Journal of Surgical Oncology 2015;112:310–314
Robotic Inguinal Hernia Repair JOSE E. ESCOBAR DOMINGUEZ, MD,1 ANTHONY GONZALEZ, CHARAN DONKOR, MD1,2*
1,2 MD, FACS, FASMBS, AND
1
Baptist Health South Florida, Baptist Health Medical Group 2 Florida International University College of Medicine
Inguinal hernias have been described throughout the history of medicine with many efforts to achieve the cure. Currently, with the advantages of minimally invasive surgery, new questions arise: what is going to be the best approach for inguinal hernia repair? Is there a real benefit with the robotic approach? Should minimally invasive hernia surgery be the standard of care? In this report we address these questions by describing our experience with robotic inguinal hernia repair.
J. Surg. Oncol. 2015;112:310–314. ß 2015 Wiley Periodicals, Inc.
KEY WORDS: robotic TAPP; robotic herniorrhaphy; robotic hernioplasty
INTRODUCTION Hernias have been documented in history dating back to the ancient greco-roman times. It was clear that the role of surgery in hernia treatment was performed for the most part in large and incarcerated hernias. Treatment of groin hernias has gone through 5 major eras [1,2,3]: The 1st era includes the Egyptian papyrus Ebers that describes the hernia as a “swelling that comes out when one coughs.” The most essential knowledge of the hernia was derived from the Greek physician Galen, and this remained valid throughout the Middle Ages. The 2nd era began in the Renaissance and “herniology” grew rapidly as knowledge in surgical anatomy increased. The treatment however was still unsatisfactory and was done mainly for life threatening disease. In the 3rd era, anesthesia and aseptic technique led to advancement in the technique of hernia surgery. This was evidenced by significantly lower complications. Recurrence rates however, were still 100% at four years. The 19th to mid 20th century brought about the 4th era, where repair was under tension. Bassini introduced his method of hernia repair in which he reconstructed the posterior wall of the inguinal canal. Shouldice then described his repair in which he imbricated the transversalis fascia and strengthened the posterior of floor of the inguinal canal with four layers of fascia and aponeuroses. His recurrence rate was reported as 3%, a drastic improvement. The 5th era marked the repair without tension first popularized by Lichtenstein, by the use of a prosthetic component to strengthen the posterior wall of the inguinal canal. He published 1,000 cases of this type of repair and demonstrated no recurrences at 5 years. The advent of laparoscopy and robotics seem to be evolving hernia treatment to a 6th era. The first laparoscopic repair was reported in 1979 by P. Fletcher, where he laparoscopically closed the neck of the sac. In the 1990s, the two main techniques for laparoscopic hernia repair were developed and refined [4,5]. Keys to these approaches were gaining understanding of the anatomy from a posterior view. Vascular injury, bladder injury, nerve entrapment and inadequate repair were a concern in its beginning stages. The two laparoscopic herniorrhaphy techniques that are currently being performed for inguinal hernia repair are the Trans Abdominal Pre Peritoneal approach (TAPP) and the Totally Extra Peritoneal approach (TEP). To the best of our knowledge, no technique has been proven superior. Both TAPP and TEP have similar operative times, post-operative pain, return to work and recurrences. The minimally invasive technique is favored in certain patient populations including young healthy patients, patients with known bilateral inguinal hernias and recurrent hernias [6].
ß 2015 Wiley Periodicals, Inc.
TAPP herniorrhaphy can be performed either robotic or laparoscopic. Here we present our technique in robotic TAPP herniorrhaphy developed from our experience in open and laparoscopic TAPP and TEP hernia repair.
PATIENT SELECTION The general consensus is that minimally invasive hernia surgery benefits young healthy patients, patients with bilateral hernias and those with recurrent hernias. Relative contraindications may be previous laparoscopic repair, ascites [7], peritoneal dialysis and large intrascrotal hernias. We do recognize that these are relative contraindications and believe that an experienced surgeon may feel confident in more complex cases. With the advent of robotics in our hernia repairs, we have become very liberal in our patient selection and we have few contraindications to the robotic approach. Other relative contraindications may still include multiple previous abdominal surgeries, inability to tolerate pneumoperitoneum and grossly contaminated abdominal cavity that would preclude the use of a mesh.
SURGICAL TECHNIQUE When operating with the Da Vinci Si model, trocar placement and docking are paramount to performing the inguinal hernia repair robotically. Camera port is placed at the supraumbilical region and an 8 mm trocar is placed on the right and a 5 mm trocar on the left approximately 10 cm lateral and at the level of or slightly above the
The authors, Drs. Charan Donkor and Jose Ernesto Escobar Dominguez declare they have no conflict of interest. Dr. Anthony Gonzalez has received speaker honorarium from Intuitive Surgical, Cadence Pharmaceuticals and Ethicon. He has also received research grants and participated in the scientific advisory board for Minimally Invasive Devices, Inc. *Correspondence to: Charan Donkor, MD, General and Bariatric Surgery, Baptist Health South Florida, Baptist Health Medical Group—General Surgery, Associate Professor of Surgery, Florida International University College of Medicine, 7800 SW87 Avenue, Suite B210. Miami, FL 33173. Fax: 305-595-9590. E-mail: [email protected] Received 3 February 2015; Accepted 8 March 2015 DOI 10.1002/jso.23905 Published online 7 July 2015 in Wiley Online Library (wileyonlinelibrary.com).
Robotic Inguinal Hernia Repair umbilicus (Fig. 1). It is important in patients with a smaller body habitus not to place trocars too lateral as this will create difficulty when it comes to suturing laterally. The purpose of the 8mm trocar is to allow mesh and needle placement into the abdomen, allows the use of a needle driver with suture cut and the scissors with electrocautery. Docking the robot can be done with patient in lithotomy (Fig. 2) or the supine position (Fig. 3). Our position of choice is supine with moderate Trendelenburg. The robot may be docked from a side position while patient is supine, and this will allow for repair of both sides. The newer Xi model allows for simplicity in patient set up. Docking is from either side and trocars are placed at the level of the umbilicus transversely. We prefer to perform our robotic inguinal hernia repair through a transabdominal pre-peritoneal approach. The knowledge of the inguinal anatomy in this approach is different than open or TEP, the initial landmarks in the peritoneal cavity are: medial umbilical ligament (MUL, lateral umbilical ligament), internal inguinal ring, external iliac vessels and gonadal vessels. A curvilinear peritoneal incision is performed with the robotic hot shears between the anterior superior iliac spine (palpated by the assistant) and the medial umbilical ligament. An incision is created that will allow dissection of Cooper’s ligament and a peritoneal flap that will accommodate the appropriate sized mesh comfortably. Dissection of the preperitoneal fat can be done bluntly and with modest use of cautery being careful not to injure the inferior epigastric vessels. Creating too large a flap can add to the operative time in unnecessary dissection. The peritoneal flap should fit snug to the mesh without “mesh rolling.” This will also prevent mesh migration that is critical in the first two weeks after repair. When making the incision, it is prudent to be cognizant of the lateral corner, because if the flap extends too lateral, this can create technical difficulty when closing the peritoneal flap. Dissecting Cooper’s ligament, just lateral to the symphysis pubis, immediately after creating the peritoneal flap will help in recognizing the preperitoneal anatomy. It is good practice to first dissect and identify Cooper’s ligament before addressing the rest of the dissection. Having Cooper’s ligament in view serves as a useful landmark especially when the hernia sac is a large and obscuring the field of dissection. Once Cooper’s ligament is identified, a lateral dissection of the preperitoneal space is required leaving the hernia sac dissection until the end allowing an easier identification of the spermatic cord, vas deferens and the Triangle of Doom (Fig. 4). The hernia sac must be detached completely from the spermatic cord to avoid seroma formation or hernia recurrence. In cases of very large hernia sacs like inguinoscrotal hernias in which dissection may become challenging, the sac may be transected and left in place being cautious to close the peritoneal defect once the inguinal repair is done. When the decision has been made to ligate the sac, it is best to ligate at the most narrow point possible. This will reduce the size
Fig. 1.
Port placement.
Journal of Surgical Oncology
Fig. 2.
311
Patient in the lithotomy position and robot docking.
of the defect in the peritoneal flap and therefore make it easier to close without deficit.
MESH FIXATION TECHNIQUE As established by the International Endohernia Society (IEHS) guidelines the recommended mesh size is 10 15 cm, however larger meshes (i.e. 12 17 cm) are available and recommended for direct defects larger than 3 cm and indirect defects larger than 4 cm in diameter [6]. The important sites where the mesh have to be fixated are: 1) Cooper’s ligament, 2) rectus abdominis muscle (medial to the inferior epigastric vessels), and 3) Transverse abdominis fascia slightly lateral and above the internal inguinal ring (Fig. 5). This fixation can be performed either with sutures or tacks. In our experience the 3 fixation points described above are enough for intracorporeal suturing. There are many varieties of suture available. We have found the Ethicon (Ethicon US, LLC) 0 or 2–0 prolene on a CT 1 or 2 to be optimal for mesh fixation. The sutures are cut to length of 27–30 cm and are introduced into the abdominal cavity along with the mesh before docking the robot. This saves in operative time. It is recommended to place free sutures within the abdominal wall out of the field of dissection but in view. This allows for easy retrieval and prevents misplacement of the suture within the
Fig. 3.
Patient in the supine position and robot docking.
312
Escobar Dominguez et al.
DISCUSSION Currently, the main guidelines for laparoscopic inguinal hernia repair include those developed by the International Endohernia Society (IEHS) [6], the European Hernia Society (EHS) [8] and the European Association of Endoscopic Surgery (EAES) [9]. The IEHS and EHS guidelines have been recently updated (2014) [10,11] with new and or modified recommendations.
Why the Transabdominal Preperitoneal (TAPP) Repair?
Fig. 4. Right inguinal region: 1) supravesical fossa, 2) Cooper’s ligament, 3) inferior epigastric vessels, 4) transverse arch, 5) vas deferens, 6) cord elements with gonadal vessels, and 7) peritoneal flap, triangle of Doom (solid lines), Triangle of pain (dashed lines). abdominal cavity. Once suture has been used it is replaced back in the abdominal wall until ready for removal. All needle counts are confirmed with operating surgeon, surgical technologist and circulating nurse with a needle index written on the O.R board. The technique in suturing is standard to robotic suturing. The most technically challenging part of the case is suturing to Cooper’s ligament. We recommend a back hand stitch through mesh, Cooper’s ligament and again through mesh. It is sometimes easier to visualize by switching the camera from 30 degrees up to 30 degrees down. A zero degree camera scope may also be used and is often adequate for full visualization. The anterior and lateral sutures are technically easier. We place them in the anterior abdominal wall medial to the epigastric vessels and along the lateral abdominal wall (Fig. 5).
BILATERAL INGUINAL HERNIAS AND PERITONEAL CLOSURE In our approach, we create two separate peritoneal incisions creating two peritoneal flaps for either side. In comparison, when performed while doing prostatectomy, one incision is made between the two median umbilical ligaments. In our experience we consider that such dissection is not necessary, furthermore it may distort the peritoneal flap when closure is attempted. Our two separate peritoneal incisions prove to be more than adequate for the dissection. We perform one for each inguinal region (Fig. 6) sparing the supravesical fossa in the middle to keep the flaps in a normal anatomical position, the peritoneal closure is done using a Quill (Surgical Specialties Corporation) barbed absorbable monofilament suture (PDS 2-0).
Fig. 5. Mesh fixation in right inguinal region at: 1) Cooper’s ligament, 2) lateral border of rectus abdominis muscle, and 3) transverse arch (anterolateral abdominal wall). Journal of Surgical Oncology
Although both techniques show similar long term results, it has been found recently by the IEHS that TEP has a slightly higher rate of intraoperative and postoperative surgical complications (without statistical significance) when compared to TAPP including seromas and scrotal edema; however, clinical evidence supports that TAPP requires longer operative times and a longer hospital stay [10]. TAPP also offers a greater advantage over TEP regarding contralateral hernias and incarcerated hernias. Their recommended approach for recurrent inguinal hernias is the TAPP technique by surgeons with experience in such an approach. Similar statements are also mentioned by the EHS guidelines [8]. TAPP is more advantageous in the case of an incarcerated hernia, since direct laparoscopic visualization of the bowel can rule out necrosis.
Prosthetic Mesh Since the advent of prosthetic mesh implants, there has been debate as to which mesh will have the best clinical results. The majority of meshes are polypropelene based and the pore size and relative mass of the mesh are important determinants in its performance. Large pores allow improved tissue integration and less inflammatory reaction resulting in decreased mesh distortion. Some studies have shown that a light weight mesh will be as strong as a heavy weight mesh and has improved outcomes in hernia recurrence and post-operative and chronic pain [12,13,14,15], however recent IEHS guidelines do not support this [10]. The choice of mesh seems to be highly dependent on surgeon preference. Many times surgeon preference is simply what the surgeon is familiar with. In our experience we have had good results with a light weight polypropylene mesh.
Mesh Fixation Techniques and Chronic Inguinal Pain When comparing different mesh fixation techniques one major concern arises: acute and chronic inguinal pain. It has been proposed that fixation of the mesh increases acute inguinal pain
Fig. 6. Closure of bilateral peritoneal flaps with a barbed absorbable suture, note that suturing starts on the midline. 1) peritoneal opening on the left and 2) peritoneal opening on the right.
Robotic Inguinal Hernia Repair when compared to non fixation, however new evidence supports that fixation with tacks/staples versus non fixation of the mesh are equal regarding postoperative pain. The only proven fixation method to be effective to decrease acute postoperative inguinal pain is the use of fibrin glue [10,16]. Though it has not been reported to increase hernia recurrence, special consideration has to be taken when large direct or indirect defects are found, if so mesh fixation is recommended with tacks/staples or sutures. Fibrin glue has been proposed to make a protective effect in the nerves located in the inguinal region therefore decreasing the irritant effect of the mesh when placed in direct contact with the structures [17]. Prophylactic transection of the ilioinguinal nerve has not shown to be effective in decreasing chronic inguinal postoperative pain after hernia repair [10].
Popularity of Minimally Invasive Hernia Repair and Current Robotic Inguinal Hernia Surgery Experience It has been reported that in North America laparoscopic inguinal hernia repair is not widely practiced. Different studies have shown that a large number of fellowship trained surgeons do not perform minimally invasive hernia surgery. One study in particular reported that only 77% of surgeons trained in minimally invasive surgery are performing laparoscopic inguinal hernia repairs routinely [18]. The number of non fellowship trained surgeons performing minimally invasive hernia surgery is exceptionally low. Currently in the published literature the vast majority of experience in robotic inguinal hernia repair has been done by urologists [19–24] who have dealt with this clinical entity while performing robotic assisted radical prostatectomy. They have done this without reporting an increase in morbidity rates when compared to robotically assisted radical prostatectomy alone [22]. There still does not exist a reported case series of robotic inguinal hernia repair from a general surgery standpoint. This approach has not yet been described in the clinical guidelines mentioned above. A case series of robotically assisted single port hernia surgery was reported by Tran et al, however this device is a robotic control for the conventional laparoscopic camera to avoid the use of a surgical assistant and the procedure is performed in a conventional single port laparoscopic surgery [25].
CONCLUSIONS Prospective, multicenter randomized controlled trials should be performed to gain more experience in this new emerging field of minimally invasive surgery. Adoption of this technique by urologists has been proven to be safe and effective without increasing morbidity. The benefits provided by the robotic platform include better visualization, improved ergonomics and wristed movements allowing for easier dissection. These make robotic inguinal hernia repair an excellent option. With smaller numbers of surgeons performing minimally invasive hernia surgery, it is likely that with the advent of robotics, more surgeons will adopt this technique. This will translate into many more patients benefiting from minimally invasive hernia surgery. There is a cost difference when comparing robotic TAPP vs. TEP. With the elimination of the tacker and the balloon dissector, cost can be significantly decreased in the robotic technique.
REFERENCES 1. Lau WY History of treatment of groin hernia. World J Surg. 2002;26:748–759. Epub 2002 Mar 26. 2. Legutko J, Pach R, Solecki R, et al.: The history of treatment of groin hernia. Folia Med Cracov 2008;49:57–74. Journal of Surgical Oncology
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3. Bekker J, Keeman JN, Simons MP, et al.: A brief history of the inguinal hernia operation in adults. Ned Tijdschr Geneeskd 2007;151:924–931. 4. Lokesh B, Fitzgibbons R: Laparoscopic Inguinal Hernia Repair. In: Shackelford’s Surgery of the Alimentary Tract, Seventh Edition. Yeo C, editor. Philadelphia: Elsevier; 2013. pp. 583–596. 5. Gould J. Laparoscopic versus open inguinal hernia repair. Surg Clin North Am 2008;88:1073–1081. 6. Bittner R, Arregui ME, Bisgaard T, et al.: Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011;25:2773–2843.DOI: 10.1007/s00464-011-1799-6. Epub 2011 Jul 13. 7. Silva FD, Andraus W, Pinheiro RS, et al.: Abdominal and inguinal hernia in cirrhotic patients: What’s the best approach? Arq Bras Cir Dig 2012;25:52–55. 8. Simons MP, Aufenacker T, Bay-Nielsen M, et al.: European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343–403.DOI:10.1007/s10029-0090529-7. Epub 2009 Jul 28. 9. Poelman MM, van den Heuvel B, Deelder JD, et al.: EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc 2013;27:3505–3519. 10. Bittner R, Montgomery MA, Arregui E, et al.: International Endohernia Society. Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc 2015;Feb 29:289–321. DOI:10.1007/s00464-014-3917-8. Epub 2014 Nov 15. 11. Miserez M, Peeters E, Aufenacker T, et al.: Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2014;18:151–163. DOI:10.1007/s10029-014-1236-6. Epub 2014 Mar 20. 12. Agarwal BB, Agarwal KA, Sahu T, et al.: Traditional polypropylene and lightweight meshes in totally extraperitoneal inguinal herniorrhaphy. Int J Surg 2010;8:44–47.DOI:10.1016/j. ijsu.2009.08.014. Epub 2009 Oct 22. 13. Agarwal BB, Agarwal KA, Mahajan KC: Prospective double-blind randomized controlled study comparing heavy- and light-weight polypropylene mesh in totally extraperitoneal repair of inguinal hernia: early results. Surg Endosc 2009;23:242–247. 14. Akolekar D, Kumar S, Khan LR, et al.: Comparison of recurrence with lightweight composite polypropylene mesh and heavyweight mesh in laparoscopic totally extraperitoneal inguinal hernia repair: An audit of 1,232 repairs. Hernia 2008;12:39–43. 15. Silvestre AC, de Mathia GB, Fagundes DJ, et al.: Shrinkage evaluation of heavyweight and lightweight polypropylene meshes in inguinal hernia repair: A randomized controlled trial. Hernia 2011;15:629–634. 16. Fortelny RH, Petter-Puchner AH, Glaser KS, et al.: Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: A systematic review. Surg Endosc. 2012;26:1803–1812.DOI:10.1007/s00464-0122156-0. Epub 2012 Jan 26. 17. Olcucuoglu E, Kulacoglu H, Ensari CO, et al.: Fibrin sealant effects on the ilioinguinal nerve. J Invest Surg 2011;24:267–272. DOI:10.3109/08941939.2011.590268. Epub 2011 Sep 27. 18. Trevisonno M, Kaneva P, Watanabe Y, et al.: A survey of general surgeons regarding laparoscopic inguinal hernia repair: Practice patterns, barriers, and educational needs. Hernia 2014;31:Epub ahead of print. 19. Ito F, Jarrard D, Gould JC: Transabdominal preperitoneal robotic inguinal hernia repair. J Laparoendosc Adv Surg Tech A 2008;18:397–399.DOI:10.1089/lap.2007.0093. 20. Joshi AR, Spivak J, Rubach E, et al.: DeNoto G Concurrent robotic trans-abdominal pre-peritoneal (TAP) herniorrhaphy during robotic-assisted radical prostatectomy. Int J Med Robot. 2010;6:311– 314.DOI:10.1002/rcs.334. 21. Finley DS, Rodriguez E, Jr, Ahlering TE: Combined inguinal hernia repair with prosthetic mesh during transperitoneal robot assisted laparoscopic radical prostatectomy: A 4-year experience. J Urol 2007;178:4 Pt 1 1296–1299. discussion 1299–300. 22. Lee DK, Montgomery DP, Porter JR: Concurrent transperitoneal repair for incidentally detected inguinal hernias during robotically
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assisted radical prostatectomy. Urology 2013;82:1320–1322. DOI:10.1016/j.urology.2013.08.028. Epub 2013 Oct 16. 23. Nakamura LY, Nunez RN, Castle EP, et al.: Different approaches to an inguinal hernia repair during a simultaneous robotassisted radical prostatectomy. J Endourol. 2011;25:621–624. DOI:10.1089/end.2010.0417. Epub 2011 Feb 28.
Journal of Surgical Oncology
24. Finley DS, Savatta D, Rodriguez E, et al.: Transperitoneal roboticassisted laparoscopic radical prostatectomy and inguinal herniorrhaphy. J Robot Surg 2008;1:269–272.Epub 2008 Jan 4. 25. Tran H Robotic single-port hernia surgery. JSLS 2011;15:309–314. DOI:10.4293/10868081113125733356198.
Robotic Inguinal Hernia Repair JOSE E. ESCOBAR DOMINGUEZ, MD,1 ANTHONY GONZALEZ, CHARAN DONKOR, MD1,2*
1,2 MD, FACS, FASMBS, AND
1
Baptist Health South Florida, Baptist Health Medical Group 2 Florida International University College of Medicine
Inguinal hernias have been described throughout the history of medicine with many efforts to achieve the cure. Currently, with the advantages of minimally invasive surgery, new questions arise: what is going to be the best approach for inguinal hernia repair? Is there a real benefit with the robotic approach? Should minimally invasive hernia surgery be the standard of care? In this report we address these questions by describing our experience with robotic inguinal hernia repair.
J. Surg. Oncol. 2015;112:310–314. ß 2015 Wiley Periodicals, Inc.
KEY WORDS: robotic TAPP; robotic herniorrhaphy; robotic hernioplasty
INTRODUCTION Hernias have been documented in history dating back to the ancient greco-roman times. It was clear that the role of surgery in hernia treatment was performed for the most part in large and incarcerated hernias. Treatment of groin hernias has gone through 5 major eras [1,2,3]: The 1st era includes the Egyptian papyrus Ebers that describes the hernia as a “swelling that comes out when one coughs.” The most essential knowledge of the hernia was derived from the Greek physician Galen, and this remained valid throughout the Middle Ages. The 2nd era began in the Renaissance and “herniology” grew rapidly as knowledge in surgical anatomy increased. The treatment however was still unsatisfactory and was done mainly for life threatening disease. In the 3rd era, anesthesia and aseptic technique led to advancement in the technique of hernia surgery. This was evidenced by significantly lower complications. Recurrence rates however, were still 100% at four years. The 19th to mid 20th century brought about the 4th era, where repair was under tension. Bassini introduced his method of hernia repair in which he reconstructed the posterior wall of the inguinal canal. Shouldice then described his repair in which he imbricated the transversalis fascia and strengthened the posterior of floor of the inguinal canal with four layers of fascia and aponeuroses. His recurrence rate was reported as 3%, a drastic improvement. The 5th era marked the repair without tension first popularized by Lichtenstein, by the use of a prosthetic component to strengthen the posterior wall of the inguinal canal. He published 1,000 cases of this type of repair and demonstrated no recurrences at 5 years. The advent of laparoscopy and robotics seem to be evolving hernia treatment to a 6th era. The first laparoscopic repair was reported in 1979 by P. Fletcher, where he laparoscopically closed the neck of the sac. In the 1990s, the two main techniques for laparoscopic hernia repair were developed and refined [4,5]. Keys to these approaches were gaining understanding of the anatomy from a posterior view. Vascular injury, bladder injury, nerve entrapment and inadequate repair were a concern in its beginning stages. The two laparoscopic herniorrhaphy techniques that are currently being performed for inguinal hernia repair are the Trans Abdominal Pre Peritoneal approach (TAPP) and the Totally Extra Peritoneal approach (TEP). To the best of our knowledge, no technique has been proven superior. Both TAPP and TEP have similar operative times, post-operative pain, return to work and recurrences. The minimally invasive technique is favored in certain patient populations including young healthy patients, patients with known bilateral inguinal hernias and recurrent hernias [6].
ß 2015 Wiley Periodicals, Inc.
TAPP herniorrhaphy can be performed either robotic or laparoscopic. Here we present our technique in robotic TAPP herniorrhaphy developed from our experience in open and laparoscopic TAPP and TEP hernia repair.
PATIENT SELECTION The general consensus is that minimally invasive hernia surgery benefits young healthy patients, patients with bilateral hernias and those with recurrent hernias. Relative contraindications may be previous laparoscopic repair, ascites [7], peritoneal dialysis and large intrascrotal hernias. We do recognize that these are relative contraindications and believe that an experienced surgeon may feel confident in more complex cases. With the advent of robotics in our hernia repairs, we have become very liberal in our patient selection and we have few contraindications to the robotic approach. Other relative contraindications may still include multiple previous abdominal surgeries, inability to tolerate pneumoperitoneum and grossly contaminated abdominal cavity that would preclude the use of a mesh.
SURGICAL TECHNIQUE When operating with the Da Vinci Si model, trocar placement and docking are paramount to performing the inguinal hernia repair robotically. Camera port is placed at the supraumbilical region and an 8 mm trocar is placed on the right and a 5 mm trocar on the left approximately 10 cm lateral and at the level of or slightly above the
The authors, Drs. Charan Donkor and Jose Ernesto Escobar Dominguez declare they have no conflict of interest. Dr. Anthony Gonzalez has received speaker honorarium from Intuitive Surgical, Cadence Pharmaceuticals and Ethicon. He has also received research grants and participated in the scientific advisory board for Minimally Invasive Devices, Inc. *Correspondence to: Charan Donkor, MD, General and Bariatric Surgery, Baptist Health South Florida, Baptist Health Medical Group—General Surgery, Associate Professor of Surgery, Florida International University College of Medicine, 7800 SW87 Avenue, Suite B210. Miami, FL 33173. Fax: 305-595-9590. E-mail: [email protected] Received 3 February 2015; Accepted 8 March 2015 DOI 10.1002/jso.23905 Published online 7 July 2015 in Wiley Online Library (wileyonlinelibrary.com).
Robotic Inguinal Hernia Repair umbilicus (Fig. 1). It is important in patients with a smaller body habitus not to place trocars too lateral as this will create difficulty when it comes to suturing laterally. The purpose of the 8mm trocar is to allow mesh and needle placement into the abdomen, allows the use of a needle driver with suture cut and the scissors with electrocautery. Docking the robot can be done with patient in lithotomy (Fig. 2) or the supine position (Fig. 3). Our position of choice is supine with moderate Trendelenburg. The robot may be docked from a side position while patient is supine, and this will allow for repair of both sides. The newer Xi model allows for simplicity in patient set up. Docking is from either side and trocars are placed at the level of the umbilicus transversely. We prefer to perform our robotic inguinal hernia repair through a transabdominal pre-peritoneal approach. The knowledge of the inguinal anatomy in this approach is different than open or TEP, the initial landmarks in the peritoneal cavity are: medial umbilical ligament (MUL, lateral umbilical ligament), internal inguinal ring, external iliac vessels and gonadal vessels. A curvilinear peritoneal incision is performed with the robotic hot shears between the anterior superior iliac spine (palpated by the assistant) and the medial umbilical ligament. An incision is created that will allow dissection of Cooper’s ligament and a peritoneal flap that will accommodate the appropriate sized mesh comfortably. Dissection of the preperitoneal fat can be done bluntly and with modest use of cautery being careful not to injure the inferior epigastric vessels. Creating too large a flap can add to the operative time in unnecessary dissection. The peritoneal flap should fit snug to the mesh without “mesh rolling.” This will also prevent mesh migration that is critical in the first two weeks after repair. When making the incision, it is prudent to be cognizant of the lateral corner, because if the flap extends too lateral, this can create technical difficulty when closing the peritoneal flap. Dissecting Cooper’s ligament, just lateral to the symphysis pubis, immediately after creating the peritoneal flap will help in recognizing the preperitoneal anatomy. It is good practice to first dissect and identify Cooper’s ligament before addressing the rest of the dissection. Having Cooper’s ligament in view serves as a useful landmark especially when the hernia sac is a large and obscuring the field of dissection. Once Cooper’s ligament is identified, a lateral dissection of the preperitoneal space is required leaving the hernia sac dissection until the end allowing an easier identification of the spermatic cord, vas deferens and the Triangle of Doom (Fig. 4). The hernia sac must be detached completely from the spermatic cord to avoid seroma formation or hernia recurrence. In cases of very large hernia sacs like inguinoscrotal hernias in which dissection may become challenging, the sac may be transected and left in place being cautious to close the peritoneal defect once the inguinal repair is done. When the decision has been made to ligate the sac, it is best to ligate at the most narrow point possible. This will reduce the size
Fig. 1.
Port placement.
Journal of Surgical Oncology
Fig. 2.
311
Patient in the lithotomy position and robot docking.
of the defect in the peritoneal flap and therefore make it easier to close without deficit.
MESH FIXATION TECHNIQUE As established by the International Endohernia Society (IEHS) guidelines the recommended mesh size is 10 15 cm, however larger meshes (i.e. 12 17 cm) are available and recommended for direct defects larger than 3 cm and indirect defects larger than 4 cm in diameter [6]. The important sites where the mesh have to be fixated are: 1) Cooper’s ligament, 2) rectus abdominis muscle (medial to the inferior epigastric vessels), and 3) Transverse abdominis fascia slightly lateral and above the internal inguinal ring (Fig. 5). This fixation can be performed either with sutures or tacks. In our experience the 3 fixation points described above are enough for intracorporeal suturing. There are many varieties of suture available. We have found the Ethicon (Ethicon US, LLC) 0 or 2–0 prolene on a CT 1 or 2 to be optimal for mesh fixation. The sutures are cut to length of 27–30 cm and are introduced into the abdominal cavity along with the mesh before docking the robot. This saves in operative time. It is recommended to place free sutures within the abdominal wall out of the field of dissection but in view. This allows for easy retrieval and prevents misplacement of the suture within the
Fig. 3.
Patient in the supine position and robot docking.
312
Escobar Dominguez et al.
DISCUSSION Currently, the main guidelines for laparoscopic inguinal hernia repair include those developed by the International Endohernia Society (IEHS) [6], the European Hernia Society (EHS) [8] and the European Association of Endoscopic Surgery (EAES) [9]. The IEHS and EHS guidelines have been recently updated (2014) [10,11] with new and or modified recommendations.
Why the Transabdominal Preperitoneal (TAPP) Repair?
Fig. 4. Right inguinal region: 1) supravesical fossa, 2) Cooper’s ligament, 3) inferior epigastric vessels, 4) transverse arch, 5) vas deferens, 6) cord elements with gonadal vessels, and 7) peritoneal flap, triangle of Doom (solid lines), Triangle of pain (dashed lines). abdominal cavity. Once suture has been used it is replaced back in the abdominal wall until ready for removal. All needle counts are confirmed with operating surgeon, surgical technologist and circulating nurse with a needle index written on the O.R board. The technique in suturing is standard to robotic suturing. The most technically challenging part of the case is suturing to Cooper’s ligament. We recommend a back hand stitch through mesh, Cooper’s ligament and again through mesh. It is sometimes easier to visualize by switching the camera from 30 degrees up to 30 degrees down. A zero degree camera scope may also be used and is often adequate for full visualization. The anterior and lateral sutures are technically easier. We place them in the anterior abdominal wall medial to the epigastric vessels and along the lateral abdominal wall (Fig. 5).
BILATERAL INGUINAL HERNIAS AND PERITONEAL CLOSURE In our approach, we create two separate peritoneal incisions creating two peritoneal flaps for either side. In comparison, when performed while doing prostatectomy, one incision is made between the two median umbilical ligaments. In our experience we consider that such dissection is not necessary, furthermore it may distort the peritoneal flap when closure is attempted. Our two separate peritoneal incisions prove to be more than adequate for the dissection. We perform one for each inguinal region (Fig. 6) sparing the supravesical fossa in the middle to keep the flaps in a normal anatomical position, the peritoneal closure is done using a Quill (Surgical Specialties Corporation) barbed absorbable monofilament suture (PDS 2-0).
Fig. 5. Mesh fixation in right inguinal region at: 1) Cooper’s ligament, 2) lateral border of rectus abdominis muscle, and 3) transverse arch (anterolateral abdominal wall). Journal of Surgical Oncology
Although both techniques show similar long term results, it has been found recently by the IEHS that TEP has a slightly higher rate of intraoperative and postoperative surgical complications (without statistical significance) when compared to TAPP including seromas and scrotal edema; however, clinical evidence supports that TAPP requires longer operative times and a longer hospital stay [10]. TAPP also offers a greater advantage over TEP regarding contralateral hernias and incarcerated hernias. Their recommended approach for recurrent inguinal hernias is the TAPP technique by surgeons with experience in such an approach. Similar statements are also mentioned by the EHS guidelines [8]. TAPP is more advantageous in the case of an incarcerated hernia, since direct laparoscopic visualization of the bowel can rule out necrosis.
Prosthetic Mesh Since the advent of prosthetic mesh implants, there has been debate as to which mesh will have the best clinical results. The majority of meshes are polypropelene based and the pore size and relative mass of the mesh are important determinants in its performance. Large pores allow improved tissue integration and less inflammatory reaction resulting in decreased mesh distortion. Some studies have shown that a light weight mesh will be as strong as a heavy weight mesh and has improved outcomes in hernia recurrence and post-operative and chronic pain [12,13,14,15], however recent IEHS guidelines do not support this [10]. The choice of mesh seems to be highly dependent on surgeon preference. Many times surgeon preference is simply what the surgeon is familiar with. In our experience we have had good results with a light weight polypropylene mesh.
Mesh Fixation Techniques and Chronic Inguinal Pain When comparing different mesh fixation techniques one major concern arises: acute and chronic inguinal pain. It has been proposed that fixation of the mesh increases acute inguinal pain
Fig. 6. Closure of bilateral peritoneal flaps with a barbed absorbable suture, note that suturing starts on the midline. 1) peritoneal opening on the left and 2) peritoneal opening on the right.
Robotic Inguinal Hernia Repair when compared to non fixation, however new evidence supports that fixation with tacks/staples versus non fixation of the mesh are equal regarding postoperative pain. The only proven fixation method to be effective to decrease acute postoperative inguinal pain is the use of fibrin glue [10,16]. Though it has not been reported to increase hernia recurrence, special consideration has to be taken when large direct or indirect defects are found, if so mesh fixation is recommended with tacks/staples or sutures. Fibrin glue has been proposed to make a protective effect in the nerves located in the inguinal region therefore decreasing the irritant effect of the mesh when placed in direct contact with the structures [17]. Prophylactic transection of the ilioinguinal nerve has not shown to be effective in decreasing chronic inguinal postoperative pain after hernia repair [10].
Popularity of Minimally Invasive Hernia Repair and Current Robotic Inguinal Hernia Surgery Experience It has been reported that in North America laparoscopic inguinal hernia repair is not widely practiced. Different studies have shown that a large number of fellowship trained surgeons do not perform minimally invasive hernia surgery. One study in particular reported that only 77% of surgeons trained in minimally invasive surgery are performing laparoscopic inguinal hernia repairs routinely [18]. The number of non fellowship trained surgeons performing minimally invasive hernia surgery is exceptionally low. Currently in the published literature the vast majority of experience in robotic inguinal hernia repair has been done by urologists [19–24] who have dealt with this clinical entity while performing robotic assisted radical prostatectomy. They have done this without reporting an increase in morbidity rates when compared to robotically assisted radical prostatectomy alone [22]. There still does not exist a reported case series of robotic inguinal hernia repair from a general surgery standpoint. This approach has not yet been described in the clinical guidelines mentioned above. A case series of robotically assisted single port hernia surgery was reported by Tran et al, however this device is a robotic control for the conventional laparoscopic camera to avoid the use of a surgical assistant and the procedure is performed in a conventional single port laparoscopic surgery [25].
CONCLUSIONS Prospective, multicenter randomized controlled trials should be performed to gain more experience in this new emerging field of minimally invasive surgery. Adoption of this technique by urologists has been proven to be safe and effective without increasing morbidity. The benefits provided by the robotic platform include better visualization, improved ergonomics and wristed movements allowing for easier dissection. These make robotic inguinal hernia repair an excellent option. With smaller numbers of surgeons performing minimally invasive hernia surgery, it is likely that with the advent of robotics, more surgeons will adopt this technique. This will translate into many more patients benefiting from minimally invasive hernia surgery. There is a cost difference when comparing robotic TAPP vs. TEP. With the elimination of the tacker and the balloon dissector, cost can be significantly decreased in the robotic technique.
REFERENCES 1. Lau WY History of treatment of groin hernia. World J Surg. 2002;26:748–759. Epub 2002 Mar 26. 2. Legutko J, Pach R, Solecki R, et al.: The history of treatment of groin hernia. Folia Med Cracov 2008;49:57–74. Journal of Surgical Oncology
313
3. Bekker J, Keeman JN, Simons MP, et al.: A brief history of the inguinal hernia operation in adults. Ned Tijdschr Geneeskd 2007;151:924–931. 4. Lokesh B, Fitzgibbons R: Laparoscopic Inguinal Hernia Repair. In: Shackelford’s Surgery of the Alimentary Tract, Seventh Edition. Yeo C, editor. Philadelphia: Elsevier; 2013. pp. 583–596. 5. Gould J. Laparoscopic versus open inguinal hernia repair. Surg Clin North Am 2008;88:1073–1081. 6. Bittner R, Arregui ME, Bisgaard T, et al.: Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011;25:2773–2843.DOI: 10.1007/s00464-011-1799-6. Epub 2011 Jul 13. 7. Silva FD, Andraus W, Pinheiro RS, et al.: Abdominal and inguinal hernia in cirrhotic patients: What’s the best approach? Arq Bras Cir Dig 2012;25:52–55. 8. Simons MP, Aufenacker T, Bay-Nielsen M, et al.: European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343–403.DOI:10.1007/s10029-0090529-7. Epub 2009 Jul 28. 9. Poelman MM, van den Heuvel B, Deelder JD, et al.: EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc 2013;27:3505–3519. 10. Bittner R, Montgomery MA, Arregui E, et al.: International Endohernia Society. Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc 2015;Feb 29:289–321. DOI:10.1007/s00464-014-3917-8. Epub 2014 Nov 15. 11. Miserez M, Peeters E, Aufenacker T, et al.: Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2014;18:151–163. DOI:10.1007/s10029-014-1236-6. Epub 2014 Mar 20. 12. Agarwal BB, Agarwal KA, Sahu T, et al.: Traditional polypropylene and lightweight meshes in totally extraperitoneal inguinal herniorrhaphy. Int J Surg 2010;8:44–47.DOI:10.1016/j. ijsu.2009.08.014. Epub 2009 Oct 22. 13. Agarwal BB, Agarwal KA, Mahajan KC: Prospective double-blind randomized controlled study comparing heavy- and light-weight polypropylene mesh in totally extraperitoneal repair of inguinal hernia: early results. Surg Endosc 2009;23:242–247. 14. Akolekar D, Kumar S, Khan LR, et al.: Comparison of recurrence with lightweight composite polypropylene mesh and heavyweight mesh in laparoscopic totally extraperitoneal inguinal hernia repair: An audit of 1,232 repairs. Hernia 2008;12:39–43. 15. Silvestre AC, de Mathia GB, Fagundes DJ, et al.: Shrinkage evaluation of heavyweight and lightweight polypropylene meshes in inguinal hernia repair: A randomized controlled trial. Hernia 2011;15:629–634. 16. Fortelny RH, Petter-Puchner AH, Glaser KS, et al.: Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: A systematic review. Surg Endosc. 2012;26:1803–1812.DOI:10.1007/s00464-0122156-0. Epub 2012 Jan 26. 17. Olcucuoglu E, Kulacoglu H, Ensari CO, et al.: Fibrin sealant effects on the ilioinguinal nerve. J Invest Surg 2011;24:267–272. DOI:10.3109/08941939.2011.590268. Epub 2011 Sep 27. 18. Trevisonno M, Kaneva P, Watanabe Y, et al.: A survey of general surgeons regarding laparoscopic inguinal hernia repair: Practice patterns, barriers, and educational needs. Hernia 2014;31:Epub ahead of print. 19. Ito F, Jarrard D, Gould JC: Transabdominal preperitoneal robotic inguinal hernia repair. J Laparoendosc Adv Surg Tech A 2008;18:397–399.DOI:10.1089/lap.2007.0093. 20. Joshi AR, Spivak J, Rubach E, et al.: DeNoto G Concurrent robotic trans-abdominal pre-peritoneal (TAP) herniorrhaphy during robotic-assisted radical prostatectomy. Int J Med Robot. 2010;6:311– 314.DOI:10.1002/rcs.334. 21. Finley DS, Rodriguez E, Jr, Ahlering TE: Combined inguinal hernia repair with prosthetic mesh during transperitoneal robot assisted laparoscopic radical prostatectomy: A 4-year experience. J Urol 2007;178:4 Pt 1 1296–1299. discussion 1299–300. 22. Lee DK, Montgomery DP, Porter JR: Concurrent transperitoneal repair for incidentally detected inguinal hernias during robotically
314
Escobar Dominguez et al.
assisted radical prostatectomy. Urology 2013;82:1320–1322. DOI:10.1016/j.urology.2013.08.028. Epub 2013 Oct 16. 23. Nakamura LY, Nunez RN, Castle EP, et al.: Different approaches to an inguinal hernia repair during a simultaneous robotassisted radical prostatectomy. J Endourol. 2011;25:621–624. DOI:10.1089/end.2010.0417. Epub 2011 Feb 28.
Journal of Surgical Oncology
24. Finley DS, Savatta D, Rodriguez E, et al.: Transperitoneal roboticassisted laparoscopic radical prostatectomy and inguinal herniorrhaphy. J Robot Surg 2008;1:269–272.Epub 2008 Jan 4. 25. Tran H Robotic single-port hernia surgery. JSLS 2011;15:309–314. DOI:10.4293/10868081113125733356198.
