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218
M. Sharbaugh et al.
encountered, conversion to an open procedure should always be considered, however the improved visualization and articulation of the robotic system provides a
minimally invasive approach to combat these challenging complications.
References
1. Iraniha A, Peloquin J.Long-term quality of life and outcomes following robotic assisted TAPP
inguinal hernia repair. J Robot Surg. 2018;12(2):261–9.
2. Dominguez JEE, Ramos MG, Seetharamaiah R, Donkor C, Rabaza J, Gonzalez A.Feasibility of
robotic inguinal hernia repair, a single-institution experience. Surg Endosc. 2016;30(9):4042–8.
3. Waite KE, Herman MA, Doyle PJ.Comparison of robotic versus laparoscopic transabdominal
preperitoneal (TAPP) inguinal hernia repair. J Robot Surg. 2016;10(3):239–44.
4. Lomanto D, Katara AN.Managing intra-operative complications during totally extraperitoneal
repair of inguinal hernia. J Minim Access Surg. 2006;2(3):165.
5. Menderes G, Clark M, Tower A, Azodi M.External iliac vein injury and repair during robotic-
assisted pelvic lymphadenectomy. J Minim Invasive Gynecol. 2015;22(5):718.
6. Ates M, Kinaci E, Kose E, Soyer V, Sarici B, Cuglan S, Korkmaz F, Dirican A.Corona mortis:
invivo anatomical knowledge and the risk of injury in totally extraperitoneal inguinal hernia
repair. Hernia. 2016;20(5):659–65.
7. Flechner L, Smith J, Treseler P, Maa J. Vasal injury during inguinal herniorrhaphy: a case
report and review of the literature. Perm J. 2014;18(4):85.
8. Barazani Y, Kaouk J, Sabanegh ES Jr. Robotic intra-abdominal vasectomy reversal: a new
approach to a difcult problem. Can Urol Assoc J. 2014;8(5–6):E439.
9. Trost L, Parekattil S, Wang J, Hellstrom WJG.Intracorporeal robot-assisted microsurgical
vasovasostomy for the treatment of bilateral vasal obstruction occurring following bilateral
inguinal hernia repairs with mesh placement. J Urol. 2014;191(4):1120–5.
10. Ferzli GS, Edwards ED, Khoury GE. Chronic pain after inguinal herniorrhaphy. J Am Coll
Surg. 2007;205(2):333–41.
11. Mahan MA, Kader AK, Brown JM.Robot-assisted triple neurectomy for iatrogenic inguinal
pain: a technical note. Acta Neurochir. 2014;156(1):171–5.
12. Keating JP, Morgan A.Femoral nerve palsy following laparoscopic inguinal herniorrhaphy. J
Laparoendosc Surg. 1993;3(6):557–9.
13. Garcia-Urena MA, Vega V, Rubio G, Velasco MA.The femoral nerve in the repair of inguinal
hernia: well worth remembering. Hernia. 2005;9(4):384–7.
14. Agresta F, Marzetti A, Andrea Verza L, Prando D, Azabdaftari A, Rubinato L, Vacca U,
Roveran A, Pordia R, Maria Vigna SA.Laparoscopic TAPP inguinal hernia repair: mesh xation with absorbable tacks, initial experience. J Minim Invasive Surg Sci. 2016;5(2):e35609.
15. Moreno-Egea A, Paredes PG, Perello JM, Campillo-Soto A, Baena EG, Muñoz JRO, Aguayo-
Albasini JL.Vascular injury by tacks during totally extraperitoneal endoscopic inguinal hernioplasty. Surg Laparosc Endosc Percutan Tech. 2010;20(3):e129–31.
16. Chow P-M, Su Y-R, Chen Y-S. A rare complication from total extraperitoneal (TEP) lapa-
roscopic inguinal hernia repair: bladder rupture associated with a balloon dissector. Hernia.
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JSLS. 2001;5(2):175.
18. Hudak KE, Frelich MJ, Rettenmaier CR, Xiang Q, Wallace JR, Kastenmeier AS, Gould JC,
Goldblatt MI.Surgery duration predicts urinary retention after inguinal herniorrhaphy: a single institution review. Surg Endosc. 2015;29(11):3246–50.
19. Edelman DS.Robotic Inguinal Hernia Repair. Am Surg. 2017;83(12):1418–21.
11 Adverse Events ofRobotic Transabdominal Preperitoneal Inguinal Hernia Repair
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DR.Risk factors for postoperative hematoma after inguinal hernia repair: an update. J Surg
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219
Re-operation After Robotic Inguinal Hernia Repair
JordanA.Bilezikian, RobertG.Johnson,
andWilliamW.Hope
12.1 Introduction
Roboticsurgical techniques are increasingly used for hernia repair, and robotic minimally invasive inguinal hernia repair is an area of signicant growth. This requires that
surgeons know the most appropriate techniques for reoperations. Unfortunately,there
are no published long term outcome studies. However, recurrence rates are assumed
similar to be to the laparoscopic inguinal hernia repair recurrence rates of 1–3% in
large series [1–3]. Despite a low recurrence rate for robotic inguinal hernia repairs,
the number of repairs annually requires that surgeons successfully evaluate and treat
patients that need reoperation after a robotic inguinal hernia repair.
12
12.2 Rationale forRobotic Inguinal Hernia Repair
Robotic surgical techniques were initially used in gynecologic and urologic surgery. The advantages of robotic surgery compared with traditional laparoscopic
surgery include better visualization with a high denition magnication lens and
3- dimensional viewing, better dexterity with 360 degrees of instrument rotation
with seven planes of translated wrist motion, and better ergonomics due to a more
comfortable posture for the operating surgeon [4]. Robotic hernia repairs were rst
described in conjunction with robotic prostatectomy [5]. One of the few reports
investigating transabdominal preperitoneal (TAPP) robotic inguinal hernia repair
without prostatectomy was published by Escobar Dominguez etal. and was a case
series of 78 patients at a single institution [6]. The study concluded that robotic
J. A. Bilezikian (*) · R. G. Johnson · W. W. Hope
New Hanover Regional Medical Center, Wilmington, NC, USA
e-mail: Jordan.Bilezikian@nhrmc.org; Bobby.Johnson@nhrmc.org;
William.Hope@nhrmc.org
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_12
221
222
Fig. 12.1 Robotic suture
closure of peritoneum
during robotic inguinal
transabdominal
preperitoneal (TAPP)
hernia repair
J. A. Bilezikian et al.
TAPP inguinal hernia repair wasa safe approach with several advantages compared
with the laparoscopic approach [6].
Robotic inguinal hernia repair is based on the principles of the laparoscopic
TAPP and is well described elsewhere in this book (Chaps. 8 and 9). Proposed
benets for robotic inguinal hernia repair include easier suturing compared with the
laparoscopic approach and potential for avoiding the use of penetrating tacker xation and the ease of closing/suturing the peritoneum compared with laparoscopic
suturing or tacker xation. Barbed suture has gained popularity with surgeons as
the suture of choice for the peritoneal closure; however, more research is needed to
compare this with traditional methods (Fig.12.1). Another potential advantage is
that it can facilitate the use ofa minimally invasive approach for operations that are
too technically difcult for a laparoscopic approach.
12.3 Indications forReoperative Inguinal Hernia Repair
The most common reason for reoperation after inguinal hernia repair is recurrence
(Fig.12.2). Despite many improvements in the repair technique, recurrences still
occur, and there is no current evidence to support watchful waiting in patients with
recurrence, so reoperation is usually recommended [3].
Reoperation is indicated for other reasons such as infection, bowel obstruction,
and chronic pain. Discussion of these indications is outside the scope of this chapter. However, chronic groin pain, which occurs less often after minimally invasive
repairs than after open repairs, is a complex chronicproblem [3]. Although chronic
groin pain is still not entirely understood, there are several treatment algorithms to
guide surgeons with managingthis complex problem (see Chap. 6) [3, 7].
12.4 Reasons forFailure ofRobotic Inguinal Hernia Repair
Robotic inguinal hernia repairs and laparoscopic inguinal hernia repairs fail
for similar reasons. Intrinsic/demographic risk factors for recurrence include
anatomy, female gender, and abnormal collagen metabolism [3]. Obesity is an
12 Re-operation After Robotic Inguinal Hernia Repair
Fig. 12.2 Recurrent
inguinal hernia following
a robotic repair. A medial
defect is present just
underneath the previously
placed mesh.This
waslikely due to
inadequate xation or
poor placement of the
initial mesh
223
acquired risk factor for recurrence [3]. Perioperative risk factors for recurrence
include poor surgical technique, low surgical volume, and/or surgical inexperience. [3]. Poor surgical technique leading to recurrence often includes medial
recurrence at the angle between the rectus sheath and the inguinal ligament,
which is often a consequence of inadequate mesh xation, inadequate mesh size,
or inadequate hernia defect coverage due to poor location the mesh over the
defect [8].
12.5 Strategies forReoperative Surgery
Because there is no literature to support the use of watchful waiting in recurrent inguinal hernias, most patients without contraindications should be offered surgery [3].
When planning reoperative inguinal hernia repair surgery, apply the same prin-
ciples as any reoperative surgery. Obtain and review the operative report from the
original surgery. Specically, note the surgical technique, type of mesh, type of xation, and closure of peritoneum employed (for example,if a TAPP was used). These
are importantpieces of information to acknowledge when planning a laparoscopic
or robotic reoperation.
Some patients needing reoperative hernia surgery following failed robotic
repair have already undergone an open repair with mesh, which may have
beenthe reason robotic repair was recommended. These operations can be challenging and have high complication rates. Due to many clinical variables that
complicate decision making, these patients should be treated individually with
no clear recommendation for one specictechnique or method. Surgeons treating these patients should be well versed in many inguinal hernia repair methods/
techniques. Recent guidelines recommend referral of these patients to an expert
hernia surgeon [3].
224
J. A. Bilezikian et al.
12.6 Treatment Options forRecurrent Inguinal Hernia
Following Robotic Repair
12.6.1 Open Repair
An open repair is the easiest and most often used method for reoperation after a
failed robotic inguinal hernia repair. However, this is often debated. Recent international guidelines for hernia management recommend that a laparoscopic/minimally invasive repair be used after a failed open repair, and an open repair should
be used after a failed laparoscopic/minimally invasive repair [3]. By extending the
understandthat a robotic inguinal hernia repair is a minimally invasive repair, many
surgeons agree with the option of an open repair after a failed robotic repair.
The justication for this is avoidance of scar tissue at the time of reoperation,
which some published case series have reported to increase complications [3].
Because robotic inguinal hernia repair requires taking down theperitoneum and
placing mesh in the preperitoneal space, reoperation in this area can be difcult
due to scartissue. This plane lled with scar tissue is avoided by approaching the
inguinal hernia recurrence anteriorly.
The most common anterior approach for hernia repair after failed robotic/
minimally invasive hernia repair is the Lichtenstein hernia repair (Fig.12.3). This
approach avoids entering the preperitoneal space, which can be scarred from previous surgery [3]. However, ifsurgeons choose an open repair, theyshould use the
anterior approach of their choice.
12.6.2 Laparoscopic Repair
Laparoscopic repair is not generally recommended due to the potentially higher
rate of complications and difculties associated with reoperativelaparoscopic hernia surgery after failed laparoscopic/minimally invasive repairs. Although it is not
Fig. 12.3 Open anterior
Lichtenstein repair of
recurrent inguinal hernia
following a robotic
inguinal hernia repair.
Surgeons should use the
open anterior technique of
their choice following a
failed minimally invasive
repair
12 Re-operation After Robotic Inguinal Hernia Repair
225
recommended, it is still an option chosen by some surgeons. There can be several
drawbacks to this option including the difculty with scar tissue and dissection
planes especially around important areas such as the iliac vein, iliac artery, spermatic cord vessels, and vas deferens. One commonly encountered problem associated with reoperative minimally invasive hernia repair in the TAPP approach is
management of the peritoneum. The peritoneum can be densely adherent to the
previous mesh, which can cause large holes in the peritoneum and can be very difcult to close laparoscopically. In cases whenone is unable to completely cover the
newly placed mesh with peritoneum, coated mesh products should be used.
12.6.3 Robotic Repair
Although an open repair is the most common and most commonlyrecommended
operation following a failed laparoscopic/minimally invasive inguinal hernia repair,
surgeons experienced with robotic surgery have approached these robotically
(Fig.12.4). Several reasons are used to justify a robotic reoperation including better visibility and dexterity as well as the improved ability to close large holes in the
peritoneum with suturing. However,there are no published studies to support these
claims. Additionally, it is not uncommon to have a patient present that has undergone failedopen and laparoscopic hernia repairs.
A robotic reoperative hernia repair can be very complex and have many possible
complications including injury to the spermatic cord, vas deferens, and an increased
risk of bleeding [9, 10].
One potential benet of the roboticreoperative approach is the ability to clearly
identify the mechanism of failure of the previous robotic repair. Although some
information can be gleaned from an open repair, in our experience, placing a laparoscope for diagnostic laparoscopy often provides a clear picture of the mechanism
of recurrence. Better visualization for the surgeon, which has been well described,
is another potential benet of using robotic technology for reoperation [4]. This is
important to evaluate vascular structures and nerves, which can be distorted due to
the scar tissue and mesh.
A major difculty with reoperative laparoscopic inguinal hernia repair for recur-
rence is management of the peritoneum during TAPP repairs. Due to scar tissue and
Fig. 12.4 Robotic
reoperative inguinal
hernia repairfollowing
previous robotic inguinal
hernia repair. The
previous mesh/peritoneum
was dissected and a new
mesh placed to cover the
recurrent defect. The old
mesh is seen incorporated
into the robotic peritoneal
closure
226
J. A. Bilezikian et al.
mesh, maintenance of a good preperitoneal plane is difcult, and holes or tears in
the peritoneum can occur. While there are methods to help close these using the laparoscopic technique (suturing, Endoloops, tacks), these maneuvers can be challenging and time consuming. The improved ability to suture using robotic technology
and easier recreation/repair of the peritoneum are important factors when deciding
which technique to use when a difcult operation is expected.
12.7 Special Considerations
Although robotic inguinal hernia repair is based on the laparoscopic TAPP repair,
there are subtle differences that can impact reoperative surgery. However,very little
is known about this topicdue to the paucity of literature.
One interesting issue related to robotic inguinal hernia repair is peritoneal closure
using a barbed suture (i.e., V-lock, Medtronic, Minneapolis, MN). This is a fairly
new technique and was popularized by the robotic technique. As with all new techniques, new challengesand complications have been reported including peritoneal
disruption [11, 12]. During initial experiences with robotic inguinal hernia repair,
some surgeons did not use the barbed suture as intended and did not “back-track” or
tie the suture. This was thought to cause some of the peritoneal breakdowns. These
breakdowns in the peritoneumcan cause small bowel obstructions when bowel herniates in the preperitoneal space and is called a preperitoneal hernia [12].
Another reported complication associated with barbed suture use is the bowel or
omentum adhering to the barbs of the suture when a large amount of extra suture is
left in the peritoneal cavity [13] (Fig.12.5). To date, there has been no reported erosion of barbed suture into the intestine; however, one should be aware of potential
complications associated with this new technique of closing the peritoneum.
Fig. 12.5 Omentum
adherent in two places to
barbed sutures previously
placed during a robotic
inguinal hernia repair
12 Re-operation After Robotic Inguinal Hernia Repair
227
12.8 Conclusions
Failed robotic inguinal hernia repairs are usually caused by technical issues. In general, the repairs should be done using an anterior (Lichtenstein) approach. In certain
patients, a minimally invasive approach can be considered. In these patients, robotic
reoperation is recommended due to better visibility and improved ability to suture
the peritoneum.
References
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standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature. Surg Endosc. 2010;24:3026–30. https://doi.org/10.1007/s00464-010-1079-x.
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Surg. 2012;397:271–82. https://doi.org/10.1007/s00423-011-0875-7.
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A.Feasibility of robotic inguinal hernia repair, a single-institution experience. Surg Endosc.
2016;30:4042–8. https://doi.org/10.1007/s00464-015-4717-5.
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repair. Ann Surg. 2001;234:122–6.
11. Cueto J, Vazquez JA, Solis MA, Valdez G, Valencia S, Weber A.Bowel obstruction in the post-
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repair: case report and review of the literature. Hernia. 2008;12:535–7. https://doi.org/10.1007/
s10029-008-0341-9.
13. Tagliaferri EM, Wong Tavara SL, Abad de Jesus JL, Bergmann H, Hammans S, Seidlmayer
CM.Small bowel obstruction SBO after TAPP repair caused by a self-anchoring barbed suture
device for peritoneal closure: case report. J Surg Case Rep. 2018;2018:rjy165. https://doi.
org/10.1093/jscr/rjy165.
Part III
Ventral and Incisional Hernia