Episode 46: Laparoscopy for Hernia Repairs | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Hello everyone. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. I am your host every Tuesday on hernia talk. You can follow me on Twitter and Instagram at hernia doc. Many of you are joining us as a Facebook Live on my homepage, and at the end of this session, I’ll make sure that you have access to the full hour of today’s webinar and q and a on my YouTube channel. Today’s guest is a close friend of mine, someone who is future big time leader in the hernia world. She’s already has a lot of leadership roles, but I personally think she’ll be the next president. So Dr. Ajita Prabhu, she’s a laparoscopic surgeon out of Cleveland Clinic in Ohio. You can follow her on Twitter at Ajita Prabhu MD. Please give a warm welcome to Dr. Prabhu. Welcome.

Speaker 2 (00:54):

Hi. Thank you so much for having me. Nice to see you always.

Speaker 1 (00:58):

You are on the hierarchy to be the next president. No,

Speaker 2 (01:02):

I am currently the treasurer of the America Hernia Society.

Speaker 1 (01:05):

All right. So if there needs to be a vote, you have my vote. If there’s no need to vote, then you deserve it regardless. I’m really happy. I’ve known, I think when you came on the board right, for the American Hernia Society, I don’t think I knew. I feel like it’s even fellowship.

Speaker 2 (01:26):

I think it’s fellowship. No, I think it’s probably been like we’re going on like seven, eight years maybe.

Speaker 1 (01:32):


Speaker 2 (01:33):

Yeah, it’s a long time. It’s good.

Speaker 1 (01:35):

Yeah. Where did you do your fellowship?

Speaker 2 (01:37):

Was it I did my fellowship at the previously known as Carolina’s Medical Center. Oh, Carolina now known as I think Atrium Health. Is that right?

Speaker 1 (01:46):

Yes. Atrium Health. Yeah, yeah, yeah, absolutely. Okay, cool. So maybe you can share a little bit about yourself. We have a couple of questions that have been kind of posted. We can go through that, but maybe a little bit about what you do and how much your practice is minimally invasive. Sure. The question we had was what is laparoscopic surgery and how is that different from robotic surgery or what do you see that, where do you see those two as?

Speaker 2 (02:16):

Okay, great. First of all, just for a little bit of introduction, I’ve been in practice for about 11 years now. I graduated from my fellowship in 2010, and I initially started in private practice in Denver, and I was there for probably about three years or so before moving to Cleveland. And then, as you may know, I was previously at Cleveland Medical Center and now at the Cleveland Clinic for the past five years, my practice is almost entirely hernia related and hernia complication related. And I would say probably somewhere between 30 and 40% of my practice would be minimally invasive, I would say is a Oh, okay. Conservative estimate. I do a fair amount of open stuff these days, but that’s primarily related to Mesh infections or recurrent hernias or some fistula things, so things like that or operations that require kind of big scar resections and that type of, yes.

Speaker 2 (03:10):

Now, when it comes to minimally invasive surgery, I love it. It’s my probably first love. I’ve always enjoyed it and I do a fair amount of laparoscopic surgery and robotic surgery, still laparoscopic surgery. To your point before, what is the difference between the two? So both of them, as many people may know, occur through small incisions for laparoscopy, usually the surgeon is standing at the bedside and we will use long instruments through the small incisions to accomplish whatever task we’re trying to accomplish. And I often use laparoscopy for inguinal hernia repair, ventral hernia repair, para esophageal or hiatal hernia repair. The difference between that and robotic surgery is that robotic operations are also done through small incisions and the instruments go through there, but the surgeon is sitting at a console with very fine control of the ends of the instruments, but we’re not actually holding the instruments in our hands. There’s some pretty major differences between the two. One primarily being that when we do robotic surgery as being a prolific robotic surgeon, I think we can use the wristed instruments in many different ways similar to how we use our hands in real life. And that transmits our motions through to the patient in a really helpful way to do accurate surgery. So as far as what I do robotically, I still do a fair amount of anything from small to medium, fairly large size hernias robotically. I usually use it for mostly ventral hernia repair.

Speaker 2 (04:45):

I’ll stop there and let you say something you didn’t expect that I would like to talk over the whole time you

Speaker 1 (04:50):

No, of course I did. This is, I’m just here as a moderator. Honestly, I feel that you may know I’ve been doing this since the beginning of the pandemic, and I feel that, I don’t know, not only do I enjoy doing it, but I feel that I get to just kind of listen to you guys talk, learn from you. I get to learn more about you. I didn’t know you were in private practice in Denver initially. That’s kind of a unique path to go to private practice and then go into a highly academic program, though you’re also clinically very busy.

Speaker 2 (05:24):

It wasn’t my life plan. Oh,

Speaker 1 (05:26):

Okay. Can you share why you made that decision

Speaker 2 (05:31):

To Oh, sure. It was actually just kind of a series of events that occurred. As I’ve shared with you before, I have twins and during the time that I was graduating from Fellowship, I was carrying my twins and we had moved to Denver and then unexpectedly had a year where I had to take off work just related to that pregnancy. And so at that time, there were no academic jobs available, Denver, but we already lived there. And so I took the private practice jobs that were available. However, I will say it was a really great formative experience for me. I’ll say I had some really great partners and really enjoyed my time there. And at the same time, I wanted to do more kind of complex hernia repair and I was in more general surgery type of practice, which was fun. And it was a great way to start as an attending. And then I got a great opportunity. A friend of mine called and recruited me to Cleveland, and that’s how I ended up there. So yeah, it was a transition. It wasn’t planned, but I enjoyed it.

Speaker 1 (06:31):

Well, I mean, I was not interested in hernia surgery when I was a resident. Were you when you were a resident?

Speaker 2 (06:37):

Not at all. Yeah. In fact, I would say it’s probably one of the least glamorous type of things that a surgeon can say they’re interested in. It is they’re so easy to come by hernias that it almost seems a little untoward to say that that’s what you’re interested in. And at the time that I graduated from fellowship and likely when you graduated also from your training, it wasn’t kind of like the sexy thing to do in that way, but I think the

Speaker 1 (07:03):

Field, but don’t you think now it kind of is?

Speaker 2 (07:05):

Yes. I think that over time it has really kind of changed. I think the field has changed primarily because we don’t just look at it as just a hernia anymore. I think it’s more complex disease. I think that there is a fair amount that goes into the care of these patients, and I think the treatment of them is really important. And also we’re shifting from just do we have a recurrence or do we not have a recurrence to what is our quality of life? How are we feeling with this hernia? How are things going? So I would just say things have developed tremendously over the past decade, at least since I’ve been involved. And I do think that it’s turned into something popular, but no, it wasn’t. It was never in my plan. But now it’s been a really good thing in my life.

Speaker 1 (07:47):

Yeah, I think a lot of us had a love for laparoscopy and now robotic surgery, but mostly laparoscopy and hernia was one of those things that not many people were doing laparoscopically, at least not during my training. It’s grown. It’s still not a commonly performed operation nationally. We still have more open hernias done than laparoscopic interestingly. But I’d like to know your opinion. What do you prefer to do everything laparoscopically or robotically, and what do you see as why you choose to offer laparoscopic or robotic surgical options?

Speaker 2 (08:25):

That’s a great question. So first of all, I will just say this is different for every surgeon. These are very personal choices and as surgeons, I would like to think that we all offer our patients the operations in the way that we perform them the best. So some surgeons I think are very facile laparoscopically. Other ones are better on the robot. And I think that that is a personal thing. Just related to surgeons, their experience, their skill and their interest areas or areas of interest. I should say. For me personally, it depends on what I’m doing. Generally speaking, I do robotic surgery when it comes to ventral hernia repairs. And the thing that I really like about ventral hernia repairs on the robot is that I can close the muscle together, I can sew it together nicely and I can do small to medium sized hernias in certain ways.

Speaker 2 (09:16):

And then these days I’m doing a little bit more robotic abdominal wall reconstruction for patients who have more complex hernia disease. And the thing that I really like about it for that is the ability to essentially recreate an operation in a robotic fashion that previously we would’ve done through a big incision. And I think that, yeah, for the right patients, I really do think that that probably offers a benefit of a improved not only hospital length of stay, but also post-operative recovery. And I’m still pretty selective about who I offer that to. That’s something that I’ve been doing for a few years now, and I continue to get better at it, but I haven’t really gone to the extreme of saying I’m going to do really big hernias in that way in my practice. It just doesn’t fit right. Now as far as laparoscopic stuff goes, for the straightforward things that I’ve done, hundreds if not thousands of such as lap inguinal, para esophageal hernia repairs, hiatal hernia repairs, that’s where I’m most comfortable laparoscopically. So I typically offer those to patients in that way for kind of routine stuff. I would say for inguinal, I haven’t personally done complex disease in that way, although I know that you do. I think if I’m correct, a fair amount of that and I haven’t gone that way with it yet for a complex inguinal disease because I have a partner who does the majority of that type of stuff, David. So that hasn’t been my application for it. For routine stuff, I mostly do laparoscopy.

Speaker 1 (10:43):

Yeah, I agree. I think what I see, which is a dilemma, is that I think that as a hernia specialist to be kind of brand yourself as a specialist, you should be able to offer all different surgical options, lap, robotic, open, Mesh, non Mesh because when the patient comes to you, often I see the patient goes to a surgeon, they know how to do surgery the same way they learn maybe in residency or they have a favorite way of doing things and they offer it for everyone, fat, then male, female, older, younger, it doesn’t matter. And it’s like one size fits all. And that may be okay in a small town because resources are limited. Not everyone can offer every type of procedure, but I think to truly get the best option for women, I tend not to do anterior Mesh repairs for thin people, I tend not to put Mesh in them.

Speaker 1 (11:38):

For obese people or robotic or recurrent hernias, you’re more likely to use Mesh. You’re more likely to do it laparoscopically or robotically. For Mesh removals, I was doing them all lap for the inguinal. Now I do it robotically, but I’m okay doing either one. It kind of depends on their risk factors. So there’s a lot, there’s like the algorithm is very complicated or can be very complicated. And I feel that for patients, what the message I have to patients tell me if yours is different is all things being equal. Laparoscopy is a better option. You have less infections, shorter recovery time that’s been shown for pretty much all hernia repairs, better long-term outcomes. But laparoscopy may not be ideal for every single patient If you have Crohn’s disease, I wouldn’t put Mesh in intra abdominally laparoscopically trying. I agree with that. Trying stay external depends on your surgical history.

Speaker 1 (12:43):

So that’s kind of the shtick that sometimes I have patients, I just want to find someone to do this laparoscopically or I had a patient on one of these posts, I’m looking for a surgery who does a Marcy repair? And I’m like, that’s a very specific question and why? And I just read that Marcy’s the best repair. Marcy’s not the best repair. It’s actually not indicated for an adult male. And so you kind of need to educate the patient. But I feel that there’s so much when you do your research and when you teach, you kind of have big picture and yet someone who’s not medical or not a hernia surgeon may kind of read one article or three articles and be totally skewed like this patient who thought they need a Marcy repair and they may think, I must have this done robotically or laparoscopically, and that may not be the best just because it’s better in general for that specific patient. I feel like we need to tailor it. I don’t know. What are your thoughts on that?

Speaker 2 (13:50):

Oh, I 1000% agree with everything you just said. Yeah. I also think even among those things that you said, even more so probably some of us, I would say at least in my own experience, there’s certain operations that I’m definitely better at. There’s certain operations that I have less experience with. And I think it’s really important to have a direct and kind of open conversation about that. So if there’s something that I don’t do, I usually just tell the patient outright, I don’t do that thing or in my hands, you’re probably best served with X, Y, and Z approach. So even in the gamut of kind of operations that we can do for patients, there are certain ones that we’re going to do better and certain ones that I think maybe are best served by somebody else performing them. And I think we kind of owe it to our patients not only to tailor the care, but also to be upfront in that.

Speaker 1 (14:34):

Yeah, I totally agree. One of the questions is regarding whether robotic surgery similar to laparoscopic requires insufflation of the abdominal cavity. Answer is yes, yes, it’s exactly the same. And then secondly, I’ve noticed a rather high incidence of diastasis recti following lap surgery, and this seems more than anecdotal. What are your thoughts?

Speaker 2 (15:02):

Well, I think we would have to know a little bit more background about what that question entails. For me, recto diastasis is usually a naturally occurring thing. It certainly can be seen after laparoscopic surgery if the patient has what we call an eventration of their Mesh, where the Mesh is bow out a little bit. But I don’t think I understand fully the context of that question enough to answer. But do

Speaker 1 (15:24):

You think insufflation of 15 millimeters of mercury will cause a diastasis?

Speaker 2 (15:31):

No, I don’t agree. Think so.

Speaker 1 (15:33):

Yeah, it does not. There’s no studies I’ve shown it. There’s plenty of opportunities to study that. I treat a lot of patient with diastasis. I don’t think any of them actually have ever had laparoscopic surgery. And yet I do a lot of laparoscopic surgery and people don’t come back and say, yeah, what’s this bulge I had? Now since your surgery, it’s possible that people are more aware of their abdominal wall after some type of operation, but as far as I know, there’s zero evidence that 15 millimeters of mercury will cause pressure, will cause a diastasis cough. Causes more than that. Bending, I agree, causes more than that. So I would say that the concept that it’s a rather high incidence, I’ve never seen that. Would love to see where you have that kind of in there. All right. Next question. I’m just going to run through these with you. Is that cool? Yeah. If a patient has had two open incisional surgeries in the past, one vertical and one horizontal and then you have a new hernia, would laparoscopy be considered?

Speaker 2 (16:43):

I mean it depends on what the hernia looks like and what they’ve had before for prior surgery, I would say depending, also depending on the size of the hernia itself. So there are a lot of things that go into that. I would say that two hernia operations before still does not preclude a minimally invasive approach. I think you potentially could still consider any patient for that. Now, that’s not a kind of blanket statement. I think every patient is different and I think every patient’s surgical problems are different. So I would have to see. But yeah, I would say that’s still within the realm of possibility.

Speaker 1 (17:20):

Yeah, totally agree. And I think the more experience we have with laparoscopy and now robotic and I keep using both terms now, there’s no good term to, I guess we could call it all minimally invasive surgery. But what we mean is we’re pretty much using those terms interchangeably in that the approach is very similar, even though the technology is slightly different, the more experience we have, the more we kind of push the envelope envelope to do more and more cases. I remember when I was a resident that was very early on, gallbladder surgery was pretty routine, but appendix surgery was kind of maybe a se more senior resident case. It wasn’t a junior resident case. And if they had any prior surgery we thought, oh yeah, let’s try do it laparoscopically will be yet now we do redo surgeries and we do redo surgeries laparoscopically all the time. Sure. In fact, intestinal surgery lysis from prior open surgery is often approach laparoscopically first. What would a surgeon choose to do both robotic and open at the same time? For abdominal me,

Speaker 2 (18:33):

That’s an almost never event for me except for the one kind of consideration I can think of that I will sometimes do is if I’m doing an abdominal wall reconstruction robotically. But if there’s a very large hernia act that’s voluminous that I want to resect at the time of the operation or if there’s a scar that needs to be resected and revised, although that’s a very select kind of patient population because for the majority of those, they have pretty large hernias and I prefer to do them open. But in the instance that I’m talking about, if there is a perceived benefit to removing that hernia sac, I might make a small incision on top of where I’ve done my robotic operation and resect that hernia sac, lay out my Mesh and then close the muscle and go. That’s the only for me personally, I think that’s the only indication I can think of.

Speaker 1 (19:20):

Yeah, I agree. Many surgeons have dabbled in, let me fix the hernia from the inside robotically and then deal with the scar and extra skin on the outside in an open fashion as like a hybrid operation. I don’t usually do that. I just, it’s like all or done, but I can see an argument for doing that. And then do you feel that robotic surgery is better for reconstruction of the abdominal wall?

Speaker 2 (19:50):

Yeah, I mean I have limited experience in doing this laparoscopically. I have a lot of experience doing it open and then I would say moderate, modest experience with doing robotic abdominal wall reconstruction. So I would just say for me, laparoscopy for abdominal wall reconstruction is certainly attainable. It’s achievable. It’s not enjoyable for me to be honest with you, and I’m not sure that I am as facile with that operation or find it to be as technically rewarding as it is robotically. So I would just say, and if we’re talking about minimally invasive approaches to abdominal wall reconstruction for the right patients, I prefer to do that robotically if it’s not a planned open operation.

Speaker 1 (20:34):

The way I describe robotic, which I was not a fan of it when it first came out, I felt that if you can do something laparoscopically, why do you need a 2 million machine to do the same thing? Perfect. And yet the one reason why I am doing things robotically is in situations where I would otherwise really do it open. In other words, I feel that the amount of surgical kind of motion that I can replicate is as if I’m sitting inside the belly and sewing myself as opposed to laparoscopically. It’s a bit more difficult. The angles are a little bit more difficult to sew. So in that respect, I became a fan. I think I saw a video that Conrad put up long, long time ago on his website before he was giving talks. And I was like, oh, I didn’t think of that for robotics. I was just thinking of al hernias, measureables, ventral hernias. I was doing fine with those lap. I didn’t understand why I needed the robot. And then once he did a big abdominal wall reconstruction with the transverses abdominal release, the tar and all that, I was like, oh, okay, that’s interesting. I can’t do that lap. So obviously there are some surgeons like Belyansky and Burakoff who do those lap, but that’s a very, very technically challenging for senior to do lap.

Speaker 1 (22:00):

Question about bloating. Do you see patients get very bloated in the first recovery stages of either lap or robotic inguinal or ventral hernia repairs? What’s that all about? What happened to your, sorry,

Speaker 2 (22:16):

I think I accidentally muted.

Speaker 1 (22:17):


Speaker 2 (22:18):

There you go. Okay. Thank you. So as far as bloating after surgery goes, I think that’s mostly related to sometimes patients getting ilias or they get constipated where their bowels don’t work particularly well after surgery. I have to say things aren’t working immediately after a laparoscopic inguinal hernia repair. I’m always, the first thing that comes to mind because of the approach that I use for a lap inguinal is are we sure that there’s not a bowel obstruction occurring because of where we close a peritoneum? I’ve never had to remit somebody for that problem, but I’m always kind of on the lookout for that. So if immediately after surgery patient’s vomiting and bloated and stuff, I’m kind of on high alert for that issue. Outside of that, I would just say there’s a not 0% chance of getting an ilias after the surgery and you kind of have to just wait for things to wake up. But outside of that, related to the insufflation itself, I would say no.

Speaker 1 (23:12):

Yeah, I agree. I wonder if some of the bloating people have is just an inflammatory reaction of having had surgery inside the abdomen. They’re still eating, they’re still having bowel movements, but they’re just bloated. And I’ve seen it even with open ventral, sorry, open small umbilical hernias as well as you must have. So it may be more of a inflammatory reaction from the surgery. And once you kind of heal all that, then the bloating should go away. You should not have persistent bloating. What do you think about a patient who’s had multiple laparoscopic, okay, the patient who’s had tummy tuck then has had multiple laparoscopic operations. Do you find that those patients are more or less challenging?

Speaker 2 (23:59):

In what regard

Speaker 1 (24:00):

That the tummy tuck, does the tummy tuck affect your ability to insufflate and go inside the belly and do your operation?

Speaker 2 (24:07):

Not necessarily. I mean, I think abdominal wall compliance has more to do with the musculature than anything else. So I would say in the absence of very tight scars like tight puckered scars, I would say most people have a decent amount of insufflation. I don’t have to, I’ve not done a fair amount of laparoscopy on post abdominalplasty patients. It occurs every once in a while, but it’s not common. You

Speaker 1 (24:32):

Need to move to Beverly Hills

Speaker 2 (24:36):

Questionnaire. Probably

Speaker 1 (24:38):

Better tummy tuck than

Speaker 2 (24:39):

I’m, the only thing I would say is, and I don’t know how you feel, I’m curious to hear what you think about this, but for me, if somebody’s had an abdominalplasty, I generally try to stay away from the belly button for approach to get it. Yes. Cause I’m afraid of devascularizing that. Yeah. So I usually will kind of get my incisions off of that. But outside of that, I don’t think that insufflation has been a big deal that I’ve noted. But you may be, I think you have better experience.

Speaker 1 (25:03):

It’s a little tighter. It depends on how strong that tummy tuck is in flattening out the belly. In some situations I’ve seen it where I can’t get as much space to work in inside the belly as I would like because the belly doesn’t as much, especially extra peritoneal interabdominal is a little bit easier. And then, yeah, absolutely got to be careful of that belly button. You can still use their scar because if they have a new belly button, you can use that scar and go in. But I wouldn’t look around too much with the area because the blood flow to the area is very tenuous and you can, it’s uncommon, but you can still risk losing the belly button blood flow to it now then do you, on that note, the other question is, okay, now I’ve had a tummy tuck and multiple laparoscopic operations.

Speaker 1 (25:57):

Could that undo my tummy tuck? I would say no. That’s still a very difficult thing to suggest. Now if you have scars through, you’re about through your tummy tuck and then the people that close it, don’t close it back. You can lose your tummy tuck integrity, but just plain laparoscopy and the insufflation from that, I don’t think it’s enough to through your tummy tuck. All right. Next question. I have a Inguinal hernia that is hard to palpate on exam, but is there present on ultrasound with Valsalva and causes retractile testicle? Have you ever seen this before?

Speaker 2 (26:39):

Yes. I think probably all of us who treat inguinal hernia have seen this before. Yes. I would also say some patients with an inguinal hernia will have kind of what’s called, I don’t know what you call it. I’ve called it a kind of an exuberant cream hysteric response where the testicle comes really high up and sometimes that is not related to the hernia itself, kind of the exuberant cream hysteric response. It can be, but not in my experience, it’s not always made better by an inguinal hernia repair. And you may be better suited to comment on that than I am too Shirin. So yes, I think that can cause it, but it’s not clearly related to it getting better in my experience.

Speaker 1 (27:24):

So one thing you’re absolutely right because just because you can’t feel a bulging hernia on examination doesn’t mean you don’t have a hernia. It goes by symptoms. A history of super important imaging can help support that history. In other words, you have symptoms of groin pain, testicle around lower back into the inner thigh activity related pain, and then you get an ultrasound and it confirms anal hernia. So that those are two things that are supporting each other. In my experience, if you’re really, really careful and you use a very light touch and follow the inguinal canal, you can either elicit the pain as well or you can kind of feel a fullness there that’s not there normally. And so that may be enough of a physical exam to support the symptoms and the imaging. This issue of retractile testicles an interesting one.

Speaker 1 (28:21):

In males, the cremasteric reflex allows a testicle to go up and about up and down, but there are situations where men report the testicle completely retracting into their groin. Yes, that’s not normal. And if that is going there, you must be ruled out for a hernia. And that’s as the cause of this, number one. And number two, something that I’ve learned, which I’ll share with you, is if they do have that history and then you fix their hernia, it’s imperative to make sure that their testicle comes back down all the way to the scrotum once you’re done. Because I’ve had one patient who I never appreciated that their testicle was never completely descended, and they’ve had a lifelong problem of undescended testicle. It was always kind of in the groin and then a little bit in the scum, but not completely down. And so when you had a laparoscopic repair, it completely scarred up and we had to release that scar and actually do an orchiopexy and lengthened the spermatic core, all these urology things that we’re not taught how to do to bring him more of an external testicle because for lifelong, he’s had these retractable testicle and that spermatic cord has just shortened.

Speaker 1 (29:42):

So it’s like a short.

Speaker 2 (29:43):

Before we leave that topic, I have questions about that. Actually, I, I’d love to hear about this a little bit more because I’ve seen probably two or three of these, I would say in the past six months, even more than I’ve ever seen in my whole practice. And so my few questions for you about that specifically. Number one, yeah, do you have a preferred approach for those? And number two, if you see that in absence of a clinically relevant hernia, how do you proceed?

Speaker 1 (30:11):

So I’m a big advocate of imaging. Obviously that’s been kind of my thing because I treat a lot of women and women tend not to have the bulging and imaging can demonstrate these hidden or occult hernias, which are explaining their symptoms. So if the symptoms are hernia alike and the imaging is there and this and the exam is kind of equivocal, then I do offer surgery. And we actually looked at our data to look at how important history is and how predictive history is in whether a hernia repair will cure them. And we found key questions in our questionnaire that were highly predictive. So we presented that data at the HS, I think this past year, and hopefully the paper will get published soon so that we can kind of share this high yield questions about that. But the key though is regardless of whatever surgery you do in people with known retractile testicle, they should be also consented for an orchiopxy at the same time as the surgery because the testicle is so mobile that in the recovery stage it may retract up without you knowing, and then the Mesh is there or the surgery scars, whatever, and it scars it up in a higher place and it’s very uncomfortable for the patient.

Speaker 1 (31:31):

So I’ve changed my practice and anyone who has a retractile testicle, I include orchiopexy and their consent. And it’s a pretty simple operation from a

Speaker 2 (31:43):

Disco transcript.

Speaker 1 (31:45):

Yeah. Well, from the bottom, they do it from the bottom, totally separate from my incision. Okay, got it. Scrotal, inferior scrotal. Yeah. Yeah. And it’s something that, I mean, I didn’t really think about it much until I had this one patient. And in retrospect, obviously it’s uncommon. Usually it’s just a hernia. They’ve never had to retract all testicle before. All of a sudden they have it and it’s because they have a hernia that accommodates a testicle to move into it. But if they have a lifelong problem like that, then I would do orchiopexy. They probably should have needed one long time ago, and now they also have a hernia or something like

Speaker 2 (32:23):

That. Now they get two, four.

Speaker 1 (32:25):

Yeah, yeah. Okay. So this is a question about inflammatory response to Mesh. For patients who have developed a high inflammatory response to Mesh and need the Mesh of the abdominal wall removed, how do you treat a hernia if the hernia recurs after the Mesh removal?

Speaker 2 (32:45):

That is a great question. So I mean, I think that there’s no kind of pat answer to this. Number one, I will say as I have kind of progressed throughout my career, I’m more a little bit more kind of open to the conversation about Mesh resection than I used to be. I would say when I first started, because without question, there are patients who get better after their Mesh is removed and we can’t fully explain why. Although I think the comment about an inflammatory response to Mesh probably is somewhere on the path to the right answer as far as then closing the defect, I typically use a slowly absorbing monofilament suture to close whatever muscular defect is left after the Mesh is resected. Yeah. The next question is if somebody recurs after that, what do you offer them? And I would just simply say there’s no great answer to that question.

Speaker 2 (33:39):

There are some slowly reabsorbing meshes that are available. And I would say I’ve not been outright confronted with that issue in that way because most of the times we’re taking it out for infection or some other reason and not for an inflammatory reason. But I would say I would be willing to offer a patient a slowly absorbing Mesh as kind of the bailout option if they get a recurrence, just with the understanding that we don’t really have enough information long term on how we don’t have a big group of patients to follow to say how they deal with that. We know it’s relatively safe, we just know that they might get a recurrence again as well.

Speaker 1 (34:16):

Yeah, there’s no perfect Mesh is what I’d like to say. And everyone reacts differently. So what I’ve done is back in the day we would use biologic, and biologic is completely absorbable, and the results are that they recur at a much higher rate than, it’s not a hundred percent, but it’s a pretty high rate. I think it’s somewhere between 40 and 60% will recur of biologic. And then there’s a synthetic absorbable. Now the phasix, which you’re referring to, which absorbs

Speaker 2 (34:50):

And bio A too

Speaker 1 (34:51):

Both and bio, correct. Thank you. Which absorbs, I don’t know when the bio absorbs, but pH is around 18 months.

Speaker 2 (34:58):

I think Bio A is closer to six. I want to say it’s shorter. It’s like six months or something

Speaker 1 (35:02):

Than six months. And most biologics is around eight or nine months. I’ve become a big fan of the hybrid Mesh. So it’s biologic Mesh with some permanent suture through it. It’s polypropylene suture right now. The only company making something like that is called Tela Bio. They make ovitex mush. And what I like about it is that I feel it, it’s almost all biologic already. It’s like 96% biologic, so minimum. So what you have is a very low inflammatory foundation, and there’s just a bit of suture through it that gives you some support to reduce the hernia recurrence you see with a biologic. That said, it’s not like it’s perfect, you know, can get a Mesh reaction from that too. But the inflammatory potential is much, much lower.

Speaker 2 (35:58):

I agree. I mean, I think that kind of model of Mesh has a very kind of promising future and we’ll have to see if, but I agree conceptually. It’s definitely very interesting.

Speaker 1 (36:09):

All right. This patient has had two laparoscopic inguinal hernias, one open inguinal hernia and a robotic recurrent Inguinal hernia back in 2019. He feels that the robotic didn’t work because the size of the gear was too big and that caused damage. What are your thoughts on that

Speaker 2 (36:31):


Speaker 1 (36:32):

Yeah, the gear, the robotic arms were too big.

Speaker 2 (36:40):

Oh, okay. Sorry, I didn’t understand what you were saying there.

Speaker 1 (36:46):

Do you think the size of the robotic year can cause abnormal results from robotic surgery?

Speaker 2 (36:52):

So we’re talking about four operations for the same inguinal hernia, correct?

Speaker 1 (36:56):

Sounds like it. Yeah.

Speaker 2 (36:57):

Yeah, so I mean, I would just say it’s really hard to make that kind of commentary. I would just say we use robotic surgery to do all kinds of really very accurate surgery just in life, not outside of our hernia stuff. I mean, people are doing pancreatic anastomosis and intestinal anastomosis, really fine surgery. And to be clear, the robot doesn’t really do anything on its own. So it has very little kind of its own accord type of behavior. I would just say the likelihood is not that the problem is related to what happened robotically. The problem is likely related to the inguinal canal is a very complicated anatomic structure, I would say. And it’s comprised of many other complicated anatomic structures. And I don’t think it takes too much for one small thing to put everything off, particularly in operative field. So I would just say very, very unlikely to be related to the modality of the approach, but more likely to be related to multi operative kind of settings. And I think it’s multiply operated, inguinal hernia often results in chronic groin pain, unfortunately.

Speaker 1 (38:06):

So the size of the instruments for laparoscopy ranges from five millimeters to 10 or 12 millimeters, and for most robotic surgery is eight millimeters, sometimes up to 12 millimeters. But the instruments are not bigger. So I would not blame the girth of the gear to be any different than other laparoscopic instruments or as a cause of any problem. The fact that you’ve had that sounds like four operations and you still have, you’re right that your right testicle is still always pulling up, even though the people tell me I don’t have a hernia, but I feel like I have a hernia. I mean these are all things we’re discussing right now, which is what’s the interaction of the repair with your spermatic cord technique is important. So if you were to see me, I would look at all four of your operations and see what the technique was, where they placed Mesh, if anything, what size they used, what quality of product did they fixate it or not. Everything, every little detail I think is important to try and solve this puzzle. And then you hope that you didn’t get the same thing done, just formed four times over. There should be some change in technique or approach to prevent the same thing happening again, right?

Speaker 2 (39:29):


Speaker 1 (39:32):

Okay. Do you fixate laparoscopic or robotically placed Mesh and if so, with what and two what?

Speaker 2 (39:41):

Okay. I always fixate that is just my personal bias and I know that there are many surgeons across the country with minimally invasive approach do not fixate their inguinal hernia Mesh. For me it’s a requisite and particularly if the hernia is direct versus indirect. So the closer it is to midline for me, the more likely I am, but there’s never a time that I’m not going to fixate. So for me, my standard fixation if I’m going laparoscopically is titanium tacks and titanium, more absorbable tacks depending on the situation. But basically titanium is usually the most common thing I use. I usually fixate directly to Cooper’s ligament with two or three tacks. And then same way every time I take one tack high medial taking care to avoid the epigastric vessels and one tack High lateral taking care to avoid the Ilio pubic tract, which I’m able to tell anatomically by feeling the attacker on the tip of my finger when I fixate the Mesh. And that is all of the fixation that I use. And it’s the same way every time for that. And then I would just say robotically, I typically use surgilon suture, which is a I it would say semipermanent suture that’s breathing.

Speaker 1 (40:54):

Is that nylon? Is that nylon?

Speaker 2 (40:55):

It’s kind of like a nylon silk hybrid. So there’s some aspect of it that doesn’t stay forever. And so I like it though because it’s braided and it’s very easy to tie and it holds a knot quite well. So I will usually put, if I do that robotically, I put one to Cooper’s ligament and then the other two are in the same place, one high medial, one high lateral, and that’s all the fixation I use.

Speaker 1 (41:20):

Yeah, just for there’s a question, what is Cooper’s ligament? Is it periosteum? It is not periosteum, it is the ligament on top of the bone. Correct. So it’s just a very tight ligament that it’s very strong. We use it in many different hernia repairs. I’m glad you said you’re using titanium tax. I think there’s so much hype over absorbable tacks and my personal bias, I don’t know if I’m right or not, is I remember when everyone was all gunk about laparoscopic ventral hernia pairs and they were tacking the hell out of it and doing all these trans fascial sutures and people said it’s the tack that’s causing the pain. And really it was the trans fascial sutures, not the tacks, but it responds to that negative sentiment against tacks. The company is like, okay, we’ll make you absorbable tacks so that you don’t get the pain anymore. So it’s like four, three or four times more expensive without I don’t think any extra benefit. And if you do have problems, you can’t find them because you can’t see them because you can’t see about imaging technically on em. MRI you can, but it’s not easy. So yeah, I would like you to consider there’s a new company, it’s super small company, but they, have you heard of the fast touch?

Speaker 2 (42:46):


Speaker 1 (42:47):

You should. You’ll follow with it. So the beauty of the titanium tack is permanent and you can, it works well. There used to be this tacker fixator by Bard, which was a little metal suture. They kind of went in a metal ring, they discontinued it and I’ve heard multiple reasons why they discontinued it. But this company makes this called fast touch. It’s basically a suture, it’s polypropylene and it’s a zip tie. It’s like putting a suture. So you put a suture here, a suture. So it’s very low

Speaker 2 (43:25):

Profile. Oh, I’ve seen that actually, you’re right. Yeah, I saw it at Sages like maybe two or three years ago. Actually somebody brought it by, but I’ve never used it before.

Speaker 1 (43:33):

I’m in love. I’m not getting, this is not like an ad or anything, but I’ve, as much as possible I’ve converted to that because it’s low profile, much less pain potential. What’s it made of? Polypropylene. It’s just a suture. Okay. It’s like a zip tie suture. I understand. They actually now have a absorbable one for people that just to meet the demands of the surgeons. But I use the permanent and it’s kind of low profile. I like that because if you do it for laparoscopic, if you’re Intraperitoneal like you won’t get the adhesion. Sometimes the tacks get plus you don’t get as much spasm if you choose to overuse it.

Speaker 2 (44:16):

I don’t know. That is interesting. I’ll have to look into that.

Speaker 1 (44:19):

Yeah, it’s like a little thing. I don’t know. I like it. What are your thoughts on Strattice and other biologic meshes?

Speaker 2 (44:28):

I mean, I would just say biologic came along as a, I think we thought when they kind of first were being developed in the 1990s is when they first came to market, I think we thought that they would be a good suitable replacement for native fascia. And fairly quickly I think surgeons discovered both in the realm of plastics and hernia surgery, that biologic Mesh somewhere within one to two years, about 50% of them are going to fail. And so the biologics then really have been relegated more in practice mostly based on folklore to contaminated or dirty cases. And there’s not necessarily evidence that they perform better in those fields than synthetic meshes in dirty fields. I would just say stay away from Mesh in any way if you can help it. So I would just say there’s a pretty significant cost differential between biologic meshes and permanent synthetic meshes. I don’t, yeah, it’s a lot. And we don’t know that their performance long-term really lends any benefit. I would just say for me, in my personal practice, I don’t use them routinely because I don’t find that there’s a benefit to patients long-term in terms of using them. And I think frankly for me, I would just say the hype has sort of outperformed the Mesh in that regard.

Speaker 1 (45:54):

Yeah, I think AlloDerm was a first biologic Mesh marketed for hernias. And that was at that time made by a company named Lifestyle. I think they went to market like 2000 or 1999, something like that. I used it first in 2002 and I became a big fan because I was working at the county, a lot of infected Mesh and infected fields. And the hype was like, whatever you sell this, it’ll be exactly like, are you so de fashion be fascia you? So Duro v Dura, and this was actually part of the marketing. Well, I mean it wasn’t a bad product, but for sure we were overusing it. It has its purpose. It should not be used for any routine operations at all. Stratus was made by the same company because as a human product, you cannot go outside the country of the human, the cadaver.

Speaker 1 (46:52):

So you can’t sell to Europe if you make these in the us. And some companies, like some countries, I think Japan was one of it, does not accept human cadaver products. So in order to expand their market lifestyle then made stratus, which was made by pick or porcine. And then by that time they were making so much money selling these measures at 10 x that 10 other companies came out with really crappy biologics, just poorly made, poorly designed. It was biologic because somebody decided to use cadaver animal or human tissue. And we had a lot of people that had just poorly, poorly done hernias with basically synthetic product which came as biological. It was so overly processed and might as well have been cardboard. So that became a surge and then it went back down. And stratus has remained as kind of a more commonly used product. But I think as with any biologic, pure biologic, like you said, there’s no role for it In most elective surgeries. There are better options out there if you need to put in a less inflammatory product and the recurrence rates are still high, you’re really depending on a good tissue repair. And if you don’t have a good tissue repair, the biologic is not going to help you be a better repair. That’s that’s the history if you want to history from that. Okay. How likely is recurrence of a hernia, umbilical hernia If you had a hernia, it was sutured only after robotic Mesh removal, and if it does recur, can you live with an umbilical hernia?

Speaker 2 (48:53):

That’s a great question. So first of all, I think a lot of that depends on how it was closed after the Mesh was removed, robotically, what the tissue was like and what the patient is like. So a little bit I would say related to do we have connective tissue disorders? Do we smoke? Are we immunosuppressed for some reason? Are we overweight? Do we have diabetes? Do we have a wound infection? There’s a lot of things that go into that. What do we use to close the muscle back together? I would say standardly, if I take a robotic, if I take a Mesh out robotically, I will just so the muscle back together using solely absorbing monofilament suture. So suture that will go away over about six months time and I tell patients,

Speaker 1 (49:34):

Or maxon is what we call in the US either PDs or Maxon. Yeah,

Speaker 2 (49:39):

I use one of those. I agree. And typically because I’m robotic, I’m using a barbed suture, a quilled suture as we call it. And I would just tell the patient there’s a pretty decent chance that you’re going to get a recurrence. I don’t really quote percentages when it comes to that because I don’t think we have enough information to fully understand that. But I would always tell people there’s a decent chance you’re going to get a recurrence. And if so, I always tell patients about umbilical hernias. The extent to which it bothers you is the extent to which it bothers me If you’re living with it and you feel fine. And I’ll throw this little tidbit in there. I have an incisional umbilical hernia and I work with some of the best hernia surgeons in the world and I haven’t gotten mine repaired and I’m doing great with it. So I would just tell you as a fellow patient, if you’re doing okay and it’s not bothering you and it’s not getting bigger, it’s not causing pain, you’re not having obstructive symptoms, I think it’s okay to watch it. I do tell patients though, to be a little bit careful. If you are watching a, now what is an incisional umbilical hernia? If it hurts, if it’s getting bigger, if there’s stuff getting stuck in it and you can’t push it back in, if you’re vomiting because of it, you need to make a move.

Speaker 1 (50:46):

Totally agree. And it sounds like it was closed with Ds, size of the size matters to the larger the hernia, the more likely that it will recur. All right. Do you want to do, I have four really complicated questions that were sent in by a international surgeon, so I don’t want to get two technical about it because of our audience, but in the next nine minutes we’ll just like go through it really rapidly.

Speaker 2 (51:11):

Let’s do it. Okay,

Speaker 1 (51:12):

Let’s do it. Ok. Question number one, patient with four times recurrent incisional hernia. Every single time it was an Onlay Mesh replacement placement. They’re now five years later with a CT showing open an opened up posterior sheath and herniation between the anterior sheath and the Onlay Mesh, what would you do?

Speaker 2 (51:36):

Okay, I’m not fully understanding why the posterior sheath is open, given that these are Onlay Mesh placements. Yeah. However, what I would say is anybody who’s got a herniation through an open posterior sheath requires an operation. First of all, yes. Second of all, I would go, I would split the Mesh down the midline, take all the adhesions down, get into the abdomen. And this for me, if the patient’s optimized, likely would be an open abdominal wall reconstruction with a retro muscular repair. I would try to remove as much of the prior Mesh as I could without destroying the abdominal wall and then leave a bunch of drains, some underneath the muscle and some in the Onlay position and get the heck out of dodge.

Speaker 1 (52:26):

Agree. Okay. Next question. What is the best approach for hernia after cardiac bypass surgery in the upper epigastrium or sub xiphoid area? Basically underneath the top of the Rives?

Speaker 2 (52:38):

I love, love this question. So first of all, it depends on how big the hernia is. Some patients have had non-union of their sternum and those patients we’ve seen a fair amount of them because where I work happens to be very busy from a cardiac surgery perspective. So if I see that, yeah, I’m going for a big open repair, retro muscular repair for that, if we’re talking about a cute little guy from the chest tubes or that kind of thing, yeah, I’m inclined to approach those with either a robotic or laparoscopic approach. I just think that it’s important to be careful because you really can’t tack above the Rives because there are described episodes of people tacking into the pericardium and patients getting into trouble because of it. Easy to be careful.

Speaker 1 (53:18):

Yeah, no tax in the heart, not a good idea.

Speaker 2 (53:20):

Tax in the heart.

Speaker 1 (53:23):

Agreed. Next one, incisional hernia After open nephrectomy, how do you repair the hernia? If the muscle also has nerve damage?

Speaker 2 (53:32):

The muscle usually has nerve damage. Yeah, there’s always going to be some amount of bulging when the muscle is denervated. If there is also a true hernia defect, I recommend, depending on where the incision is, I will often approach these from a flank approach in an open manner with a patient on their side and I make an incision directly over the hernia and do a preperitoneal or retroperitoneal approach for the Mesh so it’s not touching the intestine and then close the muscle over it. And often, if there’s no muscle over the hip, I’ll often use some bony fixation there as well.

Speaker 1 (54:04):

Awesome. And last one, same patient, open nephrectomy, no hernia, just nerve damage to the muscle. What do you offer?

Speaker 2 (54:12):

This is a sad situation and we all hate it when we see it and we all see it a lot. And I would just say for that, for me personally, there’s not an operative intervention that’s going to fix that problem. Often surgeons will talk about placating the muscle, but I think that ultimately is going to fail and lead to kind of dissatisfaction for the patient. So for me, there are really good contouring clothing out there and supportive garments, and that’s what I recommend for that problem.

Speaker 1 (54:41):

Yes, yes. It’s a very difficult problem. I see a lot of it not just from nephrectomies but also spine surgery. So I have perfected this. I think this is one of the things that I really love doing actually. So I do these open, I plicate, but I start use using a plastic surgeon with these. So I heavily plicate, like I will plicate and the plastic surgeon is like, No, do more. Like super tight. And then you place an Onlay Mesh, and the Mesh is very wide. It is secured to parts of your body that don’t move. So the Ribs, it’s true, the Ribs, the anterior superior iliac spine, the inguinal ligament, pubic bone, the contralateral kind, anterior rectus sheath or linea alba, and then all the way in the back towards the back muscles. Those patients do well and we have good results. Not that many, but we have good results so far. But that’s been the best technique I’ve been able to do because these are super difficult, never give you the best repairs, whereas like a hernia repair, it’s good, but the key is to super plicate the disease muscle and then go very wide and cover attachments to healthy normal tissue.

Speaker 2 (56:05):

I like that. That’s interesting.

Speaker 1 (56:07):

That’s my thing. I like that. Okay. For your repair occurring into periostium? Yes, I am. Yes, I am. Okay. Anything else you’d like to let me know? So if a patient wants to see you, do you have a system? Is there an online system? They do

Speaker 2 (56:28):

Absolutely. With you. So I can be found at the Cleveland Clinic. On the Cleveland Clinic main website. Now I actually have to see what the easiest way is to find me. But what a

Speaker 1 (56:42):

Home page there.

Speaker 2 (56:44):

I want to see if I come up, if you say Clean Cleveland Clinic hernia surgeon, I’m pretty sure I do. And I’m pretty easy to find. Actually, there

Speaker 1 (56:55):

Aren’t that many in the world, believe it or not.

Speaker 2 (56:59):

When I look at Cleveland Clinic neurosurgeons, it’s all like Micron.

Speaker 1 (57:06):

So Mike Rosen and Dave Krpata were both guests on hernia talk and we had a lot of fun with it, especially with Mike. We got intense philosophical. We had a lot of philosophical discussions

Speaker 2 (57:20):

With, oh, I feel very sure that happened. So if you look under hernia surgeons on Cleveland Clinic website, there’s a bunch of us listed there and there’s a whole list people there. And I’m among them. And I’d be happy to see anybody anytime. And that and my here’s, here’s what it looks like. You can’t see it probably very well, but my office number is actually on there and how to get an appointment with me.

Speaker 1 (57:46):

Yep. Perfect. All right. On that note, we will allow you to go home. Your home. Yes,

Speaker 2 (57:52):

I’m home. Yeah, it’s a pandemic.

Speaker 1 (57:55):

Stay home. But enjoy your time with your family. I really do appreciate it. You’re several hours ahead of us, and I do appreciate that everyone has a life outside of their busy, busy schedule. So on that note, Ajita, thank you so much. I do appreciate, and this is the end of us for another hour of free to talk Tuesdays. Come back next week, we have another guest. I’m super excited. Thanks everyone. One for following me and for tons of questions. We had a great, great series of questions in people interacting with us on both Facebook and Zoom. This will be posted on my YouTube channel. You can share it with your friends, learn whatever you want about laparoscopy and robotic surgery. Thank you, Dr. Prabhu. Have a great evening.

Speaker 2 (58:41):

Thank you, you too. Bye

Speaker 1 (58:43):

Bye. Thank you soon. Bye.

Speaker 2 (58:45):

Hope you. Hope to see you too soon too.