Fong_Robotic General Surgery, 1e

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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

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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