Monday, March 4, 2024

The bulge on Peggy Hudson’s belly, resembling the size of a cantaloupe, was steadily growing. Ms. Hudson, a retired airport baggage screener in Ocala, Fla., feared it would burst. According to medical records from two doctors she later consulted, the painful bulge was the result of a botched surgery. In 2021, a surgeon attempted to repair a small hole in her abdominal wall, known as a hernia, using a four-armed robot. However, instead of closing the hole, the procedure resulted in a “Mickey Mouse hernia,” where intestines spilled out on both sides of her torso.

One of the doctors she consulted, a leading hernia expert at the Cleveland Clinic, questioned whether Ms. Hudson even needed the surgery in the first place. The surgeon believed her original two-inch tear could have been patched with stitches and mesh, without the need for the complex component separation surgery. Component separation, while able to successfully close large and complex hernias and alleviate pain when performed by skilled surgeons, is being used inappropriately by many surgeons, including those self-taught through online videos.

Dr. Michael Rosen, the Cleveland Clinic surgeon who later repaired Ms. Hudson’s hernias, expressed regret for popularizing the component separation technique. He now finds himself fixing the mistakes made by other surgeons who attempted the procedure when it wasn’t warranted. Dr. Rosen described the situation as “unbelievable,” with healthy individuals undergoing a complicated procedure and ending up with devastating problems.

Ms. Hudson’s original surgeon, Dr. Edwin Menor, initially found the robotic component separation challenging and acknowledged that some of his operations were not perfect. However, he now performs component separations regularly, claiming a roughly 95 percent success rate. Dr. Menor learned the technique through events sponsored by medical device companies, such as Intuitive, which manufactures the da Vinci robot used in some component separation surgeries. Intuitive has also paid for hernia surgeons to attend training courses on how to use the robot for the procedure.

The rise of component separations can also be attributed to financial incentives. Medicare pays significantly more for a component separation compared to a simpler hernia repair, and private insurers also offer higher reimbursement rates. This financial factor has led some doctors and hospitals to perform unnecessary component separations. The federal government assigns relative value units (R.V.U.s) to medical procedures, which dictate Medicare reimbursement rates. Component separation has a high R.V.U., making it financially attractive for doctors and hospitals.

Another contributing factor to the surge in component separations is the increasing use of robots in surgery. Intuitive introduced the da Vinci robot in 2000, promoting its precision and potential for shorter recovery times. While initially successful in certain specialties, the use of robots in surgery, including hernia operations, has faced criticism and challenges, especially in terms of proper training and technique.

In conclusion, the increased utilization of component separations in hernia surgeries has caused concerns due to inappropriate usage by unskilled surgeons, financial incentives, and the inclusion of robots in the surgical process. Proper training, evaluation of necessity, and adherence to best practices are essential to ensure patient safety and optimal outcomes in hernia surgeries.

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