Hernia surgery with less pain and less down time

Hernia surgery may be one of the most common elective surgical procedures done on Cape Cod, according to Hyannis general surgeon Mathew Kalliath, DO, and eligible patients can now have the procedure performed using the new da Vinci® Xi robotic surgical system.

“(Robotic surgery) is what I offer to pretty much all my patients, as long as their co-morbidities allow for it to be done safely,” Dr. Kalliath said. “It can facilitate a safe and quick operation using minimally invasive technique and therefore less pain post-operatively and a faster recovery.”

Cape Cod Hospital installed the new da Vinci robotic system last fall. It includes updated and more refined technology and precision, using smaller, more flexible instruments, and newer camera technology that allows for better visualization than earlier versions.

Most of the operations Dr. Kalliath does with the da Vinci system are ventral and inguinal hernia repairs. A hernia is a weakness in the strength layer of the abdominal wall. Ventral hernias are located in the upper abdomen, while inguinal hernias are located in the groin. Hernias can present as bulges or lumps located at a past surgical scar, in the groin, above the navel, or other weak muscle sites. Robotic hernia repairs involve placing a surgical mesh over the bulging area against the natural lining of the abdomen, called the peritoneum.

“I take the peritoneum lining down, which exposes the hernia or the hole, and I put a mesh up against it. I suture it in place and then I close that peritoneum flap. The mesh provides the strength to prevent a recurrence,” he said.

The da Vinci® Xi system is about six feet tall with a console at which the surgeon sits and performs the surgery at the operating room bedside. The robot is ‘docked’ to the patient through tiny keyhole incisions (three small incisions), making any surgery done with the system a minimally invasive procedure. The robotic system helps the surgeon, who is viewing the surgical field through a camera view box, see 360 degrees around while inside the patient, without needing to make new incisions or adjustments to the system while the patient is under anesthesia.

Main Benefits

The main benefits of the da Vinci robotic procedure, according to Dr. Kalliath, are:

• Less invasive – For inguinal hernias, the three tiny incisions are in the upper abdomen and not in the groin, as they are with an open procedure. A ventral hernia repair also involves three small incisions instead of a large incision which may lead to intense scarring.
• Less pain – “Because incisions are much smaller, you have less pain. Most people are off narcotic pain meds 24 hours after surgery, and I encourage my patients to be up and walking on post-operative day one,” he said.
• Allows for greater flexibility – “If I go in to repair an inguinal hernia on the left and see (an undetected) one on the right, I go ahead and fix it through the same incisions.”
• Less chance of wound infection – “The incisions are located away from where the repair and mesh are, so there is less chance for wound infection and therefore less risk for mesh infection.”
• Better location of the mesh – “In open repair, we put the mesh in between or on top of the muscle layers, and there are nerves that run right through those muscle layers. In robotic repair, we put the mesh below the muscle, above the natural inner lining of the abdomen (peritoneum).”

Osterville resident Robert Singer had a left side inguinal hernia repaired in the traditional manner six years ago by Hyannis general surgeon Stephen Brooks, MD, FACS, RPVI. Dr. Brooks is also proficient in robotic surgery using the da Vinci robotic system and earlier this spring he performed a repair on an inguinal hernia on Mr. Singer’s right side.

“I can make a legitimate comparison between the two, and I can sum it up as ‘night and day,” said Mr. Singer, who is 80.

While he said both surgeries went very well, he experienced less pain and discomfort after the robotic procedure.

“When we did it six years ago, the first week was kind of uncomfortable and you’re pretty well restricted with what you can do for the first two weeks,” he said. “You’re not back to yourself for at least four weeks.”

But, after he was brought up to his room at Cape Cod Hospital after the robotic surgery, “I was ready to dance and rock ‘n roll,” he said. “I felt that good.”

Mr. Singer said he had no residual discomfort and the only reason he did not go home the same day as the surgery was because he takes a blood thinner, which required a hospital stay for a couple days before the surgery while he was taken off the medication prior to surgery and an overnight stay he was put back on it before going home, he said.

He did not need even a Tylenol after returning home, he said, and was given the green light by Dr. Brooks to resume normal activity after just three weeks.

The first surgical robot came on the market at about the same time as the Motorola Razr phone – the first iteration of the smart phone - Dr. Kalliath pointed out.

“You can imagine how far cell phones have advanced since that time, and so has the robot,” he said. “In every aspect, the robot has improved.”

The older version of the da Vinci had to be lined up at the bedside perfectly, he said. With the new system, “the way it’s designed, you can basically bring it up at any angle. It’s connected to the bed and the entire thing rotates. So, if I want to move the patient – let’s say I want to put them head down – then the robotic arms will automatically adjust so that what I’m looking at doesn’t change,” Dr. Kalliath said.

New features like this allow for a faster operation, he added. Dr. Kalliath is typically completing bilateral (left and right) hernia operations in just over one hour, he said.

There is always a chance that the surgeon will have to convert the robotic operation to an open procedure, for instance if the surgeon’s view of the area is blocked by scar tissue from a prior surgery. Dr. Kalliath always makes patients aware of this possibility; however, he said he has done more than 60 inguinal hernia cases with the robot, since arriving at CCH in late 2020, and all have been done successfully without having to convert to an open procedure. Dr. Kalliath also trained on the robotic system during his five years of general surgery residency and performed more than 250 cases using it during that time.