Robotic inguinal hernia repair with mesh

Introduction

Inguinal hernia is the most common of all primary abdominal wall hernias. Surgical repair of these constitutes 80% of all hernia operations. Over 800,000 inguinal hernias are repaired annually in the United States. Definitive treatment is surgical and can be performed under a variety of approaches including open, laparoscopic, and robotic.

Inguinal hernias are most often indirect and on the right. Men are 10 times more likely to develop an inguinal hernia than women, with an overall lifetime risk of 27%. Femoral hernias are seen twice as often in women, although femoral hernias account for less than 5% of all inguinal hernias.

Indications

Recommendation for repair is mostly based on symptoms, particularly for men. Watchful waiting in asymptomatic male patients has been shown to be safe where the risk of developing incarceration and strangulation is overall very low, at well under 1%. However, a long-term follow-up study to this revealed that cross-over to surgery, mainly due to the development of pain, occurs in the majority of patients within 10 years. Thus, for surgically fit individuals, consideration for elective repair at an opportune time is recommended.

A robotic (robot-assisted laparoscopic) inguinal hernia repair may be performed for the same indications as a conventional (open anterior) or a laparoscopic repair. An uncomplicated, unilateral, symptomatic inguinal hernia can be approached with any of the techniques according to surgeon and patient preference. However, certain situations may derive specific benefit from a minimally invasive approach as listed below. Indications for a minimally invasive inguinal hernia repair include the following:

• Bilateral or clinical suspicion of a contralateral occult hernia: The trocar position for minimally invasive repair is the same regardless of side. Therefore, if bilateral hernias are present, there are no additional incisions or trocars required. This results in reduced morbidity and shorter operative times than in open repair. Further, the initial intraperitoneal evaluation makes occult hernia identification easier.

• Femoral hernia: The exposure of a femoral hernia and assessment for placement of mesh can be a challenge from an anterior/open position. The most common open technique, the tension-free Lichtenstein repair, does not routinely address the femoral space. Modification of the technique to open the inguinal floor is needed. A minimally invasive approach allows for complete evaluation of all three potential hernia spaces consistently.

• Women : Women are more likely to develop femoral and obturator hernias. These hernias, while much less common, present with incarceration or strangulation in 35%–40% of cases. Therefore, addressing these spaces at the index operation is important to avoid costly recurrence. A large Swedish study of over 6000 patients undergoing inguinal hernia repair noted a much higher rate of femoral hernia recurrence in women. Thus, as noted above, the advantage of the minimally invasive approach for this indication is in concurrently addressing all potential spaces with a larger piece of mesh.

• Recurrence after previous open mesh repair : Attempting a repair after a previous mesh repair can be challenging regardless of approach. Conventional open repair after a previous anterior repair is technically demanding given the scar tissue and distorted anatomy. Risk of injury, morbidity, and a higher failure rate have been demonstrated. By approaching recurrence through a virgin plane, these risks can be lessened.

• Morbid obesity: Wound morbidity is a particular concern with the morbidly obese population. Larger incisions with increased soft tissue disruption are often required with the conventional anterior method. Additionally, the ability to place larger pieces of mesh for reinforcement through the smaller minimal incisions has been shown to be of great benefit.

Minimally invasive inguinal hernia repair was introduced by Ger in 1990. Benefits of this approach, including those listed above, have been widely reported. However, the adoption of minimally invasive inguinal hernia repair has plateaued. As recently as 2013, 70%–80% of all inguinal hernia repairs in the United States were still performed using an open anterior technique. ^, More recently, there has been rapid adoption of robotic applications to the field of hernia repair. Robotic assistance has the added advantage over standard laparoscopy of adding a stable and easily maneuverable camera platform with 3D capabilities and fully wristed instruments with seven degrees of motion. These advantages of the robotic platform over standard laparoscopy may allow surgeons to more widely expand the utilization of minimally invasive inguinal hernia repair. These benefits may be particularly relevant to surgeons considering a practice transition from a previously exclusive, traditional open technique. For others more proficient in minimally invasive surgery, the advantages may allow for the extension to more complex cases, such as hernia recurrence after previous laparoscopic repair or very large inguinoscrotal-type hernias. Cases that previously even a proficient laparoscopic hernia surgeon may have avoided attempting due to the limitations of traditional straight-stick laparoscopy may become manageable with the robotic platform.

Patient preparation

Ideally, a patient will be medically optimized prior to any hernia surgery so as to reduce risk of recurrence and complications. Appropriate pre-operative counseling regarding weight loss, smoking cessation, and diabetes control should be done. Preferably, those areas that can be improved should be modified prior to surgery. However, in reality, often there are barriers to achieving full optimization. Decision to proceed with surgery is a joint decision between surgeon and the patient after a thorough discussion regarding risks.

Staphylococcus aureus screening has become a more common place pre-operative step. Routine MRSA screening has been instituted in certain institutions given the increasing prevalence in the community, which has superseded hospital-acquired MRSA bacteremia globally. Selective screening can also be done. Those patients with risk factors including residence at long-term care facilities, recent hospitalization or antibiotic exposure within the last 30 days, elderly, history of COPD, or history of MRSA positive infection should be considered as they are at higher risk. A published screening strategy employed for elective total joint arthroplasty reported a 69% reduction in SSI prevalence after initiation of routine screening and decolonization. Staph aureus screening with nasal swab is performed at least 5 days prior to surgery. Decolonizing treatment consists of BID topical intranasal ointment (i.e. 2% mupirocin) and daily chlorhexidine gluconate showers for 5 days prior to surgery. Those identified as MRSA positive should also be given a dose of peri-operative Vancomycin.

Bladder decompression is important for ease and safety during the case. However, a Foley catheter is not always necessary, particularly if the patient can void completely just prior to surgery. Ultimately, routine placement is personal preference. In specific situations, catheter placement may be advisable, including with suspected sliding hernias, re-operative surgery (e.g., recurrent intraperitoneal inguinal hernia surgery), or the inability to void preoperatively (e.g., advanced age).

Hair clipping is preferable to shaving, given the higher incidence of surgical site infections with shaving. Routine clipping is personal preference. ^,

The use of routine antibiotic prophylaxis has not been definitively shown to improve infectious outcomes. The reported infection rate for inguinal hernia repair is low, at 1%–4%. Guidelines for laparoscopic inguinal hernia repair compiled by the International Endohernia Society did not find sufficient evidence to support recommendation for their routine use. Use in certain patient populations with overall increased risk of infection such as chronic immunosuppression, diabetes, or history of methicillin-resistant Staphylococcus aureus may be advisable.

Operating room setup and patient positioning

The majority of the following steps are applicable to any robotic platform. However, in this chapter I will mostly refer to the da Vinci platform (Intuitive Surgical Inc, Sunnyvale, CA, USA) as this is the one I am mostly familiar with and currently utilize.

The patient should be positioned supine on the table with the arms tucked, unless prevented by body habitus restrictions. All pressure points should be appropriately padded. If the patient has short stature or a short trunk, surgeons could consider a prone foam face pad as additional protection to the face from the elbows of the robotic arms (particularly with the Si system.)

The robot will be docked parallel to the table, driving in from the foot of the bed when using the Si system ( Fig. 7.1 ). The side of the bed for docking is determined by surgeon preference and/or operating room tower setup so as to maximize one side for bedside assistance (i.e., instrument insertion/camera cleaning). The Xi system cart can be docked from anywhere.

There are three robotic trocars used (8–8.5 mm depending on Si or Xi platform). Depending on surgeon preference for access or mesh insertion needs, an additional 5- or 10-mm laparoscopic port may also be used. In an effort to minimize costly instrumentation, only three robotic instruments are typically employed, namely, a grasper, monopolar scissors, and a needle driver. Additional laparoscopic instruments that may be needed include a second needle driver, locking grasper, or suction.

List of tools ( fig. 7.2 )

Trocars:

• Three robotic trocars: Camera 8 mm, working trocars 8 mm

• Possible additional access needs: Veress, 5-mm Optiview with 5-mm 0-degree laparoscopic camera, 10-mm Hasson port (i.e. Ethicon Endopath Ultra Veress and XCEL trocars with Optiview, Somerville, NJ, USA)

• Consider 10-mm trocar if needed for larger mesh insertion (i.e. Ethicon Endopath XCEL trocars with Optiview, Somerville, NJ, USA)

Instruments:

• Laparoscopic

  • 1.

    Laparoscopic needle driver

  • 2.

    Laparoscopic grasper

  • 3.

    Open closure needle driver/Adson forceps

  • 4.

    Suture scissors

• Robotic (All robotic instruments listed from Intuitive Surgical, Sunnyvale, CA, USA)

  • 1.

    0- or 30-degree robotic camera

  • 2.

    Grasper (i.e. Prograsp, Fenestrated Bipolar)

  • 3.

    Monopolar scissors

  • 4.

    Mega Suturecut needle driver

Suture:

• 1.

  2.0 absorbable barbed suture—6-inch length, GS needle

• 2.

  2.0 or 3.0 suture for mesh fixation (12–15 cm length), (non-absorbable for Cooper’s fixation, absorbable anywhere else)

• 3.

  4.0 absorbable subcuticular for trocar site closure – monocryl, vicryl, etc

• 4.

  If fascial closure needed (10-mm trocar site)—0 vicryl

Mesh:

• 10×15 cm or greater flat sheet permanent mesh

All key operative steps