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Medical Intel

Nov 16, 2018

Robotic surgery is one of the most effective, least invasive hernia surgery techniques. Dr. Alexandra Zubowicz discusses the benefits of robotic surgery and other hernia surgery options.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Alexandra Zubowicz, a bariatric surgeon at MedStar Washington Hospital Center.  Welcome Dr. Zubowicz.

Dr. Alexandra Zubowicz: Thank you for having me.

Host: Today we’re talking about robotic and laparoscopic repairs for hernias, which occur when an organ pushes through the muscle or tissue that holds it in place.  How do these types of repairs for hernia work and what’s the difference between them?

Dr. Zubowicz: So, there’s a wide variety of types of hernia repairs. The main categories are open repair vs laparoscopic/robotic and then repair just by primarily closing permeated tissue back together and closing it or using a piece of mesh to reinforce the repair. In terms of open vs laparoscopic/robotic repair, open repair tends to be required for really large hernias.  And that’s because we have to actually mobilize your abdominal wall muscles, put everything back inside, bring those muscles together, and then use a piece of mesh to reinforce or strengthen that repair.  For more moderate sized hernias, we can do a laparoscopic or robotic repair and that’s something that’s more in the, I’d say, 18- to 15-centimeter range.  With the advent of robotic surgery, it’s allowed us to do even larger hernias than we used to be able to do laparoscopically and you still get that repair done with the abdominal wall muscles brought back together with the mesh place, but with very small incisions.

Host: So, when you’re talking the robotic or laparoscopic vs the open what are the key differences in the way that you go about operating on an individual?

Dr. Zubowicz: So, an open repair would be a large incision encompassing the entire size of the hernia, plus a little more on either end.  The recovery rate is a little bit longer, you tend to be in the hospital a few days longer, and the infection rate is higher with open repair. In terms of laparoscopic or robotic repair, we use a series of small 5- to 8-millimeter incisions, usually 4 to 5, around the actual hernia, so people can oftentimes leave the hospital the same day or the next day.  The infection rate is lower because they don’t have a big open wound, and the results can be just as good.

Host: How are you able to get your tools and so forth in incisions that are that small? I think that’s something that’s always just boggled my mind about this.

Dr. Zubowicz: So, the best way to see how to do this is to YouTube it, which can be pretty cool. You can find almost any surgery now, done any way, on a YouTube video, but there are actual tiny instruments that we put through these small holes and, in terms of robotic surgery, we actually manipulate at a console. We do with our hands what we want the instruments inside the body to do, and the instrument inside the body does exactly what our hands are doing outside the body.

Host: So, can that sort of a robotic surgery or a minimally invasive surgery be used for any type of hernia?  You mentioned the size matters, but what about the type or the location?

Dr. Zubowicz: Especially with the advent of robotic surgery, we can do almost any type of hernia now in a minimally invasive manner, and most can be done laparoscopically minimally invasive, so if you have a groin or inguinal hernia, we can do that laparoscopic or robotically, if you have a hiatal or paraoesophageal hernia, which is a herniation into the chest, you can do that now laparoscopically or robotically. A ventral, midline, incisional - those are all kind of the same, but an abdominal wall hernia, again, that’s more about the size of it. But a lot of those can be done laparoscopically or robotically and, like I was saying, we can do somewhat larger hernias now with the advent of the improved technology of the robotic surgery.

Host: Now is this something that requires specialized training or is this something that a general surgeon could handle?

Dr. Zubowicz: In terms of straightforward hernia repairs, a general surgeon can do it, but I think it’s always better to go to someone who’s specialized in hernia surgery, especially with laparoscopic/robotic surgery. What’s important is go to someone that is capable of doing both options and let them evaluate you so if you are a candidate for a minimally invasive repair, you have that option as opposed to, you know, getting a major open repair if you don’t necessarily need it because you didn’t see someone who is trained in doing that kind of repair. I think most people would want a minimally invasive technique if both of them were options.  Some people like to just go with the tried and true. For example, with…with groin hernias, the incision’s so small for an open groin hernia repair there’s not a huge difference between doing that or doing it laparoscopically/robotically. However, if you have two groin hernias, then you’d have two big open incisions, whereas if you did it laparoscopically/robotically, you’d have the same small incisions.

Host: Is there anyone, aside from the size of that hernia, for whom minimally invasive would not be an option?

Dr. Zubowicz: Not really. There’s some people with severe heart problems that can’t withstand, the insufflation or blowing up the abdomen because it causes changes in…in blood…blood return to the heart, but that’s extremely rare. For the most part it’s really primarily just size that would determine whether or not someone can have an open versus minimally invasive repair.  The other thing would potentially be if you’ve had multiple abdominal surgeries and have lots and lots of scar tissue and we can’t get into the abdomen from the minimally invasive standpoint safely then you would potentially need to have either a conversion to open or just go with an open surgery from the get-go.

Host: If an individual opts to have the minimally invasive surgery, what does that look like from prep to recovery?

Dr. Zubowicz: So, in terms of getting a minimally invasive hernia repair, the recovery is far quicker than an open repair and people are out of the hospital 90 percent of the time the same day and a few people will stay one day but really no more than that. In terms of recovery and to get back to exercise, to get back to any sort of strenuous activity, the recommendation’s the same. Usually we want people to wait six weeks. And that’s because we really want those abdominal muscles to heal before you put a lot of extra pressure on them. You can do basic aerobic activity after about a week, but it’s really more if you’re doing weight training or extreme sports, things like that.

Host: What are some of the common fears or common questions that people have about any type of hernia surgery?

Dr. Zubowicz: So, one would be just getting general anesthesia. That can be—getting put to sleep can be a pretty scary experience.  In terms of specifically to a hernia, I think one big thing people kind of freak out about is the mesh, because there’s so many infomercials now about mesh and causing infections, and it is true, when you put a foreign body like mesh in, it does increase the infection risk, but for the vast majority of hernia repairs, the benefits of the mesh far outweigh that risk.  And the repair with mesh is…has a substantially lower recurrence rate and can really strengthen the repair.

Host: When would an individual need to have surgery for their hernia?

Dr. Zubowicz: So, in terms of when I would recommend hernia repair, would be—unfortunately kind of a complicated answer, but one—if you’re having symptoms, so if you’re having pain from it, if it’s preventing you from exercising—those are all definite reasons to come in and be evaluated to see if, you know, you’re a candidate for surgical repair. The other thing you do have to worry about is if you have a hole and something’s stuck out of it, if you can’t get it pushed back in, that can be a problem because it can cut off the blood supply, or if your intestines are in the hernia it can block your intestines. So, for the most part, if you have a hernia with something actually stuck in it, we definitely would recommend repair.

Host: Thanks for joining us today, Dr. Zubowicz.

Dr. Zubowicz: Thank you for having me.

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