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8 Routine Robotic Inguinal Hernia Repair
9. 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.
10. Dickens EO, Kolachalam R, Gonzalez A, Richardson C, D’Amico L, Rabaza J, Gamagami
R. Does robotic-assisted transabdominal preperitoneal (R-TAPP) hernia repair facilitate
contralateral investigation and repair without compromising patient morbidity? https://doi.
org/10.1007/s11701-018-0815-4.
11. Gopal SV, Warrier A.Recurrence after groin hernia repair-revisited. Int J Surg. 2013;11:374–7.
12. McKay R. Preperitoneal herniation and bowel obstruction post laparoscopic inguinal hernia
repair: Case report and review of the literature. Hernia. 2008;12:535–7.
13. Agresta F, Mazzarolo G, Bedin N.Incarcerated internal hernia of the small intestine through
a re-Approximated peritoneum after a trans-abdominal pre-Peritoneal procedure-Apropos of
two cases: Review of the literature. Hernia. 2011;15:347–50.
14. Köhler G, Mayer F, Lechner M, Bittner R.Small bowel obstruction after TAPP repair caused
by a self-anchoring barbed suture device for peritoneal closure: case report and review of the
literature. Hernia. 2015;19:389–94.
15. Fitzgerald HL, Orenstein SB, Novitsky YW.Small bowel obstruction owing to displaced spiral
tack after laparoscopic TAPP inguinal hernia repair. Surg Laparosc Endosc Percutan Tech.
2010; https://doi.org/10.1097/SLE.0b013e3181dfbc05.
16. Gersin KS, Heniford BT, Garcia-Ruiz A, Ponsky JL.Missed lipoma of the spermatic cord. A pit-
fall of transabdominal preperitoneal laparoscopic hernia repair. Surg Endosc. 1999;13:585–7.
17. Moreno-Egea A.Surgical management of postoperative chronic inguinodynia by laparoscopic
transabdominal preperitoneal approach. Surg Endosc Other Interv Tech. 2016;30:5222–7.
18. Li J, Zhang W.Closure of a direct inguinal hernia defect in laparoscopic repair with barbed
suture: a simple method to prevent seroma formation? Surg Endosc Other Interv Tech.
2018;32:1082–6.
19. Kane ED, Leduc M, Schlosser K, Parentela N, Wilson D, Romanelli JR.Comparison of perito-
neal closure versus non-closure in laparoscopic trans-abdominal preperitoneal inguinal hernia
repair with coated mesh. Surg Endosc. 2018;32:627–37.
20. Mayer F, Niebuhr H, Lechner M, Dinnewitzer A, Köhler G, Hukauf M, Fortelny RH, Bittner
R, Köckerling F.When is mesh xation in TAPP-repair of primary inguinal hernia repair
necessary? The register-based analysis of 11,230 cases. Surg Endosc Other Interv Tech.
2016;30:4363–71.
187
Robotic Repair ofGiant Inguinal Hernias
DavidS.Edelman
9.1 Introduction
Giant inguinal hernias are infrequent in developed countries, but are seen enough
times that surgeons who focus their practice on the repair of hernias need to be
familiar with the planning, performance, correction and treatment of this problem.
In situations where access to surgical care is limited, inguinal hernias that extend
into the scrotum with extension into a sac down to the mid-thigh, knee or further
are more frequently encountered. The surgical management is more challenging in
these situations. Having access to a broad variety of pre-operative, peri-operative
and post-operative assistance cannot be overstressed. A straight forward laparoscopic repair can turn into a complicated operation that every hernia surgeon should
avoid but be ready to act upon. This chapter will try to cover as many possible issues
associated with the robotic repair of giant inguinal (scrotal) hernias to better prepare
the surgeon and the entire team involved in the care of this problem.
9
9.2 History
To review the entire history of inguinal hernia repair is beyond the scope of this
chapter. To not mention some of the icons associated with the progress of inguinal hernia surgery would be an oversight. In 1884, Bassini described the extraperitoneal approach of hernia repair and reconstruction of the inguinal oor.
Theodor Bilroth in 1890 opined that mesh was the ideal material to close a hernia
defect but his meshes failed due to infection, rejection and recurrence. In the mid
1950’s, Marlex (polyolen) and polypropylene were popularized by Francis Usher
and Pierre Frauchard, separately. It was 30 years later before Stoppa and Rives
D. S. Edelman (*)
Doctor’s Hospital, Baptist Health South Florida, Miami, FL, USA
e-mail: ETSsurgeon@sweatstop.com
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_9
189
190
D. S. Edelman
introduced the concept of a giant prosthetic mesh reinforcement of the visceral sac
using Mersilene (dacron polyester). There is an excellent review of the Stoppa groin
hernia repair in the 1998 Surgical Clinics of North America by George E.Wantz
that should be reviewed by any present day hernia surgeon before tackling the preperitoneal approach to inguinal hernias or more importantly, giant scrotal hernias.
Most all of the laparoscopic methods follow the tenets set forth by these landmark
papers proposing using a mesh not less than 10×10cm in size but approaching a
12×15cm sized mesh, if possible. The discussion goes on to point out the importance of an anatomic, suture-less and tension-free repair as to result in an effective
inguinal hernia repair.
9.3 Pre-operative Preparation
The re-introduction of herniated bowel back into the abdominal cavity due to a
large, scrotal hernia will alter many aspects of a patient’s cardio-pulmonary and
vascular systems. The diaphragm will be pushed upwards and alter lung function
or decrease venous return to the heart, change portal ow to the liver or alter blood
ow in and away from the kidneys. The increase in abdominal pressure can cause
changes in the abdominal wall and can cause a breakdown of the skin which can
lead to wound dehiscence and hernia recurrence. In addition, many patients with
scrotal hernias are older and have associated cardiovascular or respiratory diseases.
Placing them under a general anesthesia will affect their peri-operative and postoperative course. Patients may need to be maintained on a ventilator after surgery.
Informing the patient of these possibilities can help them participate in their preand postoperative care. Lastly, the risk of colon cancer is rising in many parts of the
world and patients over 45 or who have a family history of colon cancer cannot be
overlooked or avoided in the preoperative work up; in other words a colonoscopy,
barium enema or CT enterography may be needed before surgery.
The surgeon who is treating this type of hernia will need to coordinate numerous
pre-operative evaluations. A concise, complete history and physical exam with clear
documentation of these ndings is the rst step. There is a need to include medications, allergies, family and social history to fully understand all of the patient’s
problems. Baseline blood work must be done which should include a complete
blood count (CBC with platelets), comprehensive metabolic panel (CMP-25: electrolytes, liver function, renal function and protein), coagulation prole (PT, PTT) as
well as a chest X-ray and an electrocardiogram (EKG). Routine cardiology and pulmonary consultation are frequently necessary. If an abnormality with the patient’s
renal function is noted on the chemistry panel, one should consider a pre-operative
nephrology consultation to allow the kidney specialist an opportunity to become
familiar with this patient before surgery and make any necessary changes in the diet
and uid balance. The knowledge that forcing the intestine back into the abdominal
cavity can decrease blood ow from the lower extremities and pelvis should alert
the surgeon to the risk of deep vein thrombosis. Placement of an IVC lter should
be considered in such situations. Some of the percutaneous lters can be removed
9 Robotic Repair ofGiant Inguinal Hernias
191
in the post-operative period and this can be discussed with the medical consultants
prior to hernia repair. Gastrointestinal (GI) consultation may be needed for assistance in the determination and completion of needed colonic endoscopic screening
and gastro-esophageal endoscopy. A barium small bowel evaluation or CT scan
with contrast may be necessary if there is any question about the contents within
the hernia sac (bowel and/or urinary bladder) and how the surgery may alter or deal
with them.
Lastly, urology and plastic surgery evaluation is commonly necessary to assist
with the operation. A massive scrotum may also cause the penis to be retracted and
make it difcult to nd it or access the urinary bladder during an operative procedure. It is not uncommon to need a cystoscopy in order to place a urinary catheter at
the start of surgery. An evaluation by the urologist prior to the day of surgery may
alleviate this disconcerting situation. Additionally, the urologist will have insight
into the proper reconstruction of the scrotum at the conclusion of the operation.
Most importantly, the spermatic cord and testicle may be involved in the hernia sac
to a point of being seriously injured during this type of hernia repair. The availability of the urologist at the time of the scrotal hernia repair could be benecial during
and after surgery if there is a question of testiclicular viability, as well.
Depending on the size of the scrotum, a scrotoplasty may be necessary. Surgeon
comfort with this along with an urologist may sufce, but if there is any question of
the need or extent of this problem when the scrotum is massive, the assistance of a
plastic surgeon is welcomed.
The ability to reduce the hernia into the abdominal cavity prior to surgery can-
not be overemphasized. Type 1 giant, scrotal hernias which may reach down to the
mid- thigh and are reducible, usually can be approached without many alterations in
pre- operative planning or surgical care. If the hernia reaches below the mid-thigh
to the knee, a Type 2 giant hernia, or below the knee, a Type 3 giant hernia, reduc-
tion of the hernia contents becomes unlikely and increased intra-abdominal pressure and loss of abdominal domain are issues that must be considered. Type 2 and
Type 3 hernias are most likely better approached with open hernioplasty and scrotal
reduction procedures. However, once the open procedure is completed, a robotic,
laparoscopic re-inforcement of the posterior inguinal oor may be a consideration
is selected instances.
9.4 Operative Techniques
Progressive pneumoperitoneum is a technique that, when combined with Botulinum
Toxin A (Botox), can increase the abdominal wall musculature length and act as a
chemical component separation. It should be started 5–6weeks prior to surgery.
Using ultrasonic or CT scan guidance, an Interventional Radiologist should inject
100–300units of Botox on each side of the abdominal wall. Stated in another way,
50units of Botox can be injected into each of the Internal Oblique, External Oblique
and Transverse abdominis muscles in the anterior axillary line on both the right and
left abdominal wall. This procedure is tolerated very well under conscious sedation.
192
D. S. Edelman
One of the main disadvantages to the use of Botox is deep muscle injury and muscle
weakness. Caution should be exercised in patients with chronic respiratory dysfunction as there have been instances of prolonged postoperative ventilation and the
need for abdominal musculature recruitment for ventilation. Inactivation of the lateral abdominal muscles may make coughing, sneezing and deep breathing difcult.
The use of an incentive spirometer device can assist the patient during this time and
is helpful to increase breathing capacity and decrease postoperative compression
atelectasis.
The effects of abdominal wall elongation from Botox will start about 2weeks
after instillation which is when Progressive Pneumoperitoneum (if needed) should
be initiated. A percutaneous or laparoscopic assisted peritoneal dialysis catheter (or
Hickman Catheter) can be placed at the same time as the Botox injection allowing 2
weeks for healing. For the initial pneumoperitoneum, it is done once or twice a day
for the rst week and weekly thereafter for a total of 4weeks. Patients may need
to be hospitalized or monitored as an outpatient to assess toleration of the progressive pneumoperitoneum. Usually within a week, the patient’s abdominal wall will
expand to accommodate the one liter of ambient air that is injected. Alternatively,
some centers will introduce the air every 2–3days in a clinic situation after the
initial introduction is completed. During the course of progressive pneumoperitoneum, the hernia contents may be able to be reduced. If this occurs, the repair of the
inguinal hernia may proceed without he need for open surgery and/or a scrotoplasty.
Bowel prep and colonoscopy can be considered a day or two prior to operative
repair of the inguinal hernia.
Complications from progressive pneumoperitoneum are not common but do
occur. Adhesions from previous surgery may be a reason for failure to establishment
of the pneumoperitoneum. Epigastric pain and the sensation of gastric fullness is
not uncommon at the time the establishment of the pneumoperitoneum. Organ rupture, bowel injury, hematoma formation, air emboli and subcutaneous emphysema
are a few of the uncommon complications that can occur from this procedure.
Performance of a robotic inguinal hernia should be the same as described in an
earlier chapter of this book. There may need to be modications to the techniques
which will include steep Trendelenburg position, placement of the cannulas higher
and above the umbilicus than one would use for a more straight forward robotic
inguinal hernia and the use of a 4th, accessory cannula for use of a grasper or fan
retractor to hold back the intestinal contents or to introduce mesh. This fourth port,
usually an 8mm cannula, may be as large as a 12mm cannula and the surgeon
should select an appropriate cannula. Usually, the 12mm cannula site may need
to be closed at the completion of the operation. I do not routinely close the 8mm
cannula sites except when it is located at the umbilicus or within an abdominal wall
hernia.
The patient should be intubated under general endotracheal anesthesia and
supine on the operating room table. The arms are usually tucked but may have to
be on arm boards if the patient is too large. With sequential compression devices
(SCD’s) on the calves, the bed should be put into as steep a Trendelenburg position
that can be tolerated. An initial effort at hernia reduction may be attempted at this
9 Robotic Repair ofGiant Inguinal Hernias
193
time. The cautery return pad is placed per hospital protocol with the cautery settings selected as low as possible to prevent inadvertent arcing of the current to the
intestines or other abdominal organs. The prepping and draping should be done very
widely to include the scrotum. A urinary drainage catheter should be considered as
many of these procedures are longer than 90min. As mentioned earlier, if the penis
is retracted, an urologist may be needed to place the catheter using cystoscopic
guidance.
Selection of the cannula sites should be far enough away from the anticipated
arcuate ligament and may be 6–8cm above the umbilicus. Accessory cannulas on
either side of the midline camera port are placed about 8–10cm laterally. If a fourth
port is deemed necessary, it can be placed in the right lower abdomen above and
away from the anterior superior iliac spine. Either a 0 ° or 30° laparoscope will be
selected depending on the comfort of the surgeon but I generally use a 0° laparoscope. Once the site is selected for the camera, I recommend on open approach into
the abdominal cavity but the operative surgeon can use a Veress needle technique or
an optical trocar. I will set the insufator to a pressure under 15mmHg and use the
lowest possible setting due to the head-down position and the ability of anesthesia
to adequately ventilate the patient. A large grasper is used in the left hand, but it is
not uncommon for me to use a regular, robotic needle holder instead. The right hand
instrument should have cautery ability and although I use the cautery hook (set at
20watts coagulating current), it is not unusual for many surgeons to use cautery
scissors or bipolar graspers instead.
All of the intestine must be reduced from the hernia sac before going any addi-
tional dissection occurs. If the bowel is adherent to the inside the hernia sac, it will
be extremely difcult to reduce it thereby increasing the risk of an injury to the
bowel. The assistant may need to push on the scrotum at this point while the surgeon
gently retracts and pulls on the mesentery of the bowel to allow the intestines to
be reduced into the abdominal cavity. It is advisable to set a timer and not labor at
this point for more than 10–15min. If the bowel cannot be reduced, consideration
should be made to temporarily stop laparoscopy and open the inguinal region with
a transverse, inguinal or lower midline incision. In this instance, it may be easier to
open, reduce the hernia, do a simple Bassini closure of the inguinal oor prior to
placing a large piece of mesh behind the hernia repair.
Once the intestine and urinary bladder are reduced, the peritoneum can be opened
lateral to the umbilical ligament at the arcuate ligament. The peritoneal dissection is
carried further laterally to the anterior axillary line (about 8–10cm). The epigastric
vessels need to be identied at this point and the dissection carried down inferiorly,
along these vessels to their takeoff from the femoral vessels. Medial to the epigastric
vessel origin, the pubic bone is identied and dissection is carried out below and
past the midline on the side of the hernia. Lateral to the epigastric vessels, any indirect hernia sac or cord lipoma are meticulously removed from the spermatic cord or
round ligament with the understanding that the femoral artery and vein are directly
below. Once the iliopubic tract is identied, the hernia sac can be followed down
along the spermatic cord or round ligament and dissected free. I do not transect
the round ligament, but some surgeons do. It is wise to assess the viability of the
194
D. S. Edelman
testicle at this time since large scrotal hernias stretch the spermatic cord structures.
The release of the tension on the spermatic cord can precipitate thrombosis of the
spermatic vasculature. Intra-operative ultrasound, if available, can be used if there
is question of vascular integrity.
If you have been successful up to this point, repair of the hernia can proceed.
Most times, the hernia defect is quite large and the additional placement of a suture
to reconstruct and imbricate the transversalis fascia to act as a “back-stop” is recommended. There are many ways to re-create a tension-free inguinal oor using
robotic needle holders in both hands (one may be a suture-cutter). For a direct hernia, I will use a 0 braided polyester suture and either do a purse string stitch tying
it to itself or a running suture by making a simple knot medially, then running the
suture lateral to the epigastric vessels and back to where I started and nally tying
an intra- corporeal knot. Alternatively, a “Barbed” suture (V-loc or Stratax) of 2–0
or 0 size, either absorbable or non-absorbable can be run by suturing the sac to itself
or the posterior pubic bone. For an indirect hernia, I start laterally with interrupted
gure 8 sutures of 0 braided polyester suture but this could be used as a running
suture. If this is chosen the surgeon should look cautiously for the nerves at the
internal ring and leave adequate spacing for the spermatic cord at the internal ring
and not place undo tension on the closure.
Finally, I will introduce a ruler and measure the operative site to use the larg-
est piece of soft polypropylene mesh that I can safely place. From Stoppa’s and
Wantz’s work, a 12×15cm or larger piece of mesh is ideal. Selection of mesh is
the surgeon’s preference and there are many types available that work well. Once
the mesh is rolled up into a “cigarette” shape, it can pass through an 8mm cannula
or the accessory 12mm cannula without much difculty. Using two needle holders
or a grasper and a needle holder, the mesh is opened completely and placed behind
the hernia repair below the pubic bone, lateral to the midline and as far lateral as
possible to the edge of the arcuate ligament onto the cord structures and iliofemoral
vessels. I prefer to spray the mesh with brin sealant, but many surgeons will place a
suture or two to prevent the mesh from moving or have the surgical assistant place a
few tacks. Some surgeons will use self-adhering mesh for this part of the procedure.
I will close the peritoneum with a running 3–0 absorbable, barbed suture. If a
12mm cannula was used, a port closure device or a simple suture closure should be
made. I will close the midline “umbilical” port site, as well. Skin closure is a surgeon’s preference, but I have used an absorbable subcuticular skin closure followed
by tissue skin adhesive for many years.
9.5 Post-operative Issues andRecommendations
Intensive care unit (ICU), a step-down “progressive care unit” (PCU) or routine
oor care should be discussed with the anesthesiologist or a pulmonologist before
the patient leaves the Post Anesthesia Care Unit (PACU). I will leave the Foley
9 Robotic Repair ofGiant Inguinal Hernias
195
catheter in overnight, start prophylactic anticoagulation (if an IVC lter was not
used) and monitor the patient carefully for the rst night or two.
Complications that need to be monitored for include:
• Elevation of the hemidiaphragm with decreased pulmonary function, rapid heart
and respiratory rate;
– post-operative portable Chest X-ray and Arterial Blood Gas in the PACU
• Increased abdominal pressure leading to lower venous return and lower cardiac
output;
• Abdominal compartment syndrome and mesenteric ischemia;
– intra-abdominal hypertension is dened as a pressure over 12 mm Hg in
adults. However, if the pressure continues to rise over 20mmHg and organs
begin to fail, the syndrome has now progressed to the end stage of the highly
fatal process termed abdominal compartment syndrome- measure lactic acid
• Low urine output due to third spacing of uids from a large operative area of
dissection or Hematoma from a large dissection area;
– post-operative serum chemistries and a complete blood counts-CBC
• Small and large bowel adhesions which may have been injured by adhesiolysis
that may cause an ileus or a post-operative intestinal obstruction;
– serial plain abdominal X-ray- KUB
• Deep vein thrombosis, pulmonary emboli or pelvic venous stasis due to return of
the intestine into the abdominal cavity;
– venous sonogram of the pelvis and lower extremity
• Urinary bladder injury or an atonic bladder when the bladder is reduced out of
the hernia defect;
• Orchitis, testicular atrophy or ischemia from the manipulation or the effects of
shortening the spermatic cord;
– testicular sonogram
• Edema of the scrotum, wound ischemia or mesh infection.
9.6 Summary
Large scrotal hernias can be approached using robotic and laparoscopic techniques. Preparation is paramount to a successful repair, no matter what technique
or approach is selected. It is not considered a complication to add an open inguinal
or midline abdominal incision to the repair of these complex hernias as there are
times when the surgeon cannot determine that the open approach is safer until the
time of surgery. A careful and well thought out pre-operative approach can optimize
the operative repair. Using appropriate consultations is encouraged. Post-operative
issues develop, not infrequently, and it may be wise to consider placement of the
patient for a day or two in the Intensive Care Unit to monitor for minor problems
before they become serious issues.
196
Acknowledgments A special thanks to Charlotte Klienman and Simone Baldeon, at the Baptist
Health Library for their assistance with this chapter.
D. S. Edelman
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Pelvic Hernias
10
RicardoZugaibAbdalla andThiagoNogueiraCosta
10.1 Introduction
Pelvic hernia is diagnosed as a protrusion of anatomical contents through the
pelvic oor. The pelvic oor is a complex anatomical environment, composed
of several overlapping myopectineal tissues, joints and bones at the base of the
cavity to assist in supporting the organs of the abdomen. All this complex reference is important to remember when we are working on the reconstruction of
pelvic anatomy [1]. The pelvic defects realize some hernia types, such as, the sciatic, obturator, para-vesical and perineal hernias. The rst three are rare entities,
mostly primary hernias [2, 3]. Primary defects are congenital, because of anatomical predisposing factors. The urogenital perineal oor has a different structure
from posterior pelvic oor. Although these types of diseases are different, they
have similarities in their treatment, but without standardization, because of their
rare presentations. Perineal or secondary hernias are usually incisional hernias
following proctectomy or abdominal perineal excision (APE) [4, 5]. They account
for 1–7% of the incisional hernias, with a rare incidence [6]. APE is the surgical
treatment for patients with distal rectal cancer in whom an anterior resection (AR)
of the rectum with anastomosis cannot be performed, leaving them with a terminal colostomy and a blind-end pelvic oor. Even though it is a radical procedure,
it has a high incidence of local recurrence, due to the extended invasion those
types of cancer possess [7]. Therefore, other techniques were created to try to
get optimal oncologic results. This was how the extralevator abdominal perineal
excision (ELAPE) was created, with a larger margin of resection in the attempt to
have better oncologic outcomes. However, with the increased resection, the incidence of perineal hernia became higher, leading to the discussion of prevention
R. Z. Abdalla (*) · T. N. Costa
Department of Digestive Surgery, Hospital das Clinicas of
University of Sao Paulo Medical School, Sao Paulo, Brazil
e-mail: ricardo.abdalla@hc.fm.usp.br
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_10
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