Episode 30: Robotic Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Welcome to Hernia Talk Live. You’re here on another Tuesday, what we call hernia talk Tuesdays. For those of the me I’m a hernia and laparoscopic surgery specialist. You can follow me at Hernia doc on Twitter and Instagram. Many of you are joining us on Facebook Live on my homepage at Dr. Towfigh and once we’re done with this session, I’ll make sure that I share it with all of you on my YouTube channel this week. We have a fantastic friend of mine all the way from Ghent, Belgium, Dr. Filip Muysoms. He is a very talented surgeon. He is one of our very well known and well respected leaders in hernia surgery and he’s really become one of the world leaders in robotic surgery. I’ve had the pleasure of visiting him at his hospital in Belgium just last year before we were not able to travel, so I’m very happy to see you Felip, thanks for joining me.

Speaker 2 (00:01:05):

Hi there. Happy to be here.

Speaker 1 (00:01:07):

I know that we have viewers also from Europe, so we changed the time for this hernia. Talk a little bit earlier so that I don’t have to interview at four o’clock, three o’clock in the morning, but also it’s still late at your time. It’s about what, 9:00 PM?

Speaker 2 (00:01:22):

Yes, 9:00 PM I hour changed the last weeks.

Speaker 1 (00:01:27):


Speaker 2 (00:01:27):

Summertime, wintertime. So it’s a bit confusing at the moment.

Speaker 1 (00:01:31):

Yeah, we fell back one hour too, so thank you for joining me. Dr. Muysoms is a general surgeon in training. When did you start using the robot?

Speaker 2 (00:01:44):

So actually September, 2016 actually I’m been a hernia surgeon and visiting congresses, being in boards of the hernia society for for almost two decades now. Yeah in 2016 I visited the American Hernia Society and seeing the use of robots by hernia surgeon, which before that I would never have thought that I would embark on that, but because my hospital bought a new robot recently and they had access time and they actually asked if we had any value for it. So one and one is two. Me being a hernia surgeon, seeing what they do in the US started doing hernia surgery with the robot, getting trained in a proper way getting proctored by some well known US surgeons during the start and really looking also on a scientific level trying to find out how does this robot potentially benefit surgical care for hernia patients. That’s right. That’s the goal and that’s the trajectory. We are now, what is it, four years? Four years later and I think we’re almost halfway. We still have a lot to prove but okay, we are working on it.

Speaker 1 (00:03:16):

So the robot we’re talking about is the Da Vinci robot. It is a product of intuitive surgical. It’s actually a company in my state of California a couple hours north of where I live, which is pretty cool. The CO is a really cool guy. He’s an engineer and what I heard is that he actually wrote all the code for this very complicated robotic platform which we use for surgery. I started getting trained in it in 2013 and it really penetrated the US market first before it moved on to the European market. It’s very expensive and so it’s often more difficult to introduce the more expensive technologies in more of a socialist type healthcare system like the Europeans have. But your hospital is very nice. I really liked it. It’s very beautiful. You walk in, it’s very open and white and bright. It doesn’t look like a hospital. Looks like a really nice

Speaker 2 (00:04:20):


Speaker 1 (00:04:21):

Yeah, it’s not as warm as a hotel, but it’s not as cold and impersonal as or weird as a hospital. It’s very nice. What’s the name of your hospital?

Speaker 2 (00:04:35):

It’s called Maria, which is a Dutch name of the St. Mary. So it’s derived from a Catholic organization

Speaker 1 (00:04:47):

And it it’s very beautiful. Very nicely run, very efficiently run. I was taking videos, you remember I was videotaping how efficient your operating room was. I think we did seven operations in one day including

Speaker 2 (00:05:04):

Emergency. We do have amazing turnover times which yeah, I do a lot of case observation. That’s a remark we get every time. So I had, that’s everybody that’s nursing and anesthesia, even the cleaning people that’s just the way, it’s a working environment, which it’s not always like this in Belgium or in Europe. It depends a lot of where you work, but I’m looking to work at the place where the dynamic is such that everybody’s proud to have a good turnover and a good efficiency level and it’s not a coincidence that the two leaders of the hospital, director of the board and the director of the hospital are both engineers. So they are really also for them. It’s also if engineering tools, if new technology comes into the clinical practice, that makes them a bit proud. So it’s a bit easier to convince them to use new technology.

Speaker 1 (00:06:08):

So just to clarify, the robot is a technology similar to other technologies like endoscopy, laparoscopy, et cetera. You are still doing the operation. Can you just talk about the transition from laparoscopy to robotics and how much control you have over the operation?

Speaker 2 (00:06:29):

So basically what I always say it is laparoscopy. So I always, if I write a letter to a general practitioner of our, I now an operation, I say robot assisted laparoscopic surgery. It is laparoscopic surgery, but you use a different tool. So the difference obviously is that in conventional laparoscopy you are standing next to the patient, you are holding the instruments in your hands and the camera is handled by another person, which is usually your assistant or resident. While when you are in the robot, you are controlling the instruments but indirectly through the robotic platform. But still you are in control. The good thing is that you’re not only controlling your two instruments, you can even add a third one if you want because you have four arms and you can also at the same time control the camera. So you are much less dependent on other factors, which the flow of the operation becomes different, but you’re still in control of everything. Every motion is controlled by yourself As a surgeon obviously that’s one of the mistakes. Sometimes you see patient, they say, oh, I don’t want to be operated by a robot. That’s a mistake. You could call it a master slave relation. So the surgeon is the master controlling the, it’s not that good comparison, but the robot really does what you want it to do. But it takes of course some training to get to a level where you become firstly proficient, firstly safe, and secondly proficient. Obviously that’s true.

Speaker 1 (00:08:18):

Yeah. So I have also patients that say things like I want you to the operation, I don’t want the robot to do it. And you’re right, actually we have more control over the entirety of the operation with the robotic platform than with laparoscopy. Because with laparoscopy have at least one other person involved to hold the camera at the least and you only have two hands. You can add extra hands, but that’s an extra person whereas you can manipulate the camera and all the instruments. And then what I found, so I was initially not a big robotics fan before 2013. There were multiple opportunities for me to get involved in it and I just didn’t do it because I’m kind of a purist and I was really good at laparoscopy and I felt that the robot was for people that weren’t really good laparoscopically. In other words I felt that I don’t need the robot because I can do everything laparoscopically.

Speaker 1 (00:09:26):

And that idea changed when I saw that the robotic platform allowed me to do operations that I actually couldn’t do laparoscopically. I didn’t know about that until more surgeons started using the robotic platform for more advanced operations like an Inguinal hernia. I still prefer to do those laparoscopically. I think the scars are prettier and smaller, but Mesh removal, we looked at our studies doing Mesh removal is much better outcome we feel with the robot than laparoscopically because they’re all these really intricate procedures like the femoral vein and so you have to take the Mesh off. The optics you get from the robot is so much better than with laparoscopy, even though we have, I think we have 4D now with laparoscopy, but with the robot it’s still much better. It’s working with a microscope. How do you feel about that? Do you also feel like that’s been one of the booms of robotics is it makes you do more than you could laparoscopically even if you’re like a fantastically gifted laparoscopic surgeon, which you are?

Speaker 2 (00:10:45):

Wow. Firstly before I went on the robot, I had the same feeling. I’m a laparoscopic surgeon, been like that for since two thousands and actually I trained a lot of people doing laparoscopic groin and people would come and visit me to see how we did that. So I was well proficient in that. But still looking at how you do it robotically with the enhanced visualization, the rested instrument, it still takes you to the next level and basically there’s another factor that it is difficult in a straightforward groin hernia to prove probably that you are benefiting the patients because the patient are doing so well after conventional laparoscopy as well. Yes, but indeed there are these cases when we looked at our data, I keep track of all my data in the registry and I saw a decline of open surgery from about 17% in about these three years to about 6%. And that is indeed these patients that we would do open after prostatectomy mash removal or recurrences after previous smash large scrotal hernia. These are hernias that I would take open and we are now taking them robotically, totally minimal invasive and that’s probably where for groin hernias there is a benefit for the large incisional hernia. The gap is wider wide because as you said, we are doing now wide incisional hernia, minimal invasive with the robot laparoscopic,

Speaker 2 (00:12:32):

Which we couldn’t do, which before we did open. So in these patients there is a hospital stay that goes from almost a small week, five six days goes down to about one to two days. And that’s what happens when you take them minimum invasive and that is very difficult or never say impossible. There are some wizards in the world doing that laparoscopically. But yes most surgeons cannot do that very well laparoscopically and the role of platform helps them to do that.

Speaker 1 (00:13:07):

Very true. We have a live question. This patient had bilateral al hernia with Mesh done laparoscopically. He’s now considering, I assume he now considering removal of Mesh and the surgeon recommends that the Mesh removal will be done robotically, but he had read that the removal surgery should be done the same way as the placement. So if he had laparoscopic Mesh Mesh placed, the removal should be done laparoscopic. And when you have an open Mesh place, the removal is also done open. Is it standard to have the removal done with a robot if the original surgery was done laparoscopically? And then what’s your answer to that?

Speaker 2 (00:13:47):

Well, basically the thing is that if you do laparoscopic surgery with Mesh, your Mesh is behind the muscles. So if you’re going to redo that open, that’s going to be very difficult because you have to go through all these muscles to arrive at the Mesh and your view is not well. So if Mesh removal in the pre plane, so behind the muscles is needed, certainly laparoscopic approach is better. The difference the distinguishment this patient has to make is that robotic surgery is laparoscopic surgery. Yes. And if somebody proposes, we want to do this robotically. The reason why this surgeon say we want to do robotically is because of the platform he has or she has better view, better visualization. He has wrist and instruments better control of the operation of the operating field to remove that Mesh. So removal of a Mesh that is placed laparoscopically if you have availability of the robot, that would certainly be my choice. And robotically robotic surgery is laparoscopic surgery?

Speaker 1 (00:15:02):

Yes. So the way I think of it is they’re perfectly interchangeable. Every single operation that’s done laparoscopically can also be done robotically. The size of the incision may go from five millimeters to eight millimeters. In some situations the placement of the incisions may be a slightly higher up or further to the one side with the robot then with the laparoscope. But in general, they’re both considered minimally invasive operations and they’re both considered to have usually better outcomes, either shorter recovery time, less pain or better long-term results than their open counterparts. So as surgeons, we’ve especially general surgeons, hernia surgeons in general of course there are exceptions that everyone think has to be tailored to the patient. In general, if you can do something minimally invasive which is either laparoscopic or robotic, then that tends to cause less injury overall to the patient and their healing is easier than open. So if someone says laparoscopic or robotic, we do use those terms sometimes interchangeably because the technique is very similar. The other question that this patient is asking is they would want to stay away from the hospital and the robot is in the hospital and they prefer to stay in a surgical center setting. What are your thoughts about, do you have robots in surgery centers?

Speaker 2 (00:16:44):

No. Well, in Belgium we have hospitals and we have nothing outside of that. You do have for certain niche like plastic surgery or eye surgery, sometimes you have centers that are outside of a hospital or separate from a hospital. Yeah, plastic surgery because it’s not reimbursed. So patients face everything while all the other surgery is usually done inside a hospital, which can be a daycare facility. So patients come in and they don’t have to sleep there, but it’s still without within the hospital building usually. So we don’t have, certainly not in Belgium we don’t have any private healthcare separate from the regular healthcare really because oh you don’t, there is not really need for that. We have good quality I think, and there’s no waiting list. We don’t have any waiting list. And reimbursement is the same. You can go all over Belgium. If you want to have your grown hand repaired by a surgeon that is on the other side of Belgium, that’s your choice. You have complete choice of that. So there would be no value actually to invest in a completely private hospital environment in Belgium. That wouldn’t work. People would not go there. Why would they go there to pay everything themselves if they can get good care without waiting lists at another place?

Speaker 1 (00:18:23):

That is so interesting because the United States, it’s different. Obviously we do have socialized medicine. We do have certain government sponsored medical insurances as well as locally supported like county, what we call county hospitals. But most care is done in a private setting of some sort. And so the economics is very important, which is why we have surgery centers running a- doing the same operation in a hospital versus a surgery center. Because of the different ways they’re regulated and they’re staffing it’s much cheaper to do the same operation as surgery center. So oftentimes we prefer to do them surgery center because it’s kind of like a lower volume and less unhealthy people. The healthy people can often get patient surgery. And so we do at the surgery center, but a robot is very expensive. The robot, we have seven robots in at Cedar Sinai, I think we’re getting one or two more and the value is over 2 million per robot.

Speaker 1 (00:19:39):

The amount of operations you have to do to pay for a 2 million robot is ridiculous. There’s no way a surgery center can afford to buy a 2 million robot. So it’s very kind of financially lean compared to a hospital. So even though I’m pitching to get a robot from my surgery center, I think in the United States there’s less than a dozen in the entire United States, less than a dozen robots that are in a outpatient surgery setting. So yes, you would have to get it done. If you want robotic surgery, most likely you’ll have to get it done in a hospitalized setting.

Speaker 1 (00:20:20):

So the flip is not true though. So there are operations that pretty much can only be done robotically with few exceptions on surgical really technically gifted surgeons, but pretty much the above average and below to below average surgeon. There are situations where you cannot do it laparoscopically, but you can it robotically. And I think that’s been one of the benefits that I’ve seen in my practice. I’ll give you examples. So I patients with really wide hernias those are almost always done open, but there are techniques like the tar that can be done robotically. There are some sort of that do it laparoscopically. It’s very technically challenging to do so much manipulation, sewing, whereas sewing with the robots super easy.

Speaker 1 (00:21:20):

In my practice I remove a lot of Mesh and I also offer a lot of non Mesh repairs. So we just published our results of non Mesh inguinal hernia repairs with the robot because you can sew in this plane, you can sew the hernia closed with no Mesh for Anglo hernias where we call that the robotic ilio pubic tract repair, our I P T. Whereas laparoscopically, that’s a very difficult angle because you don’t have the risk movements on laparoscopic instruments. We call them chopsticks, I don’t know if you call them chopsticks. They’re like straight. So it’s hard to sew. It’s like sewing with two knitting needles. And then the third operation I prefer to robotically is the Mesh removal, but I can do that lap too. It’s just I think better robotically. And the fourth one is diastasis closure. I know that can be done lap two, but it’s so much easier to do a robotic plication closure, the diastasis for people that have a hernia within a diastasis and I think gives a much better outcome. Are there any favorites that you have that you prefer the robot for?

Speaker 2 (00:22:35):

Well, I think obviously I’m a big fan of robot tar because robotic tar, which is like it’s an acronym for a technique where you divide a different planes of the abnormal wall trying to bring it wide hernias together, which has hernias. Yeah, bigger than 10 centimeters in width. So quite big hernias that otherwise you would do open. And now we’re doing a minimum invasive and these patients are doing so much better after this minimal invasive technique. This was for me the trigger to say, okay, this is going to come

Speaker 1 (00:23:12):

For me too. That was the trigger too.

Speaker 2 (00:23:15):


Speaker 1 (00:23:15):

That was my trigger too. It was the tar, it was a robotic tar. I couldn’t imagine that that’s something that they go home same day or next day where it’s open surgery. They need like three to five days in the hospital.

Speaker 2 (00:23:28):

Yeah, that’s the the first patient I saw. I said, okay, it’s coincidence when I went back and back and back every time challenging myself. And of course it’s not magic if you can still have complications. If you make a hole in a bowel, you don’t see whether you use a robot or a laparoscope or open your patient is in a lot of trouble. Yes. So it doesn’t prevent you from having complications. But on the other hand, if you are able to do this complex surgeries by minimal invasive technique, using that robotic platform to gain for the patient is huge. It’s really huge pain wise, mobilization wise, hospitalization, much shorter.

Speaker 1 (00:24:15):

So I know you do a lot of robotics teaching all over, you travel so much for that before COVID obviously. So the other thing that I know has happened in the United States, which I assume has happened elsewhere, is there’s a lot of surgeons that don’t offer laparoscopic surgery, especially for like inguinal hernias and many ventral hernias. It’s the learning curve for a laparoscopic, inguinal hernia is pretty steep. It’s something is 250, something is five, something gets 500 cases or more before you start getting a plateau in your complication rates. In the United States, what we are seeing is because the robotic platform is so much more intuitive and easier to use, that people that we’re never able to offer laparoscopic hernia repairs to their patients are now offering the robotic hernia repair instead of doing an open Mesh repair, which has much more risks of chronic pain and recurrence relative laparoscopic. So people are going from open, straight to robotic. Do you see that?

Speaker 2 (00:25:29):

No, it’s not really. The people that are training on a robotic platform at the moment in Europe are mainly also experienced laparoscopic surgeons. The penetration of laparoscopy for groin hernia repair compared to open is very, very heterogeneous across Europe. Because you might think from the US that United States of Europe that there’s a lot of cultural differences also in training A lot depends on the key opinion leaders. There’s some Scandinavian, you have different types of laparoscopic hernia repair. You have the T A P P transabdominal, you have the T E P, which is pre peritoneal. Yes, basically it’s the same operation, but it’s more like an attitude or where you were trained or personal preference of the surgeons. But you have some countries in Europe, I think it’s Sweden, that almost everybody’s doing TEP in Germany, it’s more T A P P in Denmark it’s also T A P P. And that’s because of key opinion leaders, the people that were on stage and were training other people to show them these new laparoscopic techniques in that country. Were doing one or other technique. Right. It’s very, very strange how it diverges. But also I think in Belgium it’s about 50% of groins. That would be my estimate is laparoscopic, which is that’s huge. Higher than many other countries

Speaker 1 (00:27:04):

More than the United States. Yeah.

Speaker 2 (00:27:06):

But you see a big uptake in the Scandinavian countries because they have a lot of registries there. So they see their data in Scandinavia and they start realizing that laparoscopy is really benefiting the patients. So you have a move, certainly a Scandinavia towards more and more adoption of robotic not robotic, of laparoscopic repair. But the people I train at the moment are usually well-trained laparoscopic surgeries as well.

Speaker 1 (00:27:37):

I think that’s a good thing. I think it’s a little bit odd to skip the laparoscopic learning curve and go straight to robotics. I’ll get to some of the questions we have. So one question we had was how long has a Da Vinci robot been used for surgery? I think decades, right? Almost 30 years.

Speaker 2 (00:27:59):

Well, I think the company exists 25 years. 25 years. I, I’ve met a guy that was a French doctor in Paris who did the first ventral hernia using a very, very old robot. You cannot compare what we are using now to what we had surgeons had in the beginning. And I think that was, I think 20 years ago, more or less.

Speaker 1 (00:28:28):

Was that the S? I think that was the S,

Speaker 2 (00:28:33):

Yeah, I think even before the S there was still something different. They have one at the <inaudible>, the really first ones they look Yeah, it’s like an old IBM computer and a Mac.

Speaker 1 (00:28:47):


Speaker 2 (00:28:47):

Cause it’s the evolution. It looks nicer and it’s functions better.

Speaker 1 (00:28:53):

Yeah. So there’s S. the SI, and the XI. Most hospitals now kind of have upgraded the xi and there’s other platforms that have come out too that are a bit tapered down. But at Cedar Sinai, we actually had the S until I think a year, a year and a half. A year and a half ago it finally broke down, but we had it for 10, 15 years and it’s like driving stick shift compared to an automatic. It worked fine, but it was definitely not as advanced as each generation. So there was one day where I had to be moved around for some reason because of the different rooms. So I did a case on the S, the SI and the xi and I could kind of see the evolution of the engineering <laugh> going from stick shift to fully automatic. It was pretty cool. Well the urologist in the United States, a hundred percent have switched over to robotics. There’s some that are really good laparoscopic surgeons, but the prostate and most of those operations are now done almost, I think it’s like nine in the high 90th. 90 percentile maybe 96%. Yeah,

Speaker 2 (00:30:12):


Speaker 1 (00:30:12):

I see 98%. Yeah. Something really crazy high done robotically. In fact, they almost don’t even do as much laparoscopic. It’s so interesting how as you train technology takes over for the good of a patient, but then sometimes you need to learn how to drive a stick shift and not just only a automatic, you know what I mean?

Speaker 2 (00:30:42):

Yeah, well it’s like for the people that are training now, for example, gallbladder most of the people that we’ve trained in the last years, they’ve never seen an open gallbladder operation. Yes. Because the benefit of the laproscopy is so big that you don’t want to expose your patients to the older technique being an open cholecystectomy. So being a little bit older surgeons, sometimes you get called in by a younger colleague because then now you have the baggage. From the beginning of my training,

Speaker 1 (00:31:25):

I was fortunate to have been right at the cusp. So laparoscopy was introduced in more advanced manner during my residency. So I still got to do the open appendectomies and open gallbladders and then get introduced to laparoscopic hernia repairs and so on. I think I was among the first that brought laparoscopic hernia repairs to our county hospital in Los Angeles. But yeah. So theoretically right now, robotic surgery, you’re in the same room. So the patients in the room, anesthesiologist, the nurses, you are physically there with the robot and the consults like a sitting chair. Is that something that’s going to change where the surgeon’s not even in the room anymore? Has that been a discussion?

Speaker 2 (00:32:16):

Well, I think that when you hear the history of the De Vinci robot, that originally was the original idea was from the US Army where they were thinking about having a surgeon operate from a distance so the surgeon would not be exposed to harm close to the battlefield, but could still take control and do operations a bit from a distance. I think it has been done, it has been tried and it’s possible You need a very good network. I think you need a 5G network to do that. And I was told that once that happens that it would be possible for me to operate patients from my home if needed. I wouldn’t, it would be difficult to see any good reason why we want to do that. Because you would still have somebody who is surgically qualified there to put in the trocars to dock the robot or docking The robot can be done by well-trained nursing staff or anything. But let’s say the responsibility of putting in a needle, putting in the trocar will probably not shift from a doctor to another non, how do you call it? Paramedic profession I think. Yeah, there’s there,

Speaker 1 (00:33:44):

Yes. So before the Da Vinci platform, there was, I think, was it Zeus? There was another robot and that was the first transatlantic surgery where the patient was in Strausberg and the surgeon came to New York and did a gallbladder surgery. But there was, this was way before 5g, I think it was about 20 years ago, 18 years ago, 15 years ago. And the marico was the surgeon and he noticed there was a lag because of the wiring. There was a little bit of a lag. So he had to adapt to the fact that what he was doing in New York was transmitted to, it was a successful operation, but there was a lag. And then in Canada, Canada’s more interesting country because it’s a huge amount of land and there are people that live closer to the US border, which are where most of the cities are, Toronto Montreal, Vancouver, and then way up north there are people that live there, but there may be no surgeon within hours. So there are surgeons that have dabbled in telesurgery where the patient is intubated, gets anesthesia way up north in Canada and the surgeons in Montreal doing their procedure. I mean that’s kind of interesting. But

Speaker 2 (00:35:15):

What I would see is, for example, if you have a very delicate, delicate part of an operation, let’s say another surgeon feels like this is beyond my competence, that you would be able to get another surgeon from a distance, do that small part of the operation. But that would be very, very uncommon to begin with. And on the other hand there would be a surgeon in the room taking responsibility of that patient. But let’s say I could probably do a tar operation and certain steps of the tar for somebody in the Netherlands, a surgeon there who doesn’t has have reached proficiency to do the complete operation, for example.

Speaker 1 (00:36:03):

Yeah, maybe Covid will push us towards that.

Speaker 2 (00:36:07):


Speaker 1 (00:36:09):

One of the questions was about older surgeons. So it’s true that robotic surgery ergonomically is much easier for, hasn’t been proven because there’s actually one recent study that shows it’s actually not that much better. But I personally had really bad disc disease where I need to have lumbar surgery. And during the time before my surgery I was operating still. But if I had to do laparoscopic or open surgery, I was standing and the amount of pain I was in was horrendous. Whereas the days that I had robotic surgery, oh my god, it was heaven because the ergonomically pressure was off my lower back. And from personal experience, I know that’s either, so there’s a question about now that some older surgeons should probably retire, is a robot going to make them less likely to retire because they can still do surgery? What are your thoughts on that?

Speaker 2 (00:37:17):

Well, first the ergonomic part, it is like that. And I think most people, if for example, next week on Tuesday I have five groin hernias and one ventral, that’s my operating list that’s on the robotic platform. If I would have to do that surgery all by myself from beginning to morning laparoscopically I would be broken in the end of the day, for example. Yeah, the thing is that during, for a laparoscopic groin in your repair, you’re standing next to the patient and you’re holding your insulin.

Speaker 2 (00:37:49):

And when you are operating, most of the time you’re so focused that you don’t really feel anything. But the moment you move away from that operating table, I broke my knee during soccer many years ago, my knee would always hurt, for example. And certainly if you’re going to do a long list like that unless you have a resident that can help you and do large parts of the operation so that you are scrubbing in is like 15 minutes, 20 minutes. But if you do the whole case, which is like 45 minutes completely and one after the other, then in the end of the day you are completely broken. So that’s true. Will I work longer because, no, I don’t think so. I think you have to look at it differently. If the surgeon abuses his body less during his work time, he will be able to enjoy much more his retirement because he has less phasix complaints. So we could look at it like that as well, the wellbeing of the surgeon even after his surgical career.

Speaker 1 (00:38:57):

Good for you. Yeah, I totally agree. I think the surgery is such a physical career. It really has a toll. There’s a lot of occupationally induced hazards and injuries that we get, spine disease being one of them but surgeons who have a shake or tremor that can be overcome by the robot because a robot will fine tune that and get rid of your tremor. So in some ways there is that added benefit. Right?

Speaker 2 (00:39:34):

Yeah. I see a lot of people come and visit me and do case observation like it’s called. And if they come from Scandinavia, for example, from Norway and they try to make the equation, let’s say for example in a country like Norway, the fact that it would ergonomically be better for the surgeon itself, which would be considered in that hospital like an employee or how you call that in English somebody who works for the hospital

Speaker 1 (00:40:04):

Employee, yeah.

Speaker 2 (00:40:07):

That would be taken into account of the value proposition and that might cost a little bit of money there, which probably in France or Spain, if the surgeons would try to complain and say that because of their better ergonomics, this should be taken into account the cost value proposition, sure there would be laughed away. So there’s a cultural difference certainly as Scandinavia. Ultimately I think if you would take the cost of the robot away, there’s no reason not to do every laparoscopy with the robotic platform. There are some things like a little bit bigger trocars, things like that. But in the end of the day for me, if I would have all time access I would do all my grown annual laparoscopic with the robot.

Speaker 1 (00:41:07):

With the robot. Yeah, definitely for the surgeon. It’s also very easy on our body. So that’s a good segue on the next question which is presented live, which is this patient is currently in the watchful waiting protocol for their inguinal hernia. And he says, part of me is thinking if I can hold out long enough with a small and manageable hernia, maybe when absolutely have to get it repaired, there will be newer techniques with lower risks of complications such as for chronic pain. How far away do you think we are with newer technology and is there anything in the H horizon you’d want to share with us? Where do you think we’re headed? Is there better non Mesh repairs, better robotic techniques semi biologic Mesh and so on? What are your thoughts about the horizon of Inguinal hernia repair in the next

Speaker 2 (00:42:06):

Five years? What for waiting for male patients is a sensible approach. If you have a small I know a lot of people including myself, who have a very small groan hernia, but I would never get it fixed because it doesn’t hurt me. I know it because I’m a surgeon. If I would not be a surgeon, I would not even be aware of it. Probably the likelihood that it will grow. And at one point in my lifetime I will need surgery because it will start hurting and it’ll grow is high, but the risk of waiting is not substantial. So the risk of having complications like incarceration from the watchful waiting it’s not huge. I would not expect the technology Mesh wise or technique-wise to change so dramatically in the coming decades that it would be something that you would wait for. My ultimate dream is that with artificial intelligence, I would do 1000 operations. The robot would learn how I do a growing hair repair and I would operate myself.

Speaker 1 (00:43:25):

Oh, <laugh> god,

Speaker 2 (00:43:27):

You understand?

Speaker 1 (00:43:29):

Yes, I do. That’s nuts

Speaker 2 (00:43:32):

Because I think that ultimately when you want to go for surgery, quality depends probably more of the surgeon that operates you. How often do they do this operation? Absolutely. Are they really interested in it? Do they call themselves a hernia surgeon or are they general surgeries? Surgeons that do groin hernia only infrequently, yes, that there are papers from the Netherlands where some surgeons do five grown hernia a year. Ultimately this will probably reflect in their outcomes. Luckily it’s only five patients that are at harm, but then you look like people like me and probably also you who are doing maybe 500 a year. That’s a big difference. And of course in the end of the road, nobody’s perfect. There will always be a small chance of having chronic groin pain. The selection of the patient is very important. I think also for chronic pain, we see some patients that are very nervous, very afraid, and even when they have a small groin hernia and they have some pain in the groin and you want to investigate them, you don’t even touch them, they already move away.

Speaker 2 (00:44:59):

These are people at high risk for chronic pain because they probably have a sensibility sensitivity in that groin that is at risk. So in such patients, and I try to avoid proposing them surgery if there are female patients listening, watchful waiting for females usually is not recommended because female patients show up with a higher frequency with incarcerated venia. And so usually a groan hernia in a female patients the advice probably should be to have them propose a repair although they might be have only mild symptoms. Is that also your attitude? That’s what I think that comes out of the guidelines more or less at the moment.

Speaker 1 (00:45:55):

So it’s important to note that all of the watchful waiting trials were done on men only exclusively. So we don’t know the data for women and we know that women are more likely to have femoral hernias. So if I have a patient that and femoral hernias are not appropriate for watchful waiting because of the higher risk of complications including death due to incarceration and sepsis. So I agree with you. If there’s a female, I want to always make sure they don’t have a femoral hernia. If they don’t, I do push them in the watchful waiting arm. If they are minimally symptomatic and are hesitant to have surgery understanding that we don’t really know the data for women, I would think though in that the future is bright and I feel that we have seen, we’re kind of in a situation right now, and this is my opinion, there’s an overuse of Mesh and there is an under population of hernia specialists.

Speaker 1 (00:47:08):

So like you said, in the United States, any general surgeon can do a hernia repair. But very few of us hernia specialists, very few, in fact I would say real specialists that do a hundred percent of their time hernias, I would say less than the number of fingers my hand those that do me a lot of hernia surgery, maybe less, maybe less than 50. So that’s a very small number for a big country. The same is probably true in Europe. So we are though having a uptick in people interested in hernia surgery as a specialty. And so with time we’ll have more people doing hernia surgery as a specialty and therefore outcomes should be better. And also the technology, I think the technology is shifting away from overuse of Mesh and looking at better tissue techniques. I think for example, we published our results on outcomes of robotic tissue repair.

Speaker 1 (00:48:16):

That’s appropriate for really small hernias. There are newer meshes coming out that are less inflammatory, less synthetic, more of a hybrid Mesh. And then there are actually newer sutures coming out that are less, more stronger, more tensile, less inflammatory, less of an issue with Mesh reaction or suture reaction. So we’re slowly getting there into slow process but I think we are moving in the right direction overall. We have another question which is related to we talked a lot about the pros of the robot, but as with any technology there are risks. So what do you explain the risk to be associated specifically with the robot?

Speaker 2 (00:49:09):

So for the biggest risk, I think because as we told you before, when you do, you are holding the instruments in your hands with the robot. Usually you dock the patient, which means that you’re connecting the instruments to the robot. But then sometimes the instrument has to be removed or changed to, for example, first you use a scissors and then you use a needle driver. If somebody is doing that incorrectly. That’s I think a risk that is specifically associated to the robotic platform. So there’s a very important aspect of learning and teaching people that are, they call it the bedside assist. So the person which is usually a nurse or a surgeon in training that is standing next to the patient and taking insulins in and out. And that’s probably one of the risk associated specifically to the robot. I’ve done now in these four years, about 1000 cases more or less.

Speaker 2 (00:50:18):

And I have not had any risks specifically related to that but it takes a little bit of military discipline. Certainly if you have new people in the or, we have a lot of trainees that move around. If they are at the robot for the first time, you really have to drill them and say you’re not moving anything unless I tell you to, of course, if this is a nurse practitioner next to the patient that is, you’ve done 100 operations with that nurse, they know how to do these things and you can be a little bit less strict. But certainly when you have new people it has to be more like a military drill type of atmosphere.

Speaker 1 (00:51:07):


Speaker 2 (00:51:08):

I call it. Which can be relaxed after a while, but

Speaker 1 (00:51:13):

I agree. And I think there is a certain group of patients that are very adamant against the robot. They feel a robot. It’s dangerous. I would say it’s like a car. If you don’t know how to drive a car or a fast car, then yeah, it definitely can be dangerous. And what had happened with the robot’s introduction what I understand is there were multiple serious complications of bowel injury noted by introduction of the robot to the gynecologist, which was actually before it was introduced to the general surgeons was urologists and then gynecologist because working in the pelvis is, it can be difficult laparoscopically and there are a lot of not a lot, there’s a large percentage of patients that had unacceptable injuries. We don’t really see that anymore. We have really improved a lot in education. Do you have, I know the United States, it’s probably the same in Europe, there is a very strict protocol as to the education of a surgeon before they’re allowed to operate on patients unsupervised with the robot. What is that?

Speaker 2 (00:52:29):

Yeah, I think that that’s something I do a lot of training. I’ve, in these four years I, I’ve went to, I think about 60 hospitals across Europe where I started up. And I must say that Intuitive does a very good job at taking these people through a training pathway, trying to avoid them doing clinical cases before they’re really proficient with the robot. And I must say that it has not happened to me that I went in for a clinical case that I found that a surgeon was not well prepared. It has happened that surgeons choose the role and two complicated cases as their first cases, but they were well prepared how to work the robot, how to move the instruments, how to move the camera. So because the surgeons are usually first aid, they do online training, then they have to do simulated training. If you are a pilot, you have to do a certain amount of hours, which I recommend is about 24 hours trying to work with that instrument.

Speaker 2 (00:53:42):

And then usually surgeon are taken to a lab where they do other cadaveric training and assimilation of an operation before they move on a clinical case. And when they do the first clinical case, almost 100% of surgeons are assisted by a proctor, which is a surgeon that is like me, that has come to proficiency and is there just to and most of the times when I’m there at the end of the day I say, why was I here? I was not really needed because the surgeon was able to do that. But I think for a surgeon, certainly doing his first clinical case on robotic platform gives them a certain anxiety and just anxiety and just having somebody there who’s done it so many times and has the experience just helps you to relax and to do that first operation and the end of the day pure for anatomic reasons or for technical reasons, often certainly because most of the time it’s a growing hernia. When you look at hernia surgery you’re not really needed there because most of them are already proficient in hernia surgery. They just have to learn how to work with that platform.

Speaker 1 (00:55:03):

And I think that the company has learned the importance of education as part of the rollout of their platform.

Speaker 2 (00:55:13):

I think that’s different what I’m like say second generation or third, whatever you want. Only went on the robot six years ago when already robotic surgery penetrated to general surgery people in the US to a high degree. So, so probably lessons learned there were taken seriously. And I do have the feeling that in Europe they take that very seriously and they’re doing a good job.

Speaker 1 (00:55:45):

I agree. In the last few minutes, can you share what you know about the next generation of the intuitive platform of robots? I know there’s like a single port and some other potential offerings coming. And then what do you know about other companies that are also entering the robotics market? Johnson and Johnson. Medtronic, what do you know

Speaker 2 (00:56:10):

About the Vinci platform? Indeed has a new thing. It’s not available in Europe. I think it’s available in the US already. Maybe not nationwide, but certainly at certain time. It’s called the single port. Yes, we have cool thing. It looks very cool. It’s probably also very expensive with it because it’s not interchangeable with the role robot you already have. Correct. And all instruments and the camera go to one truck car. So you have only one incision which is bigger. I think it’s 2.5 centimeters, so it’s bigger than the other incisions. But that I think certain indications will show up where it’s going to be a good platform. Not sure about hernia surgery, we don’t know might be what else they have in the pipeline eventually. You usually don’t know before it enters the market. Yeah. Cause most of this research and development is a bit sealed off from the eyes of the competitors in Europe have since I think since this year we have the CMR robotic platform, which called verses Yes.

Speaker 2 (00:57:24):

And some centers in Europe are starting to work with it. It has some features that are different from DaVinci. We know that the DaVinci of course, is an evolution of 25 years. The first robot is the first generation. So there probably will be some features that you have with the Da Vinci, which you will not yet have with the vers. It will be interesting to see. And we hope that competition of course will derive a little bit down the costs also for the users, the hospitals and the patients. And there is another robot, St. Hans, which is around for a few years. But that technologically wise until now has disappointed me a little bit. It could go more very expensive laparoscopy because it didn’t bring enough of the advantages that you have with Da Vinci platform. But also they might change, they do research and development.

Speaker 2 (00:58:26):

That was the first generation. So there will be competition and there’s some big players like Medtronic, Johnson and Johnson. But rumors are rumors since, I don’t know, five, six years. And they keep being rumors. So it’s many of these big companies, they say, okay, we are big, we have a big company. We’ll be able to provide a new robot in the short amount of time. But I think they underestimate the difficulty how DaVinci and intuitive work for 25 years coming to that level of machinery we could call it, of technical super machine. So that’s probably the reason why it’s not, but it’ll come in five years. We will probably have several companies company competing each other. It’s like Gore Jewel Mesh was the first Mesh for placement in the abdomen. Yes. Which was like 15 years ago. Now you have, I don’t know, a whole bunch of them. So competition will come and some might be better, some might be, it will be a selection. But it’s difficult to make a robot as good as the DaVinci Xi for sure.

Speaker 1 (00:59:46):

Yeah. None of them. I’ve tried many of them and they try and improve on some things like the haptics, but even that’s not so far hasn’t been done enough. All right. Do you have any parting words so that if not, this will be the end of our hernia talk together?

Speaker 2 (01:00:05):

Yeah. Okay. I would say stay safe because we are not in the best place of the world at the moment COVID wise.

Speaker 1 (01:00:15):


Speaker 2 (01:00:16):

But okay.

Speaker 1 (01:00:18):

Well I hope you all stay safe. I know Europe is having a little bit of a surge there. Certain areas of the United States also we’re surging. So November, December are going to be difficult times from infectious diseases standpoint. I hope everyone stays safe. And on that note, I want to thank you all for taking your time today. It’s election day in the United States. I hope everyone’s voted. Thank you, Dr. Muysoms, for offering you offering us your time. And I hope you go back. Your lovely doggy was in the background. It’s very cute to have him as part of our guest. And this will be posted on YouTube for everyone to rewatch and share. Thank you for following me on Twitter and Instagram at Hernia Doc and on my Facebook page at Dr. Towfigh. As I mentioned earlier, Dr. Muysoms can be found also on Twitter at Filip Muysoms. Thank you very much and hope you have a good night, Felipe.

Speaker 2 (01:01:20):

Yeah, I will.

Speaker 1 (01:01:21):

Thank you. Hope to see you soon in person.

Speaker 2 (01:01:24):

Yeah. Bye.

Speaker 1 (01:01:25):

Good evening, Denmark.

Speaker 2 (01:01:26):