Q&A on Robotic Hernia Surgery with Ajita Prabhu, MD

With interest in robotic surgery growing nationwide, Cleveland Clinic hired Ajita Prabhu, MD, to explore its potential in general surgery.

As a skilled minimally invasive surgeon and early adopter of robotic technology, Dr. Prabhu is well positioned to compare and contrast the benefits of both approaches with open surgery. We asked her to discuss her approach to evaluating the use of robotic surgery in hernia repair.

Q: Where does robotic hernia repair stand?

A: We are feeling our way to determine where this technology belongs. Here at Cleveland Clinic, we think robotic hernia repair is worth investigating and have three trials that have started are about to start. At this time, however, we are still unsure whether it offers any additional benefits over laparoscopic surgery. Robotic hernia surgery didn’t take off until 2011 to 2012, so publications by early adopters have just started to appear.

Q: What are the perceived advantages of using a robot in hernia repair?

A: There are ergonomic benefits for the surgeon because we sit at the console, rather than standing at the bedside. The robot platform offers 360-degree wrist motion, which allows us to sew the mesh in place, rather than tack it. Since tacks may cause pain after hernia repair, sewing the mesh instead may be beneficial.

For patients undergoing abdominal wall reconstruction, the robot may allow the operation to be performed through small incisions. I am among a group of surgeons who participate in the Americas Hernia Society Quality Collaborative. We just completed an evaluation of our own outcomes for robotic abdominal wall reconstruction, compared with open reconstruction, and found a two-day decrease in length of stay for those who underwent robotic repair, as opposed to open repair. This is significant.

Although I feel more research is necessary, this is certainly compelling information, which points to the need to continue investigating the platform. If, at the end of the day, there is no benefit, then of course I will abandon it.

Q: What are the challenges?

A: There is a learning curve as to proper port placement and instrument exchange. I sit at the console, so my assistant must switch out the instruments while I coordinate the camera. This is best accomplished by a team of people who are used to working together, understand the dynamic, are on board with the strategy and can work through issues. We have made a lot of progress in terms of the efficiency of performing these cases, as we have worked through some of these logistical elements.

Q: What about the cost of robotic hernia surgery?

A: There is a paucity of published data on the cost of using a robot in hernia repair. These data are difficult to get until certain factors have been established. Should the cost of the robot be amortized over each use? The instruments are reusable 10 times, so should one-tenth of their cost be included with each case? If that is the case, should we be doing the same type of cost evaluations for laparoscopy? If I do a robotic umbilical hernia repair, the patient may go home the same day. Does an earlier discharge outweigh the cost of a more expensive surgery?

There are also factors that are more difficult to quantify. If a patient returns to work sooner, does that offset the potential increased cost that may be associated with their robotic operation? Michael Rosen, MD, Director of Cleveland Clinic’s Hernia Center, is currently looking at the cost of robotic versus laparoscopic inguinal hernia repair as part of a bigger study, with the hope of finding some answers to these questions.

Q: How do you discuss robotic repair with patients?

A: When a patient comes to my office with an inguinal hernia on one side, I walk them through the benefits, risks and considerations of all three options. There are no objective data, so I can’t push them toward one option or another. I tell them the risk of chronic pain is greater with open surgery. If they are young and healthy, I tell them they might want to consider having only three small incisions. Also, patients who have hernias on both sides may benefit from a minimally invasive repair in which both hernias are repaired through the same three incisions. When that is the case, I may encourage that approach. I explain the difference between tacking and sewing the mesh. Some patients choose robotic repair, but interestingly, others ask for the procedure I’ve performed most often. My goal is that every patient understands the options, so we are on the same page.

Q: Do you have any advice for colleagues who are thinking about learning robotic hernia repair?

A: Here’s what I’d recommend:

• Spend some time with surgeons who are currently doing these types of operations, observing the flow of the case and getting information on how to get started, organize a team, etc.
• Set clear time goals for each step of the operation and convert the procedure if you are unable to attain these goals.
• Follow your patients. The use of professional society-driven databases like the Americas Hernia Society Quality Collaborative can be invaluable in providing us with information on how our patients are doing with these interventions. Part of the goal in investigating new technology involves responsibility in evaluating your own outcomes.
• Evaluate your outcomes honestly and determine if the technique is beneficial for patients.
• Write about your outcomes, so others can learn. This is how we push the envelope.