How a Lucrative Surgery Took Off Online and Disfigured Patients

The bulge on the side of Peggy Hudson’s belly was the size of a cantaloupe. And it was growing.

“I was afraid it would burst,” said Ms. Hudson, 74, a retired airport baggage screener in Ocala, Fla.

The painful protrusion was the result of a surgery gone wrong, according to medical records from two doctors she later saw. Using a four-armed robot, a surgeon in 2021 had tried to repair a small hole in the wall of her abdomen, known as a hernia. Rather than closing the hole, the procedure left Ms. Hudson with what is called a “Mickey Mouse hernia,” in which intestines spill out on both sides of the torso like the cartoon character’s ears.

One of the doctors she saw later, a leading hernia expert at the Cleveland Clinic, doubted that Ms. Hudson had even needed the surgery. The operation, known as a component separation, is recommended only for large or complex hernias that are tough to close. Ms. Hudson’s original tear, which was about two inches, could have been patched with stitches and mesh, the surgeon believed.

Component separation is a technically difficult and risky procedure. Yet more and more surgeons have embraced it since 2006, when the approach — which had long been used in plastic surgery — was adapted for hernias. Over the next 15 years, the number of times that doctors billed Medicare for a hernia component separation increased more than tenfold, to around 8,000 per year. And that figure is a fraction of the actual number, researchers said, because most hernia patients are too young to be covered by Medicare.

In skilled hands, component separations can successfully close large hernias and alleviate pain. But many surgeons, including some who taught themselves the operation by watching videos on social media, are endangering patients by trying these operations when they aren’t warranted, a New York Times investigation found.

Dr. Michael Rosen, the Cleveland Clinic surgeon who later repaired Ms. Hudson’s hernias, helped develop and popularize the component separation technique, traveling the country to teach other doctors. He now counts that work among his biggest regrets because it encouraged surgeons to try the procedure when it wasn’t appropriate. Half of his operations these days, he said, are attempts to fix those doctors’ mistakes.

“It’s unbelievable,” Dr. Rosen said. “I’m watching reasonably healthy people with a routine problem get a complicated procedure that turns it into a devastating problem.”

Ms. Hudson’s original surgeon, Dr. Edwin Menor, said he learned to perform robotic component separation a few years ago. He said he initially found the procedure challenging and that some of his operations had been “not perfect.”

Dr. Menor said that he now performs component separations a few times a week and that, with additional experience, “you improve eventually.” He said he had a roughly 95 percent success rate. In Ms. Hudson’s case, he said, the use of component separation was warranted based on the complexity of her hernia and her history of prior abdominal surgeries.

The robot comes with a built-in camera that makes it easy for doctors to record high-resolution videos of their surgeries. The videos are often shared online, including in a Facebook group of about 13,000 hernia surgeons. Some videos capture surgeons using shoddy practices and making appalling mistakes, surgeons said.

One instructional video, paid for by another major medical device company, showed a surgeon slicing through the wrong part of the muscle with the da Vinci. Experts said the result could have been devastating, turning the abdominal muscles into what one described as “dead meat.”

Peper Long, a spokeswoman for Intuitive, said the company hired “experienced surgeons” to lead its training courses. “The rise in robotic-assisted hernia procedures reflects the clinical benefits that the technology can offer,” she said.

In interviews with The Times, more than a dozen hernia surgeons pointed to another reason for the surging use of component separations: They earn doctors and hospitals more money. Medicare pays at least $2,450 for a component separation, compared with $345 for a simpler hernia repair. Private insurers, which cover a significant portion of hernia surgeries, typically pay two or three times what Medicare does.

Fixing the torn muscles of a hernia is like closing a suitcase: It’s usually not too difficult to bring the two sides together and zip it up. But a large hernia, like an overstuffed bag, doesn’t have enough slack to bring the muscles back together.

Around 2006, surgeons adapted a technique from plastic surgery, called component separation, to close large hernias. On each side of the torso, they carefully cut the muscle to create slack, resulting in something like an extra zipper in expandable luggage.

Other hernia surgeons were initially afraid to try it. They would have to make incisions that ran from the sternum down to the pelvic bone and would have to distinguish between three parallel planes of muscle, each just millimeters wide. And while making tiny cuts, they would have to carefully avoid bundles of nerves and blood vessels. Cut a bundle, and the muscle becomes useless.

Despite its difficulty, the procedure took off — and with it, the opportunity for doctors to make more money.

The federal government assigns a value to everything a doctor does, from an annual physical to a complex surgery, in order to determine how much Medicare should pay. These values — known as relative value units, or R.V.U.s — are also used by private health plans, and therefore dictate most doctors’ earnings. Many hospitals require their doctors to ring up a minimum number of R.V.U.s. Some doctors get bonuses if they exceed that goal or have their salaries docked if they fall short.

Component separation has a high value. A traditional hernia repair earns between 6 and 22 R.V.U.s for the surgeon, which for Medicare patients translates to $200 to $750. Tacking on a component separation for both sides of the torso brings in an additional 34.5 R.V.U.s., or about $1,200 more for the surgeon. (Medicare also pays the hospital for each procedure.)

When the R.V.U. system began, in 1992, component separation was part of a billing category that consisted of plastic surgery procedures such as reconstructing a patient’s torso after a traumatic accident. Because the procedure demanded a high level of skill and took so much effort, it was given a high R.V.U.

But since 2006, its use for hernias has soared, Medicare data shows.

Dr. Dickens had grown up playing video games and was immediately comfortable at the da Vinci’s remote controls, which he used for dozens of gallbladder, appendix and simple hernia surgeries. Intuitive was paying him to be a consultant. (Since 2013 he has received about $1 million.)

Now the company wanted him to jump into the Facebook fray and win over the naysayers, he said.

“We are getting decimated by this little hernia group,” Dr. Dickens recalled the company representative saying. “Can you join and help defend us?”

He and other robot enthusiasts began to sing the da Vinci’s praises in the Facebook group, he said. (He said that Intuitive did not pay him for his Facebook posts.)

Over time, the group warmed to the robot, not just for simple hernia repairs but also for more complex operations like component separations. Surgeons began posting videos showing off the new procedure, drawing dozens of positive comments.

In June of 2021, W.L. Gore & Associates, a medical device company that makes surgical mesh used in hernia repairs, posted a video tutorial on its website. It promised to be a step-by-step guide to component separation surgery.

A surgeon narrated as he cut the patient’s abdominal muscles, releasing tissue so he could close a hernia. But he was operating in the wrong place and likely created a new hernia, according to four surgeons who reviewed the video.

“It absolutely trashed the abdominal wall,” said Jeffrey Blatnik, who directs the Washington University Hernia Center. “It was so offensive to the point that we reached out to the company and told them, ‘You guys need to take this down.’”

Jessica Moran, a spokeswoman for W.L. Gore, said that after surgeons flagged the error, the company removed the video; it had been online for 10 months. “We have investigated what happened here to avoid this happening again in the future,” Ms. Moran said.

Earlier this year, Dr. Blatnik fixed a bad component separation surgery where the original surgeon had cut into the wrong muscle plane. The patient’s intestines were bulging out of her sides, another Mickey Mouse hernia.

Dr. Blatnik said he immediately recognized the name of the surgeon who had operated on the patient because that he had seen that surgeon teach component separation at a course sponsored by a device company. The surgeon has received more than $130,000 in payments over the past decade from companies including Intuitive and Bard, which manufacturers hernia mesh, The Times found.

Seven years ago, Sandy Aken said, she had a hernia the size of her fist. A surgeon in Huntington Beach, Calif., performed a component separation. Three months later, her belly was still protruding, and she felt like her guts were spilling out. She saw another doctor for help.

“This patient has a significantly compromised abdominal wall with damaged muscle due to the history of component separation,” that doctor wrote in a summary of the visit. Another hernia surgeon told her he could not fix the bulge, she said.

Ms. Aken, 64, now looks nine months pregnant. She cannot bend over without pain, a limitation that forced her to leave her job as a caregiver.

In 2018, Dr. Willie Melvin performed a component separation with the da Vinci on Jennifer Gulledge, whose large hernia made her a good candidate for the operation. But he cut into the wrong part of the muscle, leaving new holes on each side of her body and too little slack to close her original hernia, another surgeon concluded after reviewing her case.

Less than a week later, he performed an emergency surgery to close the original hernia. But the side tears remained.

Dr. Melvin declined to discuss Ms. Gulledge’s case. He said he had a lot of experience with complex hernia cases that other surgeons have referred to him and that he and his partner performed about three component separation surgeries a month. Intuitive paid him more than $25,000 last year to demonstrate his technique to other surgeons and to check the work of doctors who are new to robotic surgery.

In February 2020, Dr. Ajita Prabhu, a Cleveland Clinic hernia surgeon who has studied the frequency of failed component separation, operated on Ms. Gulledge. Dr. Prabhu told her patient that she would try her best, but that the damage from the original surgery was probably irreparable.

She was right. Even with her abdominal muscles sewed back together, Ms. Gulledge lived with intense pain. Routine tasks were difficult: When she changed her granddaughter’s diaper, she had to remind the 2-year-old not to kick “grandma’s bad belly.”

In August, Ms. Gulledge drove 700 miles to Cleveland for a follow-up appointment. She spent four days on the road, sometimes stopping every 30 minutes because it hurt too much to remain behind the wheel.

When Dr. Prabhu examined her, she confirmed Ms. Gulledge’s fear: Another hernia had opened up.

Susan Beachy contributed research and Robert Gebeloff contributed reporting.

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