Robotic General Surgery


CHAPTER 6 • Robotic Transabdominal Preperitoneal Inguinal Hernia Repair With Mesh

Closure of Peritoneal Flap The peritoneum can be closed with a variety of approaches as the robotic platform simplifies intracor poreal suturing. In general, it is advisable to close the peritoneum with an absorbable suture. It is our prefer ence to utilize barbed, slow-absorbing sutures. The clo sure of the flap should be initiated on the lateral aspect of the flap and carried medially. This intentional approach to flap closure from the lateral aspect is performed as the medial portion is typically more redundant because of the perivesical fat. If one were to begin the dissection on the medial aspect, there would be a higher likelihood of integrating too much of the peritoneal flap early in the closure, leaving excessive tension on the lateral closure. Once the primary flap is closed, the peritoneum should be assessed to confirm that no other fenestrations are present. If present, closure should be performed either with interrupted or running sutures. Upon closure of all defects, the peritoneum should be scrutinized to confirm that there is no evidence of poorly positioned mesh. Many advocate for evacuation of the preperitoneal space with an angiocatheter placed through the skin, a suction irrigator through the perito neal suture line, or a variety of other techniques. If mal positioned mesh is identified, it is imperative to reopen the peritoneal flap and develop an adequate pocket for the mesh. Case Completion All needles and sutures are removed while the surgeon is still on the console. To accomplish this safely, we posi tion the arm closest to the bedside assistant in a safe tra jectory, away from critical structures. The instrument is removed but the trocar is maintained in the docked posi tion. Using a laparoscopic needle driver, the assistant can safely insert the instrument through the trocar and travel along a predictable and guided trajectory. Once all items are removed from the field, the remaining instru ments and robotic camera are removed and the robot is undocked. All trocar sites that are off-midline or less than 1 cm are closed with subcuticular sutures for skin reapproximation. Fascial defects are closed for trocars larger than 1 cm and for 8-mm trocars that traverse the midline or a diastatic linea alba. They should be closed with interrupted slow absorbable monofilament suture (typically with an open technique to clearly identify the fascia). Our approach if a trocar is placed through an umbilical hernia defect is described previously. Skin sites are anesthetized with local anesthetic. Although we do not perform ilioinguinal or transversus abdominis plane blocks, these regional anesthetic techniques are well described and are utilized by many surgeons. The testi cles are assessed and confirmed to be in anatomic posi tion. If there is a large volume of air that has extended into the testicle, we avoid attempts at decompressing

this, in particular with overzealous decompression, as we do not want to disrupt the position of the mesh. Postoperative Pathway Extubation of patients is carefully coordinated with our anesthesia providers. We have worked closely with our anesthesia colleagues to standardize processes of care centered on the goal of postoperative anesthetic-related complications. Reversal of paralysis via selective relaxant- binding agents (eg, sugammadex) is performed. This is associated with fewer gastrointestinal side effects, fewer pulmonary complications, and reduced rates of postoper ative urinary retention. 11 The bladder catheter is removed in the postanesthesia care unit with a “fill and pull” trial. Through these processes of care, we have had essentially no cases of postoperative urinary retention, even with our program’s standardized use of bladder catheters. As such, we do not require patients to void prior to discharge. In the postanesthesia care unit, 15 mg of Toradol (ketorolac) is administered for patients who lack contrain dications to nonsteroidal anti-inflammatory medications. Patients are observed for pain control. For discharge, we initiate a course of scheduled acetaminophen and ibu profen for all patients. Every patient is sent home with a small number of opioid tablets, yet 96% of patients have reported zero opioid utilization during their postopera tive recovery for the first year of implementing our multi modal pain control pathway. For the remaining patients, no patients required more than five tablets of narcotics and there were no reported events of chronic groin pain (pain beyond 3 months from operative date). Upon discharge from the hospital, patients are encour aged to ambulate and perform activities of daily living as tolerated. Generally, we allow patients to perform any activity so long as they are not experiencing pain or severe discomfort. This recommendation holds true for the first 3 months post procedure. In the vast major ity of patients, pain subsides and activities are resumed without restrictions within 4 weeks. Patients are advised to utilize ice packs for pain and discomfort for the first 2 weeks post operation. After this period, they can uti lize heated compresses. All patients are enrolled in our program’s hernia surveillance program with telephone follow-up for hernia recurrence at 6 months post proce dure and subsequent annual screening. SHORT-TERM COMPLICATIONS

In general, robotic inguinal hernia repair is well tolerated and considered a low-risk operation. Outcomes are com parable with laparoscopic repair. Some studies have sug gested an increased operative time; however, this metric will likely improve as surgeons develop expertise in the robotic platform. 6 Although the complication burden is low, a surgeon should be aware of their potential, so that issues may be addressed appropriately when they arise. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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