March 8, 2023
Dr. Scott Coates says robotic surgery is gaining widespread use for hernia repair.
An estimated 611,000 ventral and 1 million inguinal hernia repairs are performed each year in the US, according to Healthcare Cost and Utilization Project data and the US Food and Drug Administration1; globally, these surgeries are estimated to top 20 million a year, making hernia repair one of the most commonly performed general surgery procedures in the world.2
Among the trends in hernia repair surgery are increased use of robotics, nonpermanent mesh, and shared video learning. In addition, machine learning applications are in development, including one that helps surgeons better assess the hernia patient’s risk for complications. A movement is also underway to expand hernia care using a more holistic approach that encompasses abdominal core health.
Robotic surgery, which has been around for more than 2 decades, is quickly gaining popularity for use in hernia repair surgery. Innovations in this technology have led to three-dimensional (3D) imaging of the inside of the abdomen and enabled surgeons to perform surgery through small incisions rather than the large incisions associated with traditional open surgery, resulting in less tissue damage, reduced pain, and faster postoperative recovery for patients.
“Robotic surgery is gaining widespread use for hernia repair,” said Scott D. Coates, MD, FACS, a general surgeon at Labette Health in Parsons, KS, whose own use of robotic surgery has greatly increased during the last 7 years. “Trainees have that platform as their go-to technology to repair both simple and complex hernias. Although many still use the laparoscope, use of robotic surgery is expanding rapidly.”
Some surgeons are calling the minimally invasive technology transformational. “The robotic approach allows us to perform more complex and difficult surgery than we could sometimes do with the laparoscope,” said Benjamin K. Poulose, MD, MPH, FACS, a general surgeon in the Division of General and Gastrointestinal Surgery at The Ohio State University Wexner Medical Center in Columbus.
Increased use of robotic surgery also will lead to a wealth of robust data collected through the robotics platforms, he said. This includes technical information captured during the performance of the procedures. Researchers are exploring innovative ways to analyze the rich dataset, he said.
“Combining that with visual analytics techniques, especially with minimally invasive surgery, could be a powerful way to analyze surgeries in general,” Dr. Poulose said.
Robotic surgery has been associated with higher costs, so some researchers have cautioned their colleagues to track its comparative effectiveness and not allow their enthusiasm for this new technology to outpace the need for it.3
Surgical mesh, designed to support damaged tissue around a hernia while it heals, is not the permanent solution that it was intended to be.
Using mesh to repair hernias has been one of the biggest success stories in biomedical engineering during the last 50 to 60 years, according to Dr. Poulose. Mesh has “transformed the durability of what we do as hernia surgeons into something that has been much more predictable, reliable, and has a well-defined benefit,” he said.
But using mesh to repair hernias is not the permanent solution that it was intended to be. Mesh occasionally can get infected, and hernias can recur even if permanent mesh is used. In addition, mesh-related complications are increasing in frequency as more patients live longer. Mesh also can grow into the small intestine, colon, or bladder, Dr. Poulose explained.
“Although these complications occur at a low rate, if you have one, it is obviously a big deal to you as a patient,” Dr. Poulose said. “Our job is to figure out how meshes interact with a patient’s tissue in the long-term to minimize these really impactful complications.”
Just as permanent mesh was once seen as a durable solution, it also was once thought that more mesh overlap is better than less. Recent research, however, does not necessarily support this assertion. The more overlap, the more likely there is to be postoperative pain for the patient, according to a study recently published in the Journal of the American College of Surgeons (JACS).4
Although not a perfect solution, an approach to mitigating problems associated with permanent mesh is the increased use of nonpermanent meshes such as bioresorbable mesh and absorbable mesh. Implantation of these meshes causes inflammation that strengthens the body’s native tissue and builds scar tissue to reinforce the repair.
Dr. Poulose described bioresorbable mesh as one of the emerging success stories in tissue engineering, with a similar recurrence rate to permanent meshes.4 Some types of absorbable mesh, however, have been shown to have a higher rate of recurrence in contaminated fields than permanent mesh5; this is one reason why Dr. Coates said he has not been using it as much as in the recent past.
Another approach to the mesh problem is extraperitoneal repair, often used in ventral hernia repair surgery, in which the mesh is placed outside the abdominal cavity. This method can avoid some of the issues associated with the mesh being place inside the cavity.
Finally, “no mesh” repairs are becoming more popular, especially when it comes to inguinal hernia or umbilical hernia surgery. Some repairs—such as with the Shouldice technique—can be done successfully without mesh. Even when no-mesh repair presents a higher chance of recurrence, many patients are willing to make the tradeoff, Dr. Poulose said.
To help his patients understand the risks of hernia repair surgery, Dr. Coates uses the ACS National Surgical Quality Improvement Program® (NSQIP®) Surgical Risk Calculator. Although that calculator has been effective in providing patient-specific risk information to guide surgical decision-making, he said advances in machine-learning, a branch of artificial intelligence, will help create a tool that could much more quickly identify potential risks or even potentially unnecessary procedures.
There are limitations when it comes to how data are analyzed to assess patient risks using traditional epidemiologic techniques, especially in fields like abdominal core health, Dr. Poulose explained. Evidence is emerging that machine-learning has the potential to overcome these limitations and help screen and diagnose patients, predict outcomes, and make decisions.
“One of the advantages of machine learning is you’re able to take massive amounts of data and identify patterns that we can then use to help make individualized clinical recommendations,” Dr. Poulose said.
For example, a recent JACS study examined how machine learning algorithms used readily available preoperative clinical data to accurately predict complications of abdominal wall reconstruction, offering a new way to provide a data-driven, patient-specific risk assessment for patients before they undergo the procedure.6 One of the challenges is convincing surgeons that this is a legitimate way to analyze data, he said.
Dr. Coates said he foresees other applications of machine learning, such as using it to anticipate how a person’s muscle tone will age or in conjunction with 3D printing to create mesh that precisely fits the patient. He also predicted that someday artificial intelligence will be combined with surgical robots to perform autonomous suturing.
Another trend in hernia repair is the increased use of video learning to teach surgical techniques. Hernia repair training videos are offered through social media, collaborative groups, and the ACS and other professional organizations.
“The ability for a surgeon to watch different techniques, identify one that is superior, and have that training available 24 hours a day around the world has changed hernia repair for the better,” Dr. Coates said. “Before, you had to go to a conference or another hospital to learn new techniques.”
Some researchers urge caution due to the wide range in quality of available training videos, and suggest using a peer-review process to evaluate the options.
As hernia repair surgery advances, guidelines for the various options in surgical repair also need to be updated. However, a persistent challenge to hernia repair guideline development has been the fact that there are so many effective ways to fix hernias, Dr. Poulose said. This has led to a wide variety of training and experience among hernia repair surgeons, which in turn made it difficult and controversial to establish guidelines. As a result, existing guidelines often come with weak recommendations, although a few have been upgraded to strong in recent years.7
Gathering a high volume of high-quality data over time, including those collected from robotic surgery, may help lead to stronger guidelines. “Instead of recommending one specific operation, at some point, we may be able to recommend a couple of different approaches or a couple types of mesh that can help patients in certain circumstances,” he explained.
Hernias have come to be seen as a chronic problem to be addressed over time.
“We used to think that all hernia repairs are pretty durable, and the hernia won’t come back,” Dr. Poulose said. “What we now know is that hernias, especially ventral hernia, can end up as a chronic problem for many patients, with the hernia coming back over time. When this happens, you will need an array of therapies, both surgical and nonsurgical, to keep a patient’s quality of life where it needs to be.”
There is a movement to broaden the field to encompass the health of the abdominal core. The American Hernia Society partnered with the Abdominal Core Health Quality Collaborative (ACHQC), formerly known as the Americas Hernia Society Quality Collaborative, to advocate for a field known as abdominal core health.8 This new field focuses first on maximizing the core muscle strength of patients when they are healthy, through exercise, nutrition, and physical therapy.
The Wexner Medical Center in Columbus, OH, is home to the world’s first Center for Abdominal Core Health, bringing together a multidisciplinary team of experts to help patients improve their core strength and treat problems using this holistic approach.
When problems arise like hernias, diastasis of the abdominal wall, and growths and tumors of the core, the Center convenes a multidisciplinary team to develop a personalized treatment plan for each patient.
“Our surgical specialties have evolved into fairly narrow practices, especially in academic centers,” Dr. Poulose said.
The components of the abdominal core musculature are all related, he explained. The anterior abdominal wall and flanks work together as a functional unit with the pelvic floor, diaphragm, and lower back. Problems with one component can affect the others. Evidence is building to show that fixing one part of the abdominal core (such as a ventral hernia) can positively impact the other parts.
“Our physical therapy colleagues understand this concept well. We can learn a lot from how they approach patients,” Dr. Poulose said. “We realized that we needed to think beyond fixing holes, and instead, ask if fixing that hole can improve other areas of core musculature.”
This new approach already has spawned promising research. One study shows that stabilizing the anterior abdominal wall may alleviate lower back pain, Dr. Poulose said. Another looks at how stabilizing a woman’s weak abdominal wall due to multiple pregnancies could positively impact pelvic floor function.9 Yet another shows how stabilizing the abdominal wall and fixing a hernia can improve lung function.10
“Any effort like this where we’re looking to make a monumental change in how an entire field is viewed and views itself is going to take some time,” Dr. Poulose said. “But I think our next generation of surgeons gets this idea far more than people like me who’ve been in practice for a while.”
Jim McCartney is a freelance writer.