Robotic General Surgery


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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