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Robotic General Surgery

Editor-in-Chief Yuman Fong, MD, FACS Chairman Department of Surgery City of Hope Medical Center Duarte, California

Associate Editors Loretta Erhunmwunsee, MD Associate Professor Division of Thoracic Surgery Department of Surgery City of Hope Medical Center Duarte, California Alessio Pigazzi, MD, PhD Chief of Colorectal Surgery New York-Presbyterian/Weill Cornell Medical Center New York, New York New York, New York Dana Dale Portenier, MD Chief Division of Metabolic and Weight Loss Surgery Duke University Durham, North Carolina Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 Dina Podolsky, MD Assistant Professor Columbia University Irving Medical Center

Acquisitions Editor: Keith Donnellan Development Editor: Ariel S. Winter Editorial Coordinator: Sunmerrilika Baskar Marketing Manager: Kirsten Watrud Production Project Manager: Frances M. Gunning Manager, Graphic Arts & Design: Stephen Druding Manufacturing Coordinator: Lisa Bowling Prepress Vendor: TNQ Tech

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ISBN-13: 978-1-975192-64-8

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DEDICATION

This book is dedicated to a quiet hero of robotic surgery, Dr. Mark Hideki Kawachi.

He grew up in Southern California and graduated in 1971 from the University High School of Los Angeles. He did his schooling and training at the University of Southern California (BS in Biology, 1975; MD, 1979). He then completed Urology residency at USC in 1984 under the mentorship of Donald Skinner, MD. Dr. Kawachi first assumed practice in Southern California at the Hospital of the Good Samaritan as well as at the Children’s Hospital of Los Angeles. He rose up to be director of urology at the Pacifica Hospital of the Valley and the medical director of the surgical services at the Hospital of the Good Samaritan. In 1990, he made a huge decision to return to academic medicine and completed a 2-year Urologic Oncology Fellowship at USC. After fellowship, he joined the City of Hope Cancer Center in 1992. There, along with Dr. Tim Wilson, he developed one of the best robotic urologic programs in the country, responsible for many advances in the field as well as training a whole generation of urologic surgeons. He became one of the busiest robotic surgeons in the nation and performed over 2500 cases. Many patients would fly from across the nation to be cared for by Dr. Kawachi. He also served as President of the Los Angeles Urological Society from 2002-2003. He was also one of the kindest and most thoughtful people. He always had the best interest of the patient, and the field of urology at heart. He cared very much about the urologic fellows and the young faculty. He was beloved by everyone he encountered from administrative staff, clinics, and the OR. Even though he was quiet by nature, he had a wonderful sense of humor. He is survived by his wife Sharon, two sons Kevin and Curtis, and his daughter Mackenzi Asai.

Dr. Kawachi will always be part of the history of robotic surgery. We continue to be inspired by him.

Contributors

Kumari N. Adams, MD, FACS Director IHA Thoracic Surgery Division St. Joseph Mercy Hospital Ann Harbor Ypsilanti, Michigan

Cameron A. Casson, MD General Surgery Resident Department of Surgery Washington University in St. Louis St. Louis, Missouri

Mohamed R. Ali, MD Professor and Chief of Foregut, Metabolic, General Surgery Department of Surgery University of California, Davis Sacramento, California

Amy Chappel, MS, PA-C Physician Assistant Department of Surgical Oncology Roswell Park Comprehensive Care Center Buffalo, New York Seth A. Cohen, MD, FACS Assistant Clinical Professor Department of Surgery City of Hope National Medical Center Duarte, California

Sarah Assali, DO General Surgery Resident Department of General Surgery

Allegheny Health Network Pittsburg, Pennsylvania

Michael M. Awad, MD, PhD Professor of Surgery Department of Surgery Washington University School of Medicine St. Louis, Missouri

Kimberly R. Coughlin, MD Surgeon Department of Surgery Ascension St. John Hospital Detroit, Michigan

Conrad Ballecer, MD, MS Clinical Assistant Professor of Surgery Department of Surgery Creighton University School of Medicine Phoenix Division Phoenix, Arizona

Anthony S. Dakwar, MD Assistant Professor of Oncology Department of Surgical Oncology Roswell Park Comprehensive Care Center Buffalo, New York

Marissa Beiling, DO Resident Department of General Surgery Oregon Health and Science University Portland, Oregon Jordan O. Bray, DO Contributing Author Department of General Surgery Oregon Health and Science University Portland, Oregon

Jessica Delgado, MD, MS Urology Resident Department of Urology Jackson Memorial Hospital Miami, Florida

Jacqueline Feinberg, MD Assistant Attending Gynecology Service, Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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Contributors

Melissa M. Felinski, DO, FACS, FASMBS Assistant Professor Department of Surgery The University of Texas (UTHealth), McGovern Medical School Houston, Texas Paolo Fiorini, PhD Professor Department of Engineering for Innovation Medicine University of Verona Verona, Italy

D. Brock Hewitt, MD, MPH, MS Assistant Professor of Surgery Department of Surgery NYU Grossman School of Medicine New York, New York

Taryne A. Imai, MD, MEHP, FACS Assistant Professor of Surgery; Executive Medical Director of Surgical Simulation; Associate Program Director, Cardiothoracic Surgery Program

Division of Thoracic Surgery Cedars-Sinai Medical Center Los Angeles, California

Abigail J.B. Fong, MD Thoracic Surgery Fellow University of Pittsburgh Pittsburgh, Pennsylvania Yuman Fong, MD, FACS Chairman Department of Surgery City of Hope Medical Center Duarte, California

Ashley Kerr, BSN, RN, CNOR OR Nursing Roswell Park Comprehensive Care Center Buffalo, New York

SangMin Kim, BA Medical Student

Harvard Medical School Boston, Massachusetts

Abraham Krikhely, MD, FACS, FASMBS Assistant Professor of Surgery Department of Surgery Columbia University Irving Medical Center New York, New York

Tamara M.H. Gall, BSc(hons), MBchB, MD(res), FRCS Consultant Surgeon

Department of Hepatobiliary Surgery Mater Misericordiae University Hospital Dublin, Ireland

John P. Kuckelman, DO Thoracic Surgeon

Ginger J. Gardner, MD, FACOG Vice Chair of Hospital Programs, Department of Surgery Member, Gynecology Service Memorial Sloan Kettering Cancer Center New York, New York

Department of Thoracic Surgery Brigham and Women’s Hospital Boston, Massachusetts Clayton Lau, MD Chief, Urology and Urologic Oncology Department of Surgery City of Hope National Medical Center Duarte, California

Kathryn E. Goldrath, MD Minimally Invasive Gynecologic Fellow Department of Obstetrics and Gynecology University of California, Los Angeles Los Angeles, California

Vincent P. Laudone, MD Chief of Surgery, Josie Robertson Surgery Center Memorial Sloan Kettering Cancer Center

Jesse Gutnick, MD Staff Surgeon Department of General Surgery Fairview Hospital/Cleveland Clinic Cleveland, Ohio

Jeroen Hagendoorn, MD, PhD HPB Surgeon Department of Surgical Oncology University Medical Center Utrecht Utrecht, The Netherlands Diego L. Lima, MD, MSc General Surgery Resident Department of Surgery Montefiore Medical Center The Bronx, New York Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 Professor of Clinical Urology Weill Cornell Medical College New York, New York

Contributors

Lea Lowenfeld, MD Assistant Professor of Surgery Division of Colon and Rectal Surgery, Department of Surgery Weill Cornell Medicine New York, New York Fabrizio Luca, MD, FACS, FASCRS, FSSO Professor of Surgery - Chief, Division of Colon and Rectal Surgery Department of Surgery Loma Linda University Health Loma Linda, California

Izaäk Quintus Molenaar, MD, PhD Professor of HPB Surgery HPB Surgery Regional Academic Cancer Center Utrecht University Medical Center Utrecht Utrecht, The Netherlands

Sara Monfared, MD Surgery Fellow Department of Surgery McGovern Medical School University of Texas Health Science Center at Houston Houston, Texas

Ali Mouzannar, MD Urologic Oncology Fellow

Victoria Lyo, MD, MTM, FACS Assistant Professor of Surgery Department of Surgery University of California Davis Sacramento, California

Department of Surgery/Urology Service Memorial Sloan Kettering Cancer Center New York, New York Vignesh Narasimhan, FRACS, PhD Colorectal Surgeon Department of Colorectal Surgery Monash Health Melbourne, Victoria, Australia Vahagn C. Nikolian, MD Assistant Professor of Surgery Department of Surgery Oregon Health & Science University Portland, Oregon Carolijn L.M.A. Nota, MD, PhD Surgical resident Department of Surgery University Medical Center Utrecht Utrecht, The Netherlands Yuri W. Novitsky, MD, FACS Professor of Surgery Director, Columbia Hernia Center Chief, Division of Abdominal Wall Surgery Department of Surgery Columbia University Medical Center New York, New York Steven J. Nurkin, MD, MS, FACS Chief of Colorectal Surgery Department of Surgical Oncology Roswell Park Comprehensive Care Center Buffalo, New York

Flavio Malcher, MD, MSc Director, Center for Abdominal Core Health Department of Surgery

NYU Langone Health New York, New York

John Marks, MD Chief of Colon and Rectal Cancer, Main Line Health

Lankenau Medical Center Wynnewood, Pennsylvania

M. Blair Marshall, MD Associate Chief for Quality, Promotions, Mentorship, and Inclusion Division of Thoracic and Cardiac Surgery Brigham and Women’s Hospital Boston, Massachusetts

Sukrant K. Mehta, MD, FACOG Clinical Assistant Professor

Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA Los Angeles, California

Laleh G. Melstrom, MD, MSCI, FACS Associate Professor of Surgery and Immuno ‐ Oncology Department of Surgery City of Hope Medical Center Duarte, California Leah Plumblee, MD, MS Resident Physician Department of General Surgery Medical University of South Carolina Charleston, South Carolina Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 Meenal Misal, MD Assistant Professor Department of Obstetrics and Gynecology Ohio State University Wexner Medical Center Columbus, Ohio

Contributors

Rana C. Pullatt, MD, FACS, FASMBS Director Bariatric and Robotic Surgery Medical University of South Carolina Charleston, South Carolina

Kevin M. Sullivan, MD Assistant Professor Louisiana State University New Orleans, Louisiana

Matthew M. Symer, MD, MS Research Fellow Center for Intelligent Image-guided Interventions Weill Cornell Medicine New York, New York

Mustafa Raoof, MD, FACS Assistant Professor Department of Surgery, Cancer Genetic and Epigenetics City of Hope Comprehensive Cancer Center Duarte, California Ashley A. Sanchez, BSN Medical Student Frank H Netter MD School of Medicine at Quinnipiac University North Haven, Connecticut

Nova Szoka, MD, FACS, FASMBS Assistant Professor Department of Surgery West Virginia University Morgantown, West Virginia Camryn A. Thompson, BS MD Student Duke University School of Medicine Durham, North Carolina

Lana Schumacher, MD Thoracic Surgeon Assistant Professor, Harvard School of Medicine Department of Surgery Massachusetts General Hospital Boston, Massachusetts Shinil K. Shah, DO, EdD Associate Professor Department of Surgery McGovern Medical School at UTHealth Houston, Texas Sara Shahrestani, BSc (Hon I), MD, PhD Surgical Registrar Sydney Medical School University of Sydney Sydney, New South Wales, Australia Allison M. Sih, MD Reconstructive Urology Fellow Division of Urology Department of Surgery City of Hope National Medical Center Duarte, California Camille Stewart, MD Assistant Professor of Surgery Division of Surgical Oncology Department of Surgery University of Colorado School of Medicine Aurora, Colorado Zachary E. Stiles, DO, MS Clinical Assistant Professor Department of Surgical Oncology Roswell Park Comprehensive Cancer Center Buffalo, New York

Andrew B. Thornton, MD Surgery Resident Columbia University Irving Medical Center New York, New York

Allan Tsung, MD Chief of Surgery University of Virginia Charlottesville, Virginia Simone L. Vernez, MD Department of Urology City of Hope Duarte, California

Joshua J. Weis, MD Assistant Professor Department of Surgery UT Houston Health Science Center Houston, Texas

Martin R. Weiser, MD Attending Surgeon, Stuart Quan Chair in Colorectal Surgery Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York Erik B. Wilson, MD Professor of Surgery Department of Surgery McGovern Medicine School UT Houston Health Science Center Houston, Texas Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

Contributors

Yanghee Woo, MD Associate Professor Division of Surgical Oncology Department of Surgery City of Hope Duarte, California Jane Yang, MD MIS-Colorectal Fellow Department of Colorectal Surgery

Zhizhou Yang, MD Surgical Resident Department of Surgery Massachusetts General Hospital Boston, Massachusetts Bertram Yuh, MD, MSHCPM, MISM Professor of Surgery City of Hope Cancer Center Duarte, California

Lankenau Medical Center Wynnewood, Pennsylvania

Preface

ROBOTIC SURGERY: EVOLUTION OF MIS SURGERY TO COMPUTER-AIDED AND DATA-SUPPORTED Robotic surgery has reached maturity. With over ten million procedures performed worldwide, these optically enhanced, minimally invasive procedures are allowing pre cise, complex technical surgery with rapid recovery. Once a discipline with only one FDA-approved choice in robot, new robotic platforms are now entering the market and helping drive innovation and adoption. The field of robotic surgery is evolving rapidly. Originally, robotic surgeries were only suitable for procedures restricted to a small surgical field such as for prostate or gynecologic surgery. New robotic platform designs now allow for surgery in most organs and for large surgical fields. Novel robotic designs also now allow for natural orifice (transluminal) surgery. As an academic field, robotic surgery is continuing to evolve to include use of artificial intelligence, automation, and telesurgery: all areas that will soon distinguish robotic surgery from manual laparoscopic surgery. Much data are accumulating to support the advantages of robotic surgery in terms of safety and benefits to patients. This book will present the technical aspects of many procedures as well as the clinical data that underlie the current state of the art. Robotic surgery has also been deployed worldwide. The authorship of this book reflects the international expertise that has been acquired in robotic surgery. The con tents have been chosen to reflect the practice of this technical field worldwide. With wide deployment of robots in South Korea, China, and Europe, and with recent approval for reimbursement in Japan, there will be an increasing demand for educational materials for the robotic surgeon at the entry level, as well as for the robotic surgeon expanding their repertoire. The book is separated into two parts. In the first section, the history, technical prin ciples of robotic surgery, various platforms including emerging platforms, and robotic training will be presented. In the second, practice of robotic surgery according to sur gical discipline will be presented. It will include procedures from surgical disciplines ranging from gastrointestinal surgery to endocrine surgery because it aims to be defin itive. It is also intended for robotic surgeons to see emerging technologies, and see the tricks and tools used in other disciplines for retasking in their own field. The goals of this volume are (1) to review the basics of robotic surgery including technology, facil ities, and program building; (2) discuss data-based support for use of robotic surgery in various specialties; and (3) discuss key issues related to cost, adoption, and training. This is meant to be a definitive but manageable text on the practice of robotic surgery. This book is intended to summarize the field for current and future practitioners at all levels. It is meant to be a guide for residents and fellows entering the field. It is meant to summarize the current state of the art for surgeons. It is meant as a primer for senior surgeons adapting newer technologies to their current practice. We hope that our audience of surgeons will find this useful.

A work like this is only possible because of the contributions of many. The author ship of this work includes experienced surgical oncologists, general surgeons, thoracic surgeons, gynecologic oncologists, urologists, and bariatric surgeons. We thank them for their contributions and efforts to collaborate in the creation of this comprehensive and accessible work. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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We also thank our teachers, residents, clinical fellows, and colleagues who have shared their knowledge and experience with us. We thank our patients who inspire us to constantly strive to improve the field and to be superior clinicians and technical surgeons. We thank our editors at Wolters Kluwer, Kieth Donovan and Ariel S. Winter for their guidance and feedback. Finally, we thank our families, for the patience and support they give us daily for our clinical work, and then to complete a work such as this.

Yuman Fong Loretta Erhunmwunsee Alessio Pigazzi Dina Podolsky Dana Dale Portenier

Contents

Contributors

vii

Upper Gastrointestinal Surgery 11. Antireflux Surgery 105

Preface

xiii

Cameron Casson and Michael M. Awad

SECTION 1 Background 1. History of Robotic Surgery 3 Paolo Fiorini and Yuman Fong 2. Current Robotic Platforms: Da Vinci Multiport, Da Vinci Single Port, Senhance, Versius, Hugo, Monarch, and Ion 13 Sarah Assali and Nova Szoka 3. Imaging and Display in Robotic Surgery Including Near-Infrared Fluorescence and Augmented Reality 25 Camille Stewart and Abigail J.B. Fong 4. The Robotic Team, Workflows, and Emergencies in Robotic Surgery 37 Zachary E. Stiles, Anthony S. Dakwar, Amy Chappel, Ashley Kerr, and Steven J. Nurkin 5. Simulation, Training, and Credentialing in Robotic Abdominal Surgery 45 Sara Shahrestani and Tamara M.H. Gall General Surgery 6. Robotic Transabdominal Preperitoneal Inguinal Hernia Repair With Mesh 53 Jordan O. Bray, Marissa Beiling, and Vahagn C. Nikolian 7. Robotic Extraperitoneal Repairs for Midline Hernias 65 Flavio Malcher, Diego L. Lima, and Conrad Ballecer 8. Ventral Hernia Repair—Robotic Transversus Abdominis Release 75 Kimberly R. Coughlin and Yuri W. Novitsky Bariatric Surgery 9. Robot-Assisted Bariatric Surgery 81 Leah Plumblee and Rana C. Pullatt 10. Revisions for Bariatrics: Indications, Techniques, and Outcome 95 Sara Monfared, Joshua J. Weis, Melissa M. Felinski, Shinil K. Shah, and Erik B. Wilson SECTION 2 Discipline-based Practice

12. Heller Myotomy 111

Victoria Lyo and Mohamed R. Ali 13. Gastric Surgery: Total Gastrectomy, Partial Gastrectomy, and Surgery for GIST 119 Yanghee Woo 14. Robotic Splenectomy 135 Kevin M. Sullivan and Mustafa Raoof Colorectal Surgery 15. Robotic Right and Left Colectomies With Complete Mesocolic Excision and Intracorporeal Anastomosis 147 Vignesh Narasimhan and Martin R. Weiser 16. Low Anterior Resection and Abdominoperineal Resection 157 Fabrizio Luca 17. Robotic Surgery for Inflammatory Bowel Disease 163 Matthew M. Symer and Lea Lowenfeld 18. Robotic Transanal Surgery (TaTME and Transanal Local Excision) 177 John Marks and Jane Yang

Hepatobiliary and Pancreatic Surgery 19. Robotic Cholecystectomy 185

Andrew B. Thornton and Abraham Krikhely

20. Distal Pancreatectomy 195 D. Brock Hewitt and Allan Tsung 21. Pancreaticoduodenectomy 207

Carolijn L.M.A. Nota, Izaäk Quintus Molenaar, and Jeroen Hagendoorn Thoracic Surgery 23. Esophageal Surgery (Cancer, Esophageal Diverticula, Stricture) 233 SangMin Kim, Zhizhou Yang, John P. Kuckelman, and M. Blair Marshall Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 22. Robotic Liver Resection 219 Kevin M. Sullivan and Laleh G. Melstrom

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24. Lung Surgery 245

Urologic and Gynecologic Surgery 28. Robotic Radical and Partial Nephrectomy 279 Simone L. Vernez and Clayton Lau 29. Robotic-Assisted Laparoscopic Radical Prostatectomy 289 Jessica Delgado, Ali Mouzannar, and Vincent P. Laudone 30. Ovarian and Uterine Surgery 299 Jacqueline Feinberg and Ginger J. Gardner 31. Benign Gynecologic Procedures 315 Kathryn E. Goldrath, Allison M. Sih, Sukrant K. Mehta, Meenal Misal, and Seth A. Cohen Index 329

Camryn A. Thompson, Ashley A. Sanchez, and Lana Schumacher

25. Mediastinal Procedures 253 Kumari N. Adams 26. Transbronchial Procedures 263 Taryne A. Imai

Endocrine Surgery 27. Robotic Adrenalectomy 273 Bertram Yuh and Jesse Gutnick

CHAPTER 7

Robotic Extraperitoneal Repairs for Midline Hernias Flavio Malcher, Diego L. Lima, and Conrad Ballecer

INTRODUCTION Ventral hernia repair (VHR) is one of the most per formed general surgery procedures, and the use of robotic approaches has been increasing. 1 More than two million laparotomies are performed annually in the United States, and an estimated 200,000 patients require incisional hernia repair each year. 2 Minimally invasive hernia repair ensures shorter length of stay, less post operative pain, lower surgical site infection rates and faster return to work. 3 The robotic platform is being increasingly used due to its enhanced 3D visualization, ergonomics, precision, and ability to operate high on the anterior abdominal wall as compared with standard lap aroscopy. These features allow for improved and natural intracorporeal suturing and fascial closure, extraperito neal placement of mesh, and more precise movements. 4 The robotic-assisted repair trends to be the natural pro gression of minimally invasive hernia surgery. 5,6 The literature has shown that placing mesh intra-ab dominally may increase adhesions with an increased likelihood of bowel fistula or erosions. 7,8 The robotic platform allows more precise and complex movements, enabling the surgeon to better explore different layers of the abdominal wall and allowing mesh placement in a sublay position, with no contact to the viscera. Different surgical techniques for VHR have been described through the years. Many authors have described the laparoscopic approach to VHR with the positioning of an intraperitoneal underlay mesh. 9,10 The transabdominal preperitoneal (TAPP) approach confers the possible advantage of minimal adhesion formation, even with the use of a noncoated mesh, since there is no direct contact between the mesh and the intra-abdomi nal structures. 11 Compared with laparoscopic repair, the robotic approach can facilitate the creation of peritoneal flaps and mesh fixation by suture. Furthermore, another advantage of the robotic approach is the ease to close the fascial defect, which traditionally has been the challeng ing task during a fully laparoscopic TAPP repair. 12 The Rives-Stoppa technique with the placement of mesh in the retromuscular space has been widely used for

open VHR. Its advantages are low rates of surgical-site infection and recurrence with restoration of the abdom inal wall functionality and avoiding any complication that would surface with an intraperitoneal mesh. 13-15 The enhanced-view extraperitoneal (eTEP) technique was first described by Dr. Jorge Daes for minimally inva sive inguinal hernia repairs. 16,17 The surgical steps of this technique are a fast and easy creation of extraperitoneal domain, flexible trocar setup, and a large operative field. The eTEP access for VHR was first described by a mul ticenter study by Belyansky et al. 18 Recently, the robot ic-assisted approach was reported with good short-term results. 19 Schroeder et al described the laparoscopic transab dominal technique for VHR using a lateral approach to the retromuscular plane by opening the posterior rectus sheath. 20 Although the procedure was safe and effective, the authors concluded that it was technically demanding to do it laparoscopically. With the advance of the robotic platform, surgeons have been able to per form the transabdominal retromuscular (TARM) tech nique. 21 Operative findings and outcomes from different approaches are summarized in Table 7.1 . In this chapter, we discuss different robotic surgical preperitoneal approaches for ventral hernia repair.

INDICATIONS AND PATIENT SELECTION Robotic eTEP, TAPP, and TARM have different indica tions. Computed tomography (CT) is needed to better evaluate complex or atypical ventral hernias. It can also help in identifying the location of previous meshes in recurrent hernias, evaluate alternative diagnosis such as abscess, seroma, hematoma, and endometrioma. Finally, the CT scan can help in the surgical planning and the best location to enter the abdomen without injuring any important structure. Primary small umbilical her nias can be evaluated by physical examination with no need for imaging. 31 Robotic TAPP (R-TAPP) is used for hernia defects with a defect width of less than 6 cm, in which component separation is not needed. The repair is limited to the size of the peritoneal flap. Larger fascial Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

SECTION 2 • Discipline-Based Practice - General Surgery

TABLE 7.1 Operative Findings and Outcomes in the Literature Authors N Rege et al 30 35 TARM NR NR 100.06 ± 16.89 5.11 ± 0.05 1 y LOS, Length of hospital stay; N/A, not applicable; NR, not reported; OT, operative time. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 Surgical Technique Defect Size (cm 2 ) Mesh Size (cm 2 ) OT (min) LOS Follow-Up Belyansky et al 19 29 eTEP 5.9 ± 2.7 (1.5-10.7) 532.7 ± 162.9 (240.0-840.0) N/A 0.3 ± 0.5 (0-1) (x̃ = 0) 31 ± 8.4 (24-60) months Lu et al 22 206 eTEP 5.5 ± 1.8/7.1 ± 2.6 526.3 ± 294.7/507.5 ± 178.6 120.4 ± 35.0/174.7 ± 44.9 0.2 ± 0.9/0.1 ± 0.5 5.7 ± 4.9/5.5 ± 5.9 mo Morrell et al 23 74 eTEP 5.6 (range 2-25) 456.5 (range 150-630) 174.4 (range 66-301) 1.5 (range 0-4) 231.5 (45-508) d Kudsi et al 24 153 ETEP 15.7 (11.8-1.8) 225 (225-300) 89 (60-120) NR mean 26.1 mo Kudsi et al 24 156 TAPP 3.1 (3.1-7.4) 113 (63.6-180) 58.5 (45-72) NR mean 26.1 mo Gonzalez et al 25 368 TAPP NR NR 89 (25-393) 1 30 d Allison et al 26 13 TAPP 37.39 ± 35.6 NR 131 ± 57 2.4 ± 1.1 d (range 0.25-10.0) median 23 mo Baur et al 27 118 TAPP 8.8 ± 9.4 107.8 ( ± 56.0) 82.9 ( ± 21.0) 1.5 ( ± 0.6) >6 wk Kennedy et al 28 63 TAPP 3.98 ± 2.61 NR 158.84 ± 61.5 min NR >1 mo Sharbaugh et al 29 61 TAPP NR NR NR NR 625.6 d

CHAPTER 7 • Robotic Extraperitoneal Repairs for Midline Hernias

defects greater than 7 or 8 cm or that requires compo nent separation or long “Swiss-cheese” defects are rela tive contraindications for the R-TAPP approach due to its challenging dissection. The initial indication proposed by the pioneers of the eTEP repair was primary ventral hernias associated with diastasis. There is no consensus in the literature regarding incisional hernias, body mass index (BMI), or defect size. Patients should undergo a CT scan of the abdomen and pelvis preoperatively for surgery planning. A minimal unilateral width of the rectus should be of 7.5 cm to allow proper working space for the robotic arms. Slimmer rectus may require transabdominal access ( Figure 7.1 ). A prior incision from xiphoid process to the pubic bone is a relative contraindication for eTEP. 18 Previous mesh in retromuscular or intra-abdominal posi tion; patients with contraindication for general anes thesia; and incarcerated or strangulated hernias, skin ulcerations, enterocutaneous fistulas, BMI higher than 35 kg/m 2 , and loss of domain are also contraindications to the procedure. 24,32-35 The patient is placed in the supine position. The abdom inal cavity is accessed via a Veress needle, Hasson technique, or optical entry, and pneumoperitoneum is obtained. It is important to place the three trocars as far from the defect as possible without sacrificing range of motion based on potential collision. A 12- or 8-mm trocar for the camera is placed as far lateral to the ipsi lateral edge of the defect. As a general rule the camera trocar should be a minimum of 15 cm away from the ipsilateral edge of the hernia as this allows for ideal visu alization, dissection, and instrumentation on the side SURGICAL TECHNIQUES Robotic TAPP

closest to the ports. The two additional trocars should be at least 8 mm from the camera port in order to reduce collisions. An 8-mm robotic trocar is placed in the lower lateral abdomen, and the initial 5-mm optical trocar is then replaced with an 8-mm trocar. Final configuration of the trocars for a da Vinci Xi robot are typically in a V configuration. Additional trocars on the contralat eral abdomen or an assist trocar is typically unneces sary; however, it can be inserted if the surgeon deems it necessary. Once ports are placed, the robot is docked directly over the lateral abdomen in line with the trocar sites. Optimal instrumentation consists of a grasper, monopo lar scissors, and a needle driver. A 30° up scope is used to begin the case and may need to be switched to a 0 ° or 30 ° down when progressing to the contralateral abdomen. First, the anterior abdominal wall is cleared of all adhesions to better delineate the full extent of the hernia defect as well as to identify any other sites of hernia tion. It is important to dissect carefully using monopolar energy as well as blunt dissection, as to avoid injury to the peritoneum, bowel, or omentum. An enterotomy can increase the risk of conversion to an open procedure, use of biologic mesh/primary closure, or the need for staged repair. Once adhesiolysis is complete, the peritoneal flap can be created ( Figure 7.2 ). Starting a minimum of 5 cm from the edge of the defect the peritoneum is incised using the scissors. Ideally this is made within the visible preperitoneal fat that underlies the rectus muscle. The preperitoneal plane is developed widely in a cephalad-to-caudad direction with a combination of blunt and sharp dissection. This is done by sweeping the blunt edge of the scissors to separate the peritoneum off the posterior sheath as well as using monopolar cautery carefully at areas of visi ble bleeding. The traction on the peritoneum should be

A FIGURE 7.1 CT scans of ideal indications for eTEP versus TAPP approaches for robotic repair. A, eTEP indication with 2-cm umbilical hernia defect associated with diastasis (5 cm in yellow) and wide bilateral rectus width (10 cm each side). B, Isolated small umbilical hernia defect (2 cm) without diastasis. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 B

SECTION 2 • Discipline-Based Practice - General Surgery

FIGURE 7.2 Robotic TAPP. A, Peritoneal flap creation 5 cm lateral to the defect. B, Final preperitoneal space dissection with closed defect. C, Self-gripping mesh in place. D, Final aspect of closed peritoneal flap.

gentle to avoid tearing. During dissection of the perito neum off the hernia sac, separation of tissues without creating peritoneal defects may not always be possible. These peritoneal defects can be closed with absorbable sutures or patched with the pseudosac. These defects should be repaired because if left, an intraparietal hernia can occur resulting in acute incarceration or strangula tion of omentum or bowel. The hernia sac is reduced and the dissection continues laterally. It is important to dissect the preperitoneal plane widely, 5 cm in all direc tions from the defect, in order to allow for the placement of an adequately sized mesh. If the peritoneum becomes too thin, conversion to retromuscular mesh placement versus an intraperitoneal onlay mesh can be considered. After the preperitoneal space is widely dissected, the hernia defect is primarily closed with long-lasting absorb able barbed suture in a running fashion starting approxi mately 5 to 8 mm from the fascial edge. Desufflation of the abdomen to a pressure of 6 to 8 mm Hg and adequate relaxation by anesthesia will facilitate primary closure of

the defect under less tension. The subcutaneous tissue at the dome of the defect is incorporated within the primary closure, obliterating the anterior dead space in order to minimize risk of seroma formation. Once closed, the fas cial defect size is measured once it is important to select a mesh that has 5 cm overlap in all directions. The mesh is introduced via the 8-mm trocar and placed flat against the abdominal wall. Four cardinal sutures or tacks are placed to approximate the mesh against the abdominal wall and prevent mesh migration. Additional circumferential sutures or double crown tacks are placed to ensure flat placement of mesh against the anterior abdominal wall. A fibrin sealant can also be used. Following adequate fixation and hemostasis, the peri toneum is reapproximated to completely cover the mesh with running absorbable barbed suture or tacks. All port sites are removed under direct visualization, and pneu moperitoneum is released. A 10-mm or greater port site fascia is closed with absorbable suture.

CHAPTER 7 • Robotic Extraperitoneal Repairs for Midline Hernias

ROBOTIC-ENHANCED TOTALLY EXTRAPERITONEAL The eTEP Rives-Stoppa approach for ventral hernias was the combination of two surgical techniques: the eTEP first developed for challenging minimally invasive surgery inguinal hernia repairs with the Rives-Stoppa retromuscular mesh placement. The key steps of the eTEP Rives Stoppa technique are: l Development of the retrorectus space and placement of the ports l Crossover of the midline l Development of the midline preperitoneal space and connection of the bilateral retrorectus spaces l Closure of the defect and restoration of linea alba l Mesh placement and fixation The patient is placed in the supine position. The patient’s hips are placed over the operating table’s flex ion point. The bed is flexed, extending the working space between the subcostal margin and the anterior superior iliac spine (ASIS) to create more space for port placement. Next, upon preoperative review of cross-sec tional CT imaging, the width of the retrorectus space and the position of the semilunar line is measured and subsequently marked on the patient. A 5-mm Fios port (Applied Medical) is placed in the left upper quadrant (LUQ) just medial to the semilunar line. If there are prior scars or procedures at the patient’s left side, the same approach can be performed in the right side. The retro muscular space is identified under vision after travers ing the anterior sheath and rectus muscle, then the port is directed inferiorly at a 45° angle and insufflation is initiated. Blunt dissection is performed to allow space for the second port placement 7 to 8 cm below the LUQ port 1 cm medial to the semilunar to avoid any injury to the neurovascular bundles. A spinal needle is uti lized to ensure a safe tract into the retrorectus space,

and an 8-mm robotic port is placed under direct vision. Electrocautery with a hook or Maryland dissector is used to create space inferiorly for an additional 8-mm robotic port at the left lower quadrant, 7 to 8 cm infe riorly, 1 cm medial to the semilunar line again. The camera is switched to the inferior port to complete the dissection superiorly, providing good exposure prior to docking the robot, and the initial 5-mm optical trocar is exchanged for an 8-mm robotic port. The robot is docked from the right side of the patient. The dissection should start lateral to medial toward the linea alba performing a crossover at the epigastric area, taking advantage of the preperitoneal fat tissue of the falciform ligament of the liver, starting by transecting the left posterior rectus sheath 1 cm lateral to the linea alba, dissecting posteriorly to the linea alba, and reaching the right retrorectus space by opening the right posterior rectus sheath. The hernia sac should be identified, and its contents reduced into the abdominal cavity. After the dissection is complete, any opening on the peritoneum or posterior fascia is closed using running 3-0 barbed sutures. If the patient has a concomitant dias tasis, it should be plicated, including the hernia defect’s closure in cases with a concomitant hernia defect with a running 0 barbed slowly absorbable or nonabsorbable suture ( Figure 7.3 ). Mesh might be fixed in a few points with 0 Vicryl interrupted sutures to help position it; once the mesh lays flat in the retrorectus space, the abdomen should be deflated completing the procedure. Drains are not routinely used. ROBOTIC TRANSABDOMINAL RETRORECTUS MUSCLE REPAIR In this technique, the patient is placed in a supine posi tion, pneumoperitoneum is created, and three flank ports are positioned in the left flank at the midclavicu lar line between the 12th rib and the ASIS. The robot is

A FIGURE 7.3 Robotic eTEP. A, Diastasis (green lines) plication with barbed suture. Left recuts (LR), right rectus (RR), preperitoneal fat (PF). B, Retromuscular mesh positioning under the plicated LA (blue line). Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 B PF RR RR

SECTION 2 • Discipline-Based Practice - General Surgery

docked from the patient’s right side, adhesions are lysed when necessary, and the hernia content is reduced. After preop CT is reviewed and the width of the rectus deter mined, the posterior rectus sheath is incised 1 cm medial to the semilunar line (usually 6-7 laterally to the midline defect) and the left retromuscular space is created until the linea alba is reached. The crossover follows the steps described for the eTEP technique. The defect and the diastasis are closed with a barbed suture ( Figure 7.4 ). A polypropylene mesh is placed in the retromuscular space and might be fixated using minimal transfascial sutures. The left posterior rectus sheath initial incision is closed with a running barbed suture after hemostasis is confirmed. The pneumoperitoneum is desufflated. Ports are removed under direct view, and the incision is closed properly. Drains are not routinely used. POSTOPERATIVE CARE, COMPLICATIONS, AND OUTCOMES Patients who undergo robotic extraperitoneal VHR are typically discharged home on the same day. Diet is advanced as tolerated, and patients are encouraged to ambulate early to prevent thromboembolism and post operative ileus. Postoperative ileus and pain are the most common causes for admission. Patients are discharged home when they tolerate oral intake, pain is controlled without the need for intrave nous medication, and they are ambulating. Postoperative pain is typically well controlled with oral nonsteroi dal anti-inflammatory agents with less than 3 days of narcotic requirements. Patients can use compressive abdominal binders for at least 4 weeks and are encour aged to resume normal activity but avoid lifting objects over 10 lb or doing physically strenuous activity for 4 to 6 weeks. Patients who are discharged with drains are

seen 1 to 2 weeks after surgery. The drain is removed when there is less than 50 mL drained daily. Patients with no drains have their first postoperative clinic visit 4 weeks after surgery. Outcomes Most patients do well after either an R-TAPP or retrorec tus repair. Common postoperative complications include seroma, hematoma, bleeding, and surgical-site infection. Recurrence rates range in the literature from 1% to 13% for either technique 22 ( Table 7.2 and Figure 7.5 ). Complications There are different postoperative complications reported in the literature: surgical-site infection, seroma, bleeding, hematoma, acute interparietal herniation, chronic pain, and recurrence ( Table 7.3 ). Seroma Seroma is caused by a fluid collection that presents between the mesh and the hernia sac. It typically pres ents in the first 2 weeks after surgery and does not require any intervention in most cases. Seroma is the most common complication, and it can occur in up to 18% of eTEP cases. Seroma is usually reabsorbed after 4 to 6 weeks. In patients with symptomatic seromas or seromas that persist for more than 3 months, it can be drained or aspirated under sterile conditions. The use of binders is a prophylactic measure to avoid seroma formation. Hematoma and Bleeding A postoperative hematoma is usually self-limiting and requires intervention only if it becomes infected. Bleeding

C FIGURE 7.4 Robotic TARM. A, The left retromuscular space is created until the linea alba is reached. B, The crossover follows the steps described for the eTEP technique. C, The defect and the diastasis are closed with a barbed suture. D, The posterior rectus sheath is closed with a running barbed suture after hemostasis is confirmed. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 D

CHAPTER 7 • Robotic Extraperitoneal Repairs for Midline Hernias

TABLE 7.2 Seven-Year Outcomes Comparing rv-TAPP and r-Rives Techniques in a Single Center

rv-TAPP ( n = 88)

r-Rives ( n = 30)

p -Value

Outpatient procedure n (%)

(17.0)

(10.0)

0.354

( ± 0.6)

( ± 1.7)

Length of hospital stay, days, mean (SD)

<0.001

1.5

2.7

VAS score on postoperative day 1, mean (SD) a

( ± 2.0)

( ± 1.5)

2.3

2.6

0.529

Adverse Events

Surgical-site occurrence, n (%)

(18.2)

(30.0)

0.171

Seroma , n (%)

(15.9)

(23.3)

0.358

<0.001

–Grade I

(1.1)

–Grade II

(12.5)

(16.7)

–Grade III

(2.3)

(0.0)

–Grade IV

(6.7)

Hematoma , n (%)

(3.4)

(10.0)

0.155

Skin necrosis , n (%)

(3.3)

0.085

Unscheduled presentation due to pain

(5.7)

(3.3)

0.613

Delayed onset of intestinal transit, n (%)

(1.1)

(3.3)

0.557

Pulmonary embolism, n (%)

(2.3)

0.405

Clavien-Dindo, n (Patients)

Grade I

(20)

(8)

0.661

Grade II

(2)

0.405

Grade III

(1)

0.085

Grade IV

(1)

0.085

( ± 5.6)

( ± 8.1)

CCI, mean (SD)

2.7

4.4

0.191

Follow-up after 6 wk, n (%)

Done

(84.1)

(93.3)

0.201

Recurrence

1,000

Abdominal wall pain

(6.7)

0.161

Seroma

(13.3)

(25.0)

0.155

Hematoma

(1.3)

(3.7)

0.446

CCI, Charlson Comorbidity Score; r-Rives, robotic transabdominal retrorectus mesh implantation (r-TARUP); rv-TAPP, robotic ventral transabdominal preperitoneal mesh implantation; SD, standard deviation; VAS, visual analog scale (from 1, no pain, to 10, worst pain). Modified from Baur J, Ramser M, Keller N, et al. Robotic hernia repair II. English version: robotic primary ventral and incisional hernia repair (rv-TAPP and r-Rives or r-TARUP). Video report and results of a series of 118 patients. Chirurg. 2021;92(suppl 1):15-26. a For patients with hospital stay. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

may occur due to adhesiolysis from cutting the omentum or adhesive bands. Surgeons should avoid deep sutures, and it is important to identify the epigastric vessels to avoid injury. Acute Interparietal Herniation Patients can present with signs and symptoms of small bowel obstruction acutely after surgery. This may hap pen due to interparietal herniation. A disruption in the

preperitoneal flap or small holes in the flap that were not properly closed in TAPP repairs may be responsible for herniation of small bowel. In eTEP repairs, the dis ruption of the posterior rectus sheath can lead to small bowel herniation and obstruction symptoms. This will present with an acute postoperative obstruction. Cross sectional imaging can be obtained to confirm the find ing. These acute cases should be brought back to the operating room to deal with the posterior sheath defect.

SECTION 2 • Discipline-Based Practice - General Surgery

Kaplan-Meier curve for 5-year recurrence, by year of surgery ( n = 644)

Kaplan-Meier curve for 5-year recurrence, by type of surgery ( n = 644)

100

2014 or earlier 2015 2016 2017 2018 2019 2020

rIPOM rTAPP rRS rTAR

Freedom from Recurrence (%)

Log-rank P -value: .30

Log-rank P -value: .03

Years

2014 or earlier 2015 2016

rIPOM rTAPP rRS

196 (100%) 152 (100%) 153 (100%) 138 (100%)

46 (100%) 101 (100%) 131 (100%) 86 (100%) 109 (100%) 120 (100%) 51 (100%)

158 (98.8%) 135 (97.8%) 98 (98.2%) 76 (100%)

151 (95.6%) 120 (96.4%) 38 (98.2%) 36 (100%)

38 (100%) 81 (96.4%) 99 (97.1%) 71 (100%) 89 (98.9%) 93 (100%) 0

139 (94.3%) 90 (95.6%) 18 (98.2%) 6 (100%)

56 (94.3%) 29 (93.3%) 0 1(100%)

94 (94.3%)

37 (97.4%) 75 (91.6%) 96 (96.1%) 69 (98.6%) 72 (98.9%)

37 (97.4%) 73 (90.4%) 90 (94%) 57 (98.6%)

36 (97.4%)

36 (97.4%) 52 (89.1%)

68 (93.3%) 10 (98.2%) 3 (100%)

70 (89.1%) 73 (93%)

0 0 0 0 0

2017 2018 2019 2020

Number at risk rTAR

0 0 0 0

0 0 0

0 0

Number at risk

FIGURE 7.5 Kaplan-Meier curve showing 5-year recurrence rates after robotic ventral hernia repair (rv-TAPP, r-Rives, or r-TARUP). Numbers before the parentheses represent the number of patients at risk based on follow-up. Percentages within the parentheses represent the freedom from recurrence rate. (Baur J, Ramser M, Keller N, et al. Robotic primary ventral and incisional hernia repair (rv-TAPP and r-Rives or r-TARUP). Video report and results of a series of 118 patients (vol 92, pg 15, 2021). Chirurg . 2021;92(suppl 1):27.)

This can be done via a laparoscopic or robotic approach, and the technique for fixing includes reduction of bowel and primary repair of the defect in the posterior sheath. If the defect cannot be closed primarily, an intraperito neal mesh can be used to cover the defect. CONCLUSIONS The robotic preperitoneal surgical approach for VHR is safe and effective. The preperitoneal placement of mesh requires less traumatic fixation and might prevent its contact with the viscera and, therefore, formation of adhesions, erosions, and fistulas. REFERENCES 1. Coakley KM, Sims SM, Prasad T, et al. A nationwide evaluation of robotic ventral hernia surgery. Am J Surg . 2017;214(6):1158-1163. 2. Pauli EM, Rosen MJ. Open ventral hernia repair with component separation. Surg Clin North Am . 2013;93(5):1111-1133. 3. Pahwa HS, Kumar A, Agarwal P, Agarwal AA. Current trends in laparoscopic groin hernia repair: a review. World J Clin Cases . 2015;3(9):789-792. 4. Donkor C, Gonzalez A, Gallas MR, Helbig M, Weinstein C, Rodriguez J. Current perspectives in robotic hernia repair. Robot Surg . 2017;4:57-67. 5. Pereira X, Lima DL, Friedmann P, et al. Robotic abdominal wall repair: adoption and early outcomes in a large academic medical cen ter. J Robot Surg . 2022;16(2):383-392. 6. Podolsky D, Novitsky Y. Robotic inguinal hernia repair. Surg Clin North Am . 2020;100(2):409-415. 7. Halm JA, de Wall LL, Steyerberg EW, Jeekel J, Lange JF. Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery. World J Surg . 2007;31(2):423-429; discussion 430. 8. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT. Risk of complications from enterotomy or unplanned bowel resection during elective hernia repair. Arch Surg . 2008;143(6):582-586.

TABLE 7.3 Extraperitoneal Robotic Ventral Hernia Repair Complications

Complications

Incidence

eTEP

Seroma

2.4%-18%

Retromuscular hematoma

0%-3%

Surgical-site infection

1.3%-3%

Hematoma

1.7%-7%

Posterior layer dehiscence

1%-3.4%

Recurrence

0%-3%

TAPP

Bowel injury

0.50%

Urinary retention

0.80%

Surgical-site infection

Seroma

Hematoma

Recurrence

Ileus

1.60%

TARM

Paralytic ileus

9.50%

Mesh infection

1.10%

Recurrence

5.60%

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