Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
166
12. Rab M, Ebmer J, Dellon AL.Anatomic variability of the ilioinguinal and genitofemoral nerve:
implications for the treatment of groin pain. Plast Reconstr Surg. 2001;108(6):1618–23.
13. Amid PK. Radiologic images of meshoma: a new phenomenon causing chronic pain after
prosthetic repair of abdominal wall hernias. Arch Surg. 2004;139(12):1297–8.
14. Lange JF, Kaufmann R, Wijsmuller AR, Pierie JP, Ploeg RJ, Chen DC, Amid PK.An inter-
national consensus algorithm for management of chronic postoperative inguinal pain. Hernia.
2015;19(1):33–43. https://doi.org/10.1007/s10029-014-1292-y.
15. Aavsang E, Kehlet H. The effect of mesh removal and selective neurectomy on persistent
postherniotomy pain. Ann Surg. 2009;249(2):327–34.
16. Zacest AC, Magill ST, Anderson VC, Burchiel KJ.Long-term outcome following ilioinguinal
neurectomy for chronic pain. J Neurosurg. 2010;112(4):784–9.
17. Loos MJ, Scheltinga MR, Roumen RM.Tailored neurectomy for treatment of postherniorrha-
phy inguinal neuralgia. Surgery. 2010;147(2):275–81.
18. Amid PK, Chen DC.Surgical treatment of chronic groin and testicular pain after laparoscopic
and open preperitoneal inguinal hernia repair. J Am Coll Surg. 2011;213(4):531–6.
19. Chen DC, Hiatt JR, Amid PK.Operative management of refractory neuropathic inguinodynia
by a laparoscopic retroperitoneal approach. JAMA Surg. 2013;148(10):962–7.
20. Mahan MA, Kader AK, Brown JM.Robot-assisted triple neurectomy for iatrogenic inguinal
pain: a technical note. Acta Neurochir. 2014;156(1):171–5.
I. T. MacQueen and D. C. Chen
Part II
Inguinal Hernia
Operating Room Set UpforRobotic
Assisted Inguinal Hernia Repair
AldoFafaj andAjitaPrabhu
Key Points
• Minimally invasive inguinal hernia repair is one of the recommended treatment modalities when expertise is available
• The transabdominal preperitoneal (TAPP) approach to inguinal hernia
repair is a procedure amenable to robotic assistance
• Robotic room setup and establishing a dedicated robotic surgery team play
a critical role in operating room efciency
7.1 Introduction
7
Laparoscopic surgery became integrated in the eld of general surgery after the
development of the computer video chip, which allowed magnied images to be
displayed on video monitors [1]. Since the rst laparoscopic cholecystectomy in
1987, the rapid adoption of minimally invasive techniques has changed the eld of
general surgery dramatically [1, 2]. Traditional open procedures could be performed
with small incisions which ultimately improved wound morbidity, post-operative
pain and length of hospital stay. Robot assisted surgery (RAS) continues the innovations in minimal invasive techniques. Over the years RAS has evolved from movements of the endoscope to a master-slave system which allows translation of the
surgeon’s hand motions from a remote console to various instruments inside the
patient’s body [3]. The number of robot-assisted surgical procedures is increasing
by 15% every year [4]. Improved outcomes from this technology have been well
A. Fafaj (*) · A. Prabhu
Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic
Foundation, Cleveland, OH, USA
e-mail: fafaja@ccf.org; PRABHUA@ccf.org
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_7
169
170
A. Fafaj and A. Prabhu
described in the elds of gynecology, urology and colorectal surgery [5]. Benets
include the ability for three-dimensional binocular vision, improved dexterity and
ergonomics, greater range of motion and telesurgery [4, 6, 7]. Although RAS is
younger in general surgery, it is quickly expanding [5].
Inguinal hernia repair is one of the most common procedures that a general surgeon performs [8]. The surgical management of inguinal hernias has paralleled the
natural evolution of surgical innovations [9]. Although the Lichtenstein open mesh
repairs have low rates of morbidity and mortality, the minimally invasive approach
(1) is associated with less post-operative pain, numbness, hematoma formation and
faster return to normal activity, (2) it has become the standard of care for many general surgeons, and (3) it is one of the recommended treatment modalities in capable
hands [5, 9, 10]. Despite the aforementioned benets, the laparoscopic technique
is used in less than 28% of inguinal hernia repairs [11, 12]. One of the contributing factors to this low penetrance is the steep learning curve requiring advanced
laparoscopic skills [10, 13]. The trans-abdominal pre-peritoneal (TAPP) inguinal
hernia repair is a procedure amenable to robotic assistance because it overcomes
the limitations in degrees of freedom and ergonomic challenges of the laparoscopic
approach [5, 13].
®
The most utilized master-slave system is the da Vinci
Surgical System (Intuitive
Surgical; Sunnyvale, CA) and over the years this system has been updated with ve
different models. The Xi and its predecessor Si are the two models encountered
most frequently today [3]. The use of these systems is currently evolving in the eld
of inguinal hernia repair. One of the major hurdles to overcome is the added operative time when using the robot. The standardization of the operating room setup
and the establishment of a dedicated robotic team play a critical role in the overall
efciency of the procedure. In this chapter, we will discuss the surgical personnel,
operating room set up, patient and robot positioning.
7.2 The RAS Team andOperating Room
The robotic surgery team consists of the surgeon, the rst assistant, the circulating nurse and the surgical technician. It is imperative for each member of the team
to be thoroughly knowledgeable in robotic, laparoscopic and open surgeries [14].
There are several commercially available robotic training modules and it is recommended that all team members complete these modules prior to joining the RAS
team. Because of the extra training required, it is important to have a dedicated
robotic team, if possible, as this will minimize delays due to the learning curve
associated with this technique.
The surgeon, as the leader of the team, should be familiar with each step of the
RAS in order to troubleshoot any potential problems. The rst assistant plays a critical role during the procedure and mastering not only instrument exchange but also
laparoscopic skills such as retraction, suction/irrigation and clipping will improve
the efciency of the procedure [3]. The circulating nurse and the surgical technician
7 Operating Room Set UpforRobotic Assisted Inguinal Hernia Repair
171
are the other essential members of the team. They should master the set- up of all the
different components, sterile draping, robot maneuvering in the operating room and
docking, the various instruments available and how to perform their exchange from
robotic arms. All bedside team members should be able to manually manipulate the
robot arms using the clutch buttons in order to move the ports out (“burping”) or in
(deep seating) which will allow the surgeon to reach the target anatomy or maximize the working space. Finally, they should be able to troubleshoot collision of the
arms, which can lead to instrument or drape dislodgements. Developing these skills
is essential to developing an efcient RAS team as it will prevent interruptions during the surgery which will otherwise occur if the surgeon has to re-scrub.
The operating room must accommodate all of the robotic components while
allowing the surgeon to have an unobstructed view of the patient, tension free cable
connections and pathways for the personnel to move freely and safely around the
room [3]. Some surgeons prefer to have laparoscopic instruments available in the
operating room which can be used for gaining intraperitoneal access and establishing pneumo-peritoneum. These instruments can be used to lyse any adhesions
before the robot is engaged and as a safety mechanism in case the RAS cannot be
used as planned [2]. When compared to laparoscopic instruments the robotic ones
have a more limited lifespan. The robotic arms will not function with an instrument
that has surpassed the manufacturer recommended uses. It is important to have extra
instrument trays available in the operating room as this will prevent delays during
the operation in case this problem is encountered.
Before the case starts, a team huddle is recommended and it should include the
surgeon, the anesthesiologist, the surgical assistant, the circulating nurse and the
surgical technician. This is an opportunity for the team to discuss any anesthesia
concerns, the operative plan, the available equipment, the position of the patient
cart, and the type of mesh that will be used. While this may appear time consuming
at rst, it will ensure proper surgical set up and will help anticipate any potential
problems. Finally, the team should discuss alternative approaches if the RAS does
not go as planned, conrming that the instruments required are available in the
operating room.
7.3 The Robotic Equipment
The da Vinci® Surgical System consists of three main units, the patient cart, the
surgeon console and the vision cart.
a. The patient cart has the mechanical arms, usually one camera and 3–4 instrument
arms, which translate the surgeon’s hand movements from the surgeon console
to the patient and the target anatomy. Once all the cannulas are placed, the patient
cart is maneuvered into position by the operating room staff.
b. The surgeon console is the control center for the robot arms. It allows for three
dimensional images delivered via two separate left and right images. In addition,
172
the display shows any errors encountered during the instrument exchanges, the
instrument available in each arm and the energy device. Foot pedals and two arm
controls allow the surgeon to remotely manipulate each arm on the patient cart.
When positioning the surgeon console in the operating room, it is important to
allow a direct line of sight between the surgeon and the operative eld. While the
three-dimensional image offers great detail of the target anatomy, the surgeon
cannot visualize the position of the robot arms outside the patient’s body.
Ensuring a direct line of sight gives the surgeon the ability to assess the position
of the arms with relation to the patient and the target anatomy.
c. The vision cart is similar to the laparoscopic monitor tower. It contains a two
dimensional monitor, an insufator and a light source. Both the vision cart and
surgeon console are equipped with intercom capabilities which facilitates com-
munication between the surgeon and the other members of the team.
A. Fafaj and A. Prabhu
7.4 Patient Position, Cannula Placement andRobot
Docking
7.4.1 Patient Positioning
The patient is positioned supine on the operating room table. Both arms are tucked
on the sides with foam padding, if necessary, in order to minimize pressure related
injuries. The surgeon can choose the position of the patient cart, on the side (parallel dock) or between the legs, based on their level of comfort and preference. A
lithotomy position will be necessary to accommodate the patient cart between the
patient’s legs. In our practice we nd it easier and more efcient to side dock. A
safety strap in applied across the lower extremities or across the chest if the patient
is in lithotomy. A Foley catheter is routinely inserted in all cases. The patient is then
prepped widely, and sterile drapes are applied.
7.4.2 Cannulas
Gaining access to the abdomen is done similarly to established minimally invasive
techniques. These include the open cut-down (Hasson) technique and the optical
trocar with or without Veress needle insufation. Because of the number of the cannulas and their position we elect to gain entry into the abdomen via the open cut
down technique. Incision is made at least 3cm above the umbilicus and this site is
used to place the 12mm balloon cannula where the camera will be inserted. Placing
the camera port in this position will allow better visualization and adequate working space especially when closing the peritoneum ap once the repair is completed.
After establishing pneumo-peritoneum to a pressure of 15mmHg, a laparoscopic
camera is inserted and the intra-abdominal contents are quickly surveyed. Under
visual guidance, two additional 8mm cannulas are inserted at the lateral edges of
7 Operating Room Set UpforRobotic Assisted Inguinal Hernia Repair
Fig. 7.1 Laparoscopic port
placement for robotic
inguinal hernia repair. A
12mm balloon cannula is
placed 3cm superior to the
umbilicus. Two 8mm
cannulas are placed at the
lateral edges of the rectus
sheath on either side and at
the same level as the
supraumbilical midline
cannula
173
the rectus sheath on either side and at the same level as the supraumbilical midline
cannula (Fig.7.1). Ensuring adequate space between the 8mm ports will maximize
the range of motion of each robot arm which is important when suturing. Since we
use the Si model, where the camera can be inserted through only one dedicated port,
we prefer to insert the mesh and the required sutures inside the abdomen through
the 12mm port prior to docking the camera arm. This allows for minimal undocking and redocking of the robot. If desired and available, a 5mm laparoscope can
be inserted through one of the 8mm ports to watch the mesh and sutures enter the
abdomen.
7.4.3 Robot Docking
Once all the cannulas are placed the patient is positioned in slight Trendelenburg
and the patient cart is moved into position. A two-person team is recommended for
efcient and safe maneuvering. A non-sterile team member should push the patient
cart and a second person from the team should provide audible cues in order to
facilitate movements. To avoid confusion room objects should be used for direction instead of left and right cues. For inguinal hernia repairs we prefer to side
174
A. Fafaj and A. Prabhu
dock the patient cart (Fig.7.2). Alternatively, the lithotomy patient position can be
used to dock the robot between the patient’s legs (Fig.7.3). Once the patient cart
is maneuvered into the desired position, brakes are applied automatically and each
arm can be moved independently by the sterile staff using the clutch buttons. It is
recommended that the camera arm is docked rst followed by the two additional
arms. Upon docking of each arm, the surgeon can move to the surgeon’s console.
By taking control of the camera arm, each instrument can be safely inserted by the
rst assistant under direct visualization.
Fig. 7.2 Overhead view of the operating room set up that we use for inguinal hernia repair showing the patient cart docked on the side
7 Operating Room Set UpforRobotic Assisted Inguinal Hernia Repair
175
Fig. 7.3 Overhead view of operating room set up showing an alternative position for the patient
cart. The patient is placed in lithotomy position and the patient cart is docked between the legs
7.5 Conclusion
Inguinal hernia repair is one of the most common procedures that the general surgeon perform. Despite the benets that minimally invasive techniques afford, there
is a slow adoption rate for inguinal hernia repairs, likely because of the advanced
176
A. Fafaj and A. Prabhu
laparoscopic skill required. The robotic approach overcomes the limitations in
degrees of freedom and ergonomic challenges of the laparoscopy while retaining
the same benets. As with any new technology, the RAS is not without challenges.
One of the major hurdles to overcome is the added operative time when using the
robot. The operative times have been shown to improve once past the learning curve
[15]. The standardization of the operating room setup and the establishment of a
dedicated robotic team play a critical role in the overall efciency of the procedure
and it will ensure success of the robotic inguinal hernia repair practice.
References
1. Spaner SJ, Warnock GL.A brief history of endoscopy, laparoscopy, and laparoscopic surgery.
J Laparoendosc Adv Surg Tech A. 1997;7:369–73.
2. Kroh M, Chalikonda S, editors. Essentials of robotic surgery. Cham: Springer; 2015. https://
doi.org/10.1007/978-3-319-09564-6.
3. Su L, editor. Atlas of robotic urologic surgery. Cham: Springer; 2017. https://doi.
org/10.1007/978-3-319-45060-5.
4. van’t Hullenaar CDP, Bos P, Broeders IAMJ. Ergonomic assessment of the rst assistant
during robot-assisted surgery. J Robot Surg. 2019;13(2):283–8. https://doi.org/10.1007/
s11701-018-0851-0.
5. Waite KE, Herman MA, Doyle PJ.Comparison of robotic versus laparoscopic transabdomi-
nal preperitoneal (TAPP) inguinal hernia repair. J Robot Surg. 2016;10:239–44. https://doi.
org/10.1007/s11701-016-0580-1.
6. Shah J, Vyas A, Vyas D.The history of robotics in surgical specialties. Am J Robot Surg.
2015;1:12–20. https://doi.org/10.1166/ajrs.2014.1006.
7. Altieri M, Yang J, Xu J, Talamini M, Pryor A, Telem D.Outcomes following robotic ventral
hernia repair: A study of 21, 565 patients in the state of NewYork. Surg Endosc Other Interv
Tech. 2016;30:S244.
8. Horne CM, Prabhu AS.Minimally invasive approaches to inguinal hernias. Surg Clin North
Am. 2018;98:637–49. https://doi.org/10.1016/j.suc.2018.02.008.
9. Charles EJ, Mehaffey JH, Tache-Leon CA, Hallowell PT, Sawyer RG, Yang Z.Inguinal her-
nia repair: is there a benet to using the robot? Surg Endosc. 2017;32:2131–6. https://doi.
org/10.1007/s00464-017-5911-4.
10. Dickens RGE, Amico AGLD, Rabaza CRJ.Open versus robotic - assisted transabdominal
preperitoneal (R- TAPP ) inguinal hernia repair: a multicenter matched analysis of clinical
outcomes. Hernia. 2018;22(5):827–36. https://doi.org/10.1007/s10029-018-1769-1.
11. Trevisonno M, Kaneva P, Watanabe Y, Fried GM, Feldman LS, Lebedeva E, etal. A survey of
general surgeons regarding laparoscopic inguinal hernia repair: practice patterns, barriers, and
educational needs. Hernia. 2015;19:719–24. https://doi.org/10.1007/s10029-014-1287-8.
12. Thiels CA, Holst KA, Ubl DS, McKenzie TJ, Zielinski MD, Farley DR, etal. Gender dispari-
ties in the utilization of laparoscopic groin hernia repair. J Surg Res. 2017;210:59–68. https://
doi.org/10.1016/j.jss.2016.10.028.
13. Belyansky I, Reza Zahiri H, Sanford Z, Weltz AS, Park A.Early operative outcomes of endo-
scopic (eTEP access) robotic-assisted retromuscular abdominal wall hernia repair. Hernia.
2018;22(5):837–47. https://doi.org/10.1007/s10029-018-1795-z.
14. Ross H, Lee SW, Champagne BJ, Pigazzi A, Rivadeneira DE, editors. Robotic approaches to
colorectal surgery. Cham: Springer; 2015. https://doi.org/10.1007/978-3-319-09120-4.
15. Muysoms F, Van Cleven S, Kyle-Leinhase I, Ballecer C, Ramaswamy A.Robotic-assisted
laparoscopic groin hernia repair: observational case-control study on the operative time
during the learning curve. Surg Endosc. 2018;32(12):4850–9. https://doi.org/10.1007/
s00464-018-6236-7.