Expert Outlines Steps in Adopting Robotic Inguinal Hernia Repair

David Lourié, MD,

CLEVELAND—Robotic inguinal hernia repair can be adopted safely into almost any general surgeon’s practice given the right combination of motivation, education, mentorship and follow-up, according to an expert in the field.

In a presentation at the 2024 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, David Lourié, MD, explained that adherence to a clear series of steps should enable most clinicians to become proficient in the procedure.

As he noted, successful adoption of a robotic approach to inguinal hernia repair revolves around a series of questions, beginning with “Why?”

“There’s no debating that the minute you sit down at a three-dimensional robotic console, you have improved vision of the anatomy,” said Dr. Lourié, the director of minimally invasive surgery at Huntington Health, in Pasadena, Calif. The robotic approach also improves tissue handling and energy delivery, he said.

When should you bring robotic inguinal hernia repair into your practice?

“More and more residents are either being exposed to this or go on to fellowship where they’re getting robotic experience and come out with equivalency certifications,” Dr. Lourié said. “But you can learn it any time during your career. The most important thing is you have to be committed to the process.”

Who should be learning robotic inguinal hernia repair?

General surgeons and hernia specialists are the most obvious specialists to benefit from such training, Dr. Lourié said. A high volume of hernia cases is important, as is having access to the proper equipment.

Who should be operated on?

Patient selection is critical to success, particularly at the beginning of a surgeon’s journey when the focus should be on basic cases. “You don’t want to start jumping into post-prostatectomies right away; you want nice reducible hernias,” Dr. Lourié noted.

Yet perhaps the most important question to answer when it comes to mastering the techniques of robotic inguinal hernia repair is “How?” Here Dr. Lourié recommended several important steps to be completed before training even begins:

• Establish institutional privilege in the practice before beginning training.
• Ensure the availability of a trained robotics team.
• Consider scheduling and block time to use an available robot at the institution.

Robotics training begins with the basics, generally taught by industry experts. This comprises online modules, hands-on orientation with the robot, and simulation exercises.

The next step is procedure-specific skill development, which includes both case observation as well as anatomy and pathology training. Understanding the critical view of the myopectineal orifice is paramount in inguinal hernia repair, Dr. Lourié said.

Once training is finished, surgeons will complete their skill development with a procedure-specific course, typically run by experienced surgeon educators. In addition to didactics, the course will take participants through relevant procedure steps, culminating with time on the robot console itself.

“You’ll go through an inguinal hernia repair at the course and your mentor will guide you through all the steps to prepare you for going back home,” he noted. “Hopefully you have a series of cases lined up so that you can actually start doing procedures while things are fresh in your mind.”

Once back at their practices, surgeons will benefit from continuing mentorship, regular video review of cases and collaboration with other surgeons, such as through closed-group social media sites. Eventually surgeons will become proficient at robotic inguinal hernia repair, which will lead to increasing complexity of cases.

“When you go through all of this, remember at every stage that this is different than the way we traditionally learn,” Dr. Lourié concluded. “Throw yourself into the learning curve, bring in a mentor, and lean on industry resources. Then make sure you lather, rinse and repeat every time at every step along the way,” referring to directions formerly listed on bottles of shampoo.

Dr. Lourié reported financial relationships with BD, Intuitive Surgical and Medtronic.