Two surgeons from the U.S. travelled to London to debate at the inaugural Abdominal Wall Reconstruction Europe conference. Their topic: Traditional vs. robot-assisted techniques for abdominal wall surgery.
Arguing for the traditional technique: Dr. Eric Pauli, assistant professor at Penn State Hershey.
Arguing for the robot-assisted technique: Dr. J.B. Bittner, assistant professor at the Virginia Commonwealth University School of Medicine.
Here are a few takeaways from their debate.
Takeaway #1: The quality of the repair
Traditional technique: “If you want to close the fascia,” said Dr. Pauli, “You don’t need a robot to do it.” Dr. Pauli showed an example in which he used multiple interrupted sutures and multiple knots. “That looks as nice as the picture [Dr. Bittner] showed you. It cost me less money and it took me less time.”
Robot-assisted technique: “The data is relatively small in volume,” said Dr. Bittner. “[We’re] trying to increase mesh surface interface by closing that defect. Comparing to [a procedure that uses] no defect closure, there may be low risk of recurrence. The robot can facilitate that closure when you’re not able to do it laparoscopically.”
Takeaway #2: Use with the transversus abdominis release (TAR) procedure
“TAR is my go-to [form of] component separation,” said Dr. Pauli.
Traditional technique: “Open TAR is a versatile operation,” said Dr. Pauli. “It has a very well-established low rate of hernia recurrence. There are high rates of surgical site occurrences, but these are generally minor and they can be managed at the bedside.”
Robot-assisted technique: “It’s about patient selection,” said Dr. Bittner. Patients who would otherwise have an open TAR, he said, may benefit from having the procedure done laparoscopically with a robot.
Takeaway #3: Handling and control
Traditional technique: “I feel much more facile and quick with my instrument exchanges and my field-of-view without the robot,” said Dr. Pauli. “I don’t mind that the images may not be the perfect angle. I mind substantially if I can’t change my view at will to look around corners.”
Robot-assisted technique: “It’s relatively easy to drive, especially for those who don’t perform lots of laparascopic approaches,” said Dr. Bittner. “It’s got a relatively rapid learning curve. My seven-year-old daughter can basically do the task transfers.”
“Ultimately, the reason why I have it is because of [its] excellent visualization,” said Dr. Bittner.
Takeaway #4: Pain association
Traditional technique: Dr. Pauli said that when you close fascia and put tension on the midline, you need transfascial sutures. “Those transfascial sutures, for a laparoscopic repair with a primary defect closure, are part and parcel to the repair. They hurt—that is for sure. You don’t eliminate the need for those sutures with a robot.”
Robot-assisted technique: “In my own experience—anecdotally—there’s less short-term, transfascial-suture-related pain compared to, for instance, standard IPOM repair with multiple transfascial sutures,” said Dr. Bittner.
Dr. Bittner asked the crowd, “Would you use the robot to undertake component separation techniques if it was available?” Those who agreed that they would use a robot raised a green sign. Those who disagreed raised a red sign.
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Dr. Pauli and Dr. Bittner are paid consultants of Cook Medical.