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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
260
S. Guba and R. Lu
1. The pubic tubercle must be identied and dissected beyond midline. For large direct
hernias, it is recommended to dissect to the contralateral Cooper’s ligament (CL).
All adipose tissue should be cleared from Hesselbach’s triangle, and a direct
inguinal hernia should be ruled out (Fig.20.1).
2. The bladder must be dissected 2cm below CL to facilitate mesh placement in the
space of Retzius and to prevent mesh displacement from bladder distension
(Fig.20.2).
3. A femoral hernia should be ruled out by dissecting between CL and the iliac vein
to identify the femoral orice (Fig.20.3).
4. The cord elements (vas deferens and gonadal vessels) should be parietalized such
that they lay at. The psoas muscle should be visualized, and upward traction of
the peritoneum should not trigger movement of the cord elements (Fig.20.4).
5. Cord lipomas should be reduced, which are typically lateral to the cord elements.
These lipomas can typically be reduced and placed over the mesh. However,
large cord lipomas may need to be excised to avoid mesh disruption (Fig.20.5).
6. The peritoneum should be dissected laterally beyond the ASIS and swept inferi-
orly well behind the inferior border of the mesh.
7. Perform the dissection, provide mesh coverage, and ensure that mesh and any xa-
tion is placed 2cm above an imaginary line between the internal ring and the ASIS.
8. Mesh should be placed once complete dissection and hemostasis are achieved
(Fig.20.6). The mesh should be at least 15 × 10cm, but a larger mesh may be
necessary for larger defects. One should choose a mesh that adapts to the contour
of the space and the cord structures. The mesh should lay ush against the wall
without creases or folds. Splitting of the mesh for pass-through of cord structures should be avoided. It is critical to ensure that the mesh does not “clamshell” during deation.
The dissection should be relatively avascular if the correct planes are achieved
and maintained. It is critical to understand the location of signicant neurovascular
structures and protect them from injury. The “triangle of doom” contains the iliac
vessels and is bounded by the vas deferens, gonadal vessels, and the peritoneal fold.
Fig. 20.1 Dissection of
Hesselbach’s triangle. In
this patient, a right direct
inguinal hernia is present
20 Robotic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair
Fig. 20.2 Development of
the space of Retzius.
Adequate space must be
established to prevent
mesh displacement with
bladder distension
Fig. 20.3 Identication of
the right external iliac vein
261
Fig. 20.4 Parietalization
of the cord structures.
Upward traction of the
peritoneal ap should not
cause movement of the
cord structures
262
Fig. 20.5 A large cord
lipoma encountered during
a right inguinal hernia
repair. The cord lipoma is a
piece of retroperitoneal fat
that originates from the
lateral wall and passes
through the deep inguinal
ring. Care is taken to
dissect the gonadal vessels
away medially
Fig. 20.6 Placement of
self-gripping mesh
S. Guba and R. Lu
Aggressive dissection in this area, particularly step 5 of the CV of the MPO, may
potentially cause injury to these structures. The “triangle of pain” is found laterally,
bounded by the iliopubic tract, gonadal vessels, and peritoneal fold. This area contains branches of the genitofemoral nerve and lateral femoral cutaneous nerves.
Aggressive dissection should be avoided in this region with care to leave the transversalis fascia on the side wall. Exposing bare muscle on the lateral wall may lead
to nerve injury. Approximately 40–50% of patients will have an anatomic variance
of vessels connecting the obturator and epigastric vessels known as the corona mortis or “crown of death.” Care should be given to avoid injury to these vessels while
dissecting within the retropubic space of Rezius and exposing the femoral space [11].
Mesh
As mentioned, at least a 10cm × 15cm mesh should be utilized to ensure adequate coverage of the MPO with the goal of 3–4cm of mesh overlap for any
defect(s). There are many options for mesh that are suitable for MI
20 Robotic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair
263
IHR. Differences in mesh include material, porosity, weight, and at versus
anatomic. The authors typically use a self-gripping polyester mesh. Given that
the mesh is in an extraperitoneal position, a composite mesh is not necessary.
For bilateral inguinal hernias, two meshes with adequate medial overlap
are used.
The type of mesh xation, if utilized, is typically selected based on surgeon’s
preference. Our general preference is to not xate the mesh as there is evidence supporting overall equal recurrence rates when comparing xation to non-xation and
potential for increased acute and chronic pain with xation. However, xation is
recommended for large direct defects [7, 12]. Some literature suggests that atraumatic mesh xation techniques such as with cyanoacrylate may reduce early postoperative pain [12]. No xation should be placed at or below the iliopubic tract to
avoid injury to neurovascular structures.
Closure
After verifying correct mesh placement and hemostasis, the peritoneal ap is
then closed. It is important to address any fenestrations that may cause an intraparietal hernia. Redundant hernia sacs should be excised or oversewn to prevent
intraparietal hernias. The authors use a 3-0 absorbable barbed suture for closure.
Once the peritoneal ap is closed, the robot is undocked. In our practice, we
insert a 5mm laparoscopic suction cannula into the peritoneal ap to deate the
space (Fig.20.7). Gentle pressure is applied over the patient’s groin to evacuate
additional CO2 within the scrotum. Pneumoperitoneum is then released under
direct visualization to ensure that the mesh stays at along the abdominal wall.
Should the mesh fold, pneumoperitoneum should be reestablished, and the mesh
repositioned accordingly. If a 10mm or greater-sized trocar was used, the fascial
defect should be closed.
Fig. 20.7 Deation of the
preperitoneal space. The
mesh can be seen with
good apposition to the
abdominal wall
264
S. Guba and R. Lu
Special Cases
Acute Presentation
Although not an absolute contraindication to robotic repair, acutely incarcerated
and strangulated hernias present challenges to this approach and should be performed by experienced surgeons. Preoperative reduction of hernia contents should
be attempted to facilitate minimally invasive dissection and manipulation of herniated structures. The operation is completed in the same manner as detailed earlier in
the chapter. In the setting of a large, incarcerated hernia, a releasing incision may be
made on the transversalis sling to increase the working space to assist with reduction of the sac. Furthermore, the ring can be enlarged with an anteromedial incision
for direct hernias and with an anterolateral incision for indirect hernias. Additionally,
the bedside assistant can provide external pressure to aid in reduction. If these
attempts remain unsuccessful, a hybrid approach may be completed that combines
the posterior approach with an open approach to reduce the contents of the sac [13].
In the setting of a strangulated hernia where ischemic bowel is identied intraoperatively, the contents should be observed and a decision made regarding bowel
viability. Indocyanine green may be a useful adjunct in these cases to assess viability. If bowel resection is needed, we recommend against proceeding with mesh
repair and a tissue repair should be performed either posteriorly or anteriorly.
Inguinoscrotal Hernias andLoss ofDomain
There is an increased risk of recurrence with larger hernias, especially with large
direct defects. It is recommended a larger mesh be used rather than the standard
recommended size of 10 cm × 15 cm. Medial overlap of mesh with xation to
Cooper’s ligament is critical when managing large direct hernias.
Giant inguinoscrotal hernias with loss of domain pose signicant challenges in
reduction of herniated contents. Intra-abdominal hypertension or abdominal compartment syndrome may occur due to the disproportion between the domain of the
abdominal cavity and the herniated contents, increasing the chances of perioperative complications. Botulinum toxin injection or progressive pneumoperitoneum
(PPP) may be useful adjuncts in these cases. Injection of botulinum toxin into the
muscle can cause temporary muscle paralysis that can assist with elongation of the
abdominal muscles to increase the intra-abdominal space. This generally is completed with injection spanning from 6 to 45days preoperatively. This method, however, is costly and associated with prolonged hospital stay. PPP involves gradual
insufation of CO2 into the peritoneal cavity for 1–2 weeks preoperatively to
increase intra-abdominal domain and may be combined with botulinum toxin injection. Although this is another measure that can improve overall outcomes in the
management of giant inguinoscrotal hernias, it is associated with increased hospital
stays and potential for infection [14]. In extreme cases, visceral reduction has been
20 Robotic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair
described. This can add the potential for signicant morbidity such as anastomotic
leaks, mesh infection, and cardiopulmonary compromise after reduction.
265
Concomitant Inguinal Hernia Repair andRobotic-Assisted
Radical Prostatectomy
Inguinal hernias and prostate cancer are commonly seen together in the older population. Prior studies have indicated a rate of 13–33% of concomitant inguinal hernias during prostatectomy [15]. Multiple studies demonstrate that robot-assisted
radical prostatectomy with concomitant inguinal hernia repair is safe and does not
increase mesh-related complications [16].
Common Complications
Hematomas andSeromas
Seroma and hematoma formation remains a relatively common post-operative complication of MI IHR.This is due to uid or blood collecting in the dead space that
persists after repair. Some surgeons preferentially leave drains to prevent these uid
collections. However, in our practice, we reserve drain placement for large inguinoscrotal or complex inguinal hernias. The decision for drain placement must be balanced with having a foreign body adjacent to the mesh, which theoretically may
increase the chance for infection. In a recent systematic review and meta-analysis,
placement of a closed suction drain in the preperitoneal space demonstrated signicantly lower incidence of seroma formation [17]. Most small seromas and hematomas may be managed conservatively with observation, however, those that are large
and symptomatic should be drained. One should have a low threshold to explore and
evacuate early large postoperative hematomas as they can cause signicant discomfort and mesh displacement. Postoperative hematomas after TAPP can be evacuated
laparoscopically (Figs.20.8 and 20.9). Hematomas that cause hemodynamic instability, are rapidly expanding, or have active contrast extravasation on CT imaging
should undergo urgent exploration.
Chronic Pain
Chronic pain is pain that persists over 3months after surgery. This is a signicant
postoperative complication that can have major impacts on the patient’s quality of
life. Minimally invasive surgery has a lower incidence of chronic pain when compared to open repairs [18]. There are some preoperative patient-related risk factors
for chronic pain, such as young age, female sex, preoperative pain, and chronic pain
in other locations [19]. For minimally invasive posterior approaches, extensive dissection and mesh xation should be avoided below the iliopubic tract to avoid nerve
266
Fig. 20.8 Laparoscopic
hematoma evacuation
following TAPP
Fig. 20.9 The previously
placed mesh can be seen
after clot is removed
S. Guba and R. Lu
injury. Management of chronic pain begins with conservative measures such as rest
and over-the-counter anti-inammatory medications. Neuropathic pain may be
treated with GABA modulators. Cases refractory to conservative management may
warrant nerve blocks or surgical neurectomy. Treatment adjuncts include physical
therapy and massage. A multidisciplinary approach to chronic pain patients is
paramount.
Recurrence
Recurrence rates of robotic approaches to MI IHR remain similar to open repairs
[20]. Conditions that chronically increase intra-abdominal pressure (i.e., chronic
cough, benign prostatic hyperplasia), connective tissue disorders, and infection can
increase risk for recurrence. Hernia recurrence after an anterior inguinal hernia
repair should be approached posteriorly. Recurrences with mesh plugs or other
three-dimensional mesh constructs may require partial mesh excision for satisfactory preperitoneal mesh placement (Fig.20.10). If recurrence is encountered after a
posterior repair, an anterior open approach is recommended. The previously placed
mesh is typically left in place unless there is a compelling reason for explantation
20 Robotic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair
Fig. 20.10 Excised mesh
plug. The plug would have
hindered appropriate mesh
placement
267
such as nerve entrapment. Should mesh excision be warranted, a new mesh is not
typically placed in the same setting as it may confound postoperative results.
Testicular Ischemia
Although a rare complication, injury to the spermatic vessels can lead to ischemic
orchitis. Mindfulness of the cord structures particularly while repairing large
inguinoscrotal hernias with extensive sac dissection decreases the risk of injury.
Primary abandonment of the hernia sac for large scrotal hernias has been shown to
be an effective technique to prevent this complication [21, 22].
Mesh Infection
Mesh infection can be a devastating complication. It is important to distinguish
from a supercial surgical site infection, as mesh infections tend to present in a
delayed fashion and necessitate mesh removal. Conservative treatment may be initiated rst, with mesh removal being performed at least 3months after onset of infection. The uninfected part of mesh will continue incorporation, and infected part will
further separate from tissue secondary to exudate, making mesh removal easier. If
prior posterior repair was completed, the mesh is typically removed in similar fashion, leaving the anterior anatomy intact for future repair [23].
Conclusion
Inguinal hernia repairs are among the most common major outpatient operations
performed, with a shift occurring toward minimally invasive approaches. This has
been associated with decreased early postoperative pain, earlier return to daily
activities, and decreased analgesic use compared to open repair. Furthermore, the
268
S. Guba and R. Lu
robotic platform proves to be a valuable tool in the posterior repair of inguinal hernias, allowing for improved ergonomics for the surgeon.
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