs are less restricted and less likely to experience chronic pain, even as long as 5 years after the procedure.

Open and closed
The beauty of robotics is that it gives you the best of both worlds. From a technical standpoint, it's much easier to perform most operations robotically than laparoscopically. The way your hands move and how you hold the needles is much more intuitive, much more like a replication of an open surgery.

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