Episode 77: The Boon of Robotics in Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

Everyone, it’s Dr. Towfigh, your host every week on Hernia Talk Live. I am your hernia and laparoscopic surgery specialist. Many of you are joining me on Facebook Live at Dr. Towfigh is also a live Zoom. You can figure out how to find me on Twitter and Instagram at hernia doc. And then at the end of this session, I’ll make sure that this episode and all the other episodes we’re almost up to 80 now will be available to you to watch and share on YouTube. So today’s guest is a lovely, lovely surgeon. I like to talk with surges of my generation, but this is the newer generation. They’re all into robotics and very, very talented. And this is Dr. Alisa Coker. She is a robotic surgery specialist and highly well-trained and assistant professor of surgery at Johns Hopkins Medical Center. You may have heard of it, top university and Top Medical Center in Baltimore, Maryland. You can follow her at Alisa May on Twitter and say thank you and hello and welcome to Dr. Coker.

Speaker 2 (00:01:10):

Hello everybody. I want to say thank you for having me. It’s such an honor. Dr. Towfigh flatters me too much. I do feel like I’m well trained. I’ve been very lucky to have a lot of people ahead of me that taught me well. And I want to say I am just so flattered to be here. When I was in training, Dr. Towfigh was basically the female hernia specialist. So even as a resident, I was always hearing your name, that’s love, and you were just kind of groundbreaking. So it’s nice to have a role model before you even knew you were my role model.

Speaker 1 (00:01:51):

Who is my role model is Dr. Parvez Amid. Did you ever meet him? He’s retired.

Speaker 2 (00:01:57):

Not personally. Yeah,

Speaker 1 (00:01:58):

He’s retired, but he is just, he was partners with Dr. Irving Lichtenstein. So the whole Lichtenstein hernia repair. Yeah, he’s heard of it. Yeah, exactly. He’s behind a lot of what we know about chronic pain. Triple neurectomy, he helped vent like the composites meshes. All the composite mes I currently have are based on his research and very prolific writer and he’s local. What I didn’t know is he’s local. And when I was a resident I would read all these papers by him and then I went to my first American Hernia Society meeting and I met all these people whose papers I’d read and then he was one of ’em. And I was like, wait, you’re in Los Angeles? I didn’t know that. And so I really looked up to him because there’s a lot of interest in hernia surgery as a specialty nowadays. This hernia, society’s grown, et cetera. There really wasn’t, back then there was a very small group and they kind of did their own thing and kept themselves and it wasn’t so mainstream where sages and all these American colleges, surgeons and all these societies that are huge now have a big, big hernia component to them.

Speaker 2 (00:03:21):

It took a while, but I think hernias have become sexy. Yes, yes. It used to be the thing that no one really wanted to study or everyone, everyone’s like, ah, anyone can do a hernia. Well, it turns out not everyone can do a hernia well and probably it’s best left to the people who are trained to do so. Right.

Speaker 1 (00:03:39):

And when you were in residency training, did you like hernias or how did you get involved in the whole including, because it’s a big part of what you do, it’s not all of what you do.

Speaker 2 (00:03:49):


Speaker 1 (00:03:49):

Yeah, it’s a big part.

Speaker 2 (00:03:51):

Yeah, I, I love my practice. It’s nice to have some variety. I probably do about a third of bariatric or weight loss surgery and then the rest is pretty equally split between for good or anti-reflux surgery and then hernias the rest and that’s hernias, all comers open, incisional hernias, inguinal hernias. And I do them in all methods too. Open surgery, obviously I’m a big proponent and I love using the robot, but I do a lot of different applications to fix them. But in residency, I don’t remember having a huge love for them right away necessarily. But I think a lot of surgeons are influenced by the people they work with who kind of take them under their wings. And I did my residency at the University of California San Diego with Dr. Jacobson

Speaker 1 (00:04:42):

Where I went to the

Speaker 2 (00:04:44):

Southern California represent. Yes. And he is a big hernia surgeon. I know him as well. And I enjoyed working with him and I enjoyed learning his trade. Really. That’s what it felt like. It felt like a specialized craft and it was just really fun to learn with him. And I knew that I wanted to be in that area of what you call minimally invasive surgery. The surgeons that specialize in the small doing surgery through small incisions, and maybe it doesn’t make sense right away when, but they’ve become the hernia specialist for the most part. So my fellowship in minimally invasive surgery was really an apprenticeship model where I spent half the year doing forgo anti-reflux bariatric and the other half of the year hanging out with Dr. Jacobson learning hernias.

Speaker 1 (00:05:41):

Yeah, yeah. I hate hernia. I was a resident, absolutely. But because I didn’t understand it, and it wasn’t until my first year in as my first job where I went to the American Hernia Society meeting, I was like, oh, that’s kind of cool. The stuff they’re talking about is way different level than what I ever consider hernias. And then the rest is kind of history. It’s become all that I do.

Speaker 2 (00:06:07):

I see it with the residents at Hopkins. The Hopkins is kind of known for big surgeries, a lot of hepato- biliary, so pancreas and liver cancers and transplant. And so when I say kind of jokingly that hernias have become sexy, it’s because those kind of things are, when you’re a young buddy surgeon, you’re like, I want to be a superhero and do really cool surgeries and save lives. And hernia doesn’t have that appeal right off the bat. Right. I still kind of joke sometimes after I fix even a small hernia, I’m like saving lives and I’m not really saving lives. But what you learn to take satisfaction in is that you are really improving lives. You see these people who have debilitating pain and are really just so frustrated with their hernia and so the ability to make their life better turns out that actually does feel pretty good.

Speaker 1 (00:07:08):

Yeah, yeah, I totally agree. Definitely. I also do the job saving lives when my trauma colleagues, friends ask me, how you doing saving lives? Because my life saving is really quality of life. I’ve proven quality of life usually. Okay. So today’s topic is to mostly on robotic surgery. I know you do a lot of that. You’re passionate about it. So I listened to your talks on it. We have a lot of questions about it and I’ve the ones that were submitted ahead of time, I already put these up on the screen so we can go through them and then as people chime in, I may kind of veer to some of the live questions, but maybe you can start with just a very simple question to be answered. Is robotics the same as laparoscopic surgery when you talk to your patients to use a term interchangeably? Or do you feel that robotics is really an evolution of laparoscopic surgery because there’s more degrees of freedom and precision? How do you view it and then how do you talk to your patients about it?

Speaker 2 (00:08:11):

We’re dive, we’re diving right in. So I think it’s important one to know anyone speaking on anything has their bias. And I am totally biased. I love robotic surgery. I really enjoy doing it and I do find that I give my patients really excellent outcomes with it, which is kind of the most important thing. So some people might answer this question differently, but what I explain robotic surgery as to my patients and I don’t use them interchangeably. Some things I do, some surgeries I do think can still be performed very well laparoscopic. And so I will tell patients that I recommend a minimally invasive approach, which really is the umbrella that covers robotic and laparoscopic surgery or an approach. And so then once I say minimally invasive in my hands, often that means I’m going to offer you a robotic approach. I feel like over the years it’s changing that more and more people do actually kind of understand what that is, but there’s a lot of people that really have no idea what to expect.

Speaker 2 (00:09:13):

And I think the biggest fear is that it’s literally a robot artificial intelligence that’s doing the operation. One, I have no interest in that. I actually like operating and I want to do it and be in control, but it’s not like that at all. So the way I describe it to patients is in both laparoscopic and robotic surgery, you have small incisions that, and you essentially have straws that will be going into your body through those small incisions. With laparoscopic surgery, I’m going to be standing there holding those instruments that are going through the straws. And with robotic surgery, the robot is standing over you essentially holding the instruments. And then I’m sitting in the corner moving the robot like a crane obturator. So I’m in complete control and the robot is just mimicking my movements. I do feel it is kind of the evolution of that. There are certainly excellent laparoscopic surgeons who I do think can provide some of the same outcomes as a robotic surgery, but I think the robot makes it kind of more even playing field for most people to get that excellent outcome and in a way that’s not quite as taxing on my body. So that’s the biggest difference I notice. Yes. So yeah,

Speaker 1 (00:10:37):

I like that. Great analogy. I should steal that. That’s a really good one because the way I always say is, well, I’m moving, but it’s hard for them to understand. But I think crane, that’s a really good one. We have a lot of technical questions about the robot, so we’re going to keep moving on.

Speaker 2 (00:10:52):

But of the people who do love the robot, I will say that’s, I use the joke that if open surgery is surgery 1.0, then laparoscopic because 2.0 and robotic is 3.0. So

Speaker 1 (00:11:05):

Oh, these are all excellent. All these talk about the perception that is so advanced with robotics compared to all the other,

Speaker 2 (00:11:17):

So with the robots, there is essentially two eyes. So two different cameras to that are we’re seeing through. And when you sit down at the robotic console, it’s an immersive experience really. So I just am sitting there and I’m looking through this goggle type thing and what’s happening is the image that I’m seeing is the combination of those two. And so you essentially get a 3D view by combining it and you can only see it at that console. So even people in the room, if they’re watching one of the screens that has a view of the surgery, they can only see one eye. So for example, sometimes one eye might get dirty, one of the cameras and I’ll say, Hey, can you clean the camera? And my assistant’s looking at me, you’re crazy. It’s perfectly clean. Why are you being so nitpicky? Which admittedly I am. But in that case I’m like, no, it’s like you’re looking at my left eye and it’s my right eye that’s filthy. So the difference, sitting at the console is really amazing.

Speaker 1 (00:12:28):

The people in the OR that we saw, can we take a look because they heard that the visualizations so different, they look, oh, that’s so cool. I can’t say it’s 3D per se, but definitely you have a depth perception that is much, much more advanced than a typical even a 4K monitor. So all our surgery centers and the hospitals now have 4K screens for laparoscopy, but the robotic view is still very different. So what are the specific contraindications for robotic surgery? Do they differ from those of laparoscopic surgery or do you treat them the same?

Speaker 2 (00:13:08):

Good questions. So reasons why I wouldn’t offer someone robotic surgery or not very different than laparoscopic surgery. I mean, first off, in order to do either of those minimally invasive approaches, the assuming we’re going into the abdomen, the patient’s abdomen essentially has to be blown up like a balloon. So we use a gas to create space and that space is required so we can put those instruments in there. And so some people might have lung conditions for example, that mean that they won’t be able to tolerate that as well. And so they may not be a good candidate. And then of course there are reasons why you might choose neither of those approaches based off patient characteristics, hernia characteristics that I would think that they’d have a better outcome with a open surgery. And then there are specific, I would say more than anything, there’s reasons I might choose the robot.

Speaker 2 (00:14:12):

So maybe someone who’s had a prostatectomy and radiation and they have an inguinal hernia, you might offer them an open approach. But if you were going to offer them a minimally invasive approach, I’d probably be more likely to go with the robot in that situation because I do feel like I have better visualization and better control of precision when you’re dealing in that preoperative field where there’s potentially scar tissue that’s more difficult to deal with. And then I will say, I think what’s been surprising to me as a surgeon in general surgeons at least it used to be, it’s easier to operate on a thinner smaller body habitus just because there’s less subcutaneous tissues to go through. Especially with open surgery, you’re not dealing with a big deep open wound. But with robotic surgery, it’s one of the few situations where if someone is too skinny, I’ll actually say, no, I’m going to do laparoscopic. And it’s because those robotic instruments are so long that I feel like you need extra room. So there are some patients that I say, no, I can’t get as much distance as I want and we’re going to laparoscopic.

Speaker 1 (00:15:31):

Yeah, I totally agree. What do you think of a trocar sizes lab versus robotic?

Speaker 2 (00:15:39):

I mean it depends on what you’re comparing obviously, because different surgeries require different trocar sizes are essentially the straws that we’re talking about that we put into to patients. There are definitely, I feel like more when it comes to hernia, there’s probably more situations where with the robot you are traded in order to use the robot a slightly bigger trocar size. So you can do the average laparoscopic hernia repair with a lot of five millimeter trocar, like little half centimeter incisions, and then the robotic trocars tend to be eight. But it’s such a minor difference that I don’t think you see much difference from the patient’s standpoint. For example, we don’t even routinely close trocars that small because they’re very low risk for hernia formation. And in my experience, there’s a rare difference. I mean maybe it’s different where you practice with all the beautiful people of la, but for the most part, most of my patients are not concerned with an incision that’s this much longer. Yeah. What about

Speaker 1 (00:16:51):

You? No, I have dropped down in a certain subpopulation, these models slash actor actresses where I use the three millimeter pediatric trocar for the inguinal hernias because

Speaker 2 (00:17:08):

That’s a different patient population, different

Speaker 1 (00:17:10):


Speaker 2 (00:17:10):

Population. And what I can’t blame them, that’s their money maker. And I think it highlights though the importance of choosing the right operation and the right tools for the right patient,

Speaker 1 (00:17:24):

Which I think is important as a, I think one thing that hernia specialists like you and I can offer is we don’t do everything just one way or just how we learned your residency. For example, it’s open, laparoscopic, robotic, smaller incisions, bigger incisions where you place the incisions. Yeah, Mesh, not Mesh. There’s all these different options out there that to be able to offer you the whole, you can tailor it. I like the word tailoring because I do feel that not one size fits all. I think women are different than men and the way that they cover from some of our hernia operations and the type of repairs they would need and benefit from larger people, different repair than smaller people. Totally agree. So I think being able to offer all those different options is a big deal. This is a interesting question. I have a lot of insightful, a very insightful audience. I made none of these up by the way. These are all submitted. So even though they sound highly technical, they’re all from viewers of, have you ever faced malfunctions of the robot such as unwanted movements?

Speaker 2 (00:18:38):

I can’t say that I have. I know that’s always the fear. I mean if anything that I have ever seen that could have gone wrong with a robot, maybe a collision between the arms externally, because there’s a lot of arms all, it’s all honestly human error and these are all things that are controllable. It’s like anything in surgery when people say I do anti-reflux procedures to and different hernia repairs. And I said, well, would you get this done? And I say yes, but I would choose the surgeon. And I think it comes down to proper training and knowing that you’re in good hands. So me, I’m neurotic about how I set the robot up. Just anything else that’s proper setup in knowing your instrument. Right, it’s ultimately an instrument. Yeah, you can cause a lot of damage. It’s a very powerful tool. And so I think if anything, it just highlights the importance of specialty training. No surgeon should be using that tool without being very comfortable with, it’s one of the reasons I’m passionate about teaching.

Speaker 1 (00:19:53):

True. There’s a lot of safety layers too. There’s a lot of points on the robot console and on the machine itself where you can just stop everything and disconnect everything and prevent any damage in case there’s some weird malfunction.

Speaker 2 (00:20:09):

And if anything does happen, what will happen? And actually I take that back, the only malfunction I’ve ever seen now is when it thought there was a malfunction and it just kind of froze up and we literally, any computer restarted it and it worked perfectly. But that’s what happens is it stops, right? Yeah. So it’s not that it goes crazy. What was that old show with the robot? It’s not like that. Yeah, it’s not like that. It would just stop working.

Speaker 1 (00:20:40):

There was a documentary that highlighted malfunctions in the robot and injury from the robot and there were some early on stages and I feel that it happened before the general surgeons really picked up robotics. It was early on, mostly gynecology that got involved and there was this lack of understanding of how powerful those arms are if you can’t see them, if you’re flailing around and possibly injuring bowel and so on, which again is much of it is human induced error. Then there were complications with perforations and so on, and that made the news a lot. So there is a little bit of backlash click against robots based on those stories and so on. But maybe you can expand a little bit about education because the company has done an excellent job, probably better than most other companies that have introduced technology in getting surgeons educated and certified.

Speaker 2 (00:21:45):

I mean, one, they essentially require it that any surgeon who starts using the robot takes a course with ’em. And that was all supervised. I can’t give you all the details of it, but essentially was required for them to get FDA clearance. And so they have to have a very structured program that’s usually, it’s actually a two day program and get essentially tested to make sure they understand the basics of the tool. And of course that’s just the bare minimum. They also have a lot of procedural specific courses. So for example, I teach multiple hernia courses for them. So people who either are just getting started with a robot or maybe they’re already comfortable doing robotic surgery in other areas, but they want to learn that specific trade. So it’s really a nice benefit. And I think any responsible surgeon takes advantage of these things. I mean I do actually, I still look for opportunities to learn new things where I can and learn from incredible peers. So I was doing, probably the last thing I started doing robotic was my bariatrics. It was kind of like my last laparoscopic holdout. And when I decided I wanted to start doing robotic bariatrics, even though I already felt very comfortable with the robot and I felt very comfortable doing bariatric surgery, it’s like why would I not take advantage of the opportunity? And I took a course on robotic bariatric surgery.

Speaker 1 (00:23:13):

So there’s an online course where you have to learn about safety, how the robot works, take exams online. You can’t even go the next step until you read all that and then take the online exam. And then there’s games that you play to. There are more technical in nature, like video games that are robot based. I love that part. That was my favorite part. I would go to the hospital early morning before they use the robots and just play those games. And then you go take your two day course and then you have to pass their hands-on exam for safety and then your hands-on exam to actually manipulate and you have to score a certain level before you can get your certificate. Then you have to go to your hospital and get proctored to do five to 10 cases right before you’re allowed to operate independently. And depending on your needs and skills level, the company is very generous in sending out flying out sergeants if there’s none locally, to physically be there in the room with you to answer questions, lead you through the process, make sure that you’re doing operations with some input from an expert. So

Speaker 2 (00:24:30):

Yeah, the hospitals have gotten really involved in the last two years too. Kind of the new frontier of safety is in hospitals actually having robotic credentialing. Where in that goes down to what you’re saying where they’re basically saying, no, you can’t use our robot unless you have a certain number of proctored cases. And usually even a ongoing re-credentialing process. So they’re looking to say, Hey, if you did less than 10 cases last year, you’re going to have to re-certify, prove you still know how to do this. And I think that’s the safe way to adopt such a powerful technology.

Speaker 1 (00:25:09):

Right? Absolutely. It’s pretty strict. Pretty strict. And our hospital is a catalyst program, so it’s one of many in the nation. So teams come in to the hospital and review how the nurses run the system, how the scrub techs function, the whole use of the surgeon, the scrub tech, the nurse, the circling nurse, the schedule, whatever. And they take that information, go back to the hospital and develop a good robotics program. So I must say they did a really, really good job as a company to assure patient safety.

Speaker 2 (00:25:54):

I’d agree.

Speaker 1 (00:25:55):

Yeah, I just have to say that because every time I talk about robotics, there’s someone that will say that robotics is unsafe or it should never be done, or there’s concern. I’m really scared because my surgeon wants to do this robotically. And in many cases there’s more safety and education done for robotic surgery than there is for open or laparoscopic. Yeah, that’s a good thing. Question about reduction regrowth in de novo adhesions. How does robotic surgery compare to open and laparoscopic surgery?

Speaker 2 (00:26:38):

Wow, I feel like that’s a high level question,

Speaker 1 (00:26:40):

Isn’t it? I think are so good.

Speaker 2 (00:26:44):

So one of the reasons that a lot of us are proponents of minimally invasive surgery, either laparoscopic or robotic, is cause there have been good studies early on in laparoscopic surgery that show it actually produces less of an inflammatory response. And we presume that translates to less likely to form these big adhesions or scar tissue within the abdomen, which can be a problem, particularly maybe down the road. So you have a great surgery and 10 years from now you have a bowel obstruction because of some scar tissue. So I don’t know that we have any great studies to definitively prove that robotic surgery causes anything less than laparoscopic surgery. I can tell you robotic surgery done well I think does create less trauma to the abdominal wall, which translates to less pain. And I think you can be more precise and in control and with that better visualization as well with the robot.

Speaker 2 (00:27:52):

So in theory you might be able to create less inflammation overall. But I can’t say, I’m not going to lie and say that I know that that’s a fact. But I definitely think any minimally invasive surgery could have a benefit compared to open surgery. But in the end it’s like anything else. There’s also just patient factors, you know, can do the same operation in one person. If you had to go back in, it looks like a bomb of scar tissue went off and then the other person looks like no one’s ever been there before. So there’s some variables that you just can’t control.

Speaker 1 (00:28:24):

Some people are just scarf forms much more than others. One of the comments made live is for me thinking robotics. I’m thinking that robotics is a must if I need surgery because I have a lot of adhesions. But just to be clear though, for the patients that are watching, not all hernia repairs can be done laparoscopic or robotic. Some of them have to be done open. Let’s say it’s an open Mesh repair and you need to remove that open Mesh, you have to go back in open. You can’t laparoscopically or robotically remove a Mesh that was placed on top of the muscle for as an example.

Speaker 2 (00:29:05):


Speaker 1 (00:29:06):

Right. Yeah.

Speaker 2 (00:29:07):

So yeah, not everything is amenable to a robotic repair. I definitely see patients who come a little disappointed because they look me up and they’re coming to me because they want a robotic surgery and I have to say that I want to give you the best repair possible. And sometimes for some patients that’s an open surgery.

Speaker 1 (00:29:25):

Yeah, that’s so true. So true. Okay, I think we answered some of these. How many ports and of which diameter are commonly used? A robotic current surgery was an eight millimeter. How do you identify a safe camera port site if they’re adhesions and Mesh? And do you always avoid Mesh areas for port placement even if the surgery is for Mesh removal?

Speaker 2 (00:29:49):

Yeah, well I think one of the very specific question, I know these people have done their research. So one the question to how many ports, I don’t think we address that. Typically it would be you’re going to have at least three and sometimes four. And occasionally someone might choose to put another one for what we call an assist port. So the robot’s not using it, but you have a bedside assistant that’s putting an instrument in through it or maybe passing your Mesh in through it. So most of my hernia repairs and the reason it makes sense, you need three cause you have one arm for your eyes and then one for each arm. So you have a right and a left arm in there.

Speaker 2 (00:30:31):

Identifying a safe, I mean I would say this is really a question about safe entry for anything and that’s going to be something that’s very specific to each patient and even to the surgeon when we compare methods for entering the abdomen for minimally invasive surgery, never has there been a study that demonstrates one is safer than the other. The safest method is going to be whatever that surgeon is best at, right? And so how I get in the residents will sometimes say like, well why don’t you do it this way? I’m like, well I do it this way because I’ve always done it this way and I have really good outcomes doing it. So I have no reason to change as long as I’m having great outcomes. But you definitely take into account previous surgeries if there’s Mesh. So for example, where I would typically put my ports for a certain surgery, if I know that someone else has already been there, I think I might encounter a lot of scar tissue. I may purposely go in a separate area where I think I might find more of a virgin field. Just to assess first,

Speaker 1 (00:31:42):

Yeah, we try not to go through Mesh. I get called in every so often for let’s say urology or gynecology operation or some cancer operation where the patients had Mesh before. And so they kind of want me there to make sure that the Mesh repair is not messed up from their operation because you do have to treat those patients slightly differently. And we’re so liberal in placing Mesh sometimes we forget that this patient has a lifetime need of maybe other operations in the future for their colon or for their gallbladder or gynecologic. So yeah, we try not to put our trocars through Mesh if possible, but sometimes it’s not possible and you have to do it safely and have different techniques of regard to that. So one of the live questions and hernia attack has created a bunch of hernia nerds.

Speaker 2 (00:32:42):

We’re hernia nerds. We

Speaker 1 (00:32:43):

Love being hernia nerds. First of all, we call ourselves hernia nerds, hernia friends. That’s a kind of hashtag that goes around Twitter, but thank you for joining me, chasing you, joins us every week actually. And I love that she does that and she’s very involved with the ACHQC actually as a patient. So why do you prefer robotic surgery?

Speaker 2 (00:33:13):

I find that I love that immersive field. Yeah, I could give you all the standard stuff. Why do people see a benefit in robotics, right? Yes. It’s the precision, it’s the wristed instruments compared to laparoscopic surgery, the excellent visualization, the ability to work in really fine teeny areas that are hard to reach otherwise. So for me working for forge surgery and for example, I’m working high up into the chest essentially we’re going through the media Steinem, which is a tunnel kind of carving up under the breastbone and it’s a small area and I feel like I can see better and have better control up there than compared to doing something open. But then also it’s just when you get passionate about something and you take an interest in it and you do it over and over again and you feel, you get good at it and you take pride in that so that when I sit at the robot I said, that’s my happy place.

Speaker 2 (00:34:09):

I know I can accomplish most things because that’s how I’m comfortable as a surgeon. If I can get my ports in and I get the robot set up, then I sit down at that console and I’m ready to rock and roll. That’s how I operate and it feels good to me. I’m comfortable there. And I say comfortable from, that’s a mental thing, but really that translates to a physical thing too. So I’m a big proponent of surgeons taking care of themselves, looking out for themselves. a lot of people, administrators for example, might only care about the bottom line, the dollar signs and not necessarily a surgeon’s comfort. And you could be thinking as a patient, well why do I care if my surgeon’s comfortable? But I’d be like, well you should do you really want someone to operate on you that they’re not focusing on you and they’re really just thinking, gosh, my neck and my shoulders hurt. They’re achy. My back feels horrible. This is a real thing. No, you want them concentrating on you and I can feel do that better robotically. And we know from all of us know unfortunately anecdotally from surgeon friends and seeing it, that laparoscopic surgery puts a lot of strain on your body. Open does as well obviously, but it’s a different type of strain. But laparoscopic in general, I always joke with minimally invasive surgery, it’s almost that we took the discomfort that the patient had open surgery and we transferred it to the surgeon.

Speaker 2 (00:35:41):

And what we’ve seen, and I’ve seen it in my own colleagues, and it’s really sad, young surgeons under the age of 40 requiring cervical fusions.

Speaker 1 (00:35:51):

Oh my lord.

Speaker 2 (00:35:53):

And not only is that unfortunate for them, but when you look at the cost of that to the healthcare system, that’s not good. So you have your surgeons that are now non-functional for months while they recover from surgery and potentially can’t continue doing what they were doing before and when we know they were facing a huge shortage of surgeons in the future, we need to keep our surgeons operating as long as possible, right? Oh sure. So we need to be comfortable.

Speaker 1 (00:36:21):

Yeah, definitely. Open surgery’s not ergonomic. You can make it so, every so often, but you still have to look down often. And that’s a big strain on the neck. So it’s cervical issue. Plus you’re standing for so long and that’s a horrible strain on lower back. So lumbar and cervical discs and diseases are rampant among US surgeons and shoulder issues too. But you’re right. When laparoscopic first came out, I was like, this is going to be great ergonomically, it’ll be so much better because you’re not leaning into the patient. But you can’t move when you’re doing laparoscopic. When you’re doing open, you can move around a little bit. You can change the weight that you bear on one leg versus the other. You can move away from the table or move back. Laparoscopic. You have to plant yourself and that kind of you like with a security guard, the security guard that just stands there and can’t move

Speaker 2 (00:37:22):

Except you’re doing a laparoscopic swan dance.

Speaker 1 (00:37:24):

Yes, this is true. Exactly right. But then I robotic surgery if done correctly. Some people don’t fix the heights of their mono monitoring chair correctly or the youth are poorly designed chair, but it isn’t very ergonomically correctly designed where your neck is at 45 and your arms are to your side and your lowers and all that. So yeah, I did have back issues and my robotic days I was like, oh thank God. Cause I was going to operate with zero pain, whereas my lap and open days, oh my god. So painful. Until eventually that cleared. But it was painful and I loved my robotic days, loved it.

Speaker 2 (00:38:19):

I mean, I can tell you I see the difference in my body now when now that I’ve transitioned to almost a entirely robotic surgeon. When I can do it robotically, I do. If I have a random day where for whatever reason I’m doing some laparoscopic cases. Yeah, it’s funny, this happened probably about a year ago and it was the next day I was like, why are my shoulders so sore? And I was like, I’m embarrassed to admit I don’t really work out very much. I was like, I know. I wasn’t like in the gym yesterday, why do I hurt? And then I realized, I’m like, oh, I was doing lap cases, it was laparoscopic surgery yesterday. So

Speaker 1 (00:38:58):

Yeah, different parts of your body are stressed for sure. Okay, so this is probably the most important question for today. Which types of hernias do best with robotic surgery? What’s your take on that?

Speaker 2 (00:39:13):

I mean, it’s a big question. I think it’s going to depend on who you’re talking to surgeon wise, what kind of repairs they can offer because there’s a huge spectrum of hernia repairs that we can offer you in terms of how we close the defects, where we put the Mesh, how we secure the Mesh. And so I think if you want low on a basic answer, probably something that’s too small, in some patients it would make sense to have an open surgery. But again, it’s going to depend on the patient. So what I’m looking at is body habitus. So you may have a small hernia, but if you have a large body habitus, I may think that you’re very high risk for recurrence in order to give you the most durable repair, want to do a robotic approach where I can get a big piece of Mesh in there for overlap for you.

Speaker 2 (00:40:12):

And then I think where the robot really shines though is in surgeries that you would’ve had to or would’ve wanted to do open otherwise for a specific technique like going in what we call a retrorectus position. So we’re able to put the Mesh right below the muscle, but in a plane that’s still technically outside of your abdomen and that that’s one of my favorite hernia surgeries. I think it’s a very good surgery, very durable, but that used to require a big open incision and those patients would be in the hospital anywhere from three to five days. And now like I said, I think it’s where the robot really shines is I can do literally an equivalent repair but through three or four small incisions and the patient goes home the next day. And so I think that’s definitely a sweet spot for robotics.

Speaker 1 (00:41:09):

Yeah, I agree. I think that certain operations are just as good lap, especially the ones where you don’t need to sew too much like a typical laparoscopic angle hernia repair, but maybe a really big one, a big scrotal one, maybe you do a better job with the laparoscopy because there with the robotics, because you can make a wider space easier or you can move further away from it. I think the flank hernias, the side with flank hernias are super perfectly suited for the robotics because you can do a better job of closing that defect and dissecting and seeing those nerves back there. And you’re often fighting with a lot of tissue, but with a robot you have extra arms to help with the retraction.

Speaker 1 (00:42:02):

I think definitely for flank, I a hundred percent try and do those as much as possible. Robotic, I must say though, I don’t know how it is that your hospital, so we currently do not have robot at the surgery center. It’s all in the main hospital. And so during the pandemic I couldn’t do any robotic surgery, so I ended up doing many things that I preferred robotically. I ended up doing lap, so because I could do it, the surgery center flying hernia and then also Mesh removal, which I was doing before the robot anyway, but you just get so spoiled when you have the

Speaker 2 (00:42:36):

Robot. Sounds painful.

Speaker 1 (00:42:38):

Yeah, but do you guys have a robot in your surgery center?

Speaker 2 (00:42:41):

We don’t. Yeah, it’s like the one thing I’m really battling right now. Overall, I think we’ve made a lot of very positive progress at my hospital and they’re very supportive of the robot. And we actually have a huge fleet. I think we have 16 now across our health system.

Speaker 1 (00:43:02):

Oh my God, that’s amazing.

Speaker 2 (00:43:03):

God, we’re a big hospital too. Our main hospital has over a thousand beds,

Speaker 2 (00:43:08):

A lot of, so a lot of surgeons use those, but we don’t have one in either of our ambulatory surgery centers yet working on it because I do think that would be a very positive thing to be able to offer the patients that, and especially in it’s a whole other, we should have a whole talk on that, on the economics of where hernia surgery is going. And now all these providers that are requiring certain diagnoses like umbilical hernias and al hernias be done in an ambulatory surgery center. And so when I have those certain insurances, I have to tell those patients, I can’t offer you a robotic approach because I don’t have a robot in our ambulatory surgery center.

Speaker 1 (00:43:53):

Oh my Lord. Yeah. I

Speaker 2 (00:43:56):

Haven’t looked. So it’s an insurance company essentially dictating what care.

Speaker 1 (00:44:01):

We don’t like that. We don’t like that at all. Wow. So Gina Adrales was one of our earlier guests on Hernia Talk. She was great. And if I recall, it was shortly after she got recruited to start really the laparoscopic kind of arm of the general surgery at Johns Hopkins where they acquired I think seven or nine, I think nine robots, nine. And it’s such a huge hospital, but it wasn’t really a very minimally invasively known hospital with telemini, but it was still an uphill struggle. And then Gina, I think telemini started that culture and then when Gina came on, it kind of blew over for general surgery and that’s amazing. 17. Wow. Yeah,

Speaker 2 (00:44:55):

Hopkins had a lot of growing up to do in general. I mean while we’re talking about Gina, I would say she’s my boss. She’s like, oh, I’m your coworker. She’s my boss. But she’s also really awesome and she’s one of the reasons I came to Hopkins, but she was believe we didn’t have a division of minimally invasive surgery until 2016, which is pretty unusual. And she was selected to be the division chief and super proud of her because she is the first female division chief in the whole

Speaker 1 (00:45:32):

System. Oh my God. Yeah. That’s crazy. Yeah, it’s a very traditional older system, especially in surgery,

Speaker 2 (00:45:41):

But things are changing. So now I’m happy to say our division, we have multiple hospitals, but directly in our main hospital. My division is basically three of us and we’re all female.

Speaker 1 (00:45:54):

Yes, I know that. And I love that. I would work for June in a heartbeat. She’s a amazing leader, just very lovely person to work with and very strong. Talk to me about large abdominal wall defects. What’s the role of robotics and can you use robotics for abdominal wall construction for the larger defects?

Speaker 2 (00:46:20):

You definitely can, I think have to, each patient needs to think about what’s important to them as well. Is it getting out of the hospital faster and recovery? Is it cosmetics? Because believe it or not, sometimes I have to tell patients I’m like the robot. Yes, it’s smaller incisions, but if you have a big gnarly hernia, maybe a big incisional hernia and you were left with a big horrible scar from it, sometimes if that’s important to you, everyone’s different. But if that’s what’s important to you, the best thing I can do is give you an open surgery and cut the scar out. But what you’re trading that for is definitely a longer hospital stay. I think it’s pretty amazing to see what surgeons have done with the robot, where they’ve taken it and how they keep pushing the limits. And so there’s a lot of great surgeons out there that are taking on more and more and they’re able to show that you can fix very large defects. Yeah, robotically.

Speaker 1 (00:47:28):


Speaker 2 (00:47:29):

Especially when you combine with other methods, whether you’re doing preoperative Botox injections to the muscle to relax everything before you try to pull it together. But I think the sky is the limit when I start thinking about what’s kind of a, we’re not going there robotically. It’s less to do with the defect itself typically, and more to do with other factors. For example, if someone had a fistula hole in their bowel that was coming out to their skin, and you’re going to have to resect that at the time of doing the hernia repair, that’s an open surgery for me all day long. I don’t see it ever being robotic, but maybe someone will curve me wrong.

Speaker 1 (00:48:16):

Can you talk about Mesh removal? Are all removals done open? Do you do the lap or robotic? How much of that is part of your practice?

Speaker 2 (00:48:30):

I don’t have a huge Mesh removal practice. I think you being and as famous as you are and getting so many people come to you with their potential complications in wanting your opinion, you probably take out a lot more than I do. But I mean, luckily most of my patients do very well and I don’t have to remove their Mesh. But occasionally I’ll have someone come to me that the most common reason would be a low grade kind of chronic infection and it’s just not clearing up. And you just at some point have to say it’s reasonable sometimes to consider trying to clear it with antibiotics and conservative management. But at some point you have to just throw up your hints. Say we just got to get the Mesh out of there. It’s just like a hip implant or a knee implant. If it gets infected, it may need to come out. And I’ve taken ’em out. It depends again on the hernia characteristics as well. But for the most part, if I can get in there and do it robotically, I will. I’ve definitely done that. And as you said, it kind of depends on where the Mesh is placed as well. So if someone did what’s called an Onlay and the Mesh is directly on top of the fascia, you’re not going to do that robotically. But if it’s in inside the abdomen, I would rather take that out robotically than open, honestly. Yeah,

Speaker 1 (00:49:53):

The general rule is if the Mesh was placed laparoscopically, robotically, then we prefer to take it out the same manner and in the same vein, if it’s placed in, if the Mesh is placed in an open manner, then we prefer to take it out done out in open manner. However, there are exceptions to all that. And I would like to say that it’s complete BS when surgeons that don’t know how to do laparoscopic or robotic, and you’ve heard this before, say, oh, I can do this better open because I can see better. I can feel better or whatever. It is complete, yes, there’s no validity to most of these people that claim that. So there are certain out there that will take out laparoscopic ty and big laparotomy, big open surgery, which makes no sense to me. Just

Speaker 2 (00:50:51):


Speaker 1 (00:50:52):

Suck it up and refer to a surgeon colleague that can do it laparoscopically and robotically and don’t mame the patient, give them a more risk for hernias and complications of nerve injuries and whatever, and have us do it laparoscopically or robotically. But yeah, you’ve heard that before, right? Yeah. Oh, I could do it better because I could see more than feel more or something like that.

Speaker 2 (00:51:20):

I mean, it’s such an archaic, stupid argument. Honestly, I don’t even really waste my time trying to convince those people otherwise. But I think it’s important for patients to understand that sometimes if you see a surgeon and they’re not talking about a certain technique, it may just be that they don’t do that technique. And a good surgeon will at least tell you that that exists if that’s an option for you and refer you to someone who may be able to offer it to you. There’s things like with certain surgeries, there’s different techniques that I don’t perform myself, but I’ll tell them I’m happy to send you to someone who can do that if you want to learn more about it.

Speaker 1 (00:52:00):

Yeah, yeah, no, I totally agree with that. And I think that we get this discussion a lot on this hernia talk live session because some patients, I don’t know if they’re not in power or they don’t feel like they can see more than one surgeon or ask about more than one surgeon. I mean, even if I need surgery, I would definitely go to get a second opinion and do my own research and learn more because that one surgeon may just be thinking one way and then the other one may be able to bring me a different viewpoint.

Speaker 1 (00:52:35):

And I think as with any specialty hernia, surgery specialists tend to know more, tend to have done more, tend to tailor better, our outcomes should be better than non-specialists. So someone wrote something about, I think my last 35 year old surgeon or 35 year surgeon said he could do my repair surgery, better open now all my nerves are damaged. We’re in a system that doesn’t want second opinions. I don’t know what system doesn’t want second opinions. Even a socialist system of medicine, you have the right to get a social second opinion. It’s really how much you advocate for your own, your own care.

Speaker 2 (00:53:25):

Yeah, I do a lot of second opinions and I’m happy to tell people when I disagree or even when I totally agree. I mean I’ll do, I’ll say like, no. And sometimes it’s a surgeon that I know very well and I’m like, that’s an excellent surgeon. I’m happy to operate if you want or you can stick there. But I agree, I would want to look around a little bit. I always tell my patients, I think it’s important to understand that especially with what we do, which is elective surgery, meaning you don’t have to have it done. You’re not coming in through the trauma bay with an emergent situation. You’ve got a rush and that it’s kind of harder to shop around. But with what we do elective surgery, it should be a partnership between the surgeon and the patient. Everyone should feel good about what’s happening.

Speaker 2 (00:54:11):

So I’m not bullying you into any particular method. And that’s why sometimes if anything, I think what my patients would tell you, they would complain about how long my clinic waits are that they come in to see me. But that’s because I spend as long as needed pretty much with each patient. And sometimes that’s longer than the allotted time slot and things run over. But I want to make sure that they’ve heard about the different options and weighed them all and they feel like that’s what they want to do. Right, because I’m not just telling you what to do.

Speaker 1 (00:54:40):

Yeah. One of the comments says traveling to an expert certainly adds another layer of difficulty, which is true and cost, but it often is necessary for specialty care. Have hernia, will travel, fix hernia. I would travel too. Sometimes. I’ve had to travel sometimes to my patients, but those were very rare. Usually they come to me, but okay. The next first couple of questions that are more like just wondering. During incisional and other ventral hernia pairs are muscles themselves as opposed to fascia ever suture directly to other muscles are directly to the best one used. You tend to to not sum the muscle itself,

Speaker 2 (00:55:25):

The fascia is the strong stuff, but you have to understand it’s intimately related to the muscle. So it’s covering the muscle. And so we’re doing our best to pull the muscles, especially if you’re talking about a midline hernia. I would like to get those muscles close together. But I agree, I try to actually taking bites of the muscle because then you’re just injuring it and potentially causing more pain as well.

Speaker 1 (00:55:54):

Next, the same line is, I have read that you cannot suture muscle because the risk of suture pullout. Is this true or a myth?

Speaker 2 (00:56:02):

I mean, I think we kind of answered that. Is that in general you want to secure, for example, suture and Mesh to fascia? What’s strong? Yeah, I don’t think the muscle just isn’t even necessary.

Speaker 1 (00:56:17):

And it definitely pulls through no strength in muscle. Do muscles have to be sewn to more substantial structures such as tendons, ligaments, fascia, cartilage, or can the muscle be sewn to another muscle? We tend not to sow muscle and muscle. We tend not to sow muscle. I’ll just say that at least not for any strength purposes. Let’s see.

Speaker 2 (00:56:39):

A lot of muscle questions. a lot

Speaker 1 (00:56:40):

Of muscle questions.

Speaker 2 (00:56:42):

Was this all from the same person?

Speaker 1 (00:56:44):

It was. If you sew muscle to muscle, does this require special suture techniques? Yeah, so you try and use suture techniques that reduce the suture pullout. So it’s more of what we call vertical or mattress sutures then than sutures that can kind of cut through a cheese wire, you know, don’t want that kind of situation. Okay. Another question. When does it make sense to remove a plug only as opposed to a plug and patch robotically? The plug has not migrated, but it’s probably causing pain years after a good repair. That’s a good question, because usually people have a plug and patch to two part Mesh system, but the patch is fine. It’s the plug part that is a problem. And if you go by the first logic we said, which is if surgery’s done open, then removing the Mesh from that surgery should also be done open. But now we got a situation where that may be one of the exceptions,

Speaker 2 (00:57:45):

Right? Yeah, I, and I think it depends on the indication for removal. I mean, there are definitely people have Mesh removed because they’re concerned that that’s causing a chronic pain situation. If you’re talking about a recurrent hernia, I can tell you my general philosophy, I always say it’s you don’t know what you’re going to find until you get in there. And I don’t go in there with the goal of getting all the Mesh out. The Mesh is very well ingrained and if it’s not causing any harm, I feel like you can only cause harm by pulling it all up. So if it’s in my way, if I feel like it will interrupt the integrity of the repair that I’m doing, that’s when I’ll take it out. And I’ll say probably more often than not, it’s a plug that’s causing that. Yes. And not a flat piece of Mesh especially cause that’s been done open. So you often won’t even see the open flat piece of Mesh that was put on the other side of those muscles. Yes. But that plug sometimes is very precariously placed and poking out and there’s no way that you can do a good repair without at least carving it down.

Speaker 1 (00:58:54):

Yeah, that’s absolutely true. I think the plug is the only, there’s the main exception that we have. We’re almost done. But there’s an important question about the robotic tract repair, which I was very much asked to answer. So the robotic ilio tract repair is nicely termed ripped for. It’s a non Mesh repair of the ilio ileal inguinal, sorry, of the inguinal hernia. And in my practice, in my study, we found that it’s best applied to low risk hernias. So super small hernias and thin patients where you don’t want to use Mesh for whatever reason. And the anatomic structures are Cooper’s ligament and the transverse transfer cell is arch. Let’s do this last question because I don’t want to leave anyone unanswered. Okay, last question. I have a plugin patch repair for my angle hernia. I’m now having symptoms from it. I prefer to have it removed. Can I have a tissue repair? If so, can it be done robotically? What do you think?

Speaker 2 (01:00:06):

I mean, I think we answered this a little bit. So if you had an open plug and patch repair, you’re not going to be able to likely get all that Mesh robotically. And so if you really want that Mesh out, it would have to be an open surgery. And then certainly yes, a tissue repair could be an option for you

Speaker 1 (01:00:25):

Or you may not. So if you want all the Mesh removed for whatever reason, if that’s indicated, then yeah, probably a Mesh repair, like a flat Mesh repair is preferred over a tissue repair. But in my practice, if you agree that you’re going to have maybe a 10, 15, 20% recurrence rate with a tissue repair, which we consider high is certainly an option. But in some people, if you just take out the plug, like you said, robotically, and you leave the patch, even though it’s a small patch, maybe they won’t have a hernia recurrence. Just leave alone and then just have that discussion that you may have a recurrence in the future. Cause it’s not really the best repair to just have the patch of the plug-in patch system. But

Speaker 2 (01:01:15):

Yeah, I think it’s a definitely discussion to be had though. Because what I would worry about is then you’re violating those planes and that’s kind of your best chance to do that repair from there too. So then if it comes back, it’s not quite as easy to do.

Speaker 1 (01:01:28):

Yeah, the crush is What is a plug? A plug is like a, it’s a type of Mesh. We think it’s too much Mesh in general, but it’s not a fly. It looks like a badminton.

Speaker 2 (01:01:40):

It literally is like a little badminton Mesh. There’s no better way to describe it. And no hernia nerd would ever put a plug in anybody?

Speaker 1 (01:01:50):

No, no. Our nerdiness

Speaker 2 (01:01:52):

Just say no, not

Speaker 1 (01:01:53):

Allow it. I’ll not allow it. Okay. I’m going to finish with a spinal comment that was just sent in. As a patient, I value transparency for my provider. I love that you both don’t let your pride get in the way of getting what is best for your patients. Even if that means guiding the patient to another surgeon, it gives me so much respect for you both. So thank you for that comment.

Speaker 2 (01:02:15):

Thank you.

Speaker 1 (01:02:16):

Alright, our time is up. Thank you, Alisa. This was fantastic. I really appreciate it. It

Speaker 2 (01:02:22):

Was really fun. It went really fast.

Speaker 1 (01:02:24):

It did go fast and were fun. We had fun and the questions were great, right?

Speaker 2 (01:02:28):

They really were. I’m surprised

Speaker 1 (01:02:31):

Week, which I love to do. So thank you for your time. I know it’s later in the evening than it is for me, so I appreciate that your time away from family. And thank you everyone for tuning in. This is another Tuesday night Hernia Talk Live. My name is Dr. Shirin Towfigh. Follow me on Instagram, Twitter, Facebook, and YouTube. And I’ll see you again next week. We’ll do another one of these, and I’m off to a Lakers game.

Speaker 2 (01:03:03):


Speaker 1 (01:03:04):

I hope they win, which I, I’m sure they will. You guys take care. Bye. Thank you. Bye.