Robotic inguinal hernia repair without mesh

Indications

At this time, we believe that r-IPT repair is best applied to small- or medium-sized inguinal hernias. It is not an appropriate repair technique to address femoral hernia. Common indications for r-IPT repair are listed in Table 8.1 . The ideal candidate for r-IPT repair is a patient undergoing a separate robotic procedure who is not a candidate for mesh-based inguinal hernia repair. For example, the patient may have a strangulated inguinal hernia requiring intestinal resection. With the robotic approach, the intestinal resection can be completed, followed by a tissue-based preperitoneal r-IPT repair. Another example is during robotic removal of preperitoneal inguinal mesh, such as for mesh infection, chronic pain (e.g., meshoma), or mesh reaction. Once the mesh is removed, redo mesh repair may be contraindicated or the patient may be unwilling to undergo another mesh-based repair.

Some patients may have a mesh reaction or mesh allergy; some may be at high risk for mesh reaction, allergy, or mesh-related chronic pain. These patients tend to be very thin and are often females. Other risks include autoimmune disorders and postural orthostatic tachycardia syndrome. In these situations, the use of mesh is relatively contraindicated. r-IPT repair is a minimally invasive option for their inguinal hernia repair, in comparison with the standard open anterior approach. It may be especially preferred for bilateral inguinal hernias, similar to the preference of laparoscopic repair with mesh over open repair with mesh for bilateral inguinal hernias.

Patient preparation

Preoperative preparation for r-IPT repair is similar to that for any other robotic operation. The patient must be deemed a safe candidate for general anesthesia. Also, in the case of elective hernia repair, major reversible risk factors for hernia recurrence, including chronic cough, constipation, morbid obesity, and prostatism, should be addressed. As a femoral hernia cannot be repaired with this approach, such a diagnosis should be ruled out prior to r-IPT repair.

Operating room setup and patient positioning

The patient is placed supine, with the arms padded and tucked to the sides. We recommend that the patient be placed flat and not in lithotomy, as any hip flexion may result in an inadvertently tight tissue repair. As with other pelvic operations, we recommend urinary catheterization to reduce the risk of bladder injury. The sterile preparation should include the entire anterior abdomen as well as the genital organs in case they need to be accessed intraoperatively. The patient is then placed in the Trendelenburg position.

We currently utilize the da Vinci Xi system. Prior to docking, the face of the patient must be protected from potential interaction with the arms of the robot ( Fig. 8.1 ). The robot is docked to the side of the patient; this can be either perpendicular to the bed, at an acute angle to the feet of the patient, or parallel to the feet of the patient.