Episode 88: Robotic Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hey everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly q and a with our favorite people talking about everything related to hernias. Thanks for everyone who’s joining me on Facebook Live at Dr. Towfigh and on our Zoom channel. And many of you are following me as well on Twitter and Instagram at hernia doc. Remember that at the end of this episode or all this session and all previous sessions will be uploaded on my YouTube channel. So please welcome my guest today, Dr. Andrea Pakula. So Andrea is Director of Robotic Surgery. She’s a very talented surgeon. She does so a very wide range of hernia operations. You can follow her on Facebook at Andrea Pakula 7 and on Twitter at Andrew Pakula. So please welcome Dr. Pakula. Hey.

Speaker 2 (00:00:56):

Hey, thank you so much for having me. Excited to be here.

Speaker 1 (00:00:59):

I was going to say that even though you do so many other operations, you do bariatric surgery, trauma surgery, emergency general surgery, all the different surgical subspecialties. I think your love is hernia surgery.

Speaker 2 (00:01:14):

Definitely. Definitely been, yeah, definitely passion of mine is hernia surgery, a lot of the complex stuff for sure.

Speaker 1 (00:01:22):

And did that start in your training or it happened afterwards? Cause for me in residency I had no interest. And then it happened afterwards.

Speaker 2 (00:01:29):

It actually started in training because as my residency we were busy trauma center, and with that led to a lot of big incisional hernias or bad traumas, had left an open abdomen, which some people have to have in order to get them through the traumatic injury. They were left with these giant hernias. So that was where my passion for hernias started, which was reconstructing the abdominal wall and then it’s just taken off from there.

Speaker 1 (00:01:56):

Yeah, I know that. I think trauma surgery is a number one largest predictor of incisional hernias and then colorectal surgeries. Number two, all has to do with emergency surgeries and maybe dirty or contaminated situations that give what’s called incisional hernias. So you’re in a very unique situation because you were trained, you were trained pre robotics, is that correct?

Speaker 2 (00:02:23):


Speaker 1 (00:02:23):

Like most of us. But you’ve taken on robotic surgery as not only part of your armamentarium, but you’ve really become one of the handful of leaders in the United States that really are very gifted in robotic surgery. You teach robotic surgery, you proctor it. I chose you because first of all, I miss you. It’s been a while since we’ve seen each other. It was a nice excuse to see you, but also there, there’s just a handful of you all that really are champions of this technology. So when did you learn robotic surgery and what did you say have that aha moment of like, oh, well, this is even more interesting than laparoscopic surgery, which was really your main subspecialty.

Speaker 2 (00:03:15):

Yeah, I, so I trained on the robot in 2016, and my initial reason for training was specifically for the complex abdominal wall hernias. I wanted to be able to offer minimally invasive approaches for some of these big hernias. And going through the training and seeing the benefits of the surgery, whether it was for a hernia or a gallbladder or whatever it may be, it, that’s what opened my eyes to, wow, this technology really is incredible what it’s allowed us to do. And that changed me within a year I was a full practice or total practice robotics. So now I pretty much approach almost anything that everything that I can robotically.

Speaker 1 (00:03:55):

No kidding. So almost a hundred percent robotic surgery. That’s pretty impressive. And just to clarify, you are at Adventist Health, which is a private practice hospital, and you’re in private practice,

Speaker 2 (00:04:08):


Speaker 1 (00:04:09):

Yes. And don’t you feel that private practitioners are actually more active and more gifted in many ways with robotic surgery than those that are employed in a university based teaching hospital?

Speaker 2 (00:04:22):

I do think sometimes when you’re in a bigger university type hospital, you tend to, number one, have to focus on the specialty that you might be hired for. And also, obviously those are great hospitals, they’re training institutions and we have residents in those institutions, but they’re not necessarily able to push the envelope and kind of perform outside of the box, if you will. And so it’s been great being in private because I’ve been able to do a lot more

Speaker 1 (00:04:50):

And many don’t know. But laparoscopic surgeries starred the same way. Exactly. It was mostly private practice doctors that took on the technology and started advancing it. So this is, I think, number 88. I think this is episode 88 that we’re doing. So we’ve been doing this almost two years. It’s really great. And we do get questions about robotic surgery. Maybe you can help dispel some myths. Who’s doing the operation, how autonomous is the robot? Let’s start with that. And then how is it different from laparoscopic surgery? Because I often use the terms interchangeably, but I know that technically they’re not the same,

Speaker 2 (00:05:33):

Right? No, and I get asked that a lot in the office. If I’m seeing a consultation, they’ll say, well, who’s actually going to do the surgery? Yeah. So the rope, the way that I talk about robotics, it’s just really an evolution of minimally invasive surgery. It’s the next best minimally invasive tool. So the surgeon themself is doing the operation. I have complete control over the instrumentation. What makes it robotic really is just that I control the instruments somewhat remotely. I’m sitting maybe over on the couch here where I’m controlling the instrumentation that’s actually enabling me to do the procedure. But the difference is that it’s so precise. The visualization is three-dimensional versus two-dimensional, which we see in standard laparoscopic procedures. The instruments literally articulate, so it mimics what we do open, whereas what we call traditional, we’ll say laparoscopic surgery, those instruments are, they’re like chopsticks. They don’t have risks at the end of them to be able to allow us to articulate. So that surgery or that ability with the robot makes the surgery more precise, less traumatic to the tissue, less bleeding, and overall less pain. And I really have seen a tremendous result with respect to faster recovery need for really minimal, if any narcotics at all, which has been really great for patients.

Speaker 1 (00:07:03):

That’s one of the things that I think we didn’t predict when we were doing robotic surgery, especially for the abdominal wall, is our colleagues that were starting really push the envelope and use it for these big hernias, which definitely laparoscopically almost no one was doing. We were just doing them all open and then they started doing it robotically. And whereas if they would be in the hospital three to five days minimum, they would go home the next day. And when I started doing it, I was like, I didn’t believe it, but I mean, I did believe it, but I was kind of, well, maybe it happened in some of their patients. No, literally the next one, okay, can I go home? I’m like, yeah, you can. Right. Pretty amazing. Pretty amazing. So one of our questions is how do you balance the advantage of robotic surgery versus the need to do everything via an intraabdominal approach, especially for hernia repairs or inguinal hernias? It’s an open approach. And then there’s the extra peritoneal approach, which we do laparoscopically. But with the robot, everything you have to go in the belly first. What are your thoughts on that?

Speaker 2 (00:08:13):

So there are obviously a number of hernia repair techniques, and there’s different accesses as we might call it. So as you refer or you refer to laparoscopic extra peritoneal approaches for inguinal, we do that for ventral as well. So we call it the eTEP or the extra totally enhanced, totally extra peritoneal approach. Yes. And I’m very selective as to, I take every patient as an individual, their hernia characteristics, the patient themselves, previous operations, and that’s what helps to lead, guide me as to what approach I think is going to be best for them. And then of course images, maybe CAT scan images and things like that. But you don’t have to enter the abdominal cavity. And I try to avoid that sometimes depending on what the situation is.

Speaker 1 (00:09:02):

That’s a really good point. So the eTEP, so many acronyms. First of all, I know with hernias, TAPP, TEP, eTEP,

Speaker 2 (00:09:10):


Speaker 1 (00:09:13):

Tar up, there’s all these, it’s crazy. We actually published a paper on it. It’s

Speaker 2 (00:09:17):

Like different acronyms. That’s

Speaker 1 (00:09:19):

Funny. Yes, because we had to kind of get everything somehow defined for everyone else. But originally everything was intro abdominal, and as leaders, you kind of started doing more and more. You started to say, oh, well we don’t have to do everything Intraperitoneal. We can start making tissue planes. And so both for ventral hernias, so the abdominal wall in the middle, you can make those extra peritoneal, the lateral flank ones and then also the groin. Now, that said, it is actually a much larger space that you would make with the robot usually than you would with a laparoscope. Is that fair to say?

Speaker 2 (00:10:08):

Well, I would say for, you’re talking about staying extra peritoneal?

Speaker 1 (00:10:12):


Speaker 2 (00:10:13):

I think it depends. I mean, for eTEP, for instance, for a ventral hernia, I didn’t do eTEP laparoscopically. I did tips for inguinal hernia, but not for the ventral space. You can create a much larger space because the ease of dissection with the robot is it facilitates the ability to make a much larger space, but you don’t have to, if you’re doing a pre peritoneal repair, which though we enter the abdomen, we are still placing at least our Mesh outside of the parit, outside of the abdominal cavity. Yeah, I think you can make as big a dissection laparoscopically. It’s just harder. It’s hard to dissect on the abdominal wall with those unwristed instruments.

Speaker 1 (00:10:56):

Yeah, you kind of operate, you’re standing in the ground and operating on the roof, on the ceiling. It’s kind weird. Yeah, exactly. So then the follow-up question is can you specifically address any benefits of robotic inguinal hernia repair versus let’s say laparoscopic? Are there certain patient factors that play in your decision or should patients be aware of what things may or may not be in their favor to choose a robotic inguinal hernia pair?

Speaker 2 (00:11:27):

So I will say you can do in robotic, how can I answer it? So a TEP does not just mean laparoscopic. We can do robotic TEP inguinal hernias, we just call them eTEP because our ports are placed a little higher than usual. It’s not in the same location

Speaker 1 (00:11:44):

E for extended.

Speaker 2 (00:11:45):

Extended. Yeah, exactly. For me on, I’ll be completely honest, I pretty much predominantly only will do robotic. Now whether I’m doing a TEP or a TAPP, it again depends on patient factors. So those factors would be if they have an associated ventral hernia, umbilical hernia, let’s say, or even a big hernia that for me, I’m going to be in that extra peritoneal space or outside of the abdominal cavity, then I can extend it down into the groin to fix the inguinal hernias. At the same time, if it’s an isolated inguinal hernia, I prefer to do through the abdomen what we call a TAPP approach, because I can look at the other side. So if they don’t have symptoms on the other side, we know that around 20% or so if patients will have a hernia on the other side that they don’t even know about, and I can see it and I can fix it right then and there, rather than the TEP approach where you have to completely dissect out that space in order to identify the hernia on that other side. Yeah. So that’s a benefit I think.

Speaker 1 (00:12:49):

Yeah, I agree. And then the whole open versus laparoscopic, that’s a different discussion because if you need to have an open repair, then lapper robotic doesn’t usually doesn’t make a difference. That said, I’ve always said there’s two main reasons why robotics is beneficial for surgeons to learn. One is in general for hernia surgery, laparoscopic has been a very difficult technique to master for multiple reasons. Anatomy is one of ’em, and just technique is a little bit more complicated. And the advent of robotic surgery has made it so that learning curve has been improved. So there are papers that have said somewhere between 250 and 500 inguinal hernias need to be done laparoscopically before you start kind of stabilizing in terms of your outcomes. Whereas that number, I think is down to less than a hundred for robotic surgery. So that’s one benefit. I think more surgeons, from what I understand, are doing minimally invasive surgery and offering it to their patients. Even in our hospital, there are surgeons that never offered laparoscopic inguinal and now with the robot are offering it, which I think is great because it’s a better repair. Absolutely. Shorter recovery.

Speaker 2 (00:14:12):


Speaker 1 (00:14:12):

Laparoscopic or robotic.

Speaker 2 (00:14:14):


Speaker 1 (00:14:15):

But the other thing, and I used to be, I’ll be very honest, I was a skeptic early on. I was very honest. So why would you do anything robotic when you can do a laparoscopic, it’s only for surgeons that dunno how to do laparoscopy. And I take completely take that back because the technology of robotics, and correct me if you want to add to that, is such that I can now do surgery operations. I was doing open before minimally invasively, so I was handicapped by the laparoscope laparoscopic instruments and could only offer certain operations open or laparoscopic. But now a fraction of those open surgeries I can now do minimally invasively via the robot, whereas I couldn’t before. That includes the TAR and these kind of complex abdominal wall reconstructions and most recently includes what we call Rives, the R I P T, the robotic ilio pubic tract repair, which is a non Mesh tissue-based inguinal hernia repair, which really would be super difficult to do laparoscopically. So there’s that too.

Speaker 2 (00:15:26):

Yeah, I mean the majority of surgeons that we are training now, I think we see so many that are converts. They’re open to robotic, maybe more so like you said, maybe more so than laparoscopic to robotic, although many of us may have done laparoscopy prior for some of these repairs, but so many surgeons can offer minimally invasive procedures now to their patients that they otherwise wouldn’t have before.

Speaker 1 (00:15:54):

So follow up to the last question is are there any disadvantages to the more extensive dissection in the retrorectus space with the eTEP because it’s extended TEP as opposed to regular tap?

Speaker 2 (00:16:07):

Yeah, I mean with respect to the eTEP approach and being in the retro muscular space or retrorectus space and then taking that down into the groin, there’s more chance if you’re repairing a ventral hernia with or without an inguinal, when you’re in that space, there’s a chance that you’re going to have hematoma because you’re right on bare muscle. Yeah. There’s a chance that posterior layer, that the layer that’s covering between, that’s covering the intraabdominal content, that if you happen to close that and there’s too much tension, it can open up leading to what we call an intraparietal hernia where intestine can get into that space now creating an bowel obstruction. So there’s obviously nuances to the technique for us to avoid that. But that’s the difference between, that would be the disadvantage if you’re doing a big dissection that you don’t need, but if they have an associated ventral hernia, it’s a really good repair to be able to take care of all of the hernia defects.

Speaker 1 (00:17:09):

So you work very closely with intuitive surgery, surgical, which is the company that is the current producer of the Da Vinci robot. There’s no real competition at this time for them. And you represent them in proctoring people and teaching and so on. What do you see? Do you see any concerns? One of my concerns, cause I consider myself an educator, is through lap teaching laparoscopy. There’s so many things that can go wrong and you teach the residents and the fellows and you know how not to accidentally puncture a bowel or how to carefully manipulate things because your fingers aren’t doing it. It’s an instrument that’s doing it that can be sharper, can be hot. You can’t really determine that. All you see is what you see and not everything else around you. So there are blind spots. My concern sometimes is that when people go from open to lap to robotic and don’t go through that laparoscopic learning curve, that maybe they don’t appreciate the nuances of safety. What are your thoughts on that?

Speaker 2 (00:18:21):

I think, I mean twofold. I will say it. The majority of general surgeons will have some laparoscopic experience, I would think. Okay, with cholecystectomy, gallbladders, appendectomies, even if it’s just the basic stuff. So they should have some degree of experience with laparoscopy, but no doubt, open to robotic for inguinal hernia is very stressful when I’m proctoring because they’re not necessarily familiar with that space. It’s very different anatomy. There are very important structures down there, blood vessels. But the nice thing is most surgeons will be pretty hesitant with their dissection and what they’re grabbing because they know they don’t know that space. So yeah, almost sometimes they’re more careful than, and I don’t want to say than they need to be. That’s not right. But there they’re overly careful, you know? You know what I mean? But no, absolutely. I mean there’s definitely a learning curve and if you don’t have an appreciation of, we can feel it laparoscopically. I do believe though, that there is haptic feedback with the robot, but it’s learned over time. Yes.

Speaker 1 (00:19:28):


Speaker 2 (00:19:28):

So I stress to them the need for being extra careful and really understanding the anatomy so that injuries don’t occur.

Speaker 1 (00:19:38):

Yeah. The other question that was presented was, if I have a choice between laparoscopic and robotic surgery, is there one that I should choose?

Speaker 2 (00:19:48):

I think it’s just a discussion you need to have with your surgeon. I think that you, obviously, for a surgeon, the best technique that they do is what they do best, if that kind of makes sense. So if you go to somebody that’s done hundreds of robotic cases and only a few laparoscopic, then I think you should have a robotic operation if that’s what they’re more comfortable with and vice versa. And then of course, I encourage all of my patients as well to research both robotic surgery is laparoscopic surgery. Yeah. Again, it’s just a finer, more precise technology to allow us to do it.

Speaker 1 (00:20:26):

Yeah, I feel like there’s very few situations where you would say, oh, definitely don’t do it lap or definitely don’t do it robotic. Right? Yeah. Very few situations like that. If robotic surgery allows greater precision and freedom of movement for the surgical instruments, why do they generally take longer? If that’s a question presented,

Speaker 2 (00:20:48):

I’ll kind of be blunt about that. It really depends on the surgeon and the skillset early in your learning curve. Absolutely. It’s going to take you longer because you’re learning a new technology. I am just as fast as not faster now with the majority of my robotic cases than laparoscopically. And I was, I’m a skilled, I consider myself a skilled laparoscopic surgeon. I did a lot of laparoscopy prior to robotics, but it doesn’t always take longer. It often can be faster. The efficiency of your staff, your support staff in the room, and just your skill of doing the procedure.

Speaker 1 (00:21:22):

When I was a resident, laparoscopy, laparoscopic gallbladders were a thing. Laparoscopic app appendectomy for appendicitis was not yet a thing. It was still the attendings were doing them. And then laparoscopic hiatal hernia repairs, missing fun application. Also it would be a two attending thing in as a Rives. And you just held the camera. There was not much that you would do because the attendings were on their learning curve and it took forever. Forever. And as the resident holding the camera, you like, why don’t we just do this open? I don’t understand. And now those operations are done without even questioning whether we should do our appendix surgeries or FL applications for hiatal hernias, laparoscopically versus open. So I think understanding history and the evolution of new technology and finding the pros and cons and following that is very important. I get this. I think administration focused on that a lot. Took you this long to do your robotic surgery. Yeah, but the patient went home, they don’t have a wound infection, they have a better repair. So there’s a lot to be said about that. Let’s see. Got some more questions here.

Speaker 1 (00:22:49):

Oh, okay. This has come up a couple times. So I don’t know if you’re aware, there was this Netflix documentary called The Bleeding Edge, and in it they talked about different F D A approved devices, including the robot that had associate complications and they did focus on the Da Vinci robot and the risk of complication with that specifically early on, I don’t sure the history better than me. Early on it was really initiated in gynecology and there’s a lot of risks of intestinal injury at the time, and there may have been a handful of instances where the robot kind of needed to be rebooted or got stuck or something. So can you talk about the dangers of the robot and what was it discussed at this documentary and how you could address that?

Speaker 2 (00:23:46):

Yeah, no, it’s a great question. So first and foremost, again, it’s the surgeon that’s doing the operation. It’s not the robot. Correct. So complications can happen in any type of surgery, open, laparoscopic, robotic, and obviously we do our best not to have complications. But those complications specifically for the dehisces in the gynecologic procedures, yeah, I mean I think that was really a technical problem. It’s not the fault of the robot. It’s easy to blame the robot because the surgeon doesn’t want to take blame. But if there is a failure in whatever it is that you’re doing, it’s a technical failure more commonly, not because the robot did anything wrong. So as far as safety goes, the robot is, again, it’s very safe. So many almost we fail safe, if you will, that if it’s not going to do anything without me controlling it, if I grab onto something and I take my head out of the console, the instruments won’t move. So there’s even that level of safety. Let’s say if you get into bleeding, you can control it very quickly, very easily. But for hernia surgery, I mean it is very safe. Like I said, I do pretty much all of my hernia repairs now, short of the hernias that I really can’t do on the robot, I do them robotically. So it’s really the safety is of the surgeon and what we do. It’s not the robot doing anything or causing any undue harm or unsafe unsafe practices, if that makes

Speaker 1 (00:25:19):

Sense. That’s true. And we actually publish our paper on the safety of, I do a lot of master removal for inguinal, and it’s tricky because the bladder’s there, the nerves are there, vessels are there, the major vessels to your leg are there, and the spermatic corn in males and it’s associated vessels and the Vas defen, which ones all there. So we looked at a laparoscopic way of doing it versus a robotic way. Now, fortunately everyone did well, so outcomes were basically the same. However, you had less bleeding and less injury to these major vessels, like the big vessels like your leg with the robot. And probably that’s related to the high precision and the visualization. And even if we did get into bleeding that it was easier to control. But yeah, there’s definitely that.

Speaker 1 (00:26:23):

Again, I would say look at history. So when gallbladder surgery came about, you probably know this story actually to this day, I think it’s still true that injuries to the bile ducts is much higher with laparoscopic surgery than with open surgery, even to this day. And when laparoscopic cholecystectomy came out, there was one paper that showed this multiple fold increase in bile duct injuries and so on. And these surgeons who were advocating for laparoscopic surgery and the gallbladder were, I mean there’s stories where there had literally tomatoes and eggs thrown at them, right? And they were booted out of some meetings. They weren’t allowed to present. It was a lot. There were campaigns to prevent laparoscopy. So understanding that even with laparoscopy, which right now we think definitely it’s very safe to undergo for bladder surgery, it still was not considered safer than open. And a lot of it was surgeon related. It was like surgical technique and understanding the pros and cons of maybe limitations with this technology. If you do robotic and more hernia repair, not the eTEP. So we’re talking top likely, can you fixate the Mesh with either tacks or suture to Cooper’s ligament without causing postoperative chronic pain? Or is the Cooper’s ligament a very sensitive site for fixation? That’s a good question.

Speaker 2 (00:27:59):

Yeah, it’s a very good question. So, well, first of all, I will say the beauty of the robot is that we’ve eliminated tacks.

Speaker 1 (00:28:05):

Yes, thank you. Yes,

Speaker 2 (00:28:08):

Especially, I mean, I’ll talk about anyone to answer the question, but I mean, in the ventral space, the tacks that we used to put up there were so painful to patients. And I mean we would take patients back just to remove tacks at a specific areas that may have hit a nerve that we couldn’t see.

Speaker 1 (00:28:23):

And why did we even invent tacks? Because we couldn’t suture laparoscopically.

Speaker 2 (00:28:27):

Exactly, exactly.

Speaker 1 (00:28:28):

So we’re trying to make up for the deficiency of laparoscopic surgery, which the robot took back, took back because it’s more like doing open surgery,

Speaker 2 (00:28:36):

Right? Absolutely. I love it. So for inguinal, I suture the Mesh to Cooper’s ligament. Like you asked Cooper’s ligament, is it, I can speak from my own patient experience, there’s not an increase in pain. I think the ligament itself does fine to take sutures without causing any risk of pain. Now we try not to suture into the bone causing osteitis or inflammation of the bone itself. That can probably lead to some increased pain. But we, we try to be specific as we’re playing, placing those sutures. I don’t place personally any other sutures. I only suture the Coopers. I don’t like to place them on the abdominal wall because the nerves are so variable in their distribution that even though we see the main trunks of the nerves and we try to visualize those during the operation, there are other little branches that we can’t necessarily see. And I’m always concerned that a suture will potentially grab one of those. So I plan, I place sutures to Coopers with not worrying about an increased risk necessarily of pain because we just don’t see it there. You

Speaker 1 (00:29:46):

See something. Yeah, that’s a big point that I feel like robot kind of takes us back to more original surgery, more classic surgery, more open surgery, but with the addition of extra technology. It is a very expensive technology though, I must say. But everyone seems to be okay with it now. I don’t know. I feel like, I mean, you have a community hospital. We have nine, wow, 10, actually we’re going up to 10.

Speaker 2 (00:30:12):

Well, but robot intuitive is done very well at making it easier to get a robot in the hospital. You don’t have to put that big capital lump sum purchase. They have leasing programs, they have rental programs, they have pay as you use programs, and the more you use the more it pays for itself. So they hospitals want to be able to offer it because they want surgeons to come that are going to be able to do it. And then obviously they want to promote it because they want it to pay for itself. So ultimately it’s expensive. But I think they’ve come up with ways to get around that.

Speaker 1 (00:30:46):

And I’m advocating bringing one of our robots to our surgery center because most of what I do is outpatient. There are certain inpatients that can have their prostate surgery or other kind of more complex operations in an outpatient surgery center. COVID has made it so that it’s really not feasible to do simple elective surgeries in the hospital setting when you have other sicker patients that take priority. So yeah, we tried to do that back in 20, I want to say 2014 maybe. Yeah, 2014 I think we tried to get a robot and it was just too expensive and didn’t make any sense, but now with better financing and the fact that we have 10 in the hospital, yeah, that’s pretty incredible. Yeah, we’re hoping to get one because for me it would be such a game changer to be able to do all these in the outpatient surgery center. Super excited about that. On that note, there was a discussion on hernia attack.com, which is our free discussion forum that we have for everyone about costs. So specifically if you’re a patient talking about the patient standpoint, I know the robot is expensive for the to acquire, but from a patient standpoint, does it cost more to have robotic surgery?

Speaker 2 (00:32:09):

The short answer is no. Well, I’ll answer it in two different ways. So insurance, with respect to when we submit for a surgery, whether it’s laparoscopic or robotic, it’s the same code. So there’s no increased cost to the robot. The hospital doesn’t cost more, doesn’t have an upcharge for robotic, and the surgery center does not either. Now, if you’re a cash pay, and you probably can answer this better than me, but if you’re a cash pay patient, then yes, it could be more expensive if you’re going to do it in the, for me, I don’t also have a robot in the surgery center. So if a cash pay patient and I say, we’ll do it on the robot and it’s going to be done in the hospital versus I’ll do it laparoscopically in the surgery center, it’s going to be less expensive for them in the surgery center because of just the all overhead cost. But robotic itself, if you have insurance, is exactly the same.

Speaker 1 (00:33:01):

Just to clarify on that too, it’s done by code, so there is no robotic code yet, and so you can’t tell the insurance, we’re going to charge you more because they’re like, well, it’s the same code, so what are you talking about? Even though it may be more expensive for the hassle, a lot of people don’t understand how could it be more expensive for the hospital and yet not charge the patients the same. And that’s kind of our security system of insurances and how things are paid for. But yeah, it goes by code For regard to cash, I’ve had really good luck with cash quotes, even at the hospital. And we have a, we’re concerned kind of an expensive hospital to have cash pay patients in, but they’ve been really good about it. So I think even with cash, they don’t tend to dump a lot of the cost on the patient. They’re just more volume-based and they’re hoping to capture it based on that. Let’s see, next question. After inguinal Mesh removal with the robot as opposed to laparoscopic Mesh removal, and I was talking about inguinals, but I don’t know if this question’s about Inguinals. Yes, it is about inguinals. Okay. So after inguinal Mesh removal with the robot as opposed to laparoscopic Mesh removal, does a site of the original hernia become weaker? Does a removal leave a void such that at the original hernia site, do you do much Mesh removals?

Speaker 2 (00:34:30):

I do, yeah, for both ventral and inguinal. Yeah, I do a lot of, a lot of recurrent hernias and so yeah, it depends on why I’m removing the Mesh. But yeah, I do a lot of primary tissue-based repair and yeah, you’re probably going to disagree with what I’m about to say a little bit, although

Speaker 1 (00:34:52):

We’ll see

Speaker 2 (00:34:55):

The majority of hernia repairs, it is, we’ll say ventral for anyways, standard repairs with Mesh, we know that recurrence is lower with a Mesh versus a tissue based repair. In the ventral space, inguinal, if you do a really good tissue based repair, you can have good recurrence, low recurrence rates. But if you’re removing a Mesh, I think absolutely wherever that is, the tissue’s going to be weaker and it’s definitely going to be prone to recurrence. If you don’t do any, even if you do some sort of a primary repair after you’ve removed it, the tissue is going to be weaker, scarred, and prone to a recurrence.

Speaker 1 (00:35:35):

Yeah, that’s very true. So with one exception, if you’re removing infected Mesh, there’s such a huge inventory response to that. Often, especially in the groin, when the hernias aren’t that as big as those are the abdominal wall, that huge amount of inflammation, often you can’t see anything. So you just take out the infected Mesh and deal with the infection. And about, in my experience, about 20% of them at about two years or later will get a hernia, but the majority actually don’t. Just such a huge scar response. However, if you’re removing Mesh because there’s a recurrence or there’s pain or whatever, you will have a hernia there. And then the question is always, okay, now what do I do? So if I remove the Mesh because the Mesh was balled up, I’ll put Mesh in there again because that would be the most appropriate treatment, assuming the patient agrees to that plan.

Speaker 1 (00:36:34):

But if I’m removing the Mesh because they’re somehow reacting to the Mesh or the Mesh itself is the problem, then a tissue-based repair is indicated. What you don’t want to do is remove the Mesh and don’t do anything because you’ll just have a rip rowing hernia immediately, unless every so often I see a patient, I didn’t really didn’t even know I had a hernia, they just square in there that you did, and they put some in, it was really small, let’s say. So if it was so small that it was found incidentally and someone put Mesh in that cause pain, then potentially you can remove that and you can’t really see a hernia to repair. And maybe in those occasions I’d say, okay, let’s take it out, see how you do understand that it’s very possible you’ll get a hernia again, and then we’ll deal with repairing it that time. But yeah, the scar tissue from regular Mesh repair is not strong enough to prevent a hernia repair once the Mesh is removed that we learned. Someone’s asking you where you’re from. I think they mean where do you practice? Not where are you actually from?

Speaker 2 (00:37:45):

I’m from Southern California and I practice in Simi Valley, which is in Southern California.

Speaker 1 (00:37:49):

Are you from Southern California? I didn’t know that.

Speaker 2 (00:37:51):

I’m from Chino Hills.

Speaker 1 (00:37:53):

Oh, nice. Okay. So you’re local.

Speaker 2 (00:37:56):

I’m local. I know I’m back to back closer to home from,

Speaker 1 (00:37:59):

That’s great.

Speaker 2 (00:38:00):

But yeah, I’m here in Simi Valley, which is

Speaker 1 (00:38:03):

Excellent. Okay, next question. I need a hernia pair of surgery, and I’m in so much pain right now. I could puke or cry. Let’s see, umbilical hernia is what she has right now. It’s just a tissue repair without mesh. So yeah, you could have pain from a tissue repair. Do you want to address that a little bit?

Speaker 2 (00:38:26):

Yeah, I mean the belly

Speaker 1 (00:38:27):


Speaker 2 (00:38:29):

Yeah. So one of the things I use, and I’ll still do the occasional open umbilical hernia repair, and if it’s very tiny, not place Mesh. Yeah, when I say very tiny, I’m talking one centimeter my fingertip. We know that anything larger typically will do better with Mesh probably, and I obviously can’t say for sure without seeing her, but what happens sometimes when people do an open repair or tissue bear, they don’t fully identify the incarcerated fat, the pre peritoneal fat wall that basically gets stuck in there. And if you’ve closed that and that fat is stuck in there, that can cause a lot of pain because that fat has no real good blood supply. And that seems to be a common reason, I think for pain after primary repair. If it’s a small umbilical that you know can have a little suture abscess or granuloma, you can have unlikely that nerves were gotten in a tiny little repair, but I suppose a

Speaker 1 (00:39:29):

Lot of nerve issue. Yeah,

Speaker 2 (00:39:30):

Yeah. More likely probably missed incarcerated fat is what I find when I take these patients back

Speaker 1 (00:39:36):

Or it’s just too tight of a repair. They’re trying to cinch down something larger than one or one and a half centimeters, or the patient is obese and there’s already a lot of tension there anyway, and you’re trying to really cis that close. So the pain you’re feeling is actually the sutures tearing through your muscle and unfortunately the result of that is a bigger hernia, in which case you definitely do need Mesh in the repair. Let’s see. Next question I had, oh, this one. This was someone who actually sent me this question on YouTube as well. I’d like you to answer it. So it’s a patient who talked about, where’s the question? Oh, I’m going to ask it. So this is a patient who had an open inguinal hernia repair with Mesh. Okay. Let’s say linked inside repair and then they had a wound infection and then now, so that that’s been treated, but the wound never heals. So the surgeon wants to now remove their Mesh. What are your thoughts on that?

Speaker 2 (00:40:45):

So open Lichtenstein with Mesh wound infection, the wound never healed. Correct. I mean, if you Mesh infections in the groin are extremely problematic and in my opinion, in my experience, if you don’t remove the Mesh, it’s not going to heal. So I would probably say probably do an open excision and removal of that Mesh, leave it alone, let everything heal. And when they recur, I would go in into a posterior repair or a robotic repair, assuming they’re fully clear of their infection.

Speaker 1 (00:41:22):

Yeah, I mean there’s so many factors in not healing a wound, but if it was already infected and looks like it’s e coli was the bacteria and you have some form body, it could be a suture or it could be your Mesh. Depends, that could be osteitis of infection that pre prevents you from healing. So even if you don’t have puss or drainage or anything that tells you it’s infected, that Mesh may be chronically infected. I’ve noticed in those patients also, they’re just not healthy. They kind of feel sick still. They’re fatigued. Some may have joint pain or headaches and just tired, and then you take out their infected Mesh or their Mesh that is chronically infected and they’re like, oh, I feel so much better. But it’s because you don’t see a pus and an active infection, but it’s a very low grade chronic infection that will prevent you from healing. So I know it’s a big deal to take out groin Mesh. Fortunately that’s a big deal in infected situations because everything’s kind of like mushy anyway. But yeah, you have to, if you’re not healing, infection is definitely top on the list of why you’re not healing. Going back to the question about pain, it could be a early recurrence or a missed little hernia in the belly button. What imaging would you order to help figure that out?

Speaker 2 (00:42:48):

So for any abdominal wall, so not inguinal and yeah, I’m not a huge fan of ultrasound for ventral abdominal wall hernias. I more, I would get a CT scan, non-contrast ct. It allows me to see if there’s a hernia recurrence. It allows me to see if there’s any fat within the defect that was repaired. We can often see Mesh if there was Mesh in there. And then it also is helps me to plan how I’m going to do the repair if I’m planning to bring the patient back to the operating room.

Speaker 1 (00:43:23):

Yeah, it’s very simple. I think in the United States CT scan is so much more readily available than a good ultrasound often need to get ultrasound and it gives you no information at all. Right.

Speaker 2 (00:43:33):

And it’s very dependent. It’s dependent on who’s doing the ultrasound and who’s interpreting it. Just like CT scan, but we read our own CT scan, so

Speaker 1 (00:43:42):

Right, exactly. But outside the US they tend to be more reliant on ultrasound and they’re usually better at it. I think they just do it more and see more. And then they’re handful of places around the US where they’re really good at hernia ultrasounds. I have one guy, he’s older and he’s a radiologist. He does his own hernia ultrasounds like himself. It’s not like a tech does it. They read it and he talks to the patient, he moves them around. It’s awesome. That’s great if you cannot retire, because sometimes you don’t have to get an ultrasound, I mean a CT scan if you have a good ultrasonographer, but it’s It’s far. Yeah, it’s usually hard In the United States, we don’t have good ultrasonography. Okay, next question. I had an Anglo hernia pair five years ago, and I’m still in a lot of pain. What can be done? Ooh, that’s a big question.

Speaker 2 (00:44:40):

Well, I mean, I would ask, did the pain ever go away or did it come back? Is it Its same type of pain? Yeah, because it could be that a hernia was missed, right? We’ve missed femoral hernias have been missed, direct hernias might have been missed, or a cord lipoma, which is fat along the spermatic vessels and spermatic cord. It could be a different type of pain, maybe related to a nerve injury or Mesh related pain. So what you could do is, I mean, I would start with a really good physical exam and obviously a history as I was just alluding to with those questions. And then if I felt that there was a need for imaging, then obviously we’d go to imaging

Speaker 1 (00:45:25):

For sure. I think the story is the most important. When did it start? What makes it worse? If they say, oh, I actually had this pain before the hernia repair and I still have it, well then it wasn’t your hernia, it was something else. Or I was fine five years ago. For four years, I was fine. Now this year I have problems. Well, that’s a recurrence usually, right? You don’t have hernia related complications that occur years later with the exception of maybe a weird infection, but So on that note, you mentioned cord lipoma. Can you explain what that is and why you think that may cause pain?

Speaker 2 (00:46:06):

Yeah, so basically in men in particular, and this is how I describe it to patients, to get them to understand it. So your testicles are obviously in utero, they’re up near your kidneys and they descend as through a ring, which is called the internal ring. And with that, there’s fat in that area that can track along the path that your testicle takes. Females can get lymphomas as well, just a little bit different. But basically fat can track along the spermatic cord and the blood vessels to the testicle, and that can act as a hernia in the sense that you have a ball of fat usually within the scrotal area, and so patients will feel that bulge. So yeah, if you have that, but no actual hernia defect is recognized, it doesn’t mean that you don’t have a hernia. So it’s important for us as surgeons to make sure that we look for that lipoma and we get it out of there because if we don’t, and we just place Mesh and we do a beautiful repair but have left that your symptoms are going to be unchanged. And so that’s a big part of a hernia repair for,

Speaker 1 (00:47:11):

Yeah, there’s some surgeons that say, ah, her lipomas hurt, but I think it’s trying to argue why it does hurt. I think what’s happening is the time of the hernia, these things are moving in and out or whatever, pinching, but once you fix the hernia and if you left the lipoma in place, you’ve now close the door on it, right? And you trap this fat in a limited space, and that’s where maybe the pain comes. I don’t know if that’s the right answer, but

Speaker 2 (00:47:44):

Yeah, makes

Speaker 1 (00:47:45):

Sense. Trying to logically figure out why the lipomas hurt. Of course, of course. It’s occupying a space that should not be occupied, so whatever’s nearby, sometimes people get nerve pain. That’s

Speaker 2 (00:47:59):

What I was going to say. Nerves that run along the court. So yeah, absolutely that can contribute to the pain.

Speaker 1 (00:48:05):

But it bugs me is they get nerve pain and they go see a doctor and they’re like, oh, you have nerve pain. They do nerve injections and nerve blocks, and I’ve seen people have been told that they need a spinal stimulator. All they have is a hernia.

Speaker 2 (00:48:24):

Right? Well, and

Speaker 1 (00:48:26):


Speaker 2 (00:48:28):


Speaker 1 (00:48:28):

Nerve entrapment. Oh, it must be nerve entrapment.

Speaker 2 (00:48:31):

No, and it’s really, it’s very important also when I’m talking to somebody that’s got groin pain, whether they’ve had a hernia repair or not, for them to understand that the back and the hip and the groin are very intimately related. So yes, a hernia is the easiest thing to fix. Having a hip replacement or back surgery not as easy. Yes, us taking you for a known hernia and fixing that is fine, but if something persists and you don’t have a recurrence, you don’t have a retained cord lipoma or what have you, there’s no Mesh issue, then the other things need to be investigated because potentially that is the cause of the problem. And I’ve seen that where it’s like, oh, you know what? Yeah, I needed a hip replacement, so I’ll send Very

Speaker 1 (00:49:11):

True. It’s so true a labral tear or bursitis or something. We have had a couple different really great orthopedic surgeons on where we discuss how hip problems and orthopedic problems can cause groin pain, and it’s so important to have that visualization. What I tell the patients is, you don’t just wake up one day and your nerve gets, that doesn’t happen. Now if someone stabbed you in the nerve, okay, I couldn’t understand that, but short of that, that just doesn’t happen. So I don’t understand the logic when people are taken down this whole nerve pain pathway when all they need was a hernia repair. Going back to the lipoma question, can you get the lipoma out robotically without widening and traumatizing the deep ring? These are great questions.

Speaker 2 (00:50:00):

I know. Well, it’s a good question. So if you had a repair and it was done laparoscopic or robotic, and the Mesh is there, we have to take down that Mesh in order to get to the lipoma, and it can be done, absolutely can be done, but no, you can’t just get to the lipoma without taking that flap down. Again, getting that Mesh out of the way and going in, you’re not necessarily traumatizing the ring, but you have to get through the previous repair. Now, if it was done open previously it, then no, it, it’s not anything different now you’re just going from behind or if it was done posteriorly previously, then you can go open just to look for the cord lipoma. How do you like

Speaker 1 (00:50:49):

These? Yeah, yeah. Well, I think the question is just the act of removing a lipoma that may be large. Does that in and of itself stretch out the area or cause damage?

Speaker 2 (00:51:02):

Yeah, no, I mean we’ve pulled some really large lipomas out it. I don’t think it distorts or disrupts the ring. It’s not supposed to be there. That fat’s not supposed to be there. So that being there is more probably disruptive to the ring than us removing it.

Speaker 1 (00:51:23):

Yeah. Yeah, I agree. It mean muscles stretch, stretch, we’re good. We’re not injuring the muscle. Going back to the gentleman who probably has a Mesh infection and is being told that he needs his groin Mesh removed, how dangerous is that? What are the likelihood of him being maimed or having major complications from it?

Speaker 2 (00:51:47):

So I know this was open, done, open, it’s going back and doing any sort of redo in a plane that has already been operated on obviously is going to have a little bit more risk for potential injury because the area is scarred, so it’s going to be more difficult to identify the nerves potentially. There are some vessels, obviously not doing it robotically or laparoscopically, it’s a little different. But I would say nerve injury can happen if they’re not able to identify the nerves, depending on where that Mesh or what type of Mesh, you said Lichtenstein, but if a plug was placed or anything else was placed, now we’re talking about a Mesh that’s deep inside that could be attached to blood vessels and other things. So it can be obviously risky as long as it’s just, hopefully it’s known where the Mesh is and the surgeon understands. Yeah,

Speaker 1 (00:52:45):

It’s so important to know your anatomy and that although it hernia repairs considered such an easy operation, the anatomy is one of the more difficult areas of the body. Absolutely. And you have urologists that work there and gynecologists that work in that region and nearby orthopedic surgeons and general surgeons, and none of us really master any of it. Yeah, I work a lot with them. So one of the things I love about what I do is I do operate with these other specialists and I get to see their train of thought, their approach, their techniques. Yeah, it’s really nice to work with other specialties. I really like that. Part of what I do just joined and said, I have a miniature basketball size umbilical hernia. I’m supposed to have robotic surgery. What are the chances of damage to the intestine with this approach? I am all of a sudden freaking out because my hernia is so huge.

Speaker 2 (00:53:43):

Mini basketball, those little hoops that you have in your office,

Speaker 1 (00:53:46):

I think those Nerf ones. Yeah.

Speaker 2 (00:53:50):

Well, again, I think it’s important What I don’t think that whether it’s laparoscopic or robotic, you’re the biggest risk, I guess for injury is going to be entry into the abdominal cavity. And there a number of ways that we do that so that we’re careful so that we avoid injury. Doing it robotically does not necessarily mean you’re going to have a higher risk of injury. The important thing is that the surgeon understand they’re going to give you a good repair. So if it’s a, there’s actually, this is something we didn’t touch on, but you may have a basketball size bulge, right, of intestine or fat that’s coming into that defect. But the hernia itself could be much smaller and vice versa. It could be a very large defect that has a bulge. So understanding the different techniques as to how to repair it is what is more important, I think, to make sure that you have a good repair. The risk of injury, though there is extremely, extremely low. We have to be very careful, obviously and make sure that we’re not injuring anything either on entry or in reducing the intestine that’s stuck in the hernia. But these risks are very low,

Speaker 1 (00:55:03):

Really. I feel that it’s very technique and surgeon dependent. The surgeon with the light touch open probably has a light touch laparoscopically and vice versa. You can injure bowel with open surgery. So much to, I also say this about all these Mesh lawsuits, there’s so many Mesh companies are being sued, whereas if you look at it like the surgeon used the wrong Mesh, but the wrong technique or exactly, those were complications induced by the surgeon, not because of the Mesh itself. So surgeon technique and is very important. Do you have any tips on how they should find the right surgeon? Do you think they should ask certain questions? I always say they should have at least 50% of their practice should be hernias to be considered like a specialist. Otherwise, you’re a general surgeon.

Speaker 2 (00:55:55):

No, I agree. I think if you’re looking specifically for hernia, you can do just that. You can Google hernia specialist, you can look at reviews if they have them. You can talk to other patients that may have had surgery by that surgeon. And just because you go see a surgeon for a consultation doesn’t mean that that has to be the surgeon that you’re going to have operate. So come with questions. Yeah, true. The more informed you are and the more questions that the surgeon has asked and can answer, can help you decide if it’s the right person for you or right surgeon for you. But I encourage everybody to do their research on the surgeon and the different hernia repair techniques. I like it when they come to me with a holistic questions.

Speaker 1 (00:56:43):

Yeah, I totally agree with that. Mostly because, I mean, you like it because you enjoy what you do. Some surgeons get pissed off at it and that’s, I think that’s a red flag, red flag, right? Yeah. Move on to the next surgeon that really loves what they do and is exciting to help clear up answers for you. And I feel that I see a lot of patients that just fly or do telehealth or something because they’ve, they’ve got one answer and now they just want a second opinion, which is totally fine run. And I always ask them, you see and where they tell you, and I’ll try and give you my perspective. I’ll be like, oh yeah, I totally agree. That’s absolutely what I would do. Or hear other choices for your repair. My concern is these people, they have just a little umbilical hernia or just a little inguinal hernia, don’t do their research and then now they’re in trouble.

Speaker 2 (00:57:42):


Speaker 1 (00:57:43):

Yeah. Okay. Going back to the gentleman who’s had five years of pain when they had their anal hernia repair the pain then after the surgery is the same as it is now. He feels a lot of pressure stabbing and finding it hard to stand tall, especially in the morning. Oh, interesting. Was this laparoscopic surgery? I don’t remember. Yeah. Depends on the type of her, we don’t know what type of hernia repair,

Speaker 2 (00:58:13):

Right? I

Speaker 1 (00:58:15):

Mean, I don’t assume it’s a Mesh repair, but I don’t know if it was a laparoscopic or open

Speaker 2 (00:58:22):

The pressure and stabbing obviously leads you to think that it’s either, well, it’s hard to say without asking more questions. And it was there prior.

Speaker 1 (00:58:31):

No, it was there since immediately after the surgery. Not before the surgery.

Speaker 2 (00:58:36):

The same as it was directly after repair. Yeah. Okay. So I mean, again, I think that either laparoscopic, he’s responding. Oh, okay.

Speaker 1 (00:58:47):


Speaker 2 (00:58:48):

Great. So laparoscopic. So I would say it’s either potentially that the Mesh is folded. I’ve, we’ve seen that where patients will come with a lap, I’m going to say laparoscopic, but it could be robotic. It’s the same minimally invasive or fair. Yeah. That they issues with bending or sitting or folding. And that could be from Mesh having folded, causing some discomfort. Yeah. If it was a shooting burning type pain, obviously we worry about nerve injury, but if it’s pressure specific to a point, I think that could be due to a Mesh related problem. But again, the first thing that I would rule out is a recurrence and or missed hernia. Because it happens. Yeah. Maybe the Mesh, maybe the dissection wasn’t big enough to expose the femoral or direct or a cord lipoma and all of those things. So yeah, it really is. This can be dealt with. It just we would need a good exam and obviously a number of other questions that we would be asking and potentially some imaging.

Speaker 1 (00:59:53):

This clue of finding it hard to stand tall, I feel sometimes the Mesh is put in too T in the beginning, so it’s not following the contour of the pelvis, but it’s kind of tight. And then as we know, Mesh also shrinks a little bit after surgery, so now it’s even tighter. And so they feel like they’re being pulled in or they can’t hyperextend or kind of do a lot of their normal activities and you can’t really loosen up those meshes. You have to just redo it. But if you have imaging and it doesn’t show what you said, which was a hernia recurrence or a balling up of the Mesh, then sometimes it’s too tight of a Mesh and it just kind of needs to be redone. That’s some one thing that I’ve seen before. Yeah. Can you believe it? We have a whole hour that’s gone. Gone already.

Speaker 2 (01:00:44):

This has been great. Unbelievable. I mean, really questions. Yeah. This is,

Speaker 1 (01:00:49):

You want to enjoy me again next week? Let’s do this every week.

Speaker 2 (01:00:52):

Let’s do it every week. This has been a lot of fun.

Speaker 1 (01:00:56):

Yeah, it’s been a lot of fun. Thank you so much for your time. I really appreciate it. You’re busy, you’re still at the office. You got this awesome thing in the back. Someone congratulates you, Dr. Pa, master surgeon in

Speaker 2 (01:01:09):

Communication. My office, my, no, my office staff did that. Yeah, there were balloons and everything else in here. This was a while back. They put this board together for master surgeon. It was kind of fun. So.

Speaker 1 (01:01:22):

Aw, that’s so awesome. Thank you so much. Well, thank you for your time. You’re great. I hope to see you in person pretty soon. Are you going to come to Costa Rica?

Speaker 2 (01:01:33):

That is the, so I’m not sure I was considering it April, I’m in Florida. Cause it’s in April, right?

Speaker 1 (01:01:44):

Yeah, first week of April.

Speaker 2 (01:01:45):

So yeah, so I’m in Florida for connect that week.

Speaker 1 (01:01:49):


Speaker 2 (01:01:50):

And then I’m in Iowa also doing some robotic speaking thing in Iowa in April. So I haven’t quite figured out if I’m going to be able to get to Costa Rica. I haven’t ruled it out yet.

Speaker 1 (01:02:03):

All right, well, we’ll be there waiting for

Speaker 2 (01:02:05):

You. I know I’ve, I’ve been talking about it though. I would love to go.

Speaker 1 (01:02:11):

Okay. a lot of, a lot of great conferences coming up and I hope to see you at all of them. So thank you everyone. Thank Dr. Pakula for her time, and I will see you again next week. We have another great guest. I can’t wait to discuss more topics, and we have some great stuff coming up in the future as well. Thank you for your time. Thanks for everyone for joining and such great enlightening questions. I enjoyed all of it. See you all next week. Stay healthy next day. Yes, thank you.