Robotic General Surgery

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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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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

General Surgery

will go on to develop symptoms within 10 years of diag nosis and require repair. 3 As such, patients should be informed of this reality as it may guide future decision making. The correct approach to inguinal hernia repair is directly related to the surgeon’s comfort level with cer tain techniques. However, there are numerous benefits related to minimally invasive surgery including faster recovery and less narcotic utilization—rendering it a worthwhile approach. Unfortunately, laparoscopy has traditionally been associated with poor adoption of tech niques as a function of challenging and extended learn ing curves and poor intraoperative ergonomics. 4,5 Thus, major disparities in minimally invasive inguinal hernia repair currently exist, with the vast majority (greater than 70%) of inguinal hernia repairs being performed via open technique. 1 Reassuringly, robotic technology appears to be expanding the adoption of minimally inva sive strategies for inguinal hernia repair, with anecdotal evidence of reduced learning curves, better intraopera tive optics and camera control, and improved dexterity owing to wristed instruments. 6 The transition in practice is not only among those previously performing exclu sively open repairs, but robotic technology also assists well-versed laparoscopists in conducting more advanced repairs in scenarios that have previously posed a sig nificant challenge (eg, multiple recurrent hernias with prior posterior repair, hernias in patients following prostatectomy). 7 For symptomatic patients presenting with a primary inguinal hernia, the surgeon has all options available for repair. In our practice, we offer robotic inguinal her nia repair even for uncomplicated hernias as it allows for streamlining of our perioperative processes of care, improves ability to perform operations when intraop erative assistance is limited, and facilitates education in our academic setting. Specific situations that may Robotic Transabdominal Preperitoneal Inguinal Hernia Repair With Mesh Jordan O. Bray, Marissa Beiling, and Vahagn C. Nikolian

CHAPTER 6

INTRODUCTION With more than 800,000 inguinal hernia repairs being performed annually in the United States, this procedure remains one of the most common and thus important in the general surgeon’s repertoire. 1 Despite this prevalence, definitive treatment continues to present a challenge to many surgeons due to the anatomical complexity of the region and lack of consensus on the optimal approach. 2 For these reasons, management of the inguinal hernia continues to be a highly studied and hotly debated topic. Therefore, through the combination of minimally inva sive approaches, standardization of techniques, and collaborative learning over the last several decades, sig nificant progress has been made in the understanding of abdominal wall anatomy and efficacious, durable repair. In this chapter, we discuss the indications, surgical tech niques and potential complications surrounding a mini mally invasive approach to the management of inguinal hernias. INDICATIONS FOR MINIMALLY INVASIVE INGUINAL HERNIA REPAIR Most commonly, patients will be referred for surgical consideration with symptoms such as pain or discomfort in the presence of a palpable groin bulge. In these cases, repair is often indicated following a thorough history and physical examination to exclude other symptomatic sources and evaluate the specific type of groin hernia. A small proportion of patients referred to a surgical practice will have asymptomatic inguinal hernias inci dentally identified on imaging. In this cohort, watchful waiting can be employed following thorough discussion of typical and atypical hernia symptoms with instruction to re-present if symptoms develop and/or progress. It is important to recognize that, for patients presenting with minimally symptomatic inguinal hernias, the majority

SECTION 2 • Discipline-Based Practice - General Surgery

particularly benefit from a minimally invasive, robotic- assisted approach are summarized below: l Women presenting with inguinal hernias and ingui nal hernia equivalent: Women are more likely to present with concurrent femoral or obturator her nias. Although much less common, these hernias 8 are associated with emergency hernia complications of incarceration and strangulation in 30% to 40% of patients. 2 Furthermore, recent studies have demon strated that, even when an indirect or direct ingui nal hernia is the focus of the index operation, a large proportion of women will present with recurrences through the femoral or obturator spaces. The mini mally invasive approach provides significant advan tages in identifying and treating these challenging hernias. 2 l Bilateral inguinal hernias: Management of bilateral inguinal hernias with an open approach (either with a concurrent bilateral inguinal hernia repair or staged repair of each hernia) is associated with significant convalescence and postoperative pain. Minimally invasive repair of bilateral inguinal hernias results in faster return to activity with less utilization of nar cotics without significant increase in wound mor bidity. Furthermore, minimally invasive approaches are able to readily identify and treat an occult hernia concurrently with a symptomatic hernia, obviating future anesthetic risks and perioperative morbidity for patients. l Recurrent hernia with history of prior anterior repair: In general, hernia repair is most effective if utilizing virgin planes of dissection. For patients who have had a prior open (anterior) repair, redo hernia repair is best approached via minimally invasive (poste rior) approach as it allows better visualization of the disrupted planes. If possible, the surgeon should work to learn as much as possible about the prior procedure as this can significantly impact the chal lenges that may be anticipated during the operation. Patients who have previously had open tissue-based or standard Lichtenstein repairs will generally have very little scarring or postoperative adhesions in the preperitoneal plane. In contrast, patients with opera tive history of preperitoneal mesh or mesh-plugs may present with significant adhesions to critical struc tures in the myopectineal orifice. l Patients at risk for wound complications: Many fac tors can be associated with wound complications in general surgery. Patients who are actively smoking or have poorly controlled diabetes, morbid obesity, long-term steroid use, malnutrition, and collagen vascular disease may benefit from minimally invasive approaches that minimize the potential for wound complications. Open approaches in these patient pop ulations will increase the potential for wound mor bidity, and the proximity of the surgical incision to

the mesh will further increase the potential of chronic mesh infections, which can be exceedingly challeng ing to address. Despite the numerous advantages, there are several contraindications to minimally invasive hernia repair, which are largely considered relative in nature. Absolute contraindications include any patient factors that would preclude minimally invasive technique, general anesthe sia, or intra-abdominal insufflation. Well-recognized relative contraindications include significant abdominal surgical history or risk of intra-abdominal adhesions, prior prostatectomy or any other operation that directly accessed the retropubic space, previous minimally inva sive inguinal hernia repair with no prior open procedure performed, active anticoagulation with a high risk for thromboembolic complications, cirrhosis or evidence of portal hypertension and significant abdominal wall var ices, and chronic infections at or near the area where a mesh prosthetic would be positioned. PREOPERATIVE PHASE OF CARE Minimally invasive inguinal hernia repair is a well-toler ated operation in the optimized patient. Standard opti mization strategies for ventral hernia repair (eg, smoking cessation, diabetes control, and weight loss) are not required in advance of inguinal hernia repair, although our practice is to educate and support all patients in improving the perioperative outcomes through basic prehabilitation strategies. We educate patients that activity restrictions in advance of hernia repair are only recommended if certain activities cause symptoms of inguinal pain or discomfort. Patients are informed that operative repair is usually performed on an outpatient basis and is considered a low-risk procedure. All patients in our program have a preoperative screening appoint ment with our anesthesia colleagues to ensure anesthetic risk is minimized and thoroughly discussed in advance of surgery. They are provided chlorhexidine-based body wash to be applied to their abdominal wall and groin areas before presenting to the hospital.

On the day of surgery, standard precautions and risk-mitigating strategies are taken. Although studies suggest that antibiotic prophylaxis is not indicated in this operation, our current practice is to administer routine antibiotic prophylaxis to all patients to minimize risk of wound complications. The patient is positioned supine with both arms tucked. Upon intubation, efforts are made to ensure that the endotracheal tubing is low pro file, to minimize the potential for being dislodged by the robotic arms. Hair is clipped from the entire abdominal wall and bilateral groins, followed by antiseptic prepa ration of this same area and bladder catheterization. An orogastric tube is placed to decompress the stomach as it is our preference to enter the peritoneal cavity via optical entry in the left upper quadrant. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

CHAPTER 6 • Robotic Transabdominal Preperitoneal Inguinal Hernia Repair With Mesh

ROBOTIC PLATFORM, INSTRUMENTATION, AND ROOM SETUP There are a variety of robotic platforms being intro duced to the market at this time; however, this chapter will focus on our experiences utilizing the da Vinci Xi platform (Intuitive Surgical, Sunnyvale, CA). The robot is brought in from the patient’s right side to allow for the operating surgeon to perform docking, instrument place ment, and insertion of mesh and sutures without having to move from one side of the patient to the other. The robotic tower is set for a pelvic procedure. Instruments that are utilized include the following: l Three 8-mm robotic trocars l One 12-mm robotic trocar on standby (to be used if the patient has a symptomatic or prominent umbilical hernia or if the patient’s anatomy dictates placement of heavyweight mesh, see below) l One 5-mm optical trocar for abdominal entry l Laparoscopic instruments: laparoscopic needle driver, two laparoscopic bowel graspers, laparoscopic sheers, 5-mm laparoscopic camera (0°) l Robotic instruments (Intuitive Surgical): 30° robotic camera, fenestrated Force Bipolar grasper, monopolar curved scissors, Mega Suturecut needle driver. l Robotic instruments on standby: robotic suction-irri gator, alternate bowel graspers (Coudier, Tip-Up) l Intraoperative Mesh Cart with the following options available for Bard 3D Max contoured mesh (Becton Dickinson, Franklin Lakes, NJ) l Sizes: large, extralarge l Weight: light-, mid-, regular weight l Sutures (for unilateral repair) l Two 00-absorbable barbed suture—6 in l Two 000-absorbable multifilament suture—cut to 6 in The patient is evaluated in the preoperative area where laterality of symptoms is confirmed. An examination is performed to determine the likelihood of needing to per form a bilateral repair. The patient is consented for a unilateral, possible bilateral, inguinal hernia repair with mesh, as patients with incidentally identified hernias on the contralateral side will have a high burden of con tralateral hernia symptoms to emerge if left untreated. Following a comprehensive discussion, the patient is brought to the operating room and prepared by our anesthesia colleagues for the operation. Abdominal Access and Assessment of Inguinal Hernias Following standard abdominal wall preparation, the abdomen is entered. It is our practice to enter the abdo men in the left upper quadrant with a 5-mm optical SUMMARY OF OPERATION Preoperative Process

trocar and a 5-mm laparoscope. Following insufflation of the abdomen, the patient is positioned in 10° to 25° Trendelenburg position to better visualize the inguinal region. At this time, the intraoperative team is informed whether a unilateral or bilateral repair will be performed. Figure 6.1 highlights common transabdominal findings in the myopectineal region. Mesh is requested based on the following general recommendations: l Sizing of mesh l Patient height and torso length are used to guide decision making for mesh sizing. These recommen dations are subject to change and are often made at the discretion of the operating surgeon. We do not utilize mesh that is sized smaller than 15 × 12 cm. l For patients shorter than 72 in, we favor utilizing large mesh (15 × 12 cm). l For patients taller than 72 in or with lengthier tor sos, we favor utilizing extralarge mesh (17 × 14 cm). l Weighting of mesh l Hernia characteristics guide decision making for weighting of mesh. l Lightweight mesh is used for smaller indirect hernias or femoral/obturator hernias with a low chance for mesh eventration. l For direct defects or larger inguinal-scrotal her nias with high probability of mesh eventration, heavy weight (marketed as regular-weight mesh) is utilized. l For intermediate defects, we have adopted the use of mid-weight options. Trocar Placement In an effort to reduce trocar-site incisional hernias, we avoid reflexively placing trocars along the midline, through the umbilicus, or through a diastatic linea alba. Through this practice, closure of the “central trocar” is only required in select cases. Although it may seem excessively complex, we believe strategic trocar place ment reduces downstream care utilization related to trocar site hernias and complications. Common port placements for various circumstances include the follow ing and are summarized in Figure 6.2 : l Unilateral inguinal hernia necessitating nonheavy weight mesh ( Figure 6.2A ): l An 8-mm central trocar (camera port): 2 cm ceph alad from umbilicus and 2 cm toward groin of interest. l Two 8-mm working ports: slight triangulation toward groin of interest (1-cm offset from central trocar, spaced 8 cm lateral to central trocar). l Bilateral inguinal hernias necessitating nonheavy weight mesh ( Figure 6.2B ):

l An 8-mm central trocar (camera port): 2 cm ceph alad from umbilicus and 2 cm toward surgeon- defined more-challenging groin. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

SECTION 2 • Discipline-Based Practice - General Surgery

FIGURE 6.1 Intraperitoneal view of the myopectineal orifice. A, Unlabeled. B, Landmark anatomy. C, Locations of commonly identified hernia defects.

l Two 8-mm working ports: positioned transversely relatively to central trocar (spaced 8 cm lateral to central trocar). l Unilateral inguinal hernia necessitating heavyweight mesh ( Figure 6.2c ): l A 12-mm central trocar (camera port): 2 cm ceph alad from umbilicus and 2 cm toward groin of interest. l Two 8-mm working ports: slight triangulation toward groin of interest (1-cm offset from central trocar, spaced 8 cm lateral to central trocar). l Plan for fascial closure of 12-mm central trocar with interrupted slow absorbing multifilament suture. l Unilateral or bilateral inguinal hernia repair in patients with symptomatic umbilical hernias; bilat eral inguinal hernias necessitating heavyweight mesh ( Figure 6.2D ): l A 12-mm central trocar (camera port): Placed through the umbilicus. Peritoneal Flap Development From the console, the surgeon now progresses through a minimally invasive transabdominal preperitoneal inguinal hernia repair. The peritoneal flap is initiated at Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 l Two 8-mm working ports: positioned transversely relatively to central trocar (spaced 8 cm lateral to central trocar). l Plan for fascial closure of umbilical defect with an open technique utilizing interrupted slow- absorbing monofilament suture in a transverse orientation. Upon placing trocars, the previously defined mesh and sutures are placed in the abdominal cavity to min imize future instrument exchanges or requirements for advanced bedside assistance. The robot platform is docked to the patient’s right side with initial instruments including the fenestrated Force bipolar and monopolar curved scissors.

CHAPTER 6 • Robotic Transabdominal Preperitoneal Inguinal Hernia Repair With Mesh

5 mm

8 mm 8 mm 8 mm

8 mm

12 mm

FIGURE 6.2 Strategic port placement for robotic inguinal hernia scenarios. A, Unilateral or bilateral inguinal hernia. B, Unilateral or bilat eral inguinal hernia with need for heavyweight mesh. The midline 12-mm port can be placed through the umbilicus in cases of symptom atic umbilical hernias that are planned to be repaired concurrently.

dissection is a true preperitoneal dissection, with the intermediate fascia and transversalis fascia dissected away from the peritoneal flap and toward the abdom inal side wall. Through this strategy, the nerves found on the side wall will be protected from mesh interactions that may result in chronic postoperative inguinal pain syndrome. The peritoneal flap is developed medially to the pubic symphysis and contralateral Cooper ligament, whereas lateral dissection is extended to the ipsilateral margin of the psoas. Upon developing the initial ele ments of the peritoneal flap, we are ready to obtain the critical view of the myopectineal orifice, as described by Daes and Felix. 9 Critical View of the Myopectineal Orifice Irrespective of the approach one utilizes for minimally invasive inguinal hernia repair (laparoscopic vs robotic, extraperitoneal vs transabdominal), experts now agree that obtaining a critical view of the myopectineal ori fice can help to standardize the operation and improve short- and long-term outcomes. 10 By going through this methodical approach to hernia repair, one can ensure that all potential hernia defects in the groin are addressed and that the mesh prosthetic is positioned appropriately, reducing the burden of recurrences or chronic pain. Unlike other critical views (eg, critical view of safety of laparoscopic cholecystectomy), the critical view of the myopectineal orifice is not defined by a single view, but rather a systematic approach to preperitoneal inguinal

roughly the level of the arcuate line, favoring a more cephalad position to accommodate a larger mesh. The initial peritoneal incision is extended from right to left (as the scissors are usually controlled with the right hand) with the borders of the incision being the ipsilat eral medial umbilical ligament and anterior superior iliac spine (ASIS). For bilateral hernias, we develop a single flap. While other surgeons utilize two independent flaps and maintain a central portion of peritoneum involving the median umbilical ligament, in our experience a single flap is more straightforward to navigate and facilitates retropubic dissection. Peritoneal flap development is facilitated by paying close attention to the microfascial dissection planes that exist in the region of the groin. Recognizing that there is an intermediate fascial layer that exists anterior to the peritoneum, one is able to strategically perform a preperitoneal dissection to protect structures at risk of injury related to mesh interactions. This intermedia fascia will allow dissection in the parietal compartment, which lies anterior to the intermedia fascia, or the vis ceral compartment, which is posterior ( Figure 6.3 ). On the medial aspect of the peritoneal dissection (defined as medial to the medial umbilical ligaments), the dissection progresses in the parietal compartment. At the time of mesh placement, the intermediate fascia protects the bladder from mesh-related complications. On the lateral aspect of the peritoneal flap development (defined as lateral to the medial umbilical ligament) the

SECTION 2 • Discipline-Based Practice - General Surgery

FIGURE 6.3 Developing an appropriate preperitoneal pocket for mesh. A, Lateral dissection. B, Parietalization of cord structures. C, Mesh placement. D, Mesh fixation to ipsilateral Cooper ligament.

hernia repair that allows for a reproducible approach. The following describes the critical steps to establish ing an adequate dissection of the myopectineal orifice. Figure 6.4 summarizes essential aspects of obtaining the critical view. 1. Identification of Cooper ligament and the pubic tubercle across the midline: Beyond identification of the ipsilateral Cooper ligament, we recommend aiming to identify the contralateral Cooper liga ment, in particular for cases with medial defects (eg, femoral, obturator, direct, suprapubic). 2. Evaluate for direct hernia: It is important to recog nize that many direct hernias will not have a peri toneal invagination in the transabdominal view. However, upon performing a preperitoneal dissec tion, a number of direct defects may be identified. Care should be taken to completely reduce unusual appearing fat in the space and clearly identify the ipsilateral Cooper ligament. 3. Perform an adequate retropubic dissection: To ensure that the mesh prosthesis is not dislodged with bladder distension, it is advisable to develop at least 2 centimeters of retropubic dissection between Cooper ligament and the bladder. 4. Evaluate for femoral hernia: Dissection is then car ried along Cooper ligament, medial to the femoral vein, assessing for and reducing femoral hernias.

There will likely be adipose and lymph tissue in this space, and care should be taken to avoid exces sive dissection. 5. Evaluate for indirect hernia: Next, the indirect space is evaluated. Peritoneum that is invaginating into this space should be reduced, taking care to avoid injury to the vas deferens and gonadal vessels. The cord elements should be parietalized sufficiently to ensure that the mesh prosthesis will sit flat in the space. For the vas deferens, the surgeon should care fully assess and ensure that the vas is not tented up because of attachments to the distal elements of the medial umbilical ligament. Visual cues that the dis section is complete can be performed by manipulat ing the peritoneal flap and observing if there is any movement of the cord components. With adequate parietalization, the cord contents will be indepen dent of the peritoneal flap such that manipulation of the peritoneum will not induce any movement. 6. Evaluate for a lipoma of the cord: The deep ring should be explored after reduction of a hernia sac to determine if a lipoma is present. These often appear small and inconsequential but may be the lead point for a retroperitoneal recurrence. If a cord lipoma is reduced, it is not necessary to resect the tissue but care should be taken to ensure the lipoma is positioned posterior to the mesh, ensuring it cannot track back through the

CHAPTER 6 • Robotic Transabdominal Preperitoneal Inguinal Hernia Repair With Mesh

E FIGURE 6.4 Key steps in establishing critical view of myopectineal orifice. A, Identify and dissect the pubic tubercle across the midline. B, Evaluate for a direct hernia. C, Retropubic dissection. D, Evaluate for femoral hernia. E, Evaluate for indirect hernia. F, Assess for cord lipoma. G, Ensure adequate lateral dissection. H, Imaginary line of dissection that is carried laterally. I, Place an appropriately sized mesh. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 F

SECTION 2 • Discipline-Based Practice - General Surgery

FIGURE 6.4 Cont’d

9. Placement of the mesh prosthetic only after items 1 through 8 have been completed and verified: Mesh sizing has previously been described in this chapter. We utilize Bard products and based on our sizing ascribe to a similar philosophy as Drs. Daes and Felix, ensuring a 15 by 12 cm mesh is utilized for coverage of the space. We avoid manip ulation of the mesh. Upon placement, we typically secure it to Cooper ligament at one or two fixa tion points using fast-absorbing suture (eg, Vicryl). Care is taken during fixation to ensure that secur ing the mesh does not deform the contoured mesh. For direct defects, an additional fixation stitch is placed through the contralateral Cooper ligament. Data on fixation are limited with equivalent out comes demonstrated among a variety of fixation and nonfixation strategies. We do believe that fix ation with permanent tacks or permanent suture should be avoided.

deep ring. Overdissection in this space may cause injury to surrounding structures and increase the potential for chronic postoperative pain. As such, other visual cues related to adequacy of dissection should be utilized. We regularly confirm visualiza tion of the iliopubic tract, which we consider a sur rogate for adequacy of dissection and a strategy to confirm that cord lipomas have appropriately been addressed. 7. Ensure adequate lateral dissection: Anecdotally, many consider the lateral aspect of the dissection to be the part of this operation that is most fre quently inadequately performed. One should aim to dissect the space beyond the ASIS. 8. Ensure that the pocket for mesh is well above an imaginary inter-ASIS line: This particular step is criti cal in reducing the potential for chronic postoperative inguinal pain syndrome through nerve entrapment, especially involving the ilioinguinal nerve.

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