Episode 104: How Robotics Has Advanced Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Hi everyone, it’s Dr. Towfigh. Hope you’re all well. I’m joining you from Beverly Hills at the Beverly Hills Hernia Center. I am your hernia and laparoscopic surgery specialist. You can find me on Twitter and Instagram at hernia doc. And many of you are joining me currently on Facebook at Dr. Towfigh as of Facebook Live. As always, this session and all previous sessions are available to you on my YouTube channel, and today is going to be very fun and exciting because we have very lively and talented Dr. Rockson Liu. Dr. Liu is a robotic hernia surgery specialist. He is a special interest in hernias as I do, and he practices out of Oakland, California, so northern California to my southern California. You can follow him on Facebook and Instagram at Rockson Liu. So, hi Rockson. How are you?

Speaker 2 (00:58):

Very good. I’m so excited. Shirin, thanks for the invite.

Speaker 1 (01:02):

Oh, you’re welcome. It’s my pleasure. First of all, I know you. I just grabbed your right out of office hours, so thank you for making the time. I’m always very grateful with my guests. You’re basically donate your time. So welcome Dr. Liu. So you’ve been in northern California for how long?

Speaker 2 (01:26):

17 years actually. Yeah. Yeah. I grew up in Southern California, but I decided to, well, my wife and I decided to move to Northern California because southern California was just too smoggy, too crowded, too it, and so we moved to the Bay Area and the Bay Area has become southern California the same every summer we get a ton of smoke from all the wildfire fires. Oh, traffic’s just as bad. So cow now, so

Speaker 1 (01:57):

I didn’t know you were from Southern California. Which part?

Speaker 2 (02:00):

Monterey Park.

Speaker 1 (02:01):

Oh, no kidding.

Speaker 2 (02:02):

Yeah. Yeah. Just so Los Angeles. Yeah, Los. Yeah. Yeah. That’s pretty amazing. I went to UCLA for undergrad, so I know your very well. Yeah,

Speaker 1 (02:12):

I’m a Bruin too.

Speaker 2 (02:13):

Oh, you

Speaker 1 (02:13):

Are? I’m much older than you. I graduated, how did I not know that? I’m class of 92.

Speaker 2 (02:18):

I too. We’re very close.

Speaker 1 (02:22):

Wow, that’s pretty amazing. See I to learn new things. I love your stories. And then so where’d you go after UCLA?

Speaker 2 (02:29):

I went to the Ohio State for medical school. Yes. So I was there for four years and then I went to Virginia Mason up in Seattle for my general surgery residency for five years. And then I went back to Ohio to the Cleveland Clinic for my MIS fellowship. And then after fellowship I moved to Northern California in 2005.

Speaker 1 (02:50):

That’s great. And then what got you into hernia surgery?

Speaker 2 (02:55):

So I always wanted to be a minimal invasive surgeon, so that’s why I did my MIS fellowship. And so when I joined Kaiser in 2005, I was kind of hired as the MIS complex surgery surgeon. And so I did everything. I did colectomies, hernias, adrenals, Foregut surgery, anything could do in the abdomen. Basically I did it right. And so I did a lot of, back then, back in 2005, it was all laparoscopic IPOMs, Intraperitoneal Onlay Mesh, but the Mesh in there, tacked it up, trans fascials and tackers. And so I did a lot of that and because I was the surgeon that took all the complex cases and did it midway, basically I got a lot of referrals from other surgeons for bigger hernias that they didn’t necessarily necessarily wanted to tackle open because of the morbidity of open surgery. Right. The wound issues, the potential for Mesh infections, long length of stay, things like that. So I got a lot of those patients and a lot of those patients aren’t necessarily good for laparoscopic surgery either.

Speaker 1 (04:13):


Speaker 2 (04:14):

So I did a lot of those open and got into open abdominal wall reconstruction and things like that. So that surgery has been in my history for a long time. And then when the robot came along, that’s when I really, really became passionate about hernia surgery because now really

Speaker 1 (04:34):

Interesting. Yeah.

Speaker 2 (04:36):

Now I had a better tool for performing surgeries the way I had always wanted to. But

Speaker 1 (04:43):

Yeah, so I think a lot of people don’t understand the kind of evolution that we’ve been through. So you’re absolutely right. When laparoscopic surgery came about, it was usually gynecology or gallbladder surgery was the first one. In general surgery where we had laparoscopic surgery. When we started doing hernia surgery, we had to reinvent how we did hernia surgery because it was dissimilar, not similar to how we did open hernia surgery. Correct. So you had the open surgery technique and the laparoscopic was completely different and we had to invent new instruments and invent new attackers because we were suturing, we had to invent new ways of putting in Mesh. Even the Mesh design was changed and actually we became more dependent on Mesh because there’s not a lot of suturing going on. So laparoscopic hernia repair pretty much was like a hundred percent Mesh based, and we did things we weren’t doing before.

Speaker 1 (05:42):

In retrospect, if you look back at it, we were doing things differently than the bonafide kind of understanding of hernia surgery. And then when robotics came, it’s a da Vinci robot currently. Maybe there’ll be new ones coming through, maybe in the next year or two, we don’t know. But this whole trajectory with robotic surgery, in my view, the way I always explain it, maybe you do as well, is it takes us back to how we do open surgery again, except now you have the additional technology and visualization of the robot, but the surgical technique, the grabbing and suturing and so on, is much more similar to the traditional open surgery. Which is why I think all of us were like, oh my god, hernias surgeries like, well, we can do this now. And there’s so much more you can do robotically than you can laparoscopically.

Speaker 2 (06:43):

Yeah, I completely agree. When I talked to the average person about the differences between open lap and robotic, I tried to explain that when we started doing lap ventral hernias, incision hernias, we wanted to do that because we had so much morbidity from open surgery. When you cut somebody open with a big incision, big incision, it hurts. They had to stay in the hospital for a long time with big incisional hernias. a lot of times the skin flap can die. You can get necrosis and then wound infection problems, wound infection. When you got wound infections, sometimes that can get down to the Mesh and you get Mesh infection. So there can be a lot of morbidity and when you have a lot of pain from an open operation, you don’t move as well. So you can get pneumonias, DBTs, things like that. And so that’s why we wanted to do things laparoscopically because we avoided those incisions and patients went home sooner. But we didn’t fix the hernia the same way we fixed it open, we stopped closing the defect, we stopped placing the Mesh outside the abdominal cavity. And so it’s too hard. It’s too hard to do. So we had

Speaker 1 (08:04):

A lot of limitations.

Speaker 2 (08:05):

Correct. So we had to compromise our repair so that patients could get home earlier and have less morbidity. Now with robotics, we’re marrying the best of both worlds. We have small incision, so they don’t have the morbidity of a big open incision. They can go home just as quickly as laparoscopic surgery. But we’re following all the principles we believed in when we did open surgery. Right. Yeah. We close the defect, we get that Mesh outside the abdominal cavity. And so that’s why I love robotic surgery. It’s just, yeah, let’s me do miniaturized open surgery.

Speaker 1 (08:40):

It is. And the other positive note is that for surgeons that couldn’t make that leap from open to laparoscopic surgery because the technique and the principles were all so different, the robotic has opened the door to those surgeons offering a minimally invasive option, whereas before they weren’t offering it. Right. Yeah. I feel like that’s a new cadre of surgeons that have been lifted up offering minimally invasive surgery, not just for hernias, but other things too. Because the robotic technique is so similar to open traditional surgery than the laparoscopic technique.

Speaker 2 (09:17):

Yeah, definitely. For pretty much every disease process, we treat more surgeries are able to offer minimally invasive surgery now.

Speaker 1 (09:25):

Yeah. Pretty much. Pretty cool. Yeah. See, so I used to be antirobotic like technology. I was like, why do we need this $2 million machine to do what I’m perfectly capable of doing laparoscopically? And I felt like, I don’t know, it was almost like a ego thing. I don’t need the robot. I can do this laparoscopically. Only people that can’t operate laparoscopically need the robot. Right. It’s like training wheels. And then I started seeing Conrad’s videos on doing these huge hernias, these component separation, the robotic tar robotic cloud. I was like, wait a minute, I can’t do that laparoscopically. Correct. But now that’s being done robotically. So finally I saw something that was a value added, something that I can do robotically, that I cannot do laparoscopically. And that’s what made it for me. That’s where I became a believer. What was it for you?

Speaker 2 (10:34):

A exactly the same reason. No way. It’s funny how so much alike. Yeah. It was. When I give lectures and I talk about my history, I have a picture of Conrad on my slide because it was robotar video that got me excited about robotics. And prior to that, the intuitive rep would come to my operating room and say, Hey, Rockson, you know, think you could do this complex hernia surgery better or this complex for get surgery. I’m like, no, I can do it. Well laparoscopically. Yeah. But it was the robotar. When I saw that video, I was like, I’m not doing that laparoscopically. I can’t do a laparoscopically. I don’t want to do a laparoscopically, but if I had the robot, I can serve so many patients better. So I said, I’m going to jump on the robot and do robots and do, yeah, robotic complex hernias. Yeah. That’s what got me onto the robot. And now I’m, I’ve been doing it since 2014. Now I do pretty much all my hernias on the robot just because I can do everything that I did laparoscopically better.

Speaker 1 (11:40):

I agree. It’s

Speaker 2 (11:40):

Just more precise. I could see better. I’m more comfortable sitting there. I can just do things on the roof that I couldn’t do laparoscopically. So yeah, it, it’s completely changed my practice.

Speaker 1 (11:53):

The company came to me 2011 ish, maybe 2011, 2012, and you know, have to go through courses and online courses and then take exams and then hands-on courses and then take exams. And then it was great and you had to practice and then these games you had to play and they got me start on it, but there was no follow up and I was not that interested. So I didn’t follow through. And then 2013, do you know Brian Kanyer from [inaudible]?

Speaker 2 (12:27):


Speaker 1 (12:28):

Yeah, Brian Kanyer. He was a new rep. Intuitive. Okay. He is like, no, we got to sit you down, you got to finish these courses. And he got me to dedicate the time to do it. It’s kind of like having a trainer at the gym as opposed to just going the gym yourself. And that got me, that got me involved and okay, so quick question because they’re already asking. We use the term robotar a couple times, just so you guys know. Ever since the robotic technology, we’ve been kind of cute with our acronyms. We often put a little R in front of operations to denote that it’s being done robotically. So R Tap, and you’ve heard of this talking about TAPP and TEP, but you want to explain what robotar is.

Speaker 2 (13:23):

Yeah, I’m not sure why we call robotar. We should be calling it R TAR to be consistent with Correct. The nomenclature we use for robotic hernia surgery, but somehow the term robotar, which stands for a robotic release stuck. So when we say robotar, we’re usually talking about a bigger hernia. A large hernia, maybe 10 to 15 centimeters wide. And we have to do a bilateral component separation, which is the tar part. Transverse abdominus release. Yes. So robotar is basically going into the abdomen, freeing up all the intestinal adhesion to the abdominal wall, doing the bilateral component separation, closing the peritoneal layer, the posterior recta sheath layer, and then closing the defect, the actual hernia defect, and then sandwiching a piece of Mesh in between. So that’s what we usually mean when we say robotar.

Speaker 1 (14:18):

Yeah, it used to be, we talked about component separation or muscle release. So if you have a big hole, you can’t just close it, it’s too tight. So you have to release different layers and bring them together. And that’s complicated even for open surgery. a lot of plastic surgeons do it and some general surgeons know how to do it. And then there’s an anterior poster, different ways of doing it. And then robotically, you can now do that, which is a huge deal because the open surgery, it’s a big operation, it’s really on the surgeon’s back, I’ll tell you that very long operation. And then with, you can still do that robotically and with such precision. It’s kind of a nice, actually very nice satisfying operation. Patients do very well. A three to seven day hospitalization turns into a one day hospitalization. So it’s pretty amazing. And I saw the video, my Conrad, I was like, whoa, I want to do that. If I can do that, I’ll do the robotic surgery. I don’t really need it for Anglo hernia or whatever. Yeah, yeah. That’s kind of where it went.

Speaker 2 (15:28):

Yeah. That video blew my mind and it completely changed the trajectory of my life, my professional life.

Speaker 1 (15:34):

Yes. So we have some questions for you. Okay. I’ll go ahead and read them and if when the audience asks more questions, we can just go to that. So you already talked about the exact point in which you got involved with robotic surgery. The next question I is how do you weigh the advantage of the extra surgical dexterity that you have with robotic surgery, with the risk of actually entering the A peritoneal, the abdominal category? All the intestines are, because actually maybe you can explain, it’s not necessarily true, you have to always be inside the abdomen. But go ahead and maybe explain risk benefits of robotic surgery.

Speaker 2 (16:15):

Okay. Well lemme set aside the robotic surgery part. Lemme just talk about the average way of fixing an incisional hernia. So in the front of the abdomen, in the midline, surgeons like to make long incisions to get into the abdominal cavity and that’s where a lot of incisional hernias occur. But you can get ’em in the flank in the lumbar region off the midline and the pelvis. But let’s just talk about a midline incisional hernia to fix that

Speaker 1 (16:42):

Hernia right around the belly button, let’s say.

Speaker 2 (16:44):

Yeah. So to fix that hernia, there are several things a surgeon needs to do, right? One is we need to clear the defect of any intestine. And usually most surgeons do that by going into the abdominal cavity and separating the adhesions or the scar tissue of the intestines to the abdominal wall and free them so that we don’t injure the intestines while we’re trying to fix that defect. And then after freeing that up, usually going into the abdominal cavity, we then free up, kind of clean up the edges of the hernia defect. We do our component separation. If we need to allow us to close the bigger defects, maybe we’ll have to create a pocket, let’s say in the pre partal space or the retro rectus space, these potential spaces that we have in the abdominal wall so that we can put a muscle meshal spaces behind the muscle and then we put our Mesh in, then we close the defect and we close the skin.

Speaker 2 (17:44):

Right now, there are ways to avoid having to with the scar tissue of the intestines because the riskiest part of an incisional hernia repair is actually trying to separate those adhesions, the intestinal adhesions to the abdominal wall. If we put a hole in the intestine, that increases the risk of complications by four or five folds. So we really don’t want to do that. So there are certain techniques where we can actually avoid going to the abdominal cavity. When I cut through the skin for a open incisional hernia repair, I can actually try to stay outside the S sac, the hernia S sac. So the hernia S sac is what goes through that defect with the hernia, the bowel in there. So I could actually free up the sack and push the whole sack with the intestines back into the belly without even opening up the belly. And then fix my hernia, put the Mesh and all that stuff. So with robotic surgery, we don’t actually have to always go into the abdominal cavity. So the way the early adopters of robotic hernia surgery envisioned it was putting the ports into the abdominal cavity. Traditional doing the stuff. Laparoscopic, yeah. So we go and we free up the bowel and then we fix our hernia. Well, Dr. Jorge Daes, you know, came up with this concept of eTEP. So Columbia

Speaker 2 (19:05):

From Columbia, yeah, we do lapping and or hernias. The TEP fashion, we don’t ever go into the abdominal cavity, but we could do a laparoscopically. And then he decided to extend where we put the ports and put it in a little non-traditional fashion. And then Dr. Igor Belyansky from Maryland, yeah, decided to use that eTEP technique to fix incisional hernias. And he does created a technique to perform minimally invasive surgery to fix a hernia, an incisional hernia without going into the abdominal cavity.

Speaker 1 (19:38):

And we interviewed Igor back in, I think 2020.

Speaker 2 (19:42):

Yeah, I mean he was pioneering that back in 2019, 15 or 16. And so now we have a technique of using the robot to perform eTEP surgery, thus not having to go into the abdominal cavity and fixing some pretty big hernias. And this is getting into the weeds a little bit, but we can do robotic eTEP with TAR. So we’re doing that robotic eTEP TAR, right. Instead of just robotar. So

Speaker 1 (20:09):

Many acronyms. We actually published a paper on all the hernia acronyms. Ridiculous how many acronyms we use. The gist of it is with laparoscopic surgery for abdominal wall hernias in the middle of the belly, we tend to be inside the abdomen. And for open surgery you can choose or to stay outside or stay inside, depends on the nature of the hernia. And also similar to open with robotic surgery, you can choose to stay inside or outside of the intestinal region depending on the type of hernia. So it has its risks, but definitely the risks are more similar to open surgery than laparoscopic surgery.

Speaker 2 (20:55):

I have a debate with Conrad, the guy who came up with robotar quite often on social media you get the layperson doesn’t see it because it’s on our closed Facebook page. But I am a strong believer that the eTEP technique allows me to avoid having to deal with the scar tissue. So I do a lot of eTEP incisional hernia repair.

Speaker 1 (21:17):


Speaker 2 (21:17):

Conrad says

Speaker 1 (21:18):

Something too, and you are like, oh yeah, I would totally do this eTEP

Speaker 2 (21:22):

And Conrad’s like, no, you have to lyse adhesion. So we strongly disagree on that. I respect them quite a bit, but I definitely disagree with them on the amount of license of adhesions needed.

Speaker 1 (21:33):

I agree because so there are situations where you do need to, it depends on the symptoms of the patient. Of course the patient has no intestinal symptoms. There’s really no indication to go after those intestines and add to the operation. Yeah, yeah. I’m on your side for that one. Less is more sometimes yes. Okay. More questions. Can you remain outside the abdomen to treat our recurrent hernia of the internal ring with robotic surgery? So this is a hernia of the groin as a recurrent hernia. Can you do that outside the abdomen? So extra peritoneal.

Speaker 2 (22:13):

So I need a couple more pieces of information. Let’s

Speaker 1 (22:18):

Say the hernia originally was done open,

Speaker 2 (22:21):

Then definitely. Okay. Now I don’t actually do robotic inguinal hernia repairs in a eTEP or TEP fashion, meaning I don’t do a robotic technique where I stay completely outside the abdominal academy for inguinal hernias because you do

Speaker 1 (22:38):

A traditional robotic inguinal hernia repair, which is a TAPP, which means you’re in the abdomen and then you make a flap.

Speaker 2 (22:46):

And the reason is this, to get my three robot ports in to start the operation for an inguinal hernia repair, I essentially have to do maybe about two thirds of the dissection laparoscopically. So essentially I am just doing another third of the dissection putting in the Mesh, which it doesn’t really make sense for me to dock the robot after doing that much dissection, laparoscopic. Ok. So that’s true.

Speaker 1 (23:15):

That’s a very good point.

Speaker 2 (23:16):

Actually didn’t think I just do it as a time. Now if there’s Mesh in the prerenal space already, let’s say a previous surgeon did a laparoscopic robotic repair and it’s recurred. Yes, I definitely go into the abdominal cavity. I want to see the entire pelvis and the myopectineal orifice, see where that meshes and then come up with a game plan.

Speaker 1 (23:36):

Yeah. Yeah, hundred percent. I agree. So if you had open surgery and it recurred from your hernia repair and you go in robotically, technically you can stay outside the intestines. But I do those laparoscopically because I like the extra peritoneal stay outside the intestine scenarios. I would just go in laparoscopically extra. But if you do robotically, you can do either. But if there’s Mesh there from a prior laparoscopic surgery, let’s say, definitely have to go inside the abdomen and deal with everything. It’s too dangerous and not as effective to do it otherwise.

Speaker 2 (24:13):

Yeah, yeah.

Speaker 1 (24:14):

Okay. Another question. Can you repair a diastasis recti or rectus diastasis along with a belly button hernia robotically? That’s a good question.

Speaker 2 (24:23):

Yes, we definitely can. Yeah, I think it’s a very exciting topic and it’s something hernia surgeons love to talk about and we debate with each other how it should be done, who it should be done on, and what are the indications, things like that. So the answer is yes, we can do it. Should we do it? That’s a different

Speaker 1 (24:49):

Question. Right. So very good question. So the reason why the questions being posed I believe is a belly bun hernia can be repaired a million different ways. Laparoscopic, robotic open with Mesh without Mesh, it all depends on the patient, the size, the hernia, et cetera. Then you add that extra element of there’s a separation of your rectus muscles. So diastasis recti and therefore the hernia repair is now in a thinner area than it used to be. And so I think pretty much everyone somewhat agrees that if you had the luxury of safely closing that space in addition that in addition to the belly button hernia, it’s probably a belly better belly button hernia repair. That said, it’s a much bigger operation, adds much more time and effort and risk to the operation, much more pain, longer recovery time. Some people are obese or larger or are not amenable to having that done successfully. But if it is done, it’s usually done with the robot. Although there are some really skilled laparoscopic surgeons that do it. But in the right patient, I do offer that

Speaker 2 (26:07):

For me it, there’s a lot of, definitely, there’s a lot of nuance when it comes to focusing on the dia, repairing the diastasis when somebody has a small umbilical hernia. Yes. So first of all, there are two I think, patient scenarios that I frequently encounter. Number one is the woman that’s postpartum after one or multiple pregnancies, they have diastasis where they see just a bulging ridge down the center and their belly bun’s kind of in that ridge, and they probably feel some functional deficits, meaning their abdominal wall just doesn’t feel as strong. And studies have shown that it affects maybe their ability to urinate, their ability to

Speaker 1 (26:58):

Constipation, back

Speaker 2 (26:59):

Pain, back pain, abdominal course strength, stuff like that. So that’s one group. The other group is the obese patient who has very wide dioceses. It’s not very visible unless they’re doing a sit-up, it has no effect on their function, abdominal function. So those are two very different groups and I approach ’em very different.

Speaker 1 (27:24):

Yeah, true.

Speaker 2 (27:24):

I think the women with the diastasis and it’s a functional problem, I think those should be repaired. The obese patient, I don’t think it should be touched. Okay. Yeah, agreed. So that’s why I separate them into two different groups and then how to fix them that that’s a very deep conversation, which I’m not sure we’re ready to have here.

Speaker 1 (27:50):

Okay. Next question. Are there greater benefits to using tacks, which are like these commercially made tacks versus sutures, which you can do open or robotically. Are there any benefits to using one versus the other? More specifically, which ones? Either tacking or suturing causes less pain by the patient? These are for incisional hernias.

Speaker 2 (28:11):

Yeah, when we were doing just laparoscopic hernia in incisional hernia repairs, a lot of surgeons were trying to answer the question, do sutures hurt more or do tacks hurt more? And the results were conflicting. Some studies showed that the trans fascial sutures hurt more than the tacks. Some showed the tacks hurt more, some showed that it was equivalent. So I think it’s hard to say based on the scientific literature, which ones hurt more. Now I can tell you in my practice, I don’t use any more tacks because with a robot I can suture very easily and I could be much more precise.

Speaker 1 (28:56):

I can open surgery. Yeah,

Speaker 2 (28:57):

Yeah, exactly right. The

Speaker 1 (28:59):

Tacks were invented purely because we were doing laparoscopic surgery. No one needed tacks when they were doing open surgery.

Speaker 2 (29:05):

Yep, yep. Yeah, it’s hard. Very hard to suture. Laparoscopic. That’s why we needed tacks.

Speaker 1 (29:09):

Yeah, that’s very true. I think it all has to do with tension. If you’re going to even a lightly placed tack or just as good as suturing in some cases and very tightly wound up not from a suture can be just as painful. Yeah. Here’s another question. I have an enlarged. So I have an incisional hernia from my colon surgery and they removed a foot of my colon. Now I have an in incisional hernia, I have an enlarged stomach and they say I only have one layer of my abdomen. Can that be fixed to get rid of my huge stomach sticking out like I’m pregnant?

Speaker 2 (29:49):

Yeah, usually it can be fixed just from removing the, all the layers of your abdominal should be there. The muscle, the fascia, the oblique muscles, they should all still be there. So we should be able to fix it. But I would’ve to see the abdomen and see the CT scan to make a final judgment.

Speaker 1 (30:13):

Going back to the tacks versus sutures, what do you think about fibrin glue?

Speaker 2 (30:19):

I use fibrin glue occasionally for incisional hernias. I used it for a little bit just to make sure the Mesh kind of stayed in the space with eTEP surgery. But I find that because the space is the Mesh fits the space, it’s not going to move anywhere. So I don’t use fiber glue. It’s in certain situation. Yeah, it’s not painful in certain situations where I want to use sutures or tacks, but maybe there’s some very delicate or critical structures close by. Let’s say I’m working near the heart right on the diaphragm and I don’t want to put sutures in. Maybe I’ll put fiber glue in

Speaker 1 (31:01):

Or tacks or

Speaker 2 (31:02):

Or takcs, right? Or maybe I’m in the groin and the femoral vessels or the iliac vessels are there and I don’t want to tack or suture. Maybe I’ll put fiber, use fibro glue there.

Speaker 1 (31:13):

Yeah. I used to work at USC, that was my first job, and Kuda was a friend and colleague of mine there, and he’s the one really that introduced use of fibrin glue for laparoscopic inguinal hernia pairs. So that was my introduction there. And then he did a whole pig lab and it was really great. And then we’re like, okay, what about ventral incisional hernias, like the abdominal wall? So we did a pig lab looking at fibrin glue for that, and because it was IPOM Intraperitoneal, it didn’t work. But what you’re talking about is when you’re sandwiching the Mesh amongst different layers and not just having a hang underneath the abdominal wall. In those situations there are people that use fibrin glue, but in general, pain is least when you use nothing or fibrin glue as opposed to tax or

Speaker 2 (32:02):

Sutures. It doesn’t secure as well as sutures and tax in my opinion. But it’s better than nothing. Right now there is a Cyanoacrylate and different types of surgical glue that yes, halts things better, and they use that a lot more in Europe than we do in

Speaker 1 (32:19):

Europe. I don’t think we are allowed to uses accolade. Yes. So FDA-approved in the abdomen for Americans, but it’s for Europeans. Go figure. Let’s see. What kinds of hernias are better suited to be approached robotically as opposed to laparoscopically or open?

Speaker 2 (32:41):

Well, I would say the two extremes are better for open. So the really tiny hernias like the one centimeter hernia, I think those are great. Done, open. We can study, show that if it’s one centimeter less, just a little suture through the fascia is more than enough one to two centimeters, maybe a little piece of ventralex Mesh if needed or some kind of Mesh, very easy to do, takes 30 minutes under sedation without general anesthesia, would get very good results. And then the really big ones, the massive ones were the gap is 20 centimeters wide or there’s lot of domain,

Speaker 1 (33:18):


Speaker 2 (33:18):

A domain meaning all the intestines are outside the abdominal cavity. It’s very hard to stuff it back in. Or there’s a big giant skin graft that needs to be removed or a giant scar that needs removed. Very complicated. Those should be done open. Most of the ones done in between I think should be done robotically when it’s technically possible because we’re reducing the morbidity of the operation by keeping it minimally invasive. And I can get a nice big piece of Mesh to cover the defect with good overlap robotically. So I think it really is the best operation we can offer if I had all three different approaches to choose from.

Speaker 1 (34:00):

What about inguinal hernias?

Speaker 2 (34:02):

Inguinal hernias? I like to do, if I can do it robotically, if the patients can tolerate general anesthesia and I prefer to do it robotically. The precision of robotic surgery is just incredible. I stay away from the nerves that I would normally encounter anteriorly with open surgery. So I think there’s going to be less chronic pain. I can get better Mesh overlap than I can lap or open. So I, I’d rather do it robotically for mostly rolls.

Speaker 1 (34:35):

Yeah, sounds fantastic. Does robotic surgery have a role for hernia related complications in an emergency setting?

Speaker 2 (34:45):

Interesting. Isn’t that

Speaker 1 (34:47):

A great question?

Speaker 2 (34:48):

Yeah, very good question.

Speaker 1 (34:50):

Yeah. Yeah. My followers and lovers of Hernia Talk like so smart.

Speaker 2 (34:55):

Or maybe somebody has seen the American Hernia Society agenda, the national meeting agenda, because I’m actually giving a talk on this specific topic

Speaker 1 (35:07):

In North Carolina.

Speaker 2 (35:09):

In North Carolina. So yeah, there certainly is. So a lot of patients with hernia, well, not a lot of patients, but patients come with hernias, come in with hernia related emergencies, and that’s usually with a piece of intestine stuck in there. And so as a general surgeon, we usually had to focus on the intestine first. So that’s number one. Because

Speaker 1 (35:35):

I say procedure

Speaker 2 (35:36):

First, if the intestine necrosis, perforates turns gangrenous, so we have to address that first. But if the situation arises where we can reduce a hernia or the intestine is not needing to be resected, then we can focus on that hernia. So then that becomes more of a hernia repair related emergency rather than an intestine related emergency. And in that case, we can still fix a hernia. Of course, in those settings, we do have to worry about bacteria potentially being in the area of the hernia. And if we’re thinking about using Mesh, we had to think twice about using Mesh. But there are studies out there now that show that we can use Mesh in contaminated fields or clean contaminated fields. But there are certainly situations like this that we deal with quite often.

Speaker 1 (36:32):

And used to be that was the answer was always in emergency, do not do anything laparoscopically or not robotically, but there’s been so much extra experience and comfort with these techniques that you’re not trying to prove a point of like, oh, I can do those laparoscopically, but you’re actually helping the patient in many ways to do though, so don’t, I’m not sure how they treat it for the American Board of Surgery, but when they do the oral board’s examinations, I think they’re a little bit more lenient in allowing the answer to be answered, oh, I’ll do this robotically or laparoscopically. Okay. Another very intelligent question. How is it possible to repair incisional hernias tension free while operating in a minimally invasive setting and inducing pneumoperitoneum?

Speaker 2 (37:25):

Hi, your viewers have very good questions. Isn’t

Speaker 1 (37:27):


Speaker 2 (37:27):

Good? This is great.

Speaker 1 (37:28):

I know.

Speaker 2 (37:30):

Yeah. So maybe, of course, when we do minimally invasive surgery, the belly, and we’re using co2 and the pressure is usually at 15 millimeters, mercury pressure, but we can lower and raise it, the term tension free, really repair refers to the amount of tension after we’re done with the surgery, not during the surgery. So when the belly is insufflated, yeah, there is going to be tension on the tissue, but once we release that CO2 from the abdomen and the pressure goes down to physiologic, there should be very little tension.

Speaker 1 (38:05):

It’s actually kind of nice because when you add the extra tension and you’re, you make sure even at that 10, that extra pneumoperitoneum pressure of 50 millimeters with carbon dioxide gas, if it’s not tight at that level, then when you relax the abdominal wall, then it’s definitely not going to be tight. So I kind of like that way of gauging, I always tell my residents, you don’t want a perfect repair where the Mesh is perfectly flattened and totally pristine, like a five star hotel, a bed bed that’s made, you know, don’t want that way. You want a little bit of wave, a little bit of looseness because that Mesh will shrink and the patient needs to be able to cough and bend and tie their shoelaces and reach up for in a cupboard and do things where they may have an increase in abdominal pressure just doing that one activity, getting in and out of bed, for example. You don’t want to make them like an armor of the abdominal wall. You want something to prevent the hernia and not induce pain and not tear apart.

Speaker 2 (39:12):


Speaker 1 (39:14):

Yeah. Okay. Next question. Let’s see if the next one’s even better. This is a patient who had a large incisional hernia required Mesh removal due to Mesh implant illness. What happens if this patient gets a recurrence

Speaker 2 (39:37):

Of the Yeah, it so large incisional hernia? Okay, well, so it depends on what the Mesh implant illness was and what kind of Mesh was implanted and what was removed. And we have many different Mesh options nowadays. We have the traditional polyester, polypropylene, synthetic meshes, we have the biologic meshes, and there are hundreds of those. And then we have now the synthetic resorbable ones that disappear after three months to three years. So those are all options, and that really will require an experienced surgeon to go through your history and look at exactly what Mesh caused the illness and talk to the allergists and explore that a lot more further. There’s always the option of just repairing the hernia without Mesh, but those are prone to recurrence. But you could do component separation techniques and reduce that risk. There’s also the option of not fixing the hernia, the chance of another Mesh related illness is too great.

Speaker 1 (40:55):

Yeah, those are all excellent answers. Here’s a question. I had a laparoscopic inguinal hernia repair. Why do I still get pain when lifting at the site of my hernia repair four months later, will this subside and is that normal?

Speaker 2 (41:12):

I would say four months later, still having pain is not extremely abnormal. But I wouldn’t say, I would not say it’s typical. It really depends on the level of pain. I always tell patients it takes a year for the remodeling process to finish, so the body is going through changes for an entire year. So anything that happens within that year, any symptoms can still improve and disappear after a year? Yes. Okay. So if it’s minor, I would say don’t worry too much about it if it’s not affecting your quality of life significantly, just let it be, let your body run its course and it should get better. If it’s debilitating pain, then that’s abnormal and how they should be investigated. Surgeons usually define chronic pain as pain beyond three months. That’s a pretty harsh definition. I would say it should be past a year, but we usually say it past three months because most patients after three months shouldn’t have much pain. So I would say at four months, that’s a little atypical but not unheard of. I have probably after an inguinal hernia repair, maybe one out of 15 patients having some pain at four months maybe. Yeah.

Speaker 1 (42:39):

And similar to the abdominal wall, the groin, you can also put the Mesh too tight, and I’ve seen people that kind of talk it, but they talk it so it’s perfectly flat and tight. You don’t want that. You want it to kind of fall the contour of the abdominal wall. Okay. Similar question, but different scenarios. So this patient actually had the laparoscopic inguinal hernia repair. The Mesh was removed and they had a tissue repair of their inguinal hernia and four months postoperatively, they still have pain with lifting at the side of the hernia. Is that normal after a growing tissue repair?

Speaker 2 (43:14):

Yeah, certainly. Just because there’s no Mesh doesn’t, there’s not going to an

Speaker 1 (43:19):

Natural laparoscopic.

Speaker 2 (43:20):

Yeah, for sure. Mesh came about 50 years ago, so we know exactly what happens to people who have tissue-based repair and tissue-based repair is still being done too. And because of the way social media throws these things around, people think, oh, if there’s no Mesh, then there’s not going to be any chronic pain. And that is completely not true. Correct. Okay. You can still get chronic pain even without Mesh. Correct. Now four months later, is that pain going to be permanent or not? Like I said earlier, I don’t know, we can dive into this just a little bit more, but there’s neuropathic pain and there’s nociceptive pain. If it seems like it’s neuropathic pain, meaning a nerve was trapped and there are certain symptoms to that related to that sharp burning pain that’s along the distribution of a nerve, then maybe it’s a nerve entrapment and maybe something needs to be done. But if it’s nociceptive, just kind of an ache inflammatory pain burn, like you’ve done a lot of sit ups, that kind of pain maybe will go away with time. So it really depends. Four months is not

Speaker 1 (44:39):

Tissue repairs. Tissue repairs are tighter, and so more likely to feel a pulling and tension if it’s too much pain may actually be tearing through it. So the recovery from the tissue repair is very different from robotic or laparoscopic repair. It’s longer. It’s very dependent on the surgical surgeon and their technique. And if it’s too tight or on too much tension, it may take a long time for your muscles to adapt it. There are things we can do, so I do Botox for example, into the muscle and help alleviate some of the tension and relax those muscles and that can help with the pain. And of course, like you mentioned, you got to make sure it’s not from a nerve entrapment or something else that can happen with tissue tissue repairs. Okay. Here’s another question,

Speaker 2 (45:29):

Just one more thing. And somebody who’s had previous Mesh removed. Yeah, their tissues probably more scarred, more rigid, true. And sewing that tissue back together probably would cause more pain or more likely cause

Speaker 1 (45:45):

Pain. Yeah, good point. Okay. This patient has a recurrent indirect inguinal hernia After prior open inguinal hernia repair, can this be repaired robotically TAPP or TEP? If so, how do you remove the hernia sac from the inguinal canal from the backside working for the pre peritoneal or retro rectus side without further damaging the internal ring. And then after manipulating inguinal canal, how do you buttress internal ring? So their concern is they think you’re going in there to grab the hernia sac out and maybe damaging the internal ring when you go from the backside or laparoscopically. You want to answer that

Speaker 2 (46:26):

Like an engineer question. Very specific technical question. Yeah. Yes. This is where robotic surgery shines in my opinion. But laparoscopic surgery can be done just done just as well too. But I would say in a consistent fashion, robotic surgery would be best in this situation. And when I approach a person who’s had an opening or hernia repair, I assume it’s going to be an easy operation, but sometimes it is really challenging because somehow the surgeon’s gone into the prerenal spaces space. I need to be in robotically somehow through the front. My goals for a robotic inguinal hernia repair is to essentially reduce as much of the sac as possible, but I don’t have to reduce all of it. Okay. I can leave the tip of the sack. Let’s say the sac is stuck inside the inguinal canal. I can transect the sac and then repair the hole later, right? Yeah. I’m not damaging the muscle or the abdominal wall. I’m not damaging the internal ring or the rim of the internal ring. I’m purely right dealing with the S sac, it’s like a little loner bag that’s herniating through the,

Speaker 1 (47:39):

It’s pulling on it. You’re not, yeah, you don’t have to go in there to grab it. You, you’re outside, you’re pulling on it. Correct.

Speaker 2 (47:45):

Yeah. The tricky is when the sac is really scarred to the testicular vessels and the vas and robotic surgery lets me be very precise in separating that sac so that I don’t damage those structures. And then once I have the sac out and I get the entire space created, then I can put my Mesh in there. So usually it’s not a problem for in that scenario.

Speaker 1 (48:07):

Yeah, very true. Does removing Mesh thin out the abdominal wall muscle?

Speaker 2 (48:13):

Well, it depends on what layer the Mesh was put in and the reasons for removing that Mesh. If the Mesh was placed right up against the muscle, let’s say the rectus muscle for an incisional hernia repair, to remove that Mesh, you have to carve muscle, you have to carve muscle out. There’s no way to stay in a natural plane where you can separate the muscle completely from the Mesh. So it, it’s like putting wet paper tissue in concrete and the concrete sets, there’s no way to remove just that tissue. You had to remove some of the concrete. And so yes. But if the, let’s say the Mesh was placed inside the abdominal cavity attacked to the peritoneum, you probably don’t have to remove any muscle. Correct. If there’s significant inflammation, the chronic infected cavity that has significant information and everything is sticking and stuck together, you may have to remove some muscle even though the Mesh is in the abdominal cavity. So it depends on the situation.

Speaker 1 (49:22):

True. Although we try our best to have the least amount of natural tissue come with the Mesh when we do Mesh removal. Okay. Considering the inflammatory response and an adhesion formation, is minimally invasive surgery better than open?

Speaker 2 (49:42):

I think so. I think there’s enough studies that show that minimally invasive surgery creates less adhesions and less inflammatory response.

Speaker 1 (49:50):

I guess pretty well accepted. Is robotic Mesh removable feasible for ventral hernias, especially retro muscular placed Mesh? That’s a very good question. Have you ever done that? I do

Speaker 2 (50:05):

Those, yes. I actually have. And yeah, it’s definitely possible. But why? Yeah, you’re, your patients talk a lot about Mesh removal, but yeah,

Speaker 1 (50:21):

It’s hard to get those questions answered elsewhere.

Speaker 2 (50:25):

Well, yeah, that’s true. So Mesh, the meshes that are hard to remove are the ones stuck to vessels. So the inguinal meshes that are stuck to the inferior gastric vessels, the iliac vessels, femoral vessels, those are hard to remove meshes on the abdominal wall for ventral incisional hernias. Those are almost always removable without significant damage to the abdominal wall. Correct. Yeah. Especially robotically. I can be much more precise in terms of actually removing

Speaker 1 (50:55):

The Mesh, but have you ever done a retro muscular Mesh removal robotically?

Speaker 2 (51:00):

So in eTEP, I frequently encounter Mesh in the retro muscular space actually. So previous, ventral previous open repair with the ventralex. Yes. a lot of times the surgeons end up tucking that in the retro muscular space. So I come to it and it’s in the retro muscular space when I expected intraabdominal pre repair. Yes. And I’m carving it off of the muscle and then I remove it. So I actually have remove removed quite a few of those.

Speaker 1 (51:29):

Oh God bless you. Yeah.

Speaker 2 (51:30):

And then now what? What’s happening is everybody’s trying to do robotic tap ventral hernia repairs. Yes, yes. And sometimes a peroneum is hard to take down, so they go retro muscular. Yes. And so when they have a recurrence that meshes retrorectus and I’m having to carbon

Speaker 1 (51:46):

True. How do you make an opening in the Mesh for the spermatic cord when working robotically?

Speaker 2 (51:55):

You don’t have to. Yeah. So in

Speaker 1 (51:59):

Fact, we recommend that you don’t, right?

Speaker 2 (52:01):

Yeah, yeah. Key holds. Yeah, the guidelines actually. Yeah. Yeah. Don’t do that because the Mesh will scar around the cord structures and constricted.

Speaker 1 (52:09):

I work in Beverly Hills, so I have a Hollywood agent that had the keyhole technique and the, it’s a keyhole in that you wrap the Mesh around this spermatic cord, which I know is a known technique, but we don’t like to do that. And so if it’s too tight and the Mesh also shrinks over time, it had guillotine, his entire spermatic cord.

Speaker 2 (52:35):

Oh my

Speaker 1 (52:35):

Goodness. Over time when we got in there we’re like, it’s literally the S spermatic cord was into a wall of Mesh. There was nothing. The poor guy, yeah, he’s fine now, but oh,

Speaker 2 (52:48):

He must have suffered.

Speaker 1 (52:49):

He was in a lot of pain for preventable reason. But you want to address the why we like how it is that we don’t need it. We do it for open, but we don’t do it for lab or robotic.

Speaker 2 (53:04):

Fortunately, the spermatic core structures, the testicular vessels and the vas deference, they hugged the backside of the pelvis of the pelvic wall. So once we peel, pull the hernia sac out and peel the peritoneum back, those structures are still up against the back and we can just lay our Mesh on there without having to keyhole and wrap the Mesh around those structures, because the goal is to block that hole. So for an indirect hernia, that’s where the test vessels in the vas go through the internal. As long as we get good overlap around that internal ring, the hernias not going to come back.

Speaker 1 (53:49):

Yeah. Very good. So we’re almost done with our hour, if you can believe it. Oh wow. An hour is that fast.

Speaker 2 (53:58):


Speaker 1 (53:58):


Speaker 2 (54:00):

To bring me back again, because it’s so many things to talk about,

Speaker 1 (54:03):

So much, so much, I know I say that with a lot, the more questions are coming in. So again, it’s about Mesh removal, sorry, regarding how much more damage it is during inguinal hernia, Mesh removal. And also can you damage the muscles so that you lose the function if you’re removing the Mesh off the abdominal wall?

Speaker 2 (54:29):

Yeah. For inguinal, it’s, you don’t usually damage the muscle to the extent where you’re, you’re going to lose function mean it could happen, but it’s not normal. Like I said before, most of the time we can remove the Mesh without significantly damaging muscle, even though we have to maybe cut some of the muscle and leave it on the Mesh. What I’m worried about with removing inguinal Mesh is the vessels and it stuck on the nerve. Sometimes we do have to transect the nerves, which is usually better than just injuring the nerve. So luckily inguinal Mesh removal is not very common. I think the most common meshes I removed from the groin are plugs. These little cone shape shuttle cock shape meshes that when surgeons put it in, they kind of fill a hole, but the pointy part sticks inwards and can press on internal stuff. So I remove a lot of those, and those just kind of usually be carved out without significant damage.

Speaker 1 (55:28):

Yeah, yeah, yeah. True. Do you recommend, this is is almost a rhetorical question. Do you recommend robotic eTEP for ventral hernia repair?

Speaker 2 (55:41):


Speaker 1 (55:42):

Yeah. E

Speaker 2 (55:43):

In most situations,

Speaker 1 (55:45):

Yeah. Dr. Liu and eTEP are like, yeah,

Speaker 2 (55:48):


Speaker 1 (55:48):

Yeah, yeah. They’re best for their BFFs.

Speaker 2 (55:50):

Yes, exactly. We

Speaker 1 (55:52):

Have this forum where we discuss hernias amongst each other, and I had a complicated one, and definitely I was not ever considering eTEP approach and this patient and Dr. Liu was like, oh yeah, you should have done this eat time. I’m like, what? This guy’s had two different repairs, Mesh in the RETRORECTUS space. I mean, no. Okay. On that note, we are having some very nice comments about you being a Rocks… Rockson in the Rockstar. Oh, thank you. So thank you for that and for answering so many of these questions back to back. But if patients want to see you, how can they contact you besides on social media?

Speaker 2 (56:41):

So should I get my phone number?

Speaker 1 (56:44):

Yeah. Or website or, yeah. Is it okay if they just DM you on your Facebook or Instagram? Would

Speaker 2 (56:52):

You Yeah, I have people send me instant messages on Facebook. And so I have a website, so pacific hernia.com. Yeah, that’s my website. My office is in Oakland and my phone number is (510) 465-5523. Call my office.

Speaker 1 (57:13):

Do you see any patients from, what if they’re not in California, are they able to Yeah, see you.

Speaker 2 (57:18):

I love doing video visits for folks that are not in this area. So I’ve had lot. I furthest, I think with somebody from Tennessee. I just operate on somebody from Tucson, so I, I get a lot of patients, especially patients looking for eTEP. I get surgeons from around across the country sending me patients because they don’t want to go into abdominal cavity. They don’t think anybody should. Yes. So they send them to me for eTEP. Yeah. And then I have a YouTube channel doc surgeon. Yes, that is Dr. Rockson. It’s more meant for surgeons because I train a lot of surgeons and so I put my surgical videos and I narrate them for surgeons to learn from. But you can certainly see what a eTEP operation is like, or robotic hernia operation is like. Yeah. Through

Speaker 1 (58:02):

That, which is really great. We published a paper on YouTube videos and we picked the top 50 that were the highest viewed and it’s highly variable, the quality. Yes,

Speaker 2 (58:16):

For sure.

Speaker 1 (58:18):

People that think it’s totally okay to put their hernia, hernia surgery out there and it’s the a horrible hernia repair. But I’ve seen your YouTube video channel, it’s very, very good. And how thank you. And your talks are always great and very happy to see you and catch up with you. And same here. So glad I have now that you’re outside the Kaiser season, because when you were in Kaiser, I was so limited I couldn’t get people to see because there’s very, yeah, there’s literally no one in Northern California that I like. That’s

Speaker 2 (58:52):

Yeah, very true.

Speaker 1 (58:52):

Yeah. Refer to, except you. So, but now that you’re out of the Kaiser system and you’re more available to anyone, I finally have someone to refer up north. So thank you for that.

Speaker 2 (59:03):

Yeah, thank you.

Speaker 1 (59:04):

Thank you. And on that note, everyone, that is the end of our Hernia Talk Live Q&A session. Thanks for all your questions. It was great. I’ll post it on my YouTube channel and please do follow Dr. Rockson Liu as well. And thanks for all of you who follow me on Facebook at Dr. Towfigh and Twitter and Instagram, and I’m having some fun lately with some TikToks. So hope you enjoy it and I will see you again next week. Thank you so much. Bye bye. Thank you.

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