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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
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R. Z. Abdalla and T. N. Costa
and possible treatments of this disease [8, 9]. Both can be treated either from the
abdominal cavity or from the outside, but this chapter focuses on incisional and
intra cavitary approach.
The main risk factors of the development of a perineal hernia (other than the
type of surgery performed) include: female gender (ve times more common than
men), neoadjuvant chemoradiation (very common in these types of disease), poor
nutrition, use of tobacco, wound infection and the failure to close the perineal defect
[10]. Other factors, such as, obesity and age have lower impact on hernia formation
[11]. There are no classications regarding perineal or sciatic hernias, since they are
rare; and their main treatment is not well standardized.
Symptoms range from bowel obstruction, obstipation, skin erosion, and slight
bulging in these regions. The patients can exhibit urinary problems, perineal pain or
other types of skin lesions [12]. Intractable pain must be considered as a diagnosis
of recurrent tumor. In the case of perineal hernias, most plastic surgeons can construct rotational tissue aps or primary closure, to treat them locally. Surgery from
the inside could be considered the best approach because of minimally invasive procedure principles, with less infection, decreased recovery time, and visualization of
the defect origin. This leads to better disease understanding, because there is no subcutaneous or myoaponeurotic tissue interposition. Therefore, the repair can respect
a physiologic recovery, with the help of the use of mesh [13–15]. Even though there
are a variety of procedures, the recurrence rate can still be as high as 16% [16].
Benets of the minimally invasive surgery are proven for abdominal wall defects,
however, the laparoscopic approach has only a few cases reported for this problem
due to the difculties of the deep dissection, distant adhesions, straight forward
non- articulating instruments, 2D view, difcult mesh placement and xation. The
robotic dissection is at its dawn, but working with irradiated tissue is, probably,
easier to do when compared with rigid, non-articulating laparoscopic instruments.
Robotic arm torque helps to reach more areas with less fatigue, as well as, the
relative frictionless movement can facilitate difcult dissections [17, 18]. The ideal
mesh and ideal pelvic xation of the mesh are obstacles to face with every patient,
meaning that each one must be treated with individually [19–21]. The decision varies per patient, due to their unique pathologies, with the goal of the recovery of the
whole diaphragmatic pelvis [14, 22]. With the advent of the robotic technologies,
the articulated forceps and 3D view optics, many problems can be better solved
[23]. Thus, in this chapter we present a concept-based technique of robotic treatment of the pelvic defects.
10.2 Technique
Before commencement of the procedure, the patient must be evaluated and prepared. It must be emphasized that these are mostly oncologic patients after chemotherapy and/or radiotherapy. First, a good history of symptoms and comorbidities
must be acquired from the patient. Performance status is very important, because
of the post-operative risks for complications (seroma, hematoma, post-operative
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199
a b
Fig. 10.1 (a, b) Physical exam
infection, etc.). Physical examination in performed with the patient in different positions. (Fig.10.1a, b). In order to conrm the diagnosis, a Computed Tomography
(CT) of the abdomen and pelvis should be done (Fig.10.2a, b).
When the diagnosis is made the patient must be prepared for surgery. Additional
hernia possibilities must be considered and investigated, such as parastomal hernia
or midline incisional hernia. The importance of the identication of these other
defects is to provide the team with a complete understanding of all pathologies that
need to be treated. Therefore, during the intra-abdominal view, the best repair can
be made for each case and potentially the need for more than one procedure at a
later time to repair all the hernias that are found. The robot with its longer instruments and with more freedom of movements than traditional laparoscopic instrumentation can be located on the contralateral side of the ostomy and further away
from the pelvis. This allows more possibility to determine which repair should be
done at the time of operation.
10.3 Patient Preparation andPositioning
The patient is hospitalized on the same day of the surgery. In most cases, there is no
need for bowel preparation. Once in the operating room (OR) appropriate preparation is noted in Table10.1. General anesthesia is applied with endotracheal intubation. Next, the patient receives prophylactic antibiotics and the urinary catheter as
well as the placement of peripheral lines.
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R. Z. Abdalla and T. N. Costa
Fig. 10.2 (a, b) Computed
tomography showing perineal
hernia. (Axial and Sagittal)
a
b
The patient is placed on the surgical table with both arms tucked and legs close
together, slightly spread or in lithotomy position, depending upon the necessity
to reach the perineal protrusion from the outside, especially in larger hernias.
Sometimes the legs can be spread to dock the robotic cart between them.
The patient is always secured to the table with xation straps and well protected
with chest and a head/eye protectors. A warming device placed on the chest to maintain body temperature (Fig.10.3).
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Table 10.1 Patient’s
preparation
Patient’s preparation
Antibiotics
Urinary catheter
Peripheral lines
Fixation strap
Chest protector
Head/eye protector
Endotracheal cannula
Anesthesia cannulas
Energy Cables
Colostomy closure (sterile drape)
Surgical drapes
Sterile lm
Heater device
Fig. 10.3 Patient position
The surgical skin preparation is done using chlorhexidine. The surgical drapes
are wide placed exposing all the abdominal area, extending laterally to expose both
anks. The colostomy, if present, is closed using a separate sterile surgical drape
(Fig.10.4a,b). After these steps, the anesthesia cannulas, energy cables and other
parts of the OR are secured for surgery.
202
ab
Fig. 10.4 (a, b) Drapes and marks
R. Z. Abdalla and T. N. Costa
10.4 Initiation ofSurgery
The surgery is ready to begin after all the preparations described above are completed. Entrance into the abdominal cavity to create the pneumoperitoneum is made
at the left upper quadrant using a Veress needle with the pressure of 12mmHg. The
port locations are selected choosing the perineal area as the target. When a colostomy is present, all the cannulas are placed to the right side or the fourth cannula is
changed to contralateral side. The rst cannula inserted is the optical one, 12mm,
positioned at 2cm above umbilical scar and 2cm to the patient’s right; respecting a
20cm distance from the target and aligned with the Si or Xi robotic cart.
When the camera is inserted, an initial evaluation of the abdominal cavity is done,
looking at its entirety, from liver to pelvis, searching for adhesions, the primary hernia
and other possible defects, such as: inguinal hernias, midline, parastomal or lateral incisional/ventral hernias [24]. The newest robotic generation makes it easier to investigate
the cavity and/or work viewing all of the abdomen, because of the lighter camera.
The other 8mm cannulas are placed in a slight curve, following the rule of 8–10cm
distance from each other to avoid collision during the procedure. The newer (Xi) generation is placed in a straight line at the same level of the camera with 6–8cm distance
from each other. This will facilitate manipulation and dissection closer to the instruments, when other abdominal wall hernias are noted. Arm 1 is placed in the right
patient ank, arm 2 at the mid clavicular line on the patient’s left side and arm 3in the
left iliac fossa or contralaterally when needed to be placed away from a colostomy. A
fth cannula for the assistant can be placed in the upper right quadrant (Fig.10.4b).
Caution must be taken to avoid injury to the colostomy when it exists.
In other cases, such as sciatic hernias, the optical cannula can be placed 4–5cm above
the umbilicus. In this setup the arm 1 can be placed at the right upper quadrant, arm 2in
the left upper quadrant and arm 3in the left ank. The assistant port can be between the
arms 2 and 3 at left side of the patient. In these types of hernias there is no concern of the
colostomy, and most of the patients have not had previous surgeries. The working space
is more cephalad than for the perineal incisional hernias. Because the perineal hernias
require more posterior pelvic adhesiolysis which is more distal in the abdomen cavity,
the robotic instruments will go deeper into the pelvis during the procedure.
ab
cd
ef
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203
10.5 Docking
When the cannulas are in place and position checked, it is time to dock the robot.
Using the pelvic defect as the target, the robot can dock in many positions, but
mainly from the “leg” approach. It is important that the patient extremities (head
and feet) are at the table limits as this will give more room to the robotic patient
cart approach. The arm joints should not collide with the patient’s body or operative table if we respect the operative table borders corresponding to the patient
limits.
Figures 10.5a–d show the possible dockings that can be done in the pelvic hernia
repair (the new robot generation is easier to dock, because the boom comes from
above the patient). It is benecial to repeat the same docking position, as many
times as possible.
The robot patient cart can come from the left side, with the legs close together,
pointing a little lateral: this type of docking is used to treat left sciatic hernias and
Fig. 10.5 (a–f) Docking
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R. Z. Abdalla and T. N. Costa
perineal hernias in order to protect the colostomy and treating possible paracolostomy
defects, often present in patients that have undergone APE or ELAPE (Fig.10.5e).
In the case of a right sciatic hernia the patient cart can come from the right with
the legs close together. The third option is the docking between the legs, like it is
used in prostatectomies (Fig.10.5f). In event that an emergency situation develops,
the assistant must be ready to undock the robot and take whatever action is necessary to solve the problem.
10.6 Surgical Technique
The surgical technique can be divided into sections for better understanding of the
procedure. Hence, it will be separated in: dissection/adhesiolysis, consideration of
defect closure when possible, mesh placement and xation.
10.7 Dissection/Adhesiolysis
One of the most important parts about the dissection is the identication of the
structures to be separated. Since one of the major complications of the perineal
hernia repair is bowel injury, the adhesiolysis becomes even more important. The
perineal defects are often accompanied by strong adhesions, mainly in the pelvic
area, but the entire abdominal cavity can present them. The robotic instruments
with wrist movements along with the 3D view can facilitate the management of
these adhesions, diminishing lesion incidence and making the process faster. The
plays an important role penetrating between tissues, making a “gas dissection”,
CO
2
sometimes revealing a safe plan to work.
The instruments used are: (Figs. 10.5 and 10.6)
• Monopolar scissors
• Maryland bipolar
• Cadiére with or without energy
• Double fenestrated
• Needle driver
Fig. 10.6 Instruments
10 Pelvic Hernias
Fig. 10.7 Perineal defect
(internal view)
205
The whole dissection is made using cautery, blunt dissection or cold scissors,
depending on the location and type of adhesion. In the perineal area is sometimes difcult to have the right angle to work on, but with the robotic technology, the instruments’ wrists can overcome this problem and the surgeon can dissect deeper into the
pelvis and obturator space. The assistant can push the defect from the outside, with
a lower intraabdominal pressure to reach deeper adhesions. Another important part
about the perineal hernias, is that these patients can have concomitant hernias, such
as paracolostomy or inguinal, so caution must be taken not to induce injuries.
After dissecting and lysis of all the adhesions, the defect can be seen, like any
other laparoscopic incisional hernioplasty. (Fig.10.7) At this time, it is important
to have a good description of the hernia, with accurate measurement and correct
vision of the edges, in order to choose the correct type of repair, reconstruction and
xation.
10.8 Defect Closure
There is a big discussion regarding whether to close the defect or not, in different
types of hernia (ventral, inguinal). In recent years, the majority of the papers tend
to favor the hernia closure, mainly in ventral hernias, for the mesh to lay at and
against the abdominal wall. In the perineal and obturator defects, this could be challenging, since there are few tissues to approximate and close.
Sometimes, in small defects, using the robotic instruments, such as the needle
driver, the surgeon can approximate the edges of the defect with suture and trying
to provide as little tension as possible. However, in most of the cases reported in
the literature, regarding pelvic hernias, there is no closure of the defect. In our
experience, the defect is only closed when we can provide no tension with surrounded tissues.
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R. Z. Abdalla and T. N. Costa
10.9 Mesh Placement andFixation
After dissecting and exposing the defect it is time to understand the situation and
plan its repair. There are surgical groups that repair these types of hernia from the
perineum using surgical aps without any meshes [2, 25–28]. But when this repair
is approached from the abdominal cavity it is recommended to use a mesh, since in
the majority of the times, the defect cannot be closed [6, 29–31].
The preferred type of mesh is coated mesh or double layer (i.e. tissue separating),
because there is no tissue or peritoneum to cover the mesh and they will be exposed
to the bowel. The mesh must have 3–5cm wide overlap than the original defect, in all
directions, with or without closing it. The most overlap that is obtainable is preferred.
Fixation can be done by hernia stapler (tackers) or by suture. Tackers are under a
higher risk of bleeding, because of the pelvic vessels. Suture can be done under direct
vision with delicate movements, choosing the border to pass the stitches. A big mesh
can be xed around the pelvis with a running suture over muscles posteriorly and laterally. When the mesh goes anterior, it can stay behind the bladder, over the urogenital
ligament (when it is possible to dissect and visualize) or even can go over the bladder
and xate at Cooper’s ligaments, on both sides. There are few studies comparing the
type of xation in other types of concomitant hernias, such as inguinal and ventral
[32]. At this time, the recommendation is to consider each case individually. In the
perineal hernia repair, the authors prefer to use tackers when the pelvic wall is seen,
with good results. The tackers are applied at the peripheral part of the defect and 5cm
wider in a double crown technique, with direct vision (Fig.10.8a, b).
10.10 Complications
All the types of surgery have their potential complications. In hernia surgery, those
complications can impact the treatment, the return to normal activities and the rate
of recurrence [33, 34].
One of the most common complications in laparoscopic and robotic hernia repair
is the seroma. This is caused by a uid collection localized mainly between the
repair (mesh or closure) and the skin/hernia sac. In the perineal area this is very
common due to the space and size of the hernia sac. In an effort to decrease the risk
of this development, a good practice could be plication of the hernia sac in an effort
to eliminate the dead space within the sac itself. It is essentially placing sutures in
subcutaneous tissue, what is not always possible. However, most of the seromas are
treated without any intervention [35–37].
Other major complication is bowel injury. This type of problem can lead to reop-
erations and even death. In the pelvic area it is important to do the adhesiolysis
carefully so as to avoid any bowel lesions.
Clinical complications such as pulmonary infections and embolism must be
remembered and care must focus on prevention with the use of prophylaxis an anticoagulant of choice.
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Fig. 10.8 Final view of the
repair, with the mesh placed.
(a) Internal view with
colostomy. (b) Close internal
view
a
b
Other complications such as infection, bleeding and adynamic ileus can be dif-
cult to appreciate in some cases. The main complications can be seen in Table10.2.
Seroma, infection and patient clinical decompensation must be considered in these
patients as most are at higher risk of these adverse events because they have had
previous oncologic treatment(s).
Table 10.2 Surgical
complications
Surgical complications
Seroma
Infection
Mesh migration
Bleeding
Adynamic ileus
Bowel injury
Care with colostomy
Clinical complications—Pulmonary and urinary