Inguinal Hernia Repair Techniques Innovations in Minimally Invasive Surgery 2025

The Growing Preference for Endoscopic Approaches

The landscape of inguinal hernia treatment has dramatically evolved over the last two decades, moving from traditional open procedures to highly sophisticated endoscopic methods. Inguinal Hernia Repair Techniques now heavily favor minimally invasive procedures, primarily TEP (Totally Extraperitoneal) and TAPP (Transabdominal Preperitoneal) approaches. These techniques are associated with significantly less surgical trauma, which translates directly into reduced postoperative pain and a faster return to normal activities. Data from major surgical registries indicate that more than 60% of all elective hernia repairs in major global centers utilize these advanced approaches, a figure projected to exceed 75% by 2025, underscoring the shift in clinical best practice.

Refining Minimally Invasive Surgery for Complex Cases

While the benefits of Minimally Invasive Surgery are clear for primary hernias, current innovation focuses on refining these techniques for more complex scenarios, such as recurrent or large incarcerated hernias. Specialized instruments and high-definition 3D visualization systems are key to maintaining patient safety and procedural efficiency. Laparoscopic approaches allow surgeons to repair the defect from behind the abdominal wall, providing a tension-free repair that is vital for preventing future recurrence. For clinicians and health systems interested in the technical and outcome-based data driving this revolution, further details are available in the specialist analysis on Minimally Invasive Surgery and its clinical adoption trajectory.

Accelerated Recovery Protocols and Future Training by 2025

The ultimate goal of modern Inguinal Hernia Repair Techniques is accelerated recovery, often facilitating same-day discharge. Protocols focusing on multimodal pain management, reduced general anesthesia use, and enhanced patient education are becoming the norm. By 2025, surgical training programs worldwide will place an even stronger emphasis on mastering these complex laparoscopic approaches, ensuring a high standard of competence. Furthermore, the integration of new-generation fixation methods, which eliminate the need for sharp tacks, is expected to further decrease the risk of chronic post-surgical pain, a major focus for improving long-term patient satisfaction.

People Also Ask Questions

Q: What are the main advantages of minimally invasive techniques like TEP and TAPP? A: They result in significantly less surgical trauma, leading to reduced postoperative pain and a faster return to normal activities for the patient.

Q: What percentage of hernia repairs are currently performed minimally invasively in major centers? A: Data indicates that over 60% of elective hernia repairs in major global centers currently use endoscopic approaches, a figure expected to rise to 75% by 2025.

Q: How are surgeons aiming to reduce chronic post-surgical pain in the future? A: By implementing multimodal pain management protocols, reducing general anesthesia, and using new-generation fixation methods that eliminate the need for sharp tacks.

Laparoscopic Inguinal Hernia Fixation The Growth of Advanced Mesh Materials 2024

The Shift in Mesh Philosophy

Modern hernia management is defined by the use of synthetic mesh to reinforce the weakened abdominal wall, ensuring a durable, tension-free repair. However, historical reliance on heavy, high-density mesh materials often led to concerns regarding chronic pain and foreign body sensation. Laparoscopic Inguinal Hernia Fixation has championed the adoption of lighter, large-pore mesh designs. This lighter material reduces the amount of foreign material permanently implanted, minimizing the host's inflammatory biological response without compromising the structural integrity required for long-term support. The result is a repair that is biomechanically superior and better integrated into the patient’s native tissue.

Innovations in Advanced Mesh Materials

The innovation surrounding Advanced Mesh Materials is central to improving patient quality of life. The latest materials incorporate resorbable components that provide necessary support during the initial healing phase (3 to 6 months) and then slowly dissolve, leaving behind only the essential, minimal support structure. Other cutting-edge designs feature hydrophilic properties to improve tissue ingrowth and reduce adhesion formation, a major complication following any abdominal surgery. This focus on material science directly addresses the long-term trade-offs associated with permanent implants. Clinicians seeking in-depth analysis on the regulatory and adoption trends of these Advanced Mesh Materials should consult dedicated surgical reports for a comprehensive overview of the field.

Optimizing Fixation Techniques by 2024

Beyond the mesh itself, Laparoscopic Inguinal Hernia Fixation techniques are also being optimized. While permanent tacks were once standard for securing mesh, studies have shown that they contribute to chronic localized nerve pain. In 2024, the widespread practice involves either using absorbable fixation systems, fibrin sealants, or, increasingly, no mechanical fixation at all in select cases where the mesh is large enough to remain securely placed by intra-abdominal pressure. This careful selection of fixation method based on patient risk and mesh size is a cornerstone of refined surgical practice and aims to elevate overall patient recovery metrics.

People Also Ask Questions

Q: Why are surgeons shifting to lighter mesh materials? A: Lighter, large-pore mesh reduces the amount of foreign material implanted, minimizing the host's inflammatory biological response and decreasing the risk of chronic pain.

Q: What is the benefit of using resorbable mesh components? A: They provide structural support during the critical 3 to 6-month healing phase, then slowly dissolve, leaving behind a reduced, long-term support structure.

Q: What are the preferred mesh fixation methods today compared to permanent tacks? A: Surgeons now prefer absorbable fixation systems, fibrin sealants, or utilizing intra-abdominal pressure (no fixation) in selected cases to secure the mesh.

Robotic Hernia Surgery Outcomes High-Volume Centers and Patient Recovery 2026

The Ascent of Robotics in Abdominal Wall Repair

The adoption of robotic platforms has been one of the most prominent trends in advanced abdominal surgery. Robotic Hernia Surgery Outcomes have demonstrated that this technology provides surgeons with key advantages over conventional laparoscopy, primarily through enhanced dexterity and superior 3D visualization. The wristed instruments of robotic systems allow for precise, complex suturing in tight anatomical spaces, making the closure of large defects or the intricate placement of mesh more manageable. While the learning curve is substantial, the fidelity and control offered by the robots are particularly valuable in complex or recurrent inguinal hernias where tissue planes are often scarred and distorted.

Optimizing Care in High-Volume Centers

Studies consistently show that favorable Robotic Hernia Surgery Outcomes are strongly correlated with the expertise found in High-Volume Centers. In these specialized units, optimized workflows, dedicated surgical teams, and established training pathways lead to reduced operative time and better patient results. The robotic platform’s significant upfront cost necessitates a high case volume to achieve cost-effectiveness, making centralization a key theme in its adoption. As the technology evolves, reports from these leading institutions, documented in surgical research focused on High-Volume Centers, will continue to define best practices and training standards for the future generation of hernia specialists.

Standardizing Recovery and Training by 2026

By 2026, the standardization of training protocols for robotic hernia repair is expected to become commonplace. This ensures that the benefits of enhanced dexterity and precise technique translate reliably into optimal patient recovery across a broader range of hospitals. Current data indicates that while robotic surgery for standard inguinal hernias does not dramatically improve recovery time compared to conventional laparoscopy, it significantly improves the surgeon's ergonomic position and may reduce fatigue, which indirectly enhances patient safety during long or complex cases. This dual benefit—technical advantage for the surgeon and superior outcomes for complex patients—drives its continuing integration.

People Also Ask Questions

Q: What is the main technical advantage of robotic hernia surgery over traditional laparoscopy? A: The robotic platform offers wristed instruments for enhanced dexterity and superior, high-definition 3D visualization, which is particularly useful for precise suturing in complex hernias.

Q: Why are Robotic Hernia Surgery Outcomes better correlated with High-Volume Centers? A: High case volumes ensure surgeon proficiency, optimize surgical workflows, and distribute the significant capital costs of the robotic platform, leading to better patient results.

Q: Does robotic surgery speed up recovery time for all inguinal hernias? A: For standard, primary hernias, robotic surgery does not significantly speed up patient recovery compared to conventional laparoscopy, but it improves surgeon ergonomics and is better for complex cases.

Hernia Mesh Materials Evolution The Shift to Biologic and Resorbable Implants 2025

Moving Beyond Permanent Synthetics

The history of hernia repair is closely tied to the materials used for permanent reinforcement. While synthetic polypropylene mesh revolutionized the field by dramatically lowering recurrence rates, it introduced long-term concerns regarding chronic inflammation, contraction, and foreign body reaction. Hernia Mesh Materials Evolution represents a directed effort to mitigate these risks. The modern focus is on creating scaffolds that encourage the patient's own tissue to rebuild the abdominal wall, rather than relying solely on a permanent, inert barrier. This philosophy emphasizes better tissue integration and reduced long-term immunological response.

The Promise of Biologic and Resorbable Implants

Biologic and Resorbable Implants are at the forefront of this shift. Biologic meshes, derived from decellularized animal tissue, are completely integrated and remodeled by the patient's body, theoretically offering a truly "natural" repair. However, they lack the tensile strength of synthetics and are often reserved for contaminated fields where infection risk is high. Resorbable synthetic meshes, which break down over 12-24 months while providing a scaffold, are gaining traction in elective repair. These materials offer the initial structural support required for wound healing and long-term stability without the permanent presence of foreign material. For professionals tracking clinical outcomes and material performance, a detailed review of Biologic and Resorbable Implants provides crucial data on their role in different patient populations.

Next-Generation Composites by 2025

By 2025, the most significant advancement in Hernia Mesh Materials Evolution is expected to be the rise of composite materials. These meshes combine the immediate strength of low-profile permanent polymers with resorbable components that minimize adhesion formation on the visceral side. Furthermore, new surface modifications, such as antimicrobial coatings, are being developed to reduce the risk of mesh infection, a rare but devastating complication. This combination aims to deliver the optimal balance of immediate mechanical support and superior long-term tissue integration for improved mesh longevity and patient well-being.

People Also Ask Questions

Q: What is the primary drawback of traditional synthetic polypropylene mesh? A: The risk of long-term complications, including chronic inflammation, contraction, and a persistent foreign body reaction.

Q: How do resorbable meshes provide support if they dissolve? A: They function as a scaffold, providing essential structural support during the initial 12-24 month healing phase before they are naturally broken down by the body.

Q: What is a "composite material" mesh? A: A mesh that combines the mechanical strength of a low-profile permanent polymer with an external resorbable component, often designed to prevent internal adhesion formation.

Pain Management After Hernia Repair New Protocols for Opioid-Free Recovery 2024

The Priority of Postoperative Comfort

Effective Pain Management After Hernia Repair is not just about patient comfort; it is a critical component of accelerated recovery and minimizing the use of opioid medications. Inguinal hernia surgery, while common, involves significant manipulation of sensitive tissues and nerves, leading to acute postoperative pain. Modern protocols focus intensely on preemptive and continuous nerve block techniques, which are delivered pre-operatively to dramatically reduce the amount of pain signaling immediately following the procedure. This preemptive analgesia is a cornerstone of current best practice, ensuring that pain levels remain low from the moment the patient awakens.

Achieving Opioid-Free Recovery Through Multimodal Analgesia

The global push for Opioid-Free Recovery has driven the rapid adoption of multimodal analgesia protocols. These strategies involve combining non-opioid medications—such as long-acting local anesthetics, NSAIDs, and acetaminophen—to target multiple pain pathways simultaneously. This synergy allows for powerful pain relief while minimizing the side effects and addiction risk associated with narcotics. Recent data from high-volume ambulatory centers show that over 85% of inguinal hernia patients can now be successfully discharged with little to no opioid prescription, a significant advancement from years past. Specialized reports on Opioid-Free Recovery and post-surgical pain management are instrumental in disseminating these successful protocols globally.

Future of Personalized Pain Management by 2024

By 2024, Pain Management After Hernia Repair is becoming increasingly personalized. Risk assessment tools are being developed to identify patients with pre-existing chronic pain or opioid use, who may require more intensive or specialized regional anesthesia techniques. Furthermore, enhanced patient education regarding realistic pain expectations and the appropriate use of non-narcotic medications is vital. The goal is to entirely transition away from traditional, opioid-centric prescribing guidelines, making non-narcotic pain control the absolute default for all routine inguinal hernia procedures, shortening the hospital stay and improving long-term outcomes.

People Also Ask Questions

Q: What is preemptive analgesia in hernia repair? A: It involves delivering local or regional nerve blocks before the surgery starts to significantly reduce pain signaling from the moment the patient awakens, improving initial comfort.

Q: What is multimodal analgesia and why is it preferred? A: It involves combining several non-opioid medications (local anesthetics, NSAIDs, etc.) to target multiple pain pathways simultaneously, providing effective relief with minimal addiction risk.

Q: What percentage of patients in specialized centers achieve opioid-free recovery? A: Recent data shows that over 85% of inguinal hernia patients in high-volume ambulatory centers can now be successfully discharged with little or no need for opioid prescriptions.

Diagnosis of Inguinal Hernia Advanced Imaging and Pre-Surgical Planning 2026

Beyond the Physical Examination

While the classic Diagnosis of Inguinal Hernia relies on a thorough physical examination, a significant proportion of hernias—especially early-stage or "occult" hernias—can be challenging to detect. This is particularly true in patients with severe obesity or subtle symptoms. To overcome these diagnostic hurdles, advanced imaging modalities are being integrated more frequently, especially when surgical intervention is being planned or when the source of groin pain is ambiguous. High-resolution ultrasound has become a powerful, non-invasive tool, offering excellent visualization of the abdominal wall layers and the hernial sac contents without radiation exposure, providing crucial details for surgical teams.

The Value of Pre-Surgical Planning with Advanced Imaging

The use of advanced imaging like CT or MRI for Diagnosis of Inguinal Hernia is increasingly seen as a crucial component of Pre-Surgical Planning, particularly in cases of recurrence, large defects, or when simultaneous repair of other abdominal wall issues is anticipated. These detailed scans map the exact anatomical variability of the defect, identify complex contents (e.g., bowel, bladder), and help predict the degree of tissue mobilization required. This level of detail allows the surgeon to select the optimal surgical approach (open, laparoscopic, or robotic) and the precise size and type of mesh necessary before the procedure begins. This preemptive planning is detailed in dedicated surgical reviews focusing on Pre-Surgical Planning and its correlation with improved patient safety and reduced operative time.

Integrating AI into Diagnostic Pathways by 2026

By 2026, the application of artificial intelligence will further streamline the Diagnosis of Inguinal Hernia. AI algorithms are being developed to automatically analyze standard CT and MRI scans, identifying occult or subtle defects that might otherwise be missed. This technology, known as computer-aided detection (CAD), will assist radiologists and surgeons in achieving higher diagnostic accuracy and consistency. The integration of this technology into routine clinical practice will ultimately ensure that the most appropriate and tailored surgical management is initiated for every patient based on a precise anatomical map.

People Also Ask Questions

Q: When is advanced imaging most necessary for inguinal hernia? A: When the hernia is subtle (occult), the patient has severe obesity, the diagnosis is ambiguous, or when planning surgery for recurrent or complex defects.

Q: How does advanced imaging aid in Pre-Surgical Planning? A: Detailed scans map the exact anatomical variability, identify complex contents, and allow the surgeon to select the optimal surgical approach, mesh size, and type before the procedure.

Q: What role will AI play in diagnosis by 2026? A: AI algorithms (Computer-Aided Detection) are being developed to automatically analyze standard CT and MRI scans to flag occult or subtle defects, improving diagnostic accuracy and consistency.

Recurrence Rates in Hernia Patients Strategies for Long-Term Prevention 2027

The Benchmark of Surgical Success

The long-term success of any inguinal hernia procedure is measured by its Recurrence Rates in Hernia Patients. While modern mesh-based repairs have reduced recurrence from historically high double-digit figures to generally under 5% in high-volume centers, the goal remains to push this figure even lower. Current research confirms that recurrence is not solely due to surgical technique; it is often linked to patient risk factors and failures in the body's own healing process, specifically poor native collagen deposition. Identifying and mitigating these patient-specific factors is now considered as important as the surgical execution itself.

Effective Strategies for Long-Term Prevention

Effective Strategies for Long-Term Prevention encompass both surgical and lifestyle interventions. From a technical standpoint, ensuring the correct placement and complete coverage of the mesh (tissue reinforcement) in a tension-free manner is paramount. From a patient perspective, modifying controllable risk factors is essential. For instance, data indicates that patients who actively engage in smoking cessation and manage chronic conditions that cause frequent straining (like chronic cough or severe constipation) have dramatically lower long-term recurrence rates. The commitment to these long-term lifestyle changes is detailed in the literature and reports focused on Strategies for Long-Term Prevention and patient compliance in reducing recurrence risk.

Predictive Risk Modeling by 2027

By 2027, clinical practice is moving towards a predictive risk modeling approach to manage Recurrence Rates in Hernia Patients. Algorithms combining genetic risk factors, lifestyle data, and surgical details will estimate an individual patient's probability of recurrence. This personalized risk score will dictate the intensity of the post-operative monitoring and whether a more advanced, durable mesh material is warranted. Longitudinal study data will drive the refinement of these models, ensuring that high-risk patients receive targeted, long-term follow-up necessary to ensure the durability of their repair.

People Also Ask Questions

Q: What is considered an acceptable recurrence rate for mesh-based inguinal hernia repair today? A: Modern mesh-based repairs typically achieve recurrence rates generally under 5% in specialized, high-volume centers.

Q: What non-surgical factors influence long-term recurrence risk? A: Modifiable lifestyle factors such as smoking, which hinders tissue healing, and chronic conditions like cough or constipation that cause frequent abdominal straining.

Q: How will predictive risk modeling improve recurrence prevention by 2027? A: By combining a patient's genetic factors, lifestyle data, and surgical details to generate a personalized recurrence risk score, which guides post-operative monitoring and mesh selection.

Patient-Specific Hernia Treatment Using AI for Personalized Mesh Selection 2025

The Need for a Tailored Approach

Inguinal hernias are not uniform; they vary widely in size, type, complexity, and the quality of the surrounding tissue. Historically, surgeons relied on a limited inventory of mesh materials, often using a standard product regardless of the specific defect morphology. Patient-Specific Hernia Treatment represents a significant evolution, recognizing that the optimal repair strategy—including the choice of mesh size, material, and fixation—must be perfectly tailored to the individual patient's anatomy and risk profile. This customized approach is foundational to achieving the best long-term outcome, minimizing complications like chronic pain or recurrence.

Using AI for Personalized Mesh Selection

The complexity of integrating anatomical variation, tissue quality assessments, and material performance data necessitates the use of computational tools. AI algorithms are now being developed to drive Personalized Mesh Selection. These systems analyze pre-operative imaging (CT/MRI) to precisely measure the defect and surrounding tissue, apply principles of finite element analysis (FEA) to predict mechanical stress, and cross-reference patient risk factors (e.g., smoking status, collagen disorder history). The resulting recommendation provides the surgeon with an evidence-based selection of the optimal mesh type and size, predicting which material offers the best biocompatibility and long-term durability for that specific patient. Detailed guidance on the implementation and clinical utility of these systems can be found in specialized reports on Personalized Mesh Selection based on advanced predictive modeling.

The Future of Integrated Surgical Data by 2025

By 2025, the principles of Patient-Specific Hernia Treatment are expected to be fully integrated into robotic and laparoscopic platforms. Intraoperative surgical data—such as suture tension and real-time tissue response—will feed back into the AI model, allowing for slight adjustments to technique or material placement. This integrated, closed-loop system of pre-operative planning, intra-operative execution, and post-operative monitoring will create a new standard of personalized surgical care, moving decisively beyond the reliance on standardized products for complex anatomical problems.

People Also Ask Questions

Q: Why is a standardized approach to hernia mesh selection sub-optimal? A: Inguinal hernias vary widely in size, type, and surrounding tissue quality, meaning a single, standardized mesh cannot provide the optimal long-term result for every patient.

Q: How does AI assist in Personalized Mesh Selection? A: AI analyzes pre-operative imaging, applies finite element analysis to predict stress, and cross-references patient risk factors to recommend the optimal mesh type and size for the specific defect.

Q: What is the goal of integrating AI into surgical platforms by 2025? A: To create a closed-loop system where intraoperative data feeds back into the model, allowing for real-time adjustments to surgical technique and creating a new standard of personalized care.

Tissue Engineering for Hernia Defects The Future of Bio-Integrated Repair 2027

Aiming for True Tissue Regeneration

The ultimate frontier in abdominal wall reconstruction and inguinal hernia repair is not simply reinforcement, but the complete regeneration of the native tissue. Tissue Engineering for Hernia Defects seeks to move beyond both permanent synthetics and passive biologics. This approach involves creating advanced scaffold technologies that not only provide mechanical support but also actively encourage the patient's cells and stem cells to infiltrate and deposit new, healthy collagen. The goal is a truly Bio-Integrated Repair, where the implanted device gradually dissolves, leaving behind a fully restored, functional abdominal wall structure that resists future herniation.

Advancements in Bio-Integrated Repair Technology

Research into Bio-Integrated Repair involves developing meshes seeded with autologous (patient's own) stem cells or utilizing scaffolds with controlled degradation rates and growth factor delivery. These scaffolds are designed to modulate the local host response, promoting a regenerative healing environment rather than a pro-inflammatory scarring one. This regenerative medicine approach is particularly relevant for pediatric hernias and complex abdominal wall defects where the long-term presence of synthetic mesh is undesirable. For specialists tracking the clinical translation of these complex bio-scaffolds, detailed technical performance data is synthesized in reports focusing on Bio-Integrated Repair and the necessary mechanical and biological benchmarks.

Clinical Trials and Future Availability by 2027

While still primarily in the pre-clinical and early-stage clinical trials, Tissue Engineering for Hernia Defects is rapidly maturing. By 2027, the first generation of truly regenerative meshes, likely incorporating a blend of resorbable polymers and biologically active agents, are expected to move into broader clinical usage for elective inguinal hernia repair. This will be a major step toward eliminating the concept of permanent foreign body implantation altogether, offering a permanent, biological solution based entirely on the body's own regenerative capabilities, thereby ensuring minimal long-term complication risk.

People Also Ask Questions

Q: What is the primary difference between passive mesh and tissue-engineered mesh? A: Passive mesh only reinforces the tissue, while tissue-engineered mesh actively encourages the patient’s cells and stem cells to infiltrate and regenerate new, functional native tissue.

Q: Who are the ideal candidates for a Bio-Integrated Repair? A: Ideal candidates include pediatric patients and those with complex abdominal wall defects where the long-term presence of a permanent synthetic mesh is not desired due to growth or high complication risk.

Q: What is the expected status of regenerative meshes by 2027? A: The first generation of regenerative meshes, likely composite materials incorporating biologically active agents, are expected to move into broader clinical usage for elective hernia repair.

Ambulatory Hernia Surgery Models Optimizing Same-Day Discharge Protocols 2024

The Economic and Clinical Imperative for Outpatient Care

Given the routine nature and success of modern minimally invasive techniques, the trend towards treating inguinal hernia repair in an outpatient setting is almost universal. Ambulatory Hernia Surgery Models are designed to maximize clinical efficiency and patient throughput while maintaining rigorous standards of safety and care quality. These models rely on standardized, rapid pre-operative workups and streamlined, nurse-led discharge processes. They successfully demonstrate that moving these procedures out of the main hospital and into dedicated surgical centers provides a better, more focused experience for the patient while simultaneously achieving significant cost containment for health systems globally.

Establishing Robust Same-Day Discharge Protocols

Robust Same-Day Discharge Protocols are the backbone of successful ambulatory hernia surgery. These protocols demand strict adherence to criteria such as the patient achieving stable vital signs, adequate pain control using non-opioid multimodal analgesia, the ability to tolerate fluids, and a clear understanding of discharge instructions. The success rate of same-day discharge for elective inguinal hernia repairs in dedicated centers now regularly exceeds 95%. This high success rate is testament to improved surgical techniques and the emphasis on patient education. Clinicians and administrators can access detailed blueprints for implementing these high-efficiency systems in comprehensive reports on Same-Day Discharge Protocols and the logistical steps required for their success.

The 2024 Focus on Home Monitoring and Follow-up

In 2024, the evolution of Ambulatory Hernia Surgery Models is centered on enhancing post-discharge care through remote monitoring. Instead of routine in-person follow-up visits, many centers are implementing virtual check-ins and using digital health platforms to track patient recovery milestones and pain levels from home. This remote follow-up not only reduces the burden on the patient but also allows clinical teams to rapidly identify and intervene in the rare case of a complication, such as a surgical site infection or unexpected pain. This integration of telehealth is further solidifying the shift towards a patient-centric, efficient outpatient model.

People Also Ask Questions

Q: What are the main benefits of using an Ambulatory Hernia Surgery Model? A: It increases clinical efficiency, maximizes patient throughput, provides a more focused patient experience, and achieves significant cost containment for health systems.

Q: What is the typical success rate for same-day discharge in elective hernia repair? A: In dedicated ambulatory centers, the success rate for same-day discharge in elective inguinal hernia repairs now consistently exceeds 95%.

Q: How is post-discharge care being managed in 2024? A: Post-discharge care is being enhanced through remote monitoring, including virtual check-ins and digital health platforms, allowing teams to track recovery and intervene quickly if needed, reducing the need for routine in-person visits.