My surgeon wants to use a robot to do a robotic hernia repair. Is this safe?

First, is your surgeon listening to your history carefully?

Hernia repair is a specialty, and where and how your hernia is repaired first may matter most of all.

Let’s be clear about something:  before you have any hernia repair, even a robotic hernia repair, you should make sure that you and your surgeon agree on exactly why you need hernia surgery.  Is a hernia repair absolutely necessary right now or can your hernia be observed?  What are your symptoms, and are all of your symptoms explained by your hernia?  Remember that not all hernias need to be repaired.  If your chief complaint is pain or groin pain, make sure a thorough work up is done for that pain before assuming that the pain is from a hernia.

Is robotic hernia repair a new technique?

Using the robot to do a hernia repair is a novel technique without many unbiased randomized long term outcome studies yet.  Growing rapidly as an option for inguinal and abdominal wall hernia repair since early 2014, it provides some surgeons a personal ergonomic and enabling benefit for some suturing and dissecting tasks, however there is still no proven recovery benefit regarding patient outcomes at this time when compared to the same surgery performed by laparoscopy.  Remember it is the surgeon, not the robot, that is optimizing your repair.  The robot is just an instrument and an operating platform, therefore both laparoscopy and robotic instruments are called minimally invasive surgery.  Compared to an open hernia approach, robotic instruments should provide the same advantages as have already been proven for laparoscopy, which include lower wound infection rates and in some cases less pain and thus faster recovery.  Both laparoscopy and robotics are considered minimally invasive surgery that can accomplish similar tasks on the inside, and are both considered safe options with a rapid recovery when done by experienced surgeons.

What are your expectations after the hernia surgery?

Make sure your surgeon understands your specific expectations, and more importantly that the surgeon has listened to your precise complaint carefully and has addressed all of your questions.  Make sure you understand the precise technique that will be done to you, what products will be implanted, how the mesh will be secured, and what outcomes have been like at one and three years if available.

Who controls the robot during a robotic hernia repair?

With the use of robotic technology on the rise in the operating room for hernia repair, it is important to better inform patients about it with unbiased perspectives.  Your surgeon will set up the robotic instruments, but then sit at a console away from the bedside and control the robot and the camera.  An assistant or resident will remain at the bedside and help with instrument exchanges as needed during the surgery.  After the surgery is over, your surgeon will again come to the bedside to help close the incisions.  Remember it is the surgeon, not the robot, that is optimizing your repair.  The robot is just an instrument and an operating platform.

Experience matters.

How can you figure out your surgeon’s experience?  How do you know if the technique your surgeon is offering and the implant they recommend is a technique that is also accepted by a majority of other surgeons?  One easy step you can do for yourself is to ask your surgeon how many years they have been in practice.  Then ask how many hernia repairs they do a week, month, or year.  Most surgeons perform between 250 and 500 total cases a year, with an average of around 10 to 15 hernias a month.  Some general surgeons may do as few as one hernia a week, while others may do seven per day.   Next, remember that it takes about 200 – 250 minimally invasive hernia repairs to get beyond the initial learning curve, an this is probably true for robotic surgeons wishing to embrace hernia as a specialty too.  Combine the number of years your surgeon has been in practice with the number of hernias they do per week, month, and year on average, and you can figure out if they are experienced or not.  Over time, a surgeon will adapt and modify their technique based on their own patient’s feedback.  Until there is data and outcomes to study, surgeons need to rely on anecdotal opinions, so your surgeon will explain their own opinions based on their own experiences and biases with the device.

Still not sure?  You can also ask your surgeon if it is OK for you to talk to previous patients from the past. If you choose to do so, if possible try to speak to patients from over a year ago as well as to ones who are more recent.

Is the robotic hernia repair technique “better” or “optimal” to laparoscopy, and is there any comparative outcome data?

Data is starting to emerge (as of December 2017), however the initial studies seem to mostly be authored by surgeons who also regularly consult and teach for the robot company, and so the conclusions may be biased.   Unbiased studies are underway.  Some early studies show that for some surgeons the use of the robot platform will cost the hospital system more money, but for ventral hernias it may help reduce pain during recovery if the hernia mesh is placed in the retrorectus position without tacks instead of tacking or suturing mesh.  For inguinal hernia repairs, there is still no significant advantage to the patient by having it done robotically compared to laparoscopy.  This does not mean that robotics is not safe.  The robot is definitely a safe platform to use, as long as your surgeon is a safe surgeon.  After a hernia repair, you want to have a rapid recovery with minimal complications.  You want to get back to work quickly.  Some known risks following hernia surgery include a recurrence, chronic pain, bleeding, infection, seroma, urinary retention, and bowel obstruction.  These risks exist for both robotic and laparoscopic hernia repair alike, and claims of risk reduction are not yet supported by literature.  For a surgeon to make a claim that a technique is better, or optimal, remember that they need to have statistically significant comparative outcome data followed for a minimum of one year.  Without this type of reliable outcome information, then claims that you may hear as a patient may just be personal opinions, and sometimes opinions may be misleading.  Ask your surgeon for their own outcome data involving the technique and the above outcome metrics , before they perform the procedure.  Ask to talk to other patients that have had the same procedure you are about to consider.   This information should be transparent and something the surgeon is proud to share.

Dr. Brian Jacob is a top-rated hernia surgeon and President of the International Hernia Collaboration, Inc.   Have a hernia related question?  Feel free to ask him a question or provide a comment below.