Robotic General Surgery

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CHAPTER 6 • Robotic Transabdominal Preperitoneal Inguinal Hernia Repair With Mesh

5 mm

5 mm

8 mm 8 mm 8 mm

8 mm

8 mm

12 mm

A

B

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

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