Robotic General Surgery

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SECTION 2 • Discipline-Based Practice - General Surgery

Intraoperative Bleeding and Vascular Injury Minimally invasive inguinal hernia repair is associated with a low potential for major vascular injury or need for blood transfusion. Vascular injury to the inferior epi gastric, obturator, and gonadal vessels is generally sim ply addressed with bipolar coagulation. In select cases, clip application or suture ligation can be considered. These injuries most often arise from an improper plane of dissection during peritoneal flap development and hernia sac reduction. Major vascular injury to the external iliac vessels has been described. This potential complication is more common if a prior preperitoneal dissection has been per formed. Most commonly, this complication can arise during attempts at repair of recurrent hernias in patients with preperitoneal mesh prosthesis. Although we have never personally experienced major vascular injuries, it is our practice to have a rolled sponged and 4-0 Prolene suture placed in the abdominal cavity at the time of robotic repairs with a preperitoneal mesh prothesis. Although surgical dogma would necessitate a conversion to open repair of injuries to the iliac vessels, surgeons have described robotic repair of these injuries. 7 Bladder Injury and Postoperative Urinary Retention This is a well-described complication of inguinal hernia repair and is more commonly seen with minimally inva sive approaches. Burden is increased in scenarios when the retropubic space has previously been accessed (eg, prostatectomy, prior minimally invasive surgery-based hernia repair). Our program places bladder catheters in all patients to reduce the potential for bladder disten sion, which may increase potential for injury. If an injury is identified, standard approaches to a layered bladder wall closure can be performed. Following closure, the bladder catheter should be maintained for a week prior to removal. Cystogram can be coordinated with the sur geon or urologic service. Mesh placement in the setting of injury is safe in most scenarios. If there is a history of chronic urinary tract infections, heavyweight or polyes ter mesh should be avoided in favor of lightweight or midweight microporous polyester. If permanent mesh placement is deemed to be contraindicated, a bioabsorb able mesh can be utilized. If the bladder injury occurs early in the dissection and there are concerns for moving forward with hernia repair, the bladder may be repaired and minimally invasive approach aborted in favor of an open inguinal hernia repair. Urine may be prospectively tested for presence of infection. If identified, prophylac tic antibiotics may be considered to reduce the potential for a prosthetic infection. Postoperative urinary retention is a well-known phe nomenon following minimally invasive inguinal her nia repair. The rates of occurrence vary but have been reported as high as 30%. 11 The causes are generally

considered multifactorial, with prostatic hypertrophy, age greater than 60 years, and male gender identified as potential patient risk factors. Others have identi fied perioperative processes of care such as volume of intravenous fluid administration, placement of bladder catheters, repair of bilateral hernias, and bladder manip ulation as variables that may increase the rate of post operative urinary retention. Recent studies suggest that the cause of this complication is more likely related to paralytic reversal strategies and techniques. It has been demonstrated that urinary retention is significantly reduced when reversal of paralytic agents is performed via administration of sugammadex rather than the tradi tional combination of neostigmine and glycopyrrolate. 11 As such, we have transitioned our practice to sugamma dex-based reversal. Small Bowel Obstruction Bowel obstruction following preperitoneal hernia repair should be assessed for with a high index of suspicion related to complications such as port-site hernias and interparietal hernias, which necessitate prompt surgi cal intervention. For those utilizing barbed sutures for flap closure, obstructions related to acute adhesions have been described. Should an interparietal hernia be identified, sutured closure of the defect can be accom plished. If the defect is large and there is undue tension, the defect may be patched closed with autologous tissue (eg, omentum, bladder flap) or with the use of synthetic mesh that has an antiadhesive barrier. Seroma Postoperative seromas are common and often do not necessitate intervention. Patients are informed of the potential for seromas, in particular in cases of large her nias with a scrotal component. A variety of techniques related to plication of defects, application of pressure dressings, and placement of drains have been described with no approach resulting in significant reduction in seroma rates. Large seromas associated with symptoms related to mass effect can selectively be managed with percutaneous drainage with or without injection of scle rosing agent. These interventions will increase the poten tial for “seeding” the sterile fluid.

LONG-TERM COMPLICATIONS Chronic Postoperative Inguinal Pain Chronic pain following inguinal hernia repair is a com mon, yet underreported, complication of all hernia repair strategies. It is defined as groin pain beyond the 3-month postoperative period and occurs between 5% to 15% of inguinal hernia repairs, regardless of technique. 7,12 The pain can be neuropathic or nociceptive in nature. Potential nerves that may be injured during minimally Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024