Episode 137: Future Technologies of Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:11):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly episodes of hernia related topics with me, your host, Dr. Shirin Towfigh. As you know, many of you are here as a Facebook Live, some Zoom. Thanks for following me on Facebook at Dr. Towfigh and at the end of the session. As always, this and all prior Hernia Talk Live sessions will be archived on my YouTube channel at Hernia Doc. So today we’ve got a great guest, very unique topic. Unlike previous topics, Dr. Amir Szold, I’ve known him for, I would say at least 10 years, maybe longer. He is a colleague and surgeon of mine based in Israel. But more importantly for today’s, he is a surgeon inventor, which I love because I feel like people who think inventors are just more unique people. And so you can follow him at Amiki SZ on Twitter, and please provide a very warm welcome to Amir, or as your friends call you Amiki. That’s your nickname. Yeah, they

Speaker 2 (01:22):

Do. Yeah. Hi, how are you? Thanks.

Speaker 1 (01:24):

Thanks for joining us. It’s 10:00 PM is real time right now, so I do appreciate the evening devotion. Thank you so much. We just

Speaker 2 (01:35):

Start partying at this time, so we’re fine.

Speaker 1 (01:37):

Start partying? This is true. This is true. So we saw each other in Barcelona at the European Hernia Society meeting and we were talking and you gave a fantastic lecture, fantastic talk as part of the technology session and the robotics session because you have an invention which is going in the reverse direction as most people. So most people are going big $2million robot. And you’re saying, hold on, most of the world can’t afford a $2million robot, but we can improve what we have. And you talked about your instrumentation, which is mimicking the robotic technology, but at a smaller scale. And what I loved absolutely from your talk was your analogy with the motorcycle. So a lot of people talk about the robot as like the Ferrari or the, I gave it as the S U V. It’s kind of like a unique car. It’s very expensive and takes a lot of room and very high end. And you’re saying, I loved your analogy, you said, okay, how about a motorcycle? Why can’t we have a motorcycle? It’s low in cost, it takes up very little space and you can zoom everywhere you want where cars cannot take you. So let’s start from there because I thought that was genius, the motorcycle analogy, because no one said that before. At least not that I’ve heard.

Speaker 2 (03:24):

So the idea is that I’m sure robotic surgery in many forms is going to be around for the next long time. And I think that it gives the surgeon the ability to perform complex motions more easily and it gives them better control, especially compared to the instruments that we use on a daily basis, which are really poorly designed. But I think on the other hand that especially when we speak about hernia, hernia is a very common problem. It’s very common around the world. It affects many times people at a working age, which takes them away from work, takes them away from daily life. And I think that the very expensive ways of fixing a hernia are not sustainable in our world. Not even. So I believe we should

Speaker 1 (04:28):

Cut out a little bit. My audio’s not best.

Speaker 2 (04:33):

I’m sorry.

Speaker 1 (04:39):

I would also say that I would also say that what happens is hernia is a worldwide problem. And what we see in lower income countries is they just don’t get it repaired. And then you end up as a child and you end up as an adult with these humongous hernias and it can be a huge burden and affect their ability to work and sustain a family. And I thought it was very unique at the European hernia meeting. There was a whole day devoted to robotics and I was told something like only 4% of European surgeons do robotic surgery.

Speaker 2 (05:18):

I think even less,

Speaker 1 (05:20):

Maybe even less. I joke that I joke that my hospital, which has nine robots and probably will have more, my hospital probably has more robots than many of the countries represented at the European Hernia Society meeting

Speaker 2 (05:38):

In Israel. There are 12 robots

Speaker 1 (05:41):

In the entire country. Yes. Yeah. There’s 12 robots more than 12 within a mile radius of my hospital. Yeah. Okay. So your invention currently is of a kind of mechanized, mechanized

Speaker 2 (05:59):

No, it’s not mechanized. It’s it’s completely robotic. It has motors and computer and everything. It’s very small.

Speaker 1 (06:08):

That’s true. And it, it’s handheld as opposed to being a separate machine that you have to roll into the room and take space.

Speaker 2 (06:16):

That’s what we call it human extensions. Because it’s like an extension of your hand. That’s true. Robotic extension of your hand. True. Like a, that’s true.

Speaker 1 (06:25):

And do you, I, I assume you think that that’s the future is to move away from these big, bulky robots and come up with something more practical at the med side?

Speaker 2 (06:41):

I think so. I think in order to make it both sustainable and even logistically that you can do many cases and not have to roll things in and roll things out and dock things and get a technician to do it, it slows the process very much. And we need to operate a lot of people, for a lot of people who need surgery, especially in hernia, look, there are many diseases that are basically not mechanical. So cancer is a cellular disease. So we probably, people will figure out all kinds of ways that are not just removing tumors. We’ll be operating, we’ll be using biological diseases and ion and many things, but hernia is completely mechanical. There’s no other way to fix a hernia than to fix a hernia. Yeah, you have to fix it. It’s like a flat tire. There’s no medication that you can give a flat tire to fix it. True. And there are lots of them. And there are lots of them. Really. Lots of them. Millions and millions of them.

Speaker 1 (07:44):

So many.

Speaker 2 (07:46):


Speaker 1 (07:47):

Now you’ve had a lot of inventions prior to this, just were they all in the hernia world or not

Speaker 2 (07:55):

Somewhere? Well, I think there’s one product that’s very, very ubiquitous in the US. That’s my invention, which is the echo balloon that opens up the Mesh for ventral hernia repair.

Speaker 1 (08:07):

Holds the Mesh in place. Yeah.

Speaker 2 (08:13):

Now it’s BD.

Speaker 1 (08:15):

Yes. Beton Dickinson.

Speaker 2 (08:18):

And there are some ideas that I invented that failed. I think there’s still good idea, but commercially they failed in fixation. And I’m currently helping a company that makes a self-adhesive Mesh, which is, I think it’s a cool thing. So you don’t need to fix it with any mechanical means to where it should be.

Speaker 1 (08:42):

And what are some of the other non hernia inventions you’ve been involved in?

Speaker 2 (08:47):

Oh, I was involved in the company that makes laparoscopic simulators. Oh, I remember that. Which is very now the biggest company.

Speaker 1 (08:57):

Very successful,

Speaker 2 (08:59):

Very successful company. Was involved with a company that did bowel [inaudible] and burned $70 million and shut down.

Speaker 1 (09:11):

Oh wow.

Speaker 2 (09:15):

I was involved in companies that, well, tons of things. MRI safe instruments, 21 companies basically so far.

Speaker 1 (09:28):

That’s amazing.

Speaker 2 (09:28):

And a company that is making, that was bought by Medtronic that does the fluorescence for me. The fluorescence camera for Medtronic is a company that I was involved with started 25 years ago.

Speaker 1 (09:43):

And what is your background? Do you have an engineering background?

Speaker 2 (09:47):

No, I’m a surgeon. I, I’m on being a very active clinical surgeon. I do

Speaker 1 (09:55):

Tell them how many operations you’re doing this week.

Speaker 2 (09:58):

25, 23, 23

Speaker 1 (10:00):

In one week. If a surgeon’s 23 in a month, that’s a really good month in the United States.

Speaker 2 (10:07):

No, I do do 800 to a thousand cases a year.

Speaker 1 (10:13):

And that’s in addition to all the traveling you do to all the different meetings

Speaker 2 (10:17):

And keeping

Speaker 1 (10:18):

You away from clinical?

Speaker 2 (10:20):

Well, the thousand was during Covid. Cause I didn’t travel in, but they Oh

Speaker 1 (10:25):


Speaker 2 (10:26):

So it’s more like 800 when I travel

Speaker 1 (10:28):

Plus the inventions. So when you do these inventions, you come up with an idea and you have a team that helps you or just you and somebody? So

Speaker 2 (10:38):

Depends. Some of them, I joined, I guess somebody else who had the idea, just helped them from the clinical point of view, usability and things like that. And some of them were ideas that the robot is an idea that started from my head. Then I convinced some friends to join me. Some of them were engineers and some of them were people from finance. And we formed the company and I worked there one day a week and a lot more over emails and zoom meetings and stuff like that.

Speaker 1 (11:16):

Yeah, I remember. I think you found me at stages a couple of years ago and I was blown away with that. I thought it was great. Your invention was fantastic. I’m sure it’s even better now that you’ve had a couple extra years with it.

Speaker 2 (11:34):

It seems like what my theory is, right? Because the place where it really is seems to be very successful is India.

Speaker 1 (11:42):


Speaker 2 (11:43):

Yeah. It’s now started there. It’s being marketed by a very big company called Merrill. And yeah, a lot of, a lot of people want it.

Speaker 1 (11:54):

Yeah. I think the beauty of your instrument is there’s a lot we can’t do laparoscopically. We would like to, right. Laparoscopic surgery is less invasive, less scarring, cosmetically better. Short-term recovery seems to be easier for patients and so on. But we’re technically technological challenging, limited. It’s challenging. So the other option is to do things open surgery, and sometimes you have to do that, but then if you can find something that can take all your laparoscopic surgery and do it better, but all the open surgery and still be able to do it laparoscopically, then that’s kind of where your instrument falls in, which is really, really great. And then when do you often make the device as part of your group or do you sell your idea?

Speaker 2 (12:50):

No, no. Well, companies that I started or I was in involved with as a co-founder or as a advisor, you build a company to a certain size and then you either sell it or you go public or you sell. It’s, you can’t sell just the idea. It’s too not from Israel too far away and too small.

Speaker 1 (13:19):

Got it. So you have to get involved in production of at least a first generation of your product.

Speaker 2 (13:25):

Well, I’m involved. I don’t produce it myself, but I’ve involved, I’m involved in everything. Design, production, everything as a user.

Speaker 1 (13:37):

Got it. They’re just a question. Since we brought up MRI, if we can use noise canceling headphones in the MRI, I believe they do have noise canceling headphones that are MRI safe that the radiologists use.

Speaker 2 (13:56):

Yeah. But the noise there is really strong. It’s very difficult to cancel it. And it’s not only noise, there’s also vibration that your body heals. So

Speaker 1 (14:04):

Vibration sometimes heat. Yeah. Yeah. MRIs are difficult. I never figured out why it causes so much noise. Is that all the electrons moving in one direction or it causes noise?

Speaker 2 (14:14):

No, it’s the magnet. The magnets huge. Magnets rolling around.

Speaker 1 (14:18):

But why does that cause noise?

Speaker 2 (14:21):

It’s like a huge piece of metal running around you.

Speaker 1 (14:24):

Yeah, yeah. That’s true. Okay, so we have some questions that I’d like to go through. a lot of it, the question that were sent over have to do with robotic surgery. This one, I think you’re one of the best people to answer is what do you see in the evolution of robotic and laparoscopic surgery?

Speaker 2 (14:47):

You mean in hernia? In hernia or in

Speaker 1 (14:50):

General? Mostly hernia. But yeah,

Speaker 2 (14:53):

Because I think in hernia it’s important because I think in hernia, robotics will be more ubiquitous, cheaper. Sometimes there will be several robots that are more fitted to do hernia repair, some that are less fit to do hernia repair. So there’s going to be many options that are being much more cost effective. And I think therefore, in some form or in many forms, robots are still going to be here or for a long time, especially for hernia repair, they will guide surgeons how to do the operations safer. They will have a better brain. So it’s not going to be just a mechanical system or an electromechanical system that enables you to do complex motion. But it’ll also be like a co-pilot. It’ll tell you, watch out this, watch out. This is that don’t put, the Mesh is not placed right. You don’t have enough margin.

Speaker 1 (15:52):


Speaker 2 (15:52):

Nice. And so there’s, there’s going to be some brain behind it, not just, I think the surgeon will still be doing the operation. I think we’re very, very far from autonomous surgery. And also I don’t think it’s so bad, but I think both for the decision making and for perfecting your operation, you’re going to have a robot that’s going to be your, in a way, your copilot.

Speaker 1 (16:15):

Wow. This is kind of like with the cars, you can turn on a system where it tells you that you’re off the lane.

Speaker 2 (16:22):

Yeah. So it’s actually, I think the analogy is very good because there was a huge hype about self-driving cars. But very few people really use self-driving cars for doing the entire thing. And there’s been a lot of questions about self-driving cars, the ethics and the liability thing. So I think the same goes for robots, but they will have, there’ll be a lot more assisted driving. So it’ll keep you in lane. It’ll warn you if something bad’s going to happen. Yeah. It’s suggest to take a different route. It’s going to be, it’s very, very similar to a very good, not self-driving car, but with assist. Very good assisted driving.

Speaker 1 (17:07):

Yeah. I mean my car not you can turn on or off. I turn it off because the steering wheel kind of shakes if I’m over a line. But yeah, if I’m making a turn and it thinks I’m going straight to an object, make him, it’ll stop you. Yeah. Yeah.

Speaker 2 (17:24):

It’ll even stop you.

Speaker 1 (17:25):

Yeah. If I get too close to car, it’ll stop me. Yeah, absolutely. I’ll stop you.

Speaker 2 (17:29):

So in a way, think of it.

Speaker 1 (17:32):


Speaker 2 (17:32):

Point. Robot. Robot, no matter, no matter what kind robot, if it’s connected to the visualization system, which most of them are, could be your, you’re a very good could

Speaker 1 (17:45):

I like that surgeon. a lot of the hernia surgery that the Mesh is poorly placed. I kind of like that. Maybe there’ll be a standardization that the Mesh needs to be higher or lower or it’s too wrinkled. Dissect more or it’ll

Speaker 2 (18:03):

It’ll mark. It’ll mark the area that you should cover should put it.

Speaker 1 (18:07):

Oh my god. What do you think of the us some US surgeon’s addiction to the robot? I feel like they can’t do anything unless there’s a robot nowadays.

Speaker 2 (18:19):

Well, it’s problematic when people come up and tell me robots will be, so they say smartphone started like that too. Used to be very, very expensive. Only very rich business people could afford a smartphone, a cell phone. And then it became so ubiquitous. But the first smartphone was around in 2007 and the first robot was around in 1999. And the robots hardly change. I mean they’re better, but the actual configuration of the robot, what it does, how it works, and the cost is only increased. It didn’t decrease. So it’s not the same story as the smartphone. So I think that being dependent on a robot makes you in a way a little crippled. It’s like having a car not be able to walk.

Speaker 1 (19:12):

Yeah, good point. Good point. Here’s a similar question in the same line, again, talking about the robot. So we’re talking about some type of machine learning, I guess with semi-autonomous surgical, surgical robots. I like how you call it copilot. So what do you think are some of the challenges, not technologically, but maybe ethically. Are we going to be training residents that don’t really know how to operate? If there’s a complication and there’s bleeding and you have to convert to open, do people not know how to do that anymore? That’s one of the concerns we have as people involved in residency training.

Speaker 2 (19:58):

So I think that that surgical training should include being able to deal with catastrophes in all ways that will be appropriate for the specific situation. So I think surgeons in training should be also trained in trauma, not because they’re going to be trauma surgeons, but because they can learn how to use how to deal with catastrophic events during elective surgery.

Speaker 2 (20:27):

I even encourage people who train with me to do a rotation in transplant surgery because there you learn anatomy extremely well because it’s very, very extensive operations and you learn a lot of techniques of exposure. And I think about the question that was there. So you can actually automate some parts of the operation or make them make semi, I wouldn’t make it same. I wouldn’t call it, I think it’ll be more guiding systems, defining no-fly zones in your working field. And this we are very close to, I think probably five years we’re going to be seeing very good system to show you there’s already systems out there, but specific for specific cases for laparoscopic cystectomy that the systems that show you whether you achieve the right view to safely clip and cut whatever you need to clip and cut in laparoscopic cystectomy. So I think this is going to be round and does not. And it does not necessarily have to be a part of a robot. It could be just a part of your camera that’ll have the brain in a robot. It can also limit your motion camera. Just if you connect the camera to AI, it’ll tell you, don’t go there. Don’t go there. But it can’t stop you. But a robot can actually stop you from going there.

Speaker 1 (21:55):

Yeah, it’s so interesting. My first car that I had that actually was somewhat smart, it would beep if there was something nearby, they don’t hit it. I wasn’t used to hearing the beep and I didn’t see that there was this one mirror jutting out from the wall. And as I was coming backwards with the car, it would start beeping, beeping, beeping, then beeping got louder and faster until I eventually crashed into this little mirror because I just ignored it. I didn’t even know. But the car obviously knew better than me based on the sensors that it had. Now your brain is trained to listen to all the different alarms that you have both in cars and other things really quickly. One of the questions that are live again talks about the MRIs. Do earplugs. I don’t know if you’re the MRI specialist. No, maybe you can answer this. Do earplugs reduce noise or just aggravate volume by bone conduction? Oh, they give me earplugs all the time. It actually reduces the noise because they don’t conduct, they’re like little foam pieces. Yeah,

Speaker 2 (23:08):


Speaker 1 (23:10):

Okay. Going back to your own invention, here’s a question. Are there enhancements of conventional laparoscopic instruments which is basically similar to your

Speaker 2 (23:23):

Human? That’s exactly my device. Yeah, it’s right. What is it? This slide is exactly the description of our device.

Speaker 1 (23:30):

Yeah. It retains the advantages of robotic surgery. It increases degrees of freedom from typical laparoscopic instruments. I don’t know about the 3D visualization. 3D

Speaker 2 (23:41):

Visualization you can buy separately. There are systems that are 3D that are separate from robotic systems.

Speaker 1 (23:48):


Speaker 2 (23:49):

I use them.

Speaker 1 (23:50):

Motion scaling, increased precision, that’s all of what yours use and reduces the costs.

Speaker 2 (23:57):

So our system costs, you can buy 25 systems of our systems for the cost of one big robot. So the answer is yes. And I’m sure that our system is not going to be the only one there. We just started. So I think good ideas tend to be spread.

Speaker 1 (24:19):

Yes, that’s correct. That’s so true. AI is a big deal right now. We’re talking about AI taking exams and writing reports and so on. What’s your thoughts about AI and assisting surgery?

Speaker 2 (24:36):

So this question is about augmented reality. And augmented reality has been now routinely used for many cases because for instance, when you use a fluorescent system that shows you near infrared light that you can see and it’s over cast on your screen, this is actually augmented reality because you are seeing not the reality that you can see with your own eyes, but you can see another layer of a near infrared light that can show you fluorescence, that can show you important structures in surgery and highlight them so you don’t harm them or that you harm them if you want to harm them. But you know exactly where they are. So they can show you bile ducts, they can show you ureter, they can show you all kinds of things. And I think more and more of these technologies come into their market. There’s something that’s called hyperspectral analysis.

Speaker 2 (25:30):

Hyperspectral cameras, they show you a very wide range of the unseen spectrum. And from that range you can pick different wavelength that show you and highlight different things. Nerves, for instance, is an important thing for blood vessels within fat or disease tissue like cancer cells. And that is already coming into the market soon that some of it is already there. So I think yes, we’re going to be using movement, reality and a lot of it. So basically if you think of it, technology enhances what, we have three things that work while we perform surgeries. So we have the same thing, which is usually our eyes. Some of it is tactile sensing. We have the processing, which is our brain, and we have the actin, which is our hands and our tools. All of these could be enhanced with technology. The sensing could be enhanced with tech, better tactile systems with better cameras. The processing could be enhanced with ai, which will act as some kind of a co-pilot. And the performance, the actual, the action can be enhanced with different robotic systems.

Speaker 1 (26:46):

I know there’s augmented reality that’s used for detecting cancer. So that the tumor that you remove, let’s say colon resection, you make sure that you’re within a certain range of tumor cells that you wouldn’t necessarily see with your eye that may be submucosal and so on. When I was at USC, I started a project on image-guided surgery because they do it for neurosurgery, brain and spine. But I had not leaked over to general surgery and I really thought that would be the next thing. But then I left the university and handed that off to others. But I always say if I’m in the operating room, I’m looking for something. It would be so awesome if I knew where I was based on the CAT scan or the MRI. Tell me exactly, do I make a left? Do I make a right.

Speaker 2 (27:32):

So there are systems now. Yes, there’s a beautiful project that started in France and slash that’s called a visible patient where you feed the CT scan or the MRI of the patient into the system and then you can project it in real time during surgery on the screen and use augmented reality. It’s still difficult to do, but think we’re going there. So you’re going to be working with augmented reality showing you vital organs or tumors within your visual fields when you work. So yes, it’s going there.

Speaker 1 (28:08):

Yeah. The hiccup we had was that for spine and brain, those don’t move with breathing or heart beating.

Speaker 2 (28:19):

Yeah, they’re They’re rigid. Yeah.

Speaker 1 (28:21):

So we start with a vascular model because that’s also less likely to move around. But intestines and liver and all that, they move a lot. So that was kind of the issue of trying to correct for that, the movement factor in real life. Here’s another question and it says, how should a surgeon decide if it’s worth learning a new technology and especially those that are not really widely adopted. And then how do we determine whether it’s worthwhile? Because just because there’s new technology doesn’t mean that it’s worthwhile to move forward with it. What are your thoughts about that?

Speaker 2 (29:04):

So that’s actually a very, very good question because in one hand, surgeons want to be updated and move forward with technology. On the other hand, surgeons are usually pretty conservative about, especially if they do something very well. Yeah. So there’s always a 10. There’s always a tension between these two tendencies, one’s to progress and the other is to abandon something that they do very well or something that possibly will help you do it better, but only possibly. So the thing is that data accumulates by studies. Surgeons do studies, surgeons go to meetings, surgeons share information between them and they figure it out together. But it takes time. So many things that started and somehow died. There was a big high and they died. There was a lot of, a lot of things, stuff about transluminal surgery, removing the gall bladder through the stomach and removal the bladder through the vagina and all crazy things that were done 10 years ago.

Speaker 2 (30:13):

And it was completely abandoned. Although patients were operated and some of them were very happy. But because it was cumbersome and didn’t show a very big advantage and was not pushed hard. So it sort of died away. But in a way that the robotic surgery is very appealing to patients because it sounds like you would expect from watching science fiction movies and from looking at robots making cars and production lines and robotic systems in space, you expect robots to be much more precise and much better. But what we’re using is not really a robot, it’s a system. It’s like a very expensive car with a driver. The driver is stupid if the driver is bad. Currently the robotic systems will not help him become, if his decision making is bad, it wouldn’t help him do any better decisions. It’ll just help him to do bad things more precisely.

Speaker 1 (31:19):

That’s very true. One of the things, was it you that brought up the question of whether we be more tolerant of a human surgeon making a mistake versus a robot making a mistake? I

Speaker 2 (31:34):

We’re. But we’re, because as a society, because we are human and because we sympathize with other humans and we understand how it is to make an error because we make them ourselves, we are very tolerant to human error because we live in human error all the time. But we’re completely intolerant to machine error. And it’s also that they’re all, they’re very difficult questions to answer, especially liability. For instance, if a robot tells you, I’m not even saying about MA does but only gives you advice to do something in surgery based on a hundred thousand procedures and it’s still wrong, who’s liable? And you make a bad decision because of suggestion of movement or strategy during surgery based on millions of operation analyzed by AI. And you’re making that decision using that. Who is liable? You are. Or the system or the programmer? The guy, the code writer who wrote the code. Who the company that makes the computer. Yeah. Who’s liable? Who takes responsibility for that? So our society and our legal systems and our ethics are left behind by technology, mean technology moves forwards much faster and the pace is increasing, leaving the changes that we have to do in our legal systems, in our education way behind. And we have to adopt everything to that quick, much quicker. Legislation, politics, policy, make, policy making education should change according to technology.

Speaker 1 (33:24):

What’s the status of robotics? Not just robotics but advanced technologies in just everyday surgical care in Israel,

Speaker 2 (33:33):

It says advances everywhere else, but we are much more careful about resources. So it’s much more controlled. It’s just not just an open market. And most of medicine in Israel is not for-profit.

Speaker 1 (33:48):

Got it. It’s socialized government based.

Speaker 2 (33:51):

It’s not exactly government based, but it’s the insurance there. There’s a national health insurance and there are two layers above it that are semi-private and private insurance that you can to complement it. But basically everybody in Israel is covered, well, covered very well. Then there’s no, including complex surgery and advanced medications for cancer and advanced therapy and everything. But if you want to, for instance, you want to choose your surgeon or if you want to go to advance your hospital, that’s an extra buck or better insurance. But there’s no such thing as somebody without very good basic insurance.

Speaker 1 (34:32):

So you don’t have to keep going bankrupt for healthcare reasons.

Speaker 2 (34:37):

Zero. Never. Yeah, ever. Never.

Speaker 1 (34:42):

So let’s go back to hernias because that’s what we do with our audience is mostly interested in hernias and so on. You mentioned the potential future pro projects with advances in hernia surgery. Well, one is your human extensions because similar to the advances in robotic surgery, we’re now able to do much more advanced operations that we were not able to do before. And that allows for better hernia surgery, shorter recovery time, less wounds to heal. And those of us that do robotic surgery found that there’s a specific segment of the population or segment of the surgical techniques that do much better robotically. And so I still do laparoscopic surgery. In addition, I don’t do a typical Anglo hernia robotically. And one thing that I like about your instrument is I’m not a big fan of these big eight millimeter incisions of the robot. I use five millimeter and in some patients three millimeter.

Speaker 2 (35:45):

Me too, me too

Speaker 1 (35:46):

Instruments, you don’t need big incisions and big incisions can cause ugly scars and potentially hernias. So that’s one of the drawbacks I feel is with these highly advanced technologies is you lose some of the delicacy and daintiness of that I like about surgery.

Speaker 2 (36:07):

I agree. I completely agree. And also for me, it’s also time saving not to use a robot. Cause I operate much quicker without a robot, both because of the docking and the undoing and the whole logistics around it and the actual surgery. It slows me down. Actually actually performing surgery, it slows me down.

Speaker 1 (36:25):

Yeah, yeah, I would agree with that. But your instruments are a five millimeter at this time, is that correct?

Speaker 2 (36:32):


Speaker 1 (36:33):

Yeah. Great. That’s fine. You also mentioned the self-adhesive Mesh. How is that more beneficial than the prog technology?

Speaker 2 (36:46):

Not mechanical. So in the program technology, there’s a lot of one, there’s a lot of tissue reaction around these little hooks that hold the Mesh in place. And I found meshes that stick to the surface using these little hooks like Velcro and car tissue grows around these little hooks like the Velcro hooks. Got it. And then I think that in some patients it can cause a lot of scarring, very heavy scarring and some pain. So I’m not very big fan of self condition. And also for the surgeon, there’s sometimes cumbersome to use to open and put in place and move after very cumbersome place. But there’s, there’s definitely room for that. But I don’t use this stuff so often is the idea is this Mesh is thick to a very small degree, so we can still move it around and then you do something to actually fix it in place with different chemicals or light or something like that. And it’s much more biological.

Speaker 1 (37:51):

Got it. So the glue part doesn’t activate immediately. You have to Oh

Speaker 2 (37:54):


Speaker 1 (37:55):

Turn it on somehow. Yeah. After you’re confident in the place.

Speaker 2 (37:59):

Yeah, that’s the idea.

Speaker 1 (38:02):

Is it? Yeah. There’s some idea that having the entire, from a phasix standpoint, having the entire surface adherent is better than the way we used to do it, which was you put sutures and specifically tack areas and then allow hope that the rest of the Mesh integrates. What are your thoughts on that?

Speaker 2 (38:25):

I think that that surgeons are thinking in very mechanical, simplified mechanical thinking. And they are not aware of the amazing powers of our body to fix things and by itself. So I think if the reaction to the Mesh is good and there is fast incorporation of the Mesh, it’s incredibly strong and very quickly, much quicker than we expected. So I’m not sure that you need to really fix the entire surface of a Mesh to the abdominal wall. This, it has never been proved to my knowledge. And I think that if the Mesh is made from a material, and that’s something we need to work on, if the Mesh is made from the material, it incorporates well into the body, but still maintains the strength for a long time, that’s something that will work much better than any fixation. If the Mesh is big enough. And that that’s actually something that, that’s one of the technologies that I think we’re still way back, which is Mesh because we’re using, I think that in the US there’s a lot of, there’s overreaction to Mesh and there are a lot of people making an interest for people not to meshes because they, they’re involved in lawsuits and they can make money.

Speaker 2 (39:57):

And so I think the fear from Mesh is completely exaggerated. But I think that the meshes with yours are not ideal.

Speaker 2 (40:05):

They create foreign body reaction. They cause pain. Sometimes the scar tissue and it’s not because only of the Mesh, it’s also be, it’s very, very patient dependent. So some patients with the exact same Mesh, that’s correct. They Mesh some patients would cause terrible scarring and will suffer from pain. And some patients will be perfectly incorporated. Although the technique and the Mesh are exactly the same. So meshes are something that we need to work on. I, and I don’t think that biological meshes, the current biological meshes are good enough because they slowly become scar tissue. And scar tissue is weaker than normal tissue. What we should, yes, I try to invent is a Mesh that will completely mimic normal healthy fascia or normal healthy muscle and we’ll cover a defect.

Speaker 1 (40:58):

So do you predict what we’ll be moving away from permanent implants?

Speaker 2 (41:03):

I think we’ll be moving, I will be moving to other permanent implants that will be a permanent biological scaffold that will be replaced by human, by our tissue. But that we can control what kind of tissue will be there.

Speaker 1 (41:23):

I don’t know if you remember when lifestyle first came out with AlloDerm back in like 2000, 1999, 2000, that was their thing. Whatever you sew it to, this will be a scaffold and then your body will

Speaker 2 (41:38):

Start. But it doesn’t

Speaker 1 (41:39):

Infiltrate. It never did. It never did. But you’re predicting that at some point we may be able to regenerate tissue by providing a scaffold

Speaker 2 (41:49):

That’ll have something in it that will, that’ll make your body build the actual wall that you need there and hopefully it’ll be even functional

Speaker 1 (42:02):

And functional. Yes. What are your thoughts about future synthetic Mesh implants? Newer products. Newer materials?

Speaker 2 (42:16):

So there are some products already that are just not approved in the US that are much more friendly to human tissues that are synthetic. But currently they’re only available in Europe and Asia. Not in the,

Speaker 1 (42:32):

Like the P V D F?

Speaker 2 (42:34):

Yes. I think it’s a much more friendlier synthetic material doesn’t, carries a lot less aggressive scar tissue and very nice thing in growth. And very important thing is bacterias don’t speak to it. It’s like if it gets infected, you can give the patient antibiotics and it’ll keep the Mesh in place.

Speaker 1 (42:57):

Yeah. I was told DynaMesh that makes the P V D F, which is the brand of the P F P V T F Mesh out of Germany that’s being used in many parts of Europe, maybe also Asia. They tried to penetrate the US market. It just was too onerous.

Speaker 2 (43:15):

It’s very difficult to penetrate the market because there are some giant companies that are, that actually own the entire area and they’re difficult. I use it extensively.

Speaker 1 (43:26):

You use the Dyna Mesh?

Speaker 2 (43:28):


Speaker 1 (43:29):

Is that your primary Mesh that you use?

Speaker 2 (43:32):


Speaker 1 (43:33):

And having used the prior polypropylene and maybe even polyester meshes, how as a surgeon, how does it feel differently working with the PV D F Mesh

Speaker 2 (43:46):

As in terms of the actual handling? It’s like it’s very much polypropylene, but the post-op behaves differently.

Speaker 1 (43:55):

Really? They’re not as swollen. Yeah. Locally.

Speaker 2 (44:00):


Speaker 1 (44:01):

I feel that, well it’s being proven nowadays that some of the current polypropylene meshes are using resins that have a lot more impurities than the polypropylene Marx resin that was originally used. I wonder if that’s a reason why we’re seeing so much more inflammation and local pain from hernia repairs that we didn’t see before.

Speaker 2 (44:27):

I think also that it, it’s, it’s a little details that make a difference if the Mesh is woven or not woven, for instance. Cause it’s woven, it contains a lot of small little fibers and each of these fibers sort of creates its own inflammatory reaction around it. And the bacterias can hide between these fibers.

Speaker 1 (44:50):

You think sheets are better?

Speaker 2 (44:53):

No, not sheets. But when it’s not, you can create a non-moving method, which is made of compressed Mesh compressed. So it’s not really move, I believe, but I don’t think it is when it’s been shown in labs. But I don’t think that it was shown clinically to have an advantage. But I think a big advantage except for robotics, what we really need as the next big step for hernia repair would be better tissue replacement.

Speaker 1 (45:24):

Yeah, I agree with that.

Speaker 1 (45:27):

I agree with that. I remember, I don’t know if you remember the American Hernia Society, we used to have these debates called the great debate or the great Mesh debates. I forget which term we used. And one year we had, each company was represented on a panel. So there was this surgeon that spoke on behalf of Gore. There was a surgeon that spoke on behalf of Bard at that point as Ethibond and so on. And I think, oh, before cavi, I think it was US surgical and presented why they think their Mesh is better. And I was the like the host. And I said at one point, this is a long time ago, I’m going to say it’s probably 2006, maybe five, something like that. I said at one point we’re all going to tell our grandchildren. Yeah, it’s crazy. We used to put plastic in people and we thought that was okay. And my prediction was that we were going to move towards a more natural products to implant and kind of use your own body’s

Speaker 2 (46:42):

Body it. But think of it, we use it, we use tooth fillings for the last century. They’re hardly changed. We use joints joint replacement that are still made of metal for the last 30 years.

Speaker 1 (46:59):


Speaker 2 (47:00):

They’re better, they perform better, the operations are better. But essentially we implant the same. And when you implant a need, it’s probably the weight of like 500 meshes

Speaker 1 (47:14):

And Yes, correct.

Speaker 2 (47:16):

So we are using artificial materials for materials, but we can probably find very, very sophisticated compound materials that will work better or will resemble much more in materials around our body.

Speaker 1 (47:34):

Yeah, I’m very hopeful because you may know my practice, it does cater to people that have had complications from hernia repairs. And as part of that, I’m seeing people that just in general are having a much more difficult recovery from hernia repairs than they used to. And also that we have people that their body is just reacting to whatever’s being implanted into them. Whether that’s a environmental thing or the actual product or the Mesh may be impure, we don’t know. But I’m seeing much more of it and it’s just not right. It just doesn’t, doesn’t not right to me to implant a product that I’m not sure is approved in its current state. It may have been at one time, but things may have changed. And I’m very uncomfortable with that.

Speaker 2 (48:32):

Well, I agree, but I still think that using current meshes is better than having a 30% recurrence rate.

Speaker 1 (48:46):


Speaker 2 (48:47):

Still most of the patients where you implant a Mesh, you do it the right way and you don’t fix it aggressively and you do the right dissection, they’re very happy. Most of the patients are very happy because you cater to complications. You see a lot of them. I see

Speaker 1 (49:03):

A lot of it’s completely,

Speaker 2 (49:05):

I do the same, but it’s disproportional to the number of patients that are really happy and never come back.

Speaker 1 (49:10):

Yeah. Yeah, that’s very true. One of these questions came up as we were going to start, I want to talk about it about not necessarily fixing hernias but actually detecting hernias. I misspoke earlier about augmented, about artificial intelligence, talking about augmented reality, but maybe artificial intelligence can help better detect hernias, at least on imaging. I know there are some discussions about using AI to be like your radiologist. What do you think about that?

Speaker 2 (49:48):

So first of all, what I think about is that 99% of hernias could be diagnosed without any imaging. True. It could be diagnosed by an experience doctor who knows how to examine a patient, talk to a patient and examine the patient. And in these cases, you don’t need any imaging. The imaging is needed when you are not sure that what causes the patient’s complaints, which is mostly pain.

Speaker 2 (50:21):

And then you send the patient for imaging to find reasons why the patient has pain that are to what you find on your physical examination. So if you don’t really palpate a hernia in all techniques that you learn how to palpate a hernia and the patient has a lot of pain, you need to know why the patient has pain. And then you send to imaging. The problem with ultrasound, unless you perform it yourself, which I think is a good idea, is a very good idea, is that it’s very, very operative dependent. So yeah, whoever is, and you never know if the guy who did or the person who did the ultrasound is trustworthy or are they good and who understand the real anatomy, especially in the groin of the understanding anatomy. So when I am not sure, I don’t send my patient to ultrasound. I send them either to CT scan or MRI. Yes. In Israel. In Israel we have a program that you can also send a patient for MRI on exertion, MRI, so

Speaker 2 (51:22):

You can show better hernia. And I surgeon myself, I need to learn how to look at this. And AI can help you because in these circumstances it can give you, because these are all things so can give you hints about what you’re seeing and what the thing is that growing pain, especially in young men, is an issue. And many times when there’s a very tiny hernia, you fix it, the pain doesn’t go away or even increases. And you have to be very careful with patients, even if you’re a patient, if you have growing pain, to make sure that you’re sure that the operation is actually going to help you because a very, very small hernia. That’s right. It’s not life threatening. It’s only in, it’s the only issue here is quality of

Speaker 1 (52:17):

Life. Yes. You’re not saving your life. Absolutely.

Speaker 2 (52:20):

So you have to make sure that an operation or a procedure will improve your quality of life. Cause sometimes it can worsen it.

Speaker 1 (52:28):

Very true. Which is why I’m, I’m not, I’m a big proponent of watchful waiting, especially for these patients who have no symptoms. I don’t agree that, well, you’re going to eventually need the repair done, so let’s just do it now. I think it would be, I tell

Speaker 2 (52:42):

My patients, it’s your choice. I tell my patients it’s your choice. It’s not. Yeah. If it’s going to be big, it’s going to be a bigger operation. So I have to consider that and make your decision when you’re ready for surgery, come back.

Speaker 1 (52:57):

That’s right. And what percentage of your is hernia related?

Speaker 2 (53:03):

Probably about 60%.

Speaker 1 (53:05):

Wow. That’s wonderful. Okay. I have an idea that I would love for you to be able to figure it out because you have the smarts and the team for it. We need to figure out a pain sensor. I’ll give you an example. People say they have pain, whatever. Then I take ’em to surgery. And I think based on my physical exam and the history and the imaging that their pain is from, let’s say a Mesh that’s balled up or a nerve that’s entrapped in scar tissue, I would like to know when I can stop operating. In other words, when did I address the pain? So for example, triple, I don’t think we need to do every single nerve cut. When do I know that I’ve addressed the pain by, let’s say the nerve in question and I don’t have to start looking for other reasons and do a much bigger operation. Maybe like a monitor that has a brain level scan. And then once I,

Speaker 2 (54:12):

But there’s there, there’s

Speaker 1 (54:14):

Goes down to zero. There’s already,

Speaker 2 (54:15):

There’s actually already something in this direction.

Speaker 1 (54:19):

Okay, tell me.

Speaker 2 (54:20):

But no, there is actually a way to beginning to be a way to measure pain objectively, or at least stem objectively. Yes. But it’s not a commercial product yet.

Speaker 1 (54:37):

But is that sounds doable where you know can kind of, okay, pain’s at 20 right now, and I cut this air, this nerve, let’s say, and it goes down to one.

Speaker 2 (54:48):

No problem. I got it. When you cut, the problem is that when you cut your nerves, these nerves, these patients are under some kind of anesthesia.

Speaker 1 (54:55):

So that’s true.

Speaker 2 (54:57):

And you’re blocking these nerves anyway. So essentially that’s true. So it’s going to be better to follow patients up before and after surgery, but during surgery is not, I don’t think it’s going to help you.

Speaker 1 (55:09):

I just feel like it’ll be so nice if we had a guide as to,

Speaker 2 (55:15):

I think otherwise we’ll be, for instance, to manipulate the nerve conduction externally by magnets, magnetic fields or shock, shock ultrasound, focus ultrasound. And then you can do it without surgery and go gradually and ask the patient, because this is not painful. Ask the patient, how is he doing now and how is it doing now?

Speaker 1 (55:38):


Speaker 2 (55:39):

I think this will probably, under MRI guidance, for instance, might be a good thing to do.

Speaker 1 (55:48):

Yeah. So many great ideas out there that need the idea. Then you got to be able to execute it and then it needs to be a financially solvent business plan.

Speaker 2 (56:01):


Speaker 1 (56:01):

A lot of barriers. But congratulations,

Speaker 2 (56:04):

Which is also good because then it filters out bad things.

Speaker 1 (56:09):

True. But congratulations to you for being such a great surgeon is so involved. I see it every single meeting that I go to, and then you’re operating so much so you’re helping patients on a one-to-one level, but more importantly you’re developing innovations that can improve care, especially hernia care as a whole. It’s just fantastic. I love it. If I could thank you so much. I don’t know if I could be, I’ll have the energy to ever be someone like you, but I think it’ll be an ideal life to have.

Speaker 2 (56:45):

But you’re, you do, you’re using other technologies like Zoom, for instance.

Speaker 1 (56:51):

That’s true.

Speaker 2 (56:52):

Yeah. You make it be a huge impact using a technology.

Speaker 1 (56:55):

Yeah, yeah, exactly right. Yeah, for sure. I think, I guess we’re all doing our own little part. I just love watching, right? The ideas come to fruition and then using it. I just think that’s a great cycle. So thank you for that. Yeah, I agree.

Speaker 2 (57:12):

Thank you so much.

Speaker 1 (57:13):

Yeah, I appreciate it. Okay, well everyone, that was a fantastic, fantastic hour. Hold on one second. That’s the end. Aki,

Speaker 2 (57:30):

Thank you so much.

Speaker 1 (57:31):

Thank you. And thanks to everyone who logged in live and those of you that are watching later. Thank you all for joining me on Hernia. Talk. Live. We have guests from all around the world every week. Please follow me on Twitter and Instagram at Hernia doc and on Facebook at Dr. Tofi where you can watch this video as well as on my YouTube channel at Hernia Doc. I will have another fantastic guest next week, but I appreciate you. It’s what, 11 o’clock at night right now? Yeah, it’s definitely would’ve been past my bedtime, but I do appreciate your time. Thank you so much.

Speaker 2 (58:09):


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