Robotic General Surgery

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


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

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