But is robotic surgery — in which the surgeon sits at a console controlling robotic “arms” that do the actual surgery — the right choice? Questions of a surgeon’s expertise, the type of hernia, your age and health, and cost all come into play. Here’s what you need to know.
First Things First: What Is a Hernia?
Hernias are weaknesses or defects in the peritoneum, the band of muscular tissue that keeps your abdominal organs in place. There are several types. For example, femoral hernias are uncommon, but occur mostly in women. A hiatal hernia happens when part of the stomach pushes up into the chest cavity. An umbilical hernia occurs around the belly button. And an incisional hernia is the result of a past surgical incision, explains Andrew T. Bates, MD, director of the Comprehensive Hernia Center at Stony Brook University in New York.
What Is Robotic Surgery and How Does it Differ From Laparoscopic Surgery?
Laparoscopic and robotic surgery are minimally invasive procedures for treating a hernia. “Both use small incisions and a camera, and both require operating from outside the abdomen,” says Dr. Bates. But whereas in laparoscopic surgery there’s a surgeon holding the instruments, in robotic surgery, those instruments are operated by a robot, which is controlled by the surgeon at a console. “So there’s just one step in between the surgeon and the patient,” says Bates. When compared with open hernia repair, both laparoscopic and robotic surgery lead to less postoperative pain, fewer incidences of complications such as wound infections, shorter recovery times, and a faster return to work and regular activity.
Is Robotic Surgery the Right Choice? Pros and Cons
There are a number of advantages to choosing robotic surgery. They are:
It causes less trauma and pain. “Because the robotic platform offers the surgeon better visibility and more precise movements, it results in less damage to the [surrounding] tissue, and reduces the likelihood of postoperative pain,” says Robert Amajoyi, MD, a surgeon at South Nassau Communities Hospital in Oceanside, New York. That in turn may mean that patients have a reduced need — or often no need at all — for narcotic pain relief after surgery.It allows for more complex work. The chief technical advantage of robotic surgery over laparoscopic is that the robotic instruments can be manipulated more fully than laparoscopic instruments. “Robotic instruments are articulated at their ends in the way a surgeon’s wrist is, so they have a greater degree of motion,” says Bates, adding that laparoscopic instruments are “straight.”It requires shorter hospital stays. Mostly likely thanks to reduced tissue trauma and smaller incisions, patients who undergo robotic and other minimally invasive hernia repair surgeries are back to normal activity more quickly, including possibly shorter hospital stays. A study published in February 2018 in the journal Annals of Surgery found that robotic-surgery patients who underwent a ventral hernia repair went home significantly sooner than open-surgery patients.
There are also some drawbacks you should be aware of. For example:
There’s a learning curve for the surgeon. Surgeons who use robotic platforms report that the learning curve is actually steeper going from open surgery to laparoscopic, and that going from one minimally invasive technique to another is less of a haul, but there are still physical challenges to get used to, says Bates. “You have to get used to the movements of the robot, and get comfortable with working at a console.” This means that patients considering robotic surgery should ask a lot of questions about how long the hospital has had the system and how many surgeries of the same type have been performed by their individual doctor.Surgical procedures tend to take longer. Research presented at the 2011 meeting of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed 12 cases of laparoscopic and 12 cases robotic inguinal hernia surgery repairs, matched by type of repair and the age and overall medical condition of the patients (all men). They found that the robotic procedures took “significantly longer” than the laparoscopic ones, which both increases hospital costs and poses some risks for the patient.It can be harder to place a mesh prosthesis. Many hernia repairs involve the placement of a mesh prosthetic, a small “patch” that helps close the defect and that reduces the recurrence rate of a hernia, says Bates. “During surgery, we may have to do a lot of dissection to create a pocket where the mesh can sit flat and be nicely positioned,” he explains. The space and finesse needed to do that for a larger hernia may be better suited to open surgery, he says.It can be expensive. In a paper published in October 2017 in the Journal of the American College of Surgeons, researchers reviewed the results of more than 92,000 minimally invasive surgeries — 4 percent were robotic and 96 percent laparoscopic (not all were hernia repair). Of the hernia repair procedures analyzed, costs were about 25 percent higher for robotic procedures. That said, “when [our hospital system] did a cost analysis of robotic procedures, we found that most insurance companies reimbursed a greater percentage of the cost of robotic procedures,” says Mark Haan, MD, a surgeon with Spectrum Health Reed City Hospital in Michigan. Proponents of robotic surgery contend that the increased costs of each procedure are offset by shorter hospital stay costs.
How Is the Choice Made?
The most important factor to consider — presuming you can choose either based on your overall health and the availability of a robotic surgical system in your area — is “the volume of surgeries at the center you go to, or the volume of surgeries performed by the practitioner you see,” says Bates. “What we’ve found over and over again is that the best hernia repair is the one that individual surgeon does most frequently and is most comfortable with.”
