Robotic General Surgery

55

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