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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
Routine Robotic Inguinal Hernia Repair
JosephDux, LoicTchokouani, EricaD.Kane,
andBrianP.Jacob
8.1 Introduction
Performing inguinal hernia repairs via robotic technique has become more popular
since 2013. Many debates have coincided with this growth over the value proposition of using robotic technology to perform a routine operation which already holds
a standard of fast recovery and optimized outcomes. The main argument against the
use of robotic technology in this setting is the concern of additional expense without
the improvement of outcomes compared to its laparoscopic counterpart.
Compared to open inguinal hernia repairs, robotics can afford patients the same
minimally invasive benets as laparoscopy. Advantages of a robotic approach to a
transabdominal preperitoneal (TAPP) hernia repair over laparoscopic TAPP include a
steadier camera and the ability to utilize instruments that have seven degrees of freedom
and enhanced ergonomics. Current literature has supported these benets [1], though
some of the publications are limited by author bias. At this time, the use of robotics
remains slightly more expensive than laparoscopy in many centers [2]; though, some
centers have been able to make both platforms cost neutral [3]. The robotic approach
does remain more expensive than open. Long term recurrence rates and chronic pain
rates are yet to be determined for robotic transabdominal preperitoneal (TAPP) hernia repair, but a randomized trial comparing robotic versus laparoscopic TAPP hernia
repair is underway. The results of this study will not be available until after 2020.
8
J. Dux · L. Tchokouani
Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
E. D. Kane
Department of Anesthesia, Perioperative, and Pain Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
B. P. Jacob (
Laparoscopic Surgical Center of NewYork, Icahn School of Medicine at Mount Sinai,
New York, NY, USA
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_8
*)
177
178
J. Dux et al.
The technique discussed in this chapter is only for robotic TAPP.While there are
benets to performing laparoscopic or robotic total extraperitoneal (TEP) inguinal
hernia, that description is beyond the scope of this chapter.
8.2 Patient Selection
Patient selection for robotic inguinal hernia repair is similar to that of laparoscopic repairs. The patient must be able to tolerate general anesthesia and abdominal insufation. The surgery can be performed on most body mass index up to
approximately 45. Once a patient is morbidly obese, it is always best to recommend weight loss prior to performing a robotic inguinal hernia repair, as obesity
is directly related to an increased recurrence rate [4]. Smoking cessation of a
minimum of 3–4weeks prior to surgery is strongly advised. Ongoing smoking is
not an absolute contraindication; however, it predisposes the patient to increased
adverse events post-operatively.
Previous inguinal hernia surgery should be explicitly solicited from the
patient, as well as their previous operative reports. In the case of a re-operation,
the surgeon must become familiar with the type of previous repair, indication for
repair, and type of mesh used. Patients who have undergone prior open repairs
can safely be re-operated on robotically. For those patients who have undergone
prior laparoscopic or robotic repairs, the surgeon should consider performing
these with an open technique. This said, if the surgeon is experienced with re-do
hernia repairs in the preperitoneal plane, he or she may consider approaching
these robotically.
Because of the location of the preperitoneal dissection, the surgeon should also
be specically aware of any prior prostate surgery. There is a real risk of bladder
injury when performing an adequate medial dissection when freeing up the pubic
symphysis and Cooper’s ligament. As an experienced hernia surgeon, I prefer to do
these via the Lichtenstein (open) approach; nevertheless, performing the robotic
TAPP in a patient with previous prostatectomy is still feasible in experienced hands.
Of note, all post-prostatectomy patients should have a foley catheter placed before
the surgery.
Another pre-operative concern are patients with large inguinal scrotal hernias,
which are generally better repaired by an open technique with a drain in the scrotum to help minimize seroma. While not a contraindication for the robot, the risk
of recurrence, hematoma, and seroma may be elevated in robotic TAPP for giant
inguinal scrotal hernias. Furthermore, aggressive reduction of hernia contents can
increase risk of injury.
Lower midline scars are also not a contraindication to performing robotic TAPP,
but the surgeon must be aware that adhesiolysis may be required in order to safely
perform the repair. Thus careful port placement is required to not cause injury.
8 Routine Robotic Inguinal Hernia Repair
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8.3 Surgical Technique
8.3.1 Patient Set-Up andTrocar Placement
After induction of general anesthesia and endotracheal intubation, the patient is
placed in the supine position with both arms tucked and padded at the patient’s
sides. The abdomen is prepped and draped in usual sterile fashion. Our routine is to
start with a 5mm Optiview entry using a 5mm Optiview trocar and a zero degree
5mm laparoscope. Once insufated, we then insert the three 8mm robotic trocars
assuming one has access to an Xi DaVinci system, otherwise a 12mm trocar is
inserted for the camera, and two 8mm trocars are inserted for the instruments when
working on an Si system. Alternatively, access with a Veress needle maybe be established through an 8mm supraumbilical incision if the surgeon is more comfortable
with this technique.
Three 8mm trocars are placed under direct vision: one in the supraumbilical
incision, one in the right lateral abdomen, and one in the left lateral abdomen. The
horizontal distance between each trocar is at least 8cm in the same horizontal plane.
Modications to trocar placement may be made based on patient habitus; patients
with less width may require less horizontal distance between trocars as the lateral
trocars may be impeded by the anterior superior iliac spines. The supraumbilical
port is designated as the camera port and the lateral ports as the working ports. The
patient is placed in Trendelenburg position to limit obstruction of view by intraabdominal contents. A zero-degree or a 30-degree camera can be used per surgeon
preference. For the majority of cases, we prefer a zero degree camera as it allows
better viewing for the creation and closure of the peritoneal ap, as well as adequate
dissection of the retroperitoneum. As described below, it is imperative to completely
reduce the peritoneal ap to the level of the iliac vessels to decrease the risk of mesh
folding.
For efciency, the anticipated sutures and mesh may be placed intra-abdominally
before docking of the robot. We elect to insert the sutures and secure them to the
abdominal wall away from the dissection eld but in vision prior to docking and to
insert the mesh at the time of mesh placement.
8.3.2 Dissection
After docking, we inspect both groins and decide whether the procedure will be a
unilateral or bilateral repair. The symptomatic side should be approached rst. A
curvilinear peritoneal incision is performed with monopolar curved scissors between
the anterior superior iliac spine (palpated by the assistant) and the medial umbilical
ligament. This will allow sufcient space for placement of an appropriately sized
mesh. Using Prograsp™ Forceps and the monopolar scissors, the peritoneal ap is
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Fig. 8.1 Creation of the
peritoneal ap
J. Dux et al.
carefully created (Fig.8.1). Ideally, the plane between the parietal peritoneum and
the transversalis fascia is developed. This ap is usually started at the level of the
ipsilateral anterior superior iliac spine laterally and carried medially to and including the ipsilateral umbilical ligament.
It is important to properly obtain the Critical View of the Myopectineal Orice
(CV of the MPO). The stepwise approach to obtain this view is as follows:
1. Identify and dissect the pubic tubercle across the midline and Cooper’s ligament
(CL). For large, direct hernias, extend the dissection to the contralateral CL.
2. Rule out a direct hernia. Remove any fat in the Hesselbach triangle to fully
investigate.
3. Dissect at least 2cm between CL and the bladder to facilitate at placement of
the medial and inferior edge of mesh toward the space of Retzius, thereby avoid-
ing mesh displacement caused by bladder distention.
4. Dissect between CL and the iliac vein to identify the femoral orice and rule out
a femoral hernia.
5. Dissect the indirect sac and peritoneum sufciently to parietalize the cord’s ele-
ments (Fig.8.2).
This step is often not completed, especially in a small surgical eld. To ensure
compliance with this requirement, continue to dissect until the cord’s elements
lie at. Then, visualize the psoas muscle and iliac vessels, pull the sac and peritoneum upward without triggering movement of the cord structures, and dissect
between the cord structures to avoid missing a tail of the sac.
6. Identify and reduce cord lipomas (which may appear small and unimportant
until reduced). They usually lie lateral to the cord’s elements, they should not be
confused with lymph nodes (which are generally spared). Most lipomas do not
require removal, but should be placed above the mesh to help prevent mesh rolling upward.
7. Dissect peritoneum lateral to the cord structures beyond the anterior superior
iliac spine (ASIS), with careful attention to make sure the edge of the peritoneal
ap is dissected below the level of the iliacs, and below the inferior most edge of
the mesh’s inferior border (Fig.8.3 yellow arrows).
8 Routine Robotic Inguinal Hernia Repair
Fig. 8.2 Dissection of the
indirect sac and exposure
of the cord structures
Fig. 8.3 Yellow arrows
indicate the lower level of
dissection of the ap
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8. Provide mesh coverage and ensure that mesh and mechanical xation are placed
well above an imaginary inter-ASIS line and any defects, thereby avoiding recurrence and nerve injury, especially to the ilioinguinal nerve.
8.3.3 Mesh Placement
Once the CV of the MPO is established, the mesh can be placed (Fig.8.4, cvmpo).
Mesh size should be at least 15cm×10cm, although a larger piece of mesh is
sometimes required to cover the MPO.It is our practice to use a 12 cm × 16 cm
sized mesh (Fig.8.5).
Preferably, choose mesh that adapts to the contour of the space and the cord.
It should not have undue memory. Place it without creases or folds. Splitting the
mesh should be avoided. Ensure that the lateroinferior corner lies deep against
the wall. The mesh should adequately cover the femoral space, direct space, and
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Fig. 8.4 Critical view of
the myopectineal orice
(cympo)
Fig. 8.5 Large mesh will
be secured to Cooper’s
ligament
J. Dux et al.
myopectineal orice. We routinely secure the mesh to at least Cooper’s or to the
tubercle (Fig.8.6 yellow arrow), with one xation spot, and then we will occasionally add a second xation point.
If one chooses to x the mesh, sutures may be placed medially on the abdomi-
nal wall at Cooper’s Ligament, avoiding the epigastric vessels, and laterally and
above the internal ring. The latter two xation points should be above an imaginary
inter- ASIS line to avoid injury to vascular and nervous structures, as previously
mentioned.
8.3.4 Peritoneal Closure
We close the peritoneal ap using a 2–0 or 3–0 slowly absorbable barbed suture,
approximately 15cm in length (eg. V-Loc™) (Fig.8.7).
8 Routine Robotic Inguinal Hernia Repair
Fig. 8.6 Fixation at
Cooper’s ligament plus
another site medial to the
epigastric vessels
Fig. 8.7 Flap closure
(yellow suture) with
barbed suture
183
The suture is run in one direction using a Mega Suture Cut Needle. Once closed,
the robot arms are undocked, the trocars are removed under direct vision, and the
abdomen is desufated.
It is important to desufate, then reinsufate, to conrm the mesh won’t shift
dramatically. This extra step takes a few seconds and is well worth it. Some surgeons aspirate the pneumo out of the preperitoneal space, which is another way to
assure the mesh will not clamshell.
The fascia of the trocar sites are optionally closed with gure-of-eight sutures
with 0-Vicryl, followed 4–0 Monocryl for the skin.
8.4 Recovery
The surgery is usually carried out in an ambulatory setting. The patient is monitored for a few hours in the recovery room with no ambulatory restrictions. Once
patients have voided, pain is controlled, and no other issues are present, they can
be discharged. Postoperative urinary retention (POUR) is reported in 1.25–8% of
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cases [5–7]. Minimizing POUR can be achieved by preoperative voiding, limiting
administration of IV uids, avoiding the use of tacks if possible, and minimizing
opioid use. Other risk factors include male gender, age over 50, and benign prostatic
hyperplasia [8]. Postoperative incisional pain is usually mild and lasts for several
days. Males also may experience transient testicular pain or discomfort. Most pain
can be managed with over-the-counter pain medications such as Acetaminophen or
a non- steroidal anti-inammatory. The patient may go back to their normal routine
as tolerated, with no restriction on heavy lifting. The incidence for ileus after the
surgery is not dened, but it is rare and usually self-limited. Routine follow up is
1–2weeks after the surgery, with attention to wound healing and pain management.
Another clinic visit is scheduled 3–6months later, with no requirement for further
routine follow-up visits.
J. Dux et al.
8.5 Adverse Events
The overall complication rate is reported as 7–21%, with most of complications
being grade 1–2 on the Clavien Dindo Scale. The most common complications are
urinary retention (1.25–8%), seroma (0.2–2.5%), hematoma (0.7–3.8%), and surgical site infection (0.2–3%) [1, 2, 5–7, 9, 10].
8.5.1 Small Bowel Obstruction
Small bowel obstruction (SBO), as opposed to ileus mentioned before, may be
a serious complication. Previously, it was attributed to migration of the intestine
beneath the peritoneal ap [11]. With the adoption of sutured peritoneal ap closure
the risk is minimized but still exists. Multiple reports exist of internal hernia occurring due to peritoneal ap defects formed by widely separated tacking or stapling
[12, 13]. This scenario tends to cause early post-operative SBO, at an average of
8days, compared to obstruction related to adhesive disease, which occurs around
25days. There have been case reports of exposed peritoneal ap barbed sutures as
points of obstruction as well as obstructions secondary to trocar site hernia (usually Richter’s hernia)[14, 15]. Any complaint suggestive of SBO should be taken
seriously and worked up with imaging as indicated. When diagnosed early, laparoscopic investigation can be performed safely with resolution of the obstruction.
8.5.2 Recurrence
Hernia recurrence can happen at any time after surgery. Early recurrence symptoms
can be the result of a retained cord lipoma that was not dissected properly during
the surgery [16]. Another common cause is due to “clam shelling of the mesh”
from inadequate dissection of the preperitoneal space or placement of too large a
piece of mesh. True recurrence can be direct or indirect and can result from mesh
8 Routine Robotic Inguinal Hernia Repair
migration or suboptimal repair; recently reported at a rate of 0.6–4% in two recent
publications [6, 7] Timing and indication for surgical repair is based on the patient
symptoms, complaints, and surgeon evaluation.
185
8.5.3 Chronic Pain
The incidence of postoperative inguinodynia is low, but can be debilitating and cannot be ignored. A detailed history must be taken and a complete physical exam
should be performed. Additionally, pain mapping is a very useful tool in investigating chronic groin pain. At times, cross sectional imaging may be necessary in elucidating the etiology of the pain. A stepwise approach to pain relief includes physical
therapy, anesthetic injections, and nerve ablations. Some refractory cases, however,
warrant exploration and possibly mesh removal. Surgical mesh extraction can prove
to be very successful with very specic patient selection [17].
8.6 Controversies
8.6.1 Direct Hernia Defect Closure
There are a few currently debated topics in robotic hernia repair. One of these
includes direct hernia defect closure. With use of the robotic platform, the surgeon
is able to close the defect with excellent vision. A few studies have demonstrated
a possible decrease in seroma occurrence during laparoscopic repair; however, no
clear benet exists [18] Furthermore, suturing the direct defect adds a potential risk
of chronic pain, bleeding, and damage to surrounding structures [19].
8.6.2 Mesh Fixation
The choice of mesh xation differs between surgeons. Some choose to use tackers or sutures to secure mesh and ensure adequate mesh overlap (sutures are more
commonly employed in robotic repair due to technical feasibility). Others opt to
use brin glue as their xating agent, self-xating mesh, or no additional means
of xation, avoiding securing agents all together. In reality, any method is feasible
and appropriate depending on surgeon preference and expertise. One must also
take into account the potential risks of each technique and the patients’ primary
complaint [20].
8.6.3 Non-Mesh Robotic TAPP Repairs
An evolving concept is non-mesh robotic TAPP repairs, which has become feasible
due to the increased visualization and ne articulating capabilities of the robot. With
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J. Dux et al.
the known complications of chronic pain, the utility of non-mesh repairs is being
explored. Rates of chronic pain and recurrence after a non-mesh robotic repair has
yet to be determined. As of the writing of this chapter, non-mesh robotic inguinal
hernia repairs remains experimental and should best be performed as part of a long
term study.
8.7 Conclusion
Robotic TAPP hernia repair is safe and feasible in the hands of an experienced
surgeon. It is applicable to a variety of scenarios including previous hernia repairs
(both laparoscopic and open), large scrotal hernias, previous prostatectomy, and
even feasible in patients with midline scars. Despite evidence for increased operative cost, outcomes are improved compared to open techniques and may be equivalent compared to the laparoscopic TAPP technique. Trocar site hernias remain a
unique risk compared to laparoscopy, given the procedure utilizes three 8mm trocars. Surgeons early in their learning curve may have higher recurrence rates and
potential complications compared to surgeons who are more experienced in this
technique. As the utility of the robot platform continues to evolve, outcomes will
continue to improve and options for inguinal hernia repair will expand. Further
studies should be performed to investigate outcomes comparing the different hernia
repair platforms.
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