Robotic General Surgery

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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