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 (osmag.net/vdd3cm) after study (osmag.net/js2ofe) 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.

MORE CHOICES? At the 2017 SAGES exhibit hall, Dr. Towfigh checked out what may soon be a new entry into the U.S. robot market.

With a robot, you're basically operating on the inside the way you would in an open procedure.

But on the outside, it's minimally invasive, with less scarring and all the other benefits of laparoscopy. That's a great combination.

That's also great news for patients and many providers, because it reduces the learning curve associated with the other minimally invasive approach and thereby potentially opens the door for surgeons who aren't comfortable doing hernias laparoscopically.

The learning curve with robots is likely to vary, depending on whether you have laparoscopic experience. I had already mastered laparoscopy, so it took me only about 10 cases before I felt comfortable using the robot without having a skilled surgeon beside me, and about 50 cases before I felt like an expert.

The ideal scenario in my mind wouldn't be to have surgeons go directly from open surgery to robotic surgery — in part because you have to get used to operating with no tactile sensation — with no laparoscopic experience in between, but it's happening across the nation, and so far, the outcomes seem to be fine. If it increases the number of minimally invasive inguinal hernias performed, that's a good thing.

Of course, there's no getting around it. Robots are expensive — typically in the $600,000 to $2 million range. But robotic procedures can actually be less expensive to perform, because many surgeons use expensive disposables like balloon spacemakers and tackers with laparoscopic hernia repairs. You don't need those disposables when you operate robotically. All you need is suture and mesh. So while the initial cost is high, you begin to pay back the hundreds to thousands or dollars per case with the money you can save on disposables.

That's the good news. The bad is that robots aren't really within reach for the average freestanding surgery center, at least for now, because surgery center reimbursements for inguinal hernia repairs still don't cover the fixed costs of the operation.

On top of the cost of the robot, the required instruments, which typically provide 10 uses each, run about $2,500, or about $250 per use. If you use 2 or 3 instruments per case, and add in $300 to $500 for mesh, you're likely looking at $1,200 or $1,300 of pure cost per case, not including the cost of the robot. That's close to what Medicare pays a surgery center for an inguinal hernia. And most in-network insurance companies reimburse at about the same rate.

To me, the best of both worlds is to be proficient at both laparoscopic hernia repair and robotic hernia repair. In my practice, I usually don't offer robotic repair with mesh if it's the patient's first time with a hernia repair. I still prefer laparoscopic surgery. It's fast, and I can do it in an outpatient center, whereas, for the reasons above, I have to take robotic cases to the hospital, which is a little more cumbersome. But if a first-time patient has a really large inguinal hernia, or a large direct inguinal hernia, I may opt for the robot. I also prefer the robot for revisional surgery when a laparoscopic repair has failed, or when there's a complication with a laparoscopically placed mesh.

I presented data at the 2015 Society of Gastrointestinal and Endoscopic Surgeons (SAGES) showing that outcomes are better with the robotic technique than the laparoscopic technique for mesh removal and revision surgery (osmag.net/uykvh4). The visualization is much better, so you can remove the mesh with higher precision and you're less likely to injure any of the multiple significant vessels in the area. In all, I've now done more than 150 cases with the robot, and have had good outcomes with all of them.

PAYBACK Robotic hernia repairs can be less expensive to perform than laparoscopic repairs, because they require fewer disposables.

Resisting change
Despite their advantages, it's going to be a while before we see robots in every hospital and surgery center. Not only are they expensive, but there are still plenty of non-believers. The same was true when laparoscopy first came onto the scene, of course. It's hard to believe, but surgeons were thrown out of hospitals and had their privileges revoked because they were dabbling in laparoscopy. Minimally invasive gallbladder removal — which is now done in more than 90% of cases — was considered a really big deal.

We're going through a similar situation with the robot. Most people who do just plain laparoscopic inguinal hernias don't see the benefit. They say they can do it faster and with less hassle setting up the equipment, and still achieve the same outcomes. That's true in a lot of cases, but as noted, for the many who haven't been exposed to, or mastered, the laparoscopic approach, the robot provides an opportunity for significantly better outcomes.

And incidentally, if you have a dedicated team that does only robots and if you stack your cases back to back and do them in one day, you can get to the point where you're just as efficient, maybe even more efficient, with the robot as without it.

Meanwhile, the robots are getting better and better. They're more precise than they used to be, they're more user friendly, they're easier to dock, they have lighter cameras and they have better visualization.

What they're not getting, unfortunately, is less expensive, at least so far. But indications are that the current go-to robot may soon have some competition in the U.S. If so, it will be interesting to see what sort of effect that will have.

Not Star Wars
I've never had a patient ask to have surgery done by the robot. When I offer them robotic surgery, they're more likely to say, But I want you to do it, picturing, I assume, R2D2 or C3PO hovering over the operating table, scalpel in mechanical claw. But they're OK with it when I explain that I'll be the one controlling the robot. And they're thrilled when the robot lets me minimize their pain and scarring and more quickly get them back to their everyday lives. OSM