John Fortem
Forum Replies Created
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While robot assisted surgery is an important evolutionary step in surgery, in case of hernia surgery it adds no significant value. As Good Intentions noted, it just makes the operation easier for the surgeon, ti adds accuracy and precision to the work.
I would say that in general robot assisted surgery (RAS) has an advantage over traditional video laparoscopy (VL). But laparoscopy along with robot assisted surgery is inferior to open surgery (OS) in case of hernia surgery.
RAS > VL < OS
How to know when to remove a mesh? I think you will know the answer to that question if you start having complications from the mesh implant. This can result from foreign body reject, inflammation and mesh shrinkage and adhesion to soft tissues. These complications will also depend on a number of factors, among the most important I think is at what layer of the abdominal wall the mesh is inserted.
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I understand your concern da Vinci. It’s good that you are doing your own research. The sparks or arcs are avoidable though… by not doing a robotic surgery. Is there any particular reason why you prefer laparoscopic or robotic surgery?
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I read an interesting article yesterday regarding chronic post operative inguinal pain (CPIP). You may want to read it.
https://www.degruyter.com/view/j/iss…-2017-0017.xml
Two of the predictors for chronic pain appear to be pre-operative and post-operative inguinal pain. Females also seem to be more predisposed to chronic pain. It contains a lot of interesting discussions about chronic pain. It was published in 2017, so it’s very recent, and it is a systematic overview.
The question of whether or not the use of a mesh can reduce the risk of chronic pain compared to suture repair is inconclusive.
“The use of mesh seems to reduce the risk of CPIP compared to suture repair. Many trials have investigated the question whether lightweight meshes (LWM) may reduce the risk of CPIP. The interpretation of these studies is difficult due to the large variety of mesh materials and mesh properties such as weight, pore size, tensile strength, weaving pattern, and elasticity.”
The conclusion states:
“The avoidance of chronic pain is a primary concern in inguinal hernia repair and may be considered the most important clinical outcome. This problem preceded modern mesh-based techniques; however, as recurrence rates have decreased, pain has become the more prevalent and important complication. Understanding the causative mechanisms and risk factors of inguinodynia help to prevent, diagnose, and treat this condition. Groin pain, especially in the absence of a bulge, often needs interdisciplinary diagnostics and no operation. Detailed diagnostics, meticulous operative technique with profound knowledge of the anatomy, proper nerve identification and handling, optimization of prosthetic materials, and careful fixation are of utmost importance. Further research on how to avoid CPIP and explore the effectiveness of treating it is necessary.”
This is interesting. Because when you read the statements of mesh promoters, they will all almost unanimously say that meshes have helped reduce recurrence rates down to practically zero. I agree with this author though that recurrence should not be the primary clinical outcome measure, while chronic pain should.
The author is Dr. Reinpold of Hernia Centre Hamburg-Wilhelmsburg. He does hernia surgeries both with and without the use meshes. You can read more about this doctor and the center here:
https://www.leading-medicine-guide.com/en/Specialist-Hernia-Surgery-Hamburg-Dr-Reinpold
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quote Jnomesh:I’m addition look into non mesh repairs-they will be harder to find but they are out there.
understand that with mesh they put in a pretty big piece which is standard-bigger for laparoscopic Repairs (5”x7”) which seems out of whack for a small hernia like yours but is standard procedure.
also understand that mesh is permanent and not meant to come out-there is no “do-over”. Another thing to think about if you should have post op pain you will never know for sure if it is do to the mesh itself or Bc you had preoperative.
so research the hell out of both procedures and ideally meet with a Couple of surgeons for both mesh (open/lapro) and non mesh repairs whichever route you decide to take make sure the surgeon is a hernia specialist-this means probably looking outside of a general surgeon.I can also confirm that a large piece of mesh is used in case of laparoscopic or robot assisted repair. I was watching some surgeon from India yesterday on YouTube, and he was also explaining that you have to make sure the mesh is larger than the hole. It kind of struck a cord with me. Because I was watching a Canadian documentary a few weeks ago about mesh implants, and in that documentary the activists of some British anti-mesh group were emphasizing exactly this: the mesh is larger than it has to be to cover the hole. They have to make it large for obvious reasons. Such as making sure they can fasten it properly and also give it some slack as the mesh will ultimately start to shrink eventually.
Mesh is really a bad invention if you ask me. It has no business being inside the human body. It doesn’t matter what kind or type it is, they are all more or less the same, and it’s not natural. I am even skeptical against the absorbable meshes that are up and coming. It’s incredible how infested this idea of using a mesh for hernia repairs is in the world today. If we are to use some kind of mesh in the body, we have to be absolutely certain that it is 100% compatible and thoroughly tested in the human body. Ideally, we should use a material that is as natural as our own tissues.
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So da Vinci is good for implantation and explantation of meshes? And even superior for explantation than traditional laparoscopy? Regardless of da Vinci model? I believe Xi is the latest generation of this system, gen 4. I supposed it doesn’t have to be this latest system? This is the only one that has specific wording about general (hernia) surgery in the FDA document.
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quote dog:Great Business ..one inserted it…Second remove it ..You see every one has job! Well …Will you trust surgeon who created mess in the first place to undo it? I wouldn’t
True and true…
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quote Davinciproblems:I am referencing handling and manipulating mesh
Ah yes, I see your point now. That is true… I think. It has not been cleared for implantation or explanation of a surgical mesh specifically. It is kind of assumed that it is OK… I think. But yes, it is not worded in the text. Perhaps [USER=”935″]drtowfigh[/USER] can tell you something about that?
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quote Davinciproblems:From my research, the instruments are cleared for handling soft tissue only. Do you have the clearances for handling other materials?
A hernia repair is a soft tissue repair. I’m not sure what you’re getting at?
From dvuro (da Vinci urology) website:
http://www.dvuro.com/technology.php“The PK Dissecting Forceps may only be used on soft tissue. Do not use it on cartilage, bone or hard objects. Doing so may damage the instrument or make it impossible to remove from the cannula.”
“The Harmonic ACE Curved Shears Instrument is designed to be used in conjunction with both the da Vinci System (S and Si models) and a compatible Ethicon Endo-Surgery Generator and Hand Piece. It is intended for soft tissue incisions when bleeding control and minimal thermal injury are desired. This instrument may only be used on soft tissue. Do not use it on cartilage, bone or hard objects. Doing so may damage the instrument or make it impossible to remove from the cannula.”
Again, this text passage describes how or when not to use the different instruments (of a certain da Vinci model) in urologic procedures.
“Each quarter this page will highlight the use of da Vinci advanced technology in different urologic procedures. The highlight will include an opinion from a surgeon currently using the system and technology. If you are looking for additional information on the use of the technology, please visit the da Vinci Online Community.”
What kind of surgery do you need? And what robot system and model do you plan on using?
What kind of da Vinci problem do you have Mr./Mrs. da Vinci problems? Are you a surgeon or a patient?
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On the same topic, “Intuitive Surgical wins FDA nod for inguinal hernia repairs with da Vinci Xi”
https://www.massdevice.com/intuitive…s-da-vinci-xi/
And here is the FDA document, dated 2017:
https://www.accessdata.fda.gov/cdrh_…17/K170713.pdf
Similarly, here is the indication for use:
“The Intuitive Surgical Endoscopic Instrument Control System (da Vinci Surgical System, Model lS4000) is intended to assist in the accurate control of Intuitive Surgical Endoscopic Instruments including rigid endoscopes, blunt and sharp endoscopic dissectors,scissors, scalpels, forceps/pick-ups, needle holders, endoscopic retractors, electrocautery and accessories for endoscopic manipulation of tissue, including grasping, cutting, blunt and sharp dissection, approximation, ligation, electrocautery, suturing, and delivery and placement of microwave and cryogenic ablation probes and accessories, during urologic surgical procedures, general laparoscopic surgical procedures, gynecologic laparoscopic surgical procedures, general thoracoscopic surgical procedures and thoracoscopically-assisted cardiotomy procedures. The system can also be employed with adjunctive mediastinotomy to perform coronary anastomosis during cardiac revascularization. The system is indicated for adult and pediatric use. It is intended to be used by trained physicians in an operating room environment in accordance with the representative, specific procedures set forth in the Professional Instructions for Use.”
Note how it says “urologic surgical procedures, general laparoscopic surgical procedures”. Well guess what? Hernia surgery falls under general surgical procedures. Also note that this document relates to model lS4000. So it may or may not be applicable to model SP999 indicated in the previous document. You be the judge of that.
Generally speaking though, I would not go for a laparoscopic operation of an inguinal hernia, be it robot assisted or traditional video laparoscopy. I rather put my trust in the hands of an experienced, traditional surgeon with a lot of experience, than hyped up high tech gadgets like surgical robots, plastic meshes and all that sort of thing. That’s just how I see things.
I see that there is a lot more interest in the business side of things than the medical side of things, you know in helping people get better. Which by the way should be the number one priority for any surgeon, physician or doctor. If I have a hernia, I need medical help, I need someone to help me treat it, someone who puts my well being at the front. I am not interested in filling someone’s pocket with money just for the sake of it. If you work in this field, or any kind of profession really, money should not be your first priority, you need to have passion for the job first and foremost and have people’s well being as your first priority. But in the society that we live in, that we have built, everyone is chasing the dollars, the yens, and the euros, etc. It’s a pretty cold, insensitive, unfair and unjust world that we live in. Everyone has only their own best interest in mind.
But to answer your question directly, yes, the da Vinci robotic system has been approved for general surgery procedures, including hernia surgeries. But apparently only certain models have been approved for that, as indicated in the document above. So it’s good that you do your own homework and make sure the robotic system that will be used in your operation has been approved for that type of procedure. You may also find that the same system has been approved by government or federal agencies in one part of the world but not in other parts of the world, just like with medicine. So while a system may not have been approved for one type of operation by the US regulatory agencies, it doesn’t necessarily mean it is not safe to use in that particular way. It may, or may not, have been approved in a different country, on a different continent, for the same type of operation. Regulatory approval may be under way in the US.
Don’t get too hanged up on the da Vinci. It is the best recognized and most widespread system, with about 4400 systems rolled out worldwide, and about 43000 trained surgeons. But there are many more competitors up and coming now. Some of the most notable are TransEnterix and CMR Surgical. Some of them may or may not be approved for hernia surgery. Some of them may be more or less beneficial for hernia surgery. Who knows?
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From the same document:
“Intuitive Surgical Endo Wrist® SpTM Instruments are controlled by the da Vinci® SpTMSurgical System, Model SP999, and include flexible endoscopes, blunt and sharp endoscopic dissectors, scissors, forceps/pick-ups, needle holders, endoscopic retractors, electrocautery, and accessories for endoscopic manipulation of tissue, including grasping,cutting, blunt and sharp dissection, approximation, ligation, electrocautery, and suturing through a single incision laparoscopic approach. The system is indicated for urologic surgical procedures that are appropriate for a single port approach. The system is indicated for adult use. It is intended for use by trained physicians in an operating room environment in accordance with the representative, specific procedures set forth in the Professional Instructions for Use.”
It is indicated for urologic use only?
“The system is indicated for urologic surgical procedures that are appropriate for a single port approach.”
Should we all be concerned if the system is used for hernia surgery? Is that what you’re saying?
According to the manufacturer website, it can be used, and it is used for hernia surgeries as well.
http://www.davincisurgery.com/da-vinci-general-surgery/da-vinci-hernia-surgery.php
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“Yeah… we got a couple minutes. If speakers can come up, we’ll take one or two questions and then we’ll have to end. We caught up for 20 minutes, so we did a pretty good job. Thank you speakers for doing such a good job keeping up.”
Where is the rest of the video? Where are the first 13 minutes?
Keeping up means following a strict program on what to say and not allowing time for questioning and reasoning. The only two questions they expect you to ask them is how much does it cost and when they can deliver.
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I agree on the previous statement that “initial hernia repair and fixing a failed repair are two distinct specialties”.
I have read about several cases where the surgeon gladly repairs a hernia with a mesh, but when the patient presents with complications, the surgeon agrees that the mesh is the reason for the complications and that the mesh needs to be removed. But they don’t easily agree to attempt to remove the mesh themselves, and send the patient off to see another surgeon who specializes in mesh removals.
Depending on where you live in the world, you may have to travel to another state, country or even a different continent to have the mesh removed. Just because the original surgeon doesn’t dare to attempt to remove the mesh, because of the added risks with that procedure alone. But they are all scalpel-happy to have the mesh implanted without reason or questioning…
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I found it.
I guess that answers that. It is possible to use Desarda technique even on very large ingunoscrotal hernias. So what about the Shouldice technique then?
In this case, the patient was told by another surgeon that the only way to repair his hernia was by using a mesh.
Here are some more cases of scrotal hernias repaired with the Desarda technique and the hands of Dr. Tomas.
https://ufirstrejuvenation.com/no-mesh-hernia-and-surgery-center/inguinal-hernia-surgery/
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Speaking of scrotal hernia…
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I recall seeing a video of Dr. Robert Tomas from Miami using the Desarda technique on a patient with a large hernia, but I’m not sure if it was scrotal hernia. I will try to find the video.
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This reminds me of my hernia, which goes back in when I lay down. I lay down at night with a hernia and wake up without a hernia in the morning, and then it starts coming back slowly as the day goes on. I have gone 3 days at most without any hernia.
What kind of hernia did you have and what kind of surgery did you have? Did they use a mesh to hold your hernia in place? Why did the first surgery fail?
It should be possible to rule out seroma by doing an ultrasound test.
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quote dog:I didn’t hear about modified Shouldice technique with absorbable wire?
Oops! I blame that on my bad copy and paste. I meant absorbable sutures. They are technically made of polymers.
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Phasix is the absorbable mesh? I think it’s a very interesting concept. I have been following this development for some time now.
What about the TIGR mesh? Any ongoing trials on that one? If I recall correctly, that one was recalled.
Please keep us informed doctor!
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Thank you!
Since I have had it at the same place all this time I suspect I have a direct inguinal hernia. I don’t think it’s very likely that it’s a femoral hernia, even though it is close to those structures. I think it protrudes just above the inguinal ligament close to the mid-line. So I think it’s most likely a direct hernia.
Just like Jeremy here, I am still researching my options. I am also leaning towards a non-mesh repair, most likely using the Desarda technique, or a modified Shouldice technique without a steel wire. Since my healthcare provider is only offering mesh, I will be using my savings to pay for it. It’s very important that I find a surgeon who I can put my trust in.
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My understanding is also that the original Shouldice technique relied on a steel wire for suturing. I later learned that most of the surgeons that do the Shouldice technique use a modified version of it, unless we are talking about the Shouldice Clinic where a steel wire is still used. But what kind of suture do these other surgeons use when they do the Shouldice technique?