Inguinal hernia remains a very common surgical problem with a lifetime risk of nearly 25% in men and 3% in women. Given the prevalence, nearly 20 million inguinal hernia repairs are performed each year worldwide. Traditionally, inguinal hernias have been repaired using an open technique with low morbidity. With the advent of laparoscopy, techniques such as transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) have maintained the low morbidity rates, with advantages of less postoperative pain, earlier return to regular activity, as well as the ability to detect occult contralateral hernia. The robotic platform augments the traditional laparoscopic techniques with the benefits of greater scope magnification and three-dimensional optics, Endowrist articulation, and a shorter learning curve. , For inguinal repairs, these advantages are particularly useful in reoperative or otherwise complex surgical fields wherein mesh explantation or difficult dissection may be anticipated.
Robotic transabdominal preperitoneal (rTAPP)
Umbilical access, pneumoperitoneum and working port placement lateral to the semilunar lines bilaterally
Visualization of hernia defect and inspection for contralateral defect
Incision of peritoneum from medial umbilical fold to anterosuperior iliac spine (ASIS)
Development of preperitoneal space inferiorly to Cooper’s ligament
Dissection of hernia sac from cord structures with reduction of hernia sac to the abdominal cavity
Mesh placement with coverage of myopectineal orifice (MPO)
Closure of the peritoneal defect
Desufflation, removal of ports, and facial closure
Indications and contraindications for rTAPP
In general, indications for rTAPP are similar to open and laparoscopic approaches and include symptomatic hernias. rTAPP is preferred over open repair in the setting of hernia recurrence following open repair and in the setting of bilateral hernias. Furthermore, in the setting of incarceration or suspected strangulation, a transabdominal approach allows for intraabdominal assessment of bowel viability following reduction.
Absolute contraindication to rTAPP includes patients unable to undergo general anesthesia or tolerate pneumoperitoneum, coagulopathy, and known intraabdominal infection. Relative contraindications include history of extensive abdominal/pelvic operations, including prior TAPP hernia repair, TEP hernia repair, as well as prior gynecologic and prostate procedures. The presence of a large scrotal component may prove difficult to reduce from a robotic or laparoscopic technique. In this case, open technique may be required; otherwise, if the sac is partially reduced and transected, this will almost certainly result in postoperative seroma.
Preoperative assessment should begin with a thorough history and physical examination. Key components of the history include duration of symptoms, history of incarceration, and presence or absence of obstructing symptoms. Surgical history focusing on prior surgeries, including all abdominal or pelvic procedures and prior inguinal/femoral hernia surgeries, may alter the operative approach. Finally, a careful history of the patient’s comorbidities including cardiopulmonary status, use of anticoagulant medications, as well as conditions that predispose to recurrence such as constipation, chronic cough, obstructed urination, obesity, and diabetes, which may aid in further optimization prior to repair.
Physical exam includes a thorough inspection of the bilateral groins in all patients, as well as the presence and position of the testicles in males. The clinical presentation of a hernia varies and ranges from a large scrotal hernia that is unable to be fully reduced to a fully reduced hernia sac which only provides impulse to the examiner’s finger within the canal on cough or Valsalva. If a bulge is present, it is important to note its relative location to the inguinal ligament, as femoral hernias reside inferior to the inguinal ligament. The skin should be examined for evidence of prior surgical scars.
Regarding imaging, the diagnosis of inguinal hernias remains a clinical diagnosis. Imaging, such as computed tomography or ultrasonography, is not routinely performed unless there is uncertainty regarding the diagnosis. Ultrasound can be particularly helpful in diagnosing testicular and scrotal pathology as well as inguinal lymphadenopathy.
Theater and port setup
See the box that follows for special equipment required and Fig. 56.1 for operating room setup.
Fenestrated bipolar or Force bipolar forceps
Mega suture cut needle driver
Peritoneum: 6-inch, 180-day, 3/0 barbed suture
Size appropriate medium or light weight macroporous polypropylene mesh
Laparoscopic graspers, laparoscopic suction device
Patient preparation and positioning
After induction of general anesthesia, a Foley catheter is placed in a sterile fashion, prior to positioning the patient in supine position with arms tucked. All pressure points are carefully padded, and the patient is secured to the operating table at the level of the chest and/or hips using a designated belt or tape. We use a commercially available Trendelenburg positioning pad, as the surgical table is ultimately positioned in a steep Trendelenburg position. Clipping of hair, skin preparation, and draping are performed as usual. Preoperative antibiotics are administered prior to incision.
Stages of the procedure
Port placement and robot docking
The camera port is placed either infraumbilical or supraumbilical with open Hasson technique and the abdomen is insufflated up to 15 mm Hg, according to surgeon preference. Following expansion of the abdomen, once pneumoperitoneum is achieved, two 8 mm Xi ports are placed lateral to the rectus muscles either at the level or 2 cm superior and 10 cm lateral to the umbilicus (see Fig. 56.1 ). In the patient with short umbilicus to pubis distance, you may consider placing the ports higher as this may hinder creation of flap. Inspection of the abdomen should ensure no underlying visceral injury. Both groins should be inspected for the presence of occult hernia. The robot is docked perpendicular to the patient, from either side.
Critical view of the myopectineal orifice
The concept of the critical view (CV) of the MPO has been advocated by Daes and colleagues to standardize laparoscopic hernia repair to facilitate teaching and reduce recurrences and complications. This is applicable and used in robotic inguinal hernia repair. Below are the components:
Create a peritoneal flap just medial to ASIS following arcing muscle fibers to the medial umbilical ligament ( Fig. 56.2 ). 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.
Dissect at least 2 cm between CL and the bladder to facilitate flat placement of the medial and inferior edge of mesh toward the space of Retzius, thereby avoiding mesh displacement caused by bladder distention ( Fig. 56.3 ).
Dissect between CL and the iliac vein to identify the femoral orifice and rule out a femoral hernia.
Dissect the indirect sac and peritoneum sufficiently to completely free the cord’s elements ( Fig. 56.4 ). This step is often not completed, especially in a small surgical field. To ensure compliance with this requirement, continue to dissect until the cord’s elements lie flat. Then, visualize the psoas muscle and iliac vessels, pull the sac and peritoneum upward without triggering movement of the cord’s elements, and dissect between the cord’s elements to avoid missing a tail of the sac.
Identify and reduce cord lipomas (which may appear small and unimportant until reduced). Usually 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.
Dissect peritoneum lateral to the cord’s elements laterally beyond the ASIS, sweeping it back inferiorly well behind the mesh’s inferior border.
Place the mesh only when steps 1 to 8 are completed, and hemostasis has been verified. Mesh size should be at least 15 × 10 cm, although a larger piece of mesh is sometimes required to cover the MPO. Preferably, choose mesh that adapts to the contour of the space and the cord’s elements. It should not have undue memory. Place it without creases or folds. Avoid splitting the mesh. Ensure that its lateroinferior corner lies deep against the wall and does not roll up during space deflation (use glue or careful suturing, if necessary).
Mesh placement and peritoneal closure
Following adequate exposure of the MPO, it is important to choose appropriate size mesh that covers the entire MPO without being too large, causing impedance to peritoneal closure or curling with peritoneal closure (clam shell). The monopolar scissors are then exchanged for a needle driver. We prefer a 3-point fixation with 2-0 silk suture at the pubic tubercle medially ( Fig. 56.5 ), a second medially to the inferior epigastric vessels, and a third lateral to the inferior epigastric vessels. Once the mesh is secured, the peritoneal flap is closed with a running 3-0 barbed suture ( Fig. 56.6 ). Defects in the peritoneal flap can be closed primarily with silk sutures. Each of the working ports is removed under direct visualization, the abdomen is desufflated, and the umbilical facia is closed in a standard fashion.
Immediately following the operation, the Foley catheter is removed prior to transition to the postoperative anesthesia care unit. The patient is given a regular diet in the postoperative care unit. Pain control, ambulation, and ability to void are all discharge requirements. Most patients are discharged on the day of surgery. We prefer the use of multimodal analgesia regimen including NSAIDs, acetaminophen, and methocarbamol, with judicious use of narcotics. Early and frequent ambulation is encouraged at discharge. Heavy lifting (>10 kg) is discouraged for the first 2 to 4 weeks postoperatively. The patient follows up in clinic to track progression in 1 to 2 weeks postoperatively.
The overall complication rate of rTAPP ranges 0.6% to 7%; intraoperative complications including significant vascular injury (e.g., inferior epigastric vessels, femoral vessels) or visceral injury (e.g., bowel or bladder) are rare. Postoperative procedure specific complications include urinary retention, seroma formation, inguinal neuralgia, wound infections, and recurrence. To date, only one randomized control trial comparing minimally invasive laparoscopic versus robotic approaches has been conducted and demonstrates no differences regarding postoperative complications such as pain, wound infection, or readmissions. More information regarding long-term outcomes is needed.
The use of the rTAPP approach for repair of inguinal hernias has increased dramatically over the past decade. The operative technique shares many similarities to the laparoscopic TAPP approach. Robotic technology affords the surgeon advantages of greater scope magnification, three-dimensional viewing, Endowrist articulation, improved ergonomics, and a shorter learning curve, while maintaining the benefits of less postoperative pain, earlier return to activity, and the ability to detect occult contralateral hernia.
Ventral hernias are defined as a defect in the abdominal wall resulting from disruptions of the abdominal wall musculature. Ventral hernias are classified as primary or acquired. Acquired ventral hernias, often called incisional ventral hernias, occur in the context of a prior incision leading to a defect in the abdominal wall. Whether primary or acquired, ventral hernias can range from very small to very large disruptions in the abdominal wall. Furthermore, the location of the defect can include a multitude of locations along the abdominal wall.
More than 400,000 ventral hernias are repaired each year in the United States, with nearly two in three being primary ventral hernias and the remainder being incisional ventral hernias, resulting in a cost of more than U.S. $3 billion.
Ventral hernias can be repaired through an open or minimally invasive approach. Laparoscopic repair has been utilized beginning in the 1990s. Since that time, multiple studies examining outcomes of open versus laparoscopic repairs have demonstrated lower rates of surgical site and mesh infection, less pain, and faster recovery favoring the laparoscopic approach and equivalent recurrence rates between the approaches.
With the emergence of robotic technologies, including improved optics (three-dimensional camera), increased degrees of freedom, and improved ergonomics, the benefits of a minimally invasive approach may be maintained with a shorter learning curve for the surgeon. Furthermore, complete reconstruction of the abdominal wall with closure of the defect is an additional component of a robotic repair that has not been part of the laparoscopic repair for most surgeons. Closure of the defect has resulted in decreased bulging at the operative site and improved patient reported outcomes. ,
A key component of any minimally invasive ventral hernia repair is mesh placement. Various locations for mesh placement have been described and include intraperitoneal onlay mesh (IPOM) placement, preperitoneal placement, retrorectus placement, and retrorectus placement with transversus abdominus release (TAR). While there is overlap regarding indications for each approach, it is generally agreed that defects of 1 to 3 cm be repaired with an IPOM or preperitoneal mesh placement, sparing the patient the additional morbidity of a component separation and potentially “burning the bridge” of a future component separation should the hernia recur. For defects greater than 3 cm, especially in the presence of diastasis recti, the authors prefer a minimally invasive component separation. The authors prefer a retrorectus mesh placement via a laparoscopic assisted robotic extended view total extraperitoneal (eTEP) approach, as championed by Belyanski. This approach involves entering the retrorectus space laterally at the semilunar line. From this approach, the retrorectus space can be developed without entry into the peritoneal cavity. Furthermore, for larger defects (>6 to 8 cm) a unilateral or bilateral TAR may be performed.
Robotic eTEP with TAR
Optiview access of retrorectus space with subsequent retrorectus dissection
Crossover into contralateral retrorectus space through preperitoneal space
Contralateral retrorectus space development
Unilateral or bilateral TAR just medial to epigastric perforating vessels
Development of avascular plane superior to transversalis fascia
Closure of posterior sheath and anterior facial defect
Mesh placement anterior to posterior sheath
Desufflation, removal of ports, and skin closure